Background: Major orthopaedic surgeries impose substantial physiological stress, particularly in elderly or high-risk patients. Neuraxial techniques such as spinal anaesthesia (SA) and combined spinal epidural anaesthesia (CSEA) are commonly employed, yet the optimal approach remains debated. Objective: This systematic review critically compares the clinical outcomes of CSEA and SA in patients undergoing major orthopaedic procedures, focusing on haemodynamic stability, block characteristics, analgesia duration, and complication rates. Methods: A comprehensive search identified randomized trials and observational studies comparing CSEA and SA. Primary outcomes included intraoperative haemodynamic stability, block quality, postoperative analgesia, and incidence of adverse effects. Results: Evidence consistently demonstrates that CSEA offers superior haemodynamic stability, prolonged and adjustable sensory blockade, and extended postoperative analgesia compared to SA. Complication rates, including post-dural puncture headache and urinary retention, were comparable, although CSEA was associated with fewer conversions to general anaesthesia and lower vasopressor requirements. Conclusion: CSEA provides significant clinical advantages over SA for major orthopaedic surgeries, particularly in high-risk or elderly populations requiring haemodynamic control and prolonged analgesia. Nonetheless, SA remains a practical choice for shorter, lower-risk procedures. An individualized anaesthetic strategy, based on patient and procedural factors, is advocated to optimize perioperative outcomes.