General versus neuraxial anesthesia and postoperative pneumonia after hip fracture surgery in older adults: a systematic review and meta-analysis

Background Hip fracture surgery in older adults is associated with substantial postoperative morbidity, including pneumonia. Whether the choice between general and neuraxial anesthesia influences the risk of postoperative pneumonia remains uncertain. Method We conducted a systematic review and meta-analysis in accordance with PRISMA 2020 guidelines. PubMed, Scopus, Web of Science, Cochrane Library, and Google Scholar were searched from inception to July 2026. Eligible studies compare general neuraxial or regional anesthesia in patients aged ≥75 years undergoing hip fracture surgery and reported postoperative pneumonia or related pulmonary outcomes. Random-effects models were used to pool risk ratios (RRs). Subgroup analyses examined anesthesia comparator type and study design, with sensitivity and influence analyses performed to assess the robustness of the findings. Result Eighteen studies were included in the systematic review, with 10 studies involving 76,324 participants contributing to the primary meta-analysis. General anesthesia was not significantly associated with postoperative pneumonia compared with neuraxial anesthesia (RR 1.08, 95% CI 0.98–1.19; I 2  = 27.9%). Broader pulmonary or chest infection outcomes also showed no significant difference (RR 1.07, 95% CI 0.69–1.68), although heterogeneity was substantial. In subgroup analysis, general anesthesia was associated with a higher risk of pneumonia compared with spinal anesthesia (RR 1.67, 95% CI 1.07–2.60), whereas no significant difference was observed with broader neuraxial/regional comparators (RR 1.05, 95% CI 0.95–1.16). Conclusion General and neuraxial anesthesia were not significantly different in the overall risk of postoperative pneumonia after hip fracture surgery in older adults. The higher risk observed in the spinal anesthesia subgroup warrants further investigation but does not establish superiority of either technique. Anesthetic selection should remain individualized.