This systematic review and meta-analysis included nine randomized controlled trials with a total of 3022 elderly patients undergoing hip fracture surgery, comparing spinal anesthesia to general anesthesia. Pooled outcomes of interest were intraoperative hypotension, ephedrine use and dose, blood loss, and postoperative outcomes including myocardial infarction, heart failure, stroke, postoperative nausea and vomiting, delirium, and mortality. The analysis revealed significant differences favoring spinal anesthesia in terms of reduced intraoperative hypotension and lower ephedrine doses. No significant differences were found in other outcomes. The findings suggest that spinal anesthesia may offer specific intraoperative benefits over general anesthesia for this patient population, although both techniques are similar in terms of postoperative outcomes.