SRS231 - Is povidone-iodine irrigation in spine surgery a game-changer? A meta-analysis of RCTs on surgical site infection prevention

Surgical site infections (SSIs) are a major complication in spinal surgery, especially with instrumentation, leading to higher morbidity, longer hospital stays, and increased costs. Intraoperative wound irrigation (IWI) with povidone-iodine (PI) has been suggested as a preventive measure. This systematic review and meta-analysis assessed the effectiveness of PI irrigation versus control (saline or no irrigation) in reducing SSIs and its impact on spinal fusion. Following PRISMA guidelines, we searched Ovid MEDLINE, EMBASE, Web of Science, and Cochrane Library through March 2025. Eligible studies were randomized controlled trials (RCTs) comparing PI irrigation with control in adult spinal surgery. The primary outcome was overall SSI rate; secondary outcomes included superficial and deep SSIs, fusion rates, and adverse events. Data were pooled with a random-effects model, and heterogeneity was evaluated using I². Six RCTs with 1804 patients (901 PI, 903 control) were included. PI irrigation significantly reduced overall SSI risk (0.77% versus 6.0%; RR = 0.16, 95% c.i.: 0.08–0.34; P < 0.00001; I² = 0%). Subgroup analyses showed lower superficial (RR = 0.19; 95% c.i.: 0.07–0.52; P < 0.001) and deep SSI rates (RR = 0.21; 95% c.i.: 0.08–0.52; P = 0.0009), with absolute rates reduced from 2.9% to 0.33% and 3.2% to 0.4%, respectively. Fusion outcomes were comparable (RD = 0.03; 95% c.i.: 0.00–0.06; P = 0.10). PI irrigation markedly reduces superficial and deep SSIs without compromising fusion, supporting its use as a safe, cost-effective adjunct in spinal surgery infection prevention.