spinal anesthesia vs. neve block in risk of cognitive decline

Conditions: Postoperative Cognitive Complications

Summary: hip fracture is a potentially devastating event, and serious surgical and medical complications occur frequently especially for elderly patients. delirium is one of the common complications after hip surgery. this study objective is to assess the association between type of anesthesia (nerve block vs. spinal anesthesia) and risk of cognitive decline (cd). and its secondary objective is to compare intra-operative hemodynamic changes, and post-operative pain. prospective, double blind randomized clinical trial of hip fracture patients who will be assessed for cd pre- and postoperatively, for three months after surgery. patients undergoing hip surgery will be randomized into two groups. group 1 will receive unilateral lumbosacral nerve block (sciatic nerve block and paravertebral block at levels l3-l4 and l4-l5) as well as placebo injection (1 ml normal saline) at the spinal anesthesia level (l3-l4 or l4-l5). group 2 will receive spinal anesthesia in addition to placebo injection at the sciatic, l3-l4 and l4-l5 levels.

hip fracture is a potentially devastating event, and serious surgical and medical complications occur frequently especially for elderly patients. around one-third of the patients pass away within the first post-operative year. one of the most common complications in hip fracture patients is delirium which is characterized by an acute disturbance in awareness, attention and cognitive function. delirium has a fluctuating course and is usually reversible. however, evidence suggests an association between delirium and future cognitive decline and development of dementia during months after the delirium episode. dementia is a chronic syndrome characterized by cognitive decline, impairment in activities of daily living and a change in social abilities and behavior. several risk factors are identified for preoperative and postoperative delirium including age, comorbidities, intraoperative hypotension and use of vasopressors. there is some controversy about the cognitive consequences due to the type of anesthesia used. spinal and general anesthesia are commonly used for hip surgery. an alternative technique is the combined sciatic-paravertebral block that has been used to overcome the adverse effects associated with spinal and general anesthesia. this anesthetic technique was associated with less intraoperative hypotension and reduced rate of icu admission. given the promising effect of paravertebral block on the outcome of hip surgery, we will conduct this study to assess the effect of paravertebral block on postoperative cd.

Eligibility criteria:
inclusion criteria: * admitted with a hip fracture (femoral neck, trochanteric or sub-trochanteric) * 65 years or older * 40 kgs in weight and higher exclusion criteria: * uncooperative * considered as moribund by the orthopedic surgeon at admission * alzheimer * severe cognitive impairment (mmse\<18) * absolute contraindication for spinal anesthesia (assessed preoperatively) * allergy to local anesthesia * have any severe visual disorder or debilitating vascular event

Keywords: fractures, hip nerve block spinal anesthesia nerve, sciatic paravertebral aged