Last reviewed: September 29, 2026

Either is a reasonable choice for most people. Large record studies lean toward spinal, but trials have not shown a clear winner.

With general anesthesia, you are fully asleep. With a spinal, medicine injected in the lower back numbs you from the waist down.

Studies of hundreds of thousands of knee replacements from hospital records found fewer complications with spinal, including less pneumonia, fewer readmissions, and in some studies fewer deaths. One large study found less confusion after surgery with spinal. But record studies cannot fully account for why one person was given a spinal and another was not, and not every large study found a difference in deaths.

Trials that assigned people at random are few and small. They found similar pain, complications and hospital stays. One found people were up and walking sooner after a general anesthetic given entirely through the vein. Across studies, nausea was about the same with either. Another trial found knees worked slightly better a year after spinal. None was large enough to show whether one is safer.

A spinal has its own drawbacks. Trouble passing urine afterward is more common, and occasionally a spinal does not work well enough and general anesthesia is used instead.

An international group of anesthesia experts prefers spinal for knee replacement, but calls it a weak recommendation based on low-quality evidence.

In general:

  • The choice is made with your anesthesiologist, based on your health.
  • If being awake during surgery worries you, ask about sedation.
  • Tell the anesthesia team about blood thinners, sleep apnea, lung disease or any past spine surgery.
  • Trouble passing urine after surgery is worth reporting.

Drafted with AI assistance from published sources, reviewed and edited by Babak Sheikh, MD.

Sources:

  • Memtsoudis SG, et al. Anaesthetic Care of Patients Undergoing Primary Hip and Knee Arthroplasty: Consensus Recommendations From the International Consensus on Anaesthesia-Related Outcomes After Surgery Group (ICAROS) Based on a Systematic Review and Meta-Analysis. Br J Anaesth. 2019. https://doi.org/10.1016/j.bja.2019.05.042
  • Johnson RL, et al. Neuraxial vs General Anaesthesia for Total Hip and Total Knee Arthroplasty: A Systematic Review of Comparative-Effectiveness Research. Br J Anaesth. 2016. https://doi.org/10.1093/bja/aev455
  • Harris AB, et al. Comparison of Pneumonia and Major Complications After Total Joint Arthroplasty With Spinal Versus General Anesthesia: A Propensity-Matched Cohort Analysis. J Am Acad Orthop Surg. 2024. https://doi.org/10.5435/JAAOS-D-23-00192
  • Owen AR, et al. Spinal Versus General Anaesthesia in Contemporary Primary Total Knee Arthroplasties. Bone Joint J. 2022. https://doi.org/10.1302/0301-620X.104B11.BJJ-2022-0469.R2
  • Heckmann ND, et al. Spinal Versus General Anesthesia in Total Knee Arthroplasty: Are There Differences in Complication and Readmission Rates? J Arthroplasty. 2023. https://doi.org/10.1016/j.arth.2022.10.036
  • Pugely AJ, et al. Differences in Short-Term Complications Between Spinal and General Anesthesia for Primary Total Knee Arthroplasty. J Bone Joint Surg Am. 2013. https://doi.org/10.2106/JBJS.K.01682
  • Warren J, et al. Spinal Anesthesia Is Associated With Decreased Complications After Total Knee and Hip Arthroplasty. J Am Acad Orthop Surg. 2020. https://doi.org/10.5435/JAAOS-D-19-00156
  • Harsten A, et al. Recovery After Total Intravenous General Anaesthesia or Spinal Anaesthesia for Total Knee Arthroplasty: A Randomized Trial. Br J Anaesth. 2013. https://doi.org/10.1093/bja/aet104
  • Palanne R, et al. Effects of Anaesthesia Method and Tourniquet Use on Recovery Following Total Knee Arthroplasty: A Randomised Controlled Study. Br J Anaesth. 2020. https://doi.org/10.1016/j.bja.2020.03.036
  • Rantasalo M, et al. Use of a Tourniquet and Spinal Anesthesia Increases Satisfactory Outcomes After Total Knee Arthroplasty: A Randomized Study. J Bone Joint Surg Am. 2021. https://doi.org/10.2106/JBJS.20.02080
  • Azarboo A, et al. Risk Factors of Postoperative Urinary Retention Following Total Hip and Knee Arthroplasty. Bone Jt Open. 2024. https://doi.org/10.1302/2633-1462.57.BJO-2024-0003.R1

This is general information about what published research shows. It is not medical advice and it is not about your situation. Reading it does not create a doctor-patient relationship with me. I am a retired orthopedic surgeon and I do not see patients. Talk with your own doctor before changing anything about your care. If something feels suddenly or seriously wrong, get medical care promptly rather than waiting.

This page is provided as is. I make no guarantee that it is accurate, complete or current, and medical evidence changes. Use of it is at your own risk.

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