Abstract / Summary
Spinal deformity surgery is associated with substantial blood loss and high transfusion requirements, exposing patients to the risks of allogeneic blood transfusion. Intraoperative cell salvage (ICS) is widely used in patient blood management strategies, yet its clinical efficacy and safety in spinal deformity surgery, particularly in the context of contemporary antifibrinolysis and restrictive transfusion parameters, remain uncertain. We conducted a systematic review and meta-analysis of observational studies comparing spinal deformity surgery performed with versus without ICS. PubMed, Embase, and CENTRAL were searched from inception to December 2025. Primary outcomes included transfusion volume requirements (intraoperative, postoperative, total perioperative), postoperative day 1 (POD1) hemoglobin and hematocrit, and overall complications. Secondary outcomes included the proportion of patients transfused, transfusion-related costs, and length of hospital stay. Random-effects meta-analyses were performed using restricted maximum likelihood estimation with Hartung-Knapp adjustments. Twenty-two studies comprising 2977 patients (ICS: 1851; control: 1126) were included. ICS was not associated with reductions in intraoperative (SMD 0.86, 95% CI -0.24-1.96) or total perioperative transfusion volume (SMD 1.15, 95% CI -0.75-3.05), nor with a lower likelihood of receiving any perioperative transfusion. However, ICS was associated with a modest reduction in postoperative transfusion volume (SMD 0.25, 95% CI 0.04-0.46) and higher POD1 hemoglobin (MD -0.42 g/dL, 95% CI -0.76--0.07). No significant differences were observed in overall complications, transfusion-related costs, or length of hospital stay. In contemporary spinal deformity surgery, ICS does not meaningfully reduce overall transfusion exposure but is associated with improved early postoperative erythrocyte reserve. These findings suggest that ICS functions as a transient physiologic buffer rather than a transfusion-avoidance strategy. Its routine use is unlikely to provide substantial benefit, and future studies should explore a selective, risk-adapted role for ICS in patients with anticipated major blood loss.