Introduction:
Spinal anesthesia (SA) is preferred for hip fracture surgery but can be difficult due to severe preoperative pain. This study compared prespinal analgesic techniques for improving the ease of SA and postoperative analgesia in neck of femur fractures.

Material and methods:
In a prospective, randomized, double-blind trial, 210 patients aged ≥ 60 years undergoing internal fixation of fractured neck of femur under SA were allocated to three groups. Group A received a femoral nerve block (FNB), Group B a pericapsular nerve group (PENG) block, and Group C intravenous fentanyl 1 µg kg–1 10 minutes before SA. For FNB and PENG, 20 mL of 0.25% bupivacaine was used.

Results:
The PENG group had the lowest Ease of Spinal Anesthesia (EOSA) score (median 7 [IQR 7–8]) vs. FNB 8 (7–9) and fentanyl 9 (9–10) (P < 0.001). Pain during positioning and puncture was lowest with PENG (P < 0.001). Time to first rescue analgesia was longest with PENG (8.8 ± 2.03 h, 95% CI: 8.3–9.3) compared with FNB (5.9 ± 1.5 h, 95% CI: 5.5–6.4) and fentanyl (4.2 ± 0.7 h, 95% CI: 4.0–4.4) (P < 0.001). Immediate postoperative visual analog scale (VAS) scores at 6 and 12 hours were lower with PENG; differences at 24 hours and 30 days were not significant. Hemodynamics and complication rates were largely similar across groups.

Conclusions:
In hip-fracture patients, ultrasound-guided PENG and FNB improved the ease of SA and reduced postoperative opioid use, with PENG showing the greatest benefit.