Abstract
Background Intraoperative cell salvage is widely used in pediatric scoliosis surgery to reduce allogeneic transfusion requirements. However, its clinical effectiveness and economic impact remain uncertain. The objective of this study was to evaluate the efficacy and cost implications of intraoperative cell salvage in pediatric scoliosis surgery.
Methods A retrospective observational study was conducted, including 75 patients who underwent posterior instrumented spinal fusion between 2023 and 2025 at a tertiary referral center. Patients were stratified according to the use of intraoperative cell salvage. Demographic, perioperative, and postoperative variables were analyzed, including estimated blood loss, transfusion rates, hemoglobin levels, and length of stay. Subgroup analyses by reinfused blood volume, scoliosis etiology, and a propensity score-matched analysis were performed. A cost-benefit analysis and break-even evaluation were conducted from the hospital perspective.
Results Fifty-seven patients (76%) underwent surgery with cell salvage. No significant differences were observed in postoperative transfusion rates (22.8% vs 11.1 %; P = 0.32), hemoglobin levels, or length of stay. Patients with higher reinfused blood volumes had significantly greater estimated blood loss and higher postoperative transfusion rates (41.2% vs 15.0%; P = 0.04). No reduction in transfusion rates was observed across etiological subgroups. Propensity score matching confirmed the absence of benefit. The estimated cost per transfusion episode was €4754, while the cost of cell salvage was €250 per procedure. Cost neutrality would require avoiding 1 transfusion per 19 procedures, a threshold not achieved.
Conclusion Routine intraoperative cell salvage in pediatric scoliosis surgery was not associated with reduced transfusion rates or shorter hospital stays but increased health care costs. Its use should be considered selectively.
Clinical Relevance These findings support a more selective and individualized approach to blood management in pediatric scoliosis surgery.
Level of Evidence 3.
Introduction
Pediatric scoliosis surgery involving posterior spinal instrumentation is associated with substantial intraoperative blood loss, particularly in cases with large curve magnitude or nonidiopathic etiologies. Consequently, perioperative allogeneic blood transfusion is frequently required. The need for transfusion in this setting is higher than in less extensive orthopedic procedures and has been associated with increased complication rates,1 prolonged hospital stays, and higher health care costs.
Despite modern safety protocols, allogeneic transfusion is not without risks, including immunological reactions, infectious complications, and delayed functional recovery. These concerns have led to the development of multiple blood conservation strategies in major surgery.2,3 Among them, intraoperative cell salvage systems are designed to collect, process, and reinfuse blood lost during surgery with the aim of reducing exposure to allogeneic blood products.4
Although intraoperative cell salvage is widely used in pediatric scoliosis surgery, its clinical effectiveness remains controversial. In patients with adolescent idiopathic scoliosis, some studies have reported a reduction in the volume of transfused allogeneic red blood cells when cell salvage is used,5 particularly in extensive procedures.6,7 However, other studies have failed to demonstrate a consistent reduction in overall transfusion rates or total perioperative blood product use, especially in heterogeneous pediatric populations or in nonidiopathic scoliosis, where surgical complexity itself may determine transfusion requirements regardless of cell salvage use.8
Furthermore, several studies and meta-analyses have questioned the overall benefit of cell salvage, suggesting that although it may reduce intraoperative transfusion requirements, it does not consistently decrease total perioperative allogeneic blood use or transfusion rates, and its clinical benefit may be limited in procedures with moderate blood loss.9
From an economic perspective, the cost-effectiveness of intraoperative autotransfusion remains equally uncertain. The use of cell salvage entails additional costs related to equipment, disposables, and logistics, which must be balanced against the potential savings derived from reduced transfusion requirements and shorter hospital stays. In a retrospective study of spinal instrumentation, Miao et al10 demonstrated that, despite reducing transfused volumes, intraoperative blood salvage was not cost-effective overall. Similarly, other analyses in scoliosis surgery have shown that its economic value depends largely on the volume of blood loss, with potential benefit only in cases with high anticipated blood loss, making its routine use debatable.11
In this context of heterogeneous evidence, a critical evaluation of both the clinical and economic impact of intraoperative cell salvage in real-world pediatric scoliosis surgery is warranted. The aim of this study was to determine whether, beyond any clinical effect, the use of intraoperative blood salvage systems can be considered a cost-effective strategy in a cohort of pediatric patients undergoing scoliosis surgery at a tertiary referral center.
Methods
Data Collection and Patient Selection
Following approval by the institutional review board and ethics committee (code COT26.RSI), a retrospective observational study was conducted at a tertiary-level maternal and child hospital and national referral center in Madrid, Spain, for pediatric scoliosis surgery. The requirement for informed consent was waived due to the retrospective design of the study.
All consecutive patients who underwent posterior instrumented spinal fusion for scoliosis between January 2023 and December 2025 were considered for inclusion. The inclusion criteria were (a) patients younger than 16 years at the time of surgery; (b) diagnosis of scoliosis (idiopathic, syndromic, or neuromuscular) treated with posterior instrumented fusion; (c) surgical treatment performed at a single tertiary referral center by the Orthopedic Surgery and Traumatology Department; (d) availability of complete electronic medical records with sufficient clinical and surgical data; (e) surgery performed within the defined study period; and (f) minimum follow-up of 1 year.
The exclusion criteria were (a) surgical approaches other than posterior instrumented fusion; (b) revision surgeries or reinterventions after prior spinal procedures; (c) surgeries performed for spinal pathologies other than pediatric scoliosis (including tumors, infections, fractures, or other deformities not included in the study); (d) incomplete clinical data or absence of key variables required for analysis; (e) lack of perioperative data or missing information regarding immediate postoperative evolution; and (f) loss to follow-up during the study period.
Patients were classified according to scoliosis etiology as idiopathic, syndromic, neuromuscular, or congenital/other. Additionally, patients were stratified based on the use of intraoperative cell salvage according to routine clinical practice during the study period. The use of intraoperative cell salvage followed an institutional protocol agreed upon by the Spine Surgery and Anesthesiology teams. Cell salvage was routinely used in pediatric spinal deformity surgery and was omitted only in procedures with an anticipated low risk of blood loss, such as less complex cases with a limited number of instrumented levels.
Patient Data
Data were collected from electronic medical records and perioperative registries. Variables included baseline demographic characteristics, surgical data, estimated blood loss (EBL), intraoperative allogeneic blood transfusion, reinfused blood volume, and early postoperative outcomes.
In patients in whom intraoperative cell salvage was used, the volume of reinfused blood was recorded. EBL and intraoperative allogeneic blood transfusion were also recorded for all patients. Postoperative transfusion requirements, hemoglobin evolution, and length of stay in both the intensive care unit (ICU) and the general ward were also documented.
To evaluate the relationship between reinfused volume and transfusion risk, stratified analyses were performed using clinically relevant reinfusion thresholds. Additional analyses were performed to evaluate the relationship between EBL, reinfused blood volume, and postoperative transfusion requirements. Additional subgroup analyses were conducted according to scoliosis etiology to assess whether the effect of cell salvage differed across etiological groups.
Surgical Management
All procedures consisted of posterior instrumented spinal fusion performed according to standard institutional protocols.12 Perioperative management, including anesthetic and transfusion practices, followed routine clinical guidelines. All patients were managed according to the institutional blood management protocol, including routine administration of tranexamic acid, standardized anesthetic blood-conservation measures, and conventional surgical hemostatic techniques. The use of intraoperative cell salvage followed the institutional protocol described above.
Objectives
The primary objective was to evaluate whether the use of intraoperative cell salvage was associated with a reduction in postoperative allogeneic transfusion requirements.
Secondary objectives included the analysis of hemoglobin evolution, length of ICU and hospital stay, and the evaluation of the relationship between reinfused volume and transfusion risk. Additionally, subgroup analyses were performed to explore differences according to scoliosis etiology.
Statistical Methods
Continuous variables were expressed as mean ± SD or median with interquartile range, as appropriate. Categorical variables were reported as frequencies and percentages.
Comparisons between groups were performed according to data distribution using Student’s t test or Mann-Whitney U test for continuous variables, and χ2 or Fisher’s exact test for categorical variables. Factors associated with allogeneic transfusion were assessed using multivariate logistic regression, including clinically relevant variables. A P value < 0.05 was considered statistically significant.
A 1:1 propensity score matching analysis was performed as a sensitivity analysis to reduce potential indication bias. The propensity score was estimated using clinically relevant preoperative variables, including age, preoperative hemoglobin level, Cobb angle, number of instrumented levels, and planned osteotomies. Intraoperative variables, including EBL and operative duration, were not included because they occur after the decision to use intraoperative cell salvage and may themselves be influenced by surgical complexity.
Given the observational nature of the study and the available sample size, no formal a priori power calculation was performed, and a potential type II error (beta error) was assumed, particularly in subgroup analyses.
Cost-Benefit Analysis
An economic analysis was conducted from the hospital perspective. Direct costs associated with intraoperative cell salvage, allogeneic transfusion, and hospital stay were considered, including both ICU and ward hospitalization.
A cost-effectiveness model was constructed comparing a strategy of routine cell salvage use vs no cell salvage. In addition, a break-even analysis was performed to determine the number of procedures required to achieve cost neutrality, defined as the number of cases in which a transfusion would need to be avoided to offset the cost of the device.
Ethical Issues
The study was approved by the institutional review board and ethics committee (code COT26.RSI). The requirement for informed consent was waived due to the retrospective design and the use of anonymized data.
Results
Sample Characteristics
A total of 75 patients who underwent posterior instrumented spinal fusion for pediatric scoliosis were included. Of these, 57 (76%) were treated using intraoperative cell salvage.
Both groups were comparable in terms of baseline demographic and surgical characteristics, with no statistically significant differences observed between them (Table 1). Mean age, number of instrumented levels, and preoperative hemoglobin levels were similar between groups. Patients treated with cell salvage had higher EBL (930 ± 360 mL vs 760 ± 270 mL), although this difference did not reach statistical significance (P = 0.08). Likewise, no differences were found in postoperative hemoglobin levels, ICU stay, or total hospital length of stay.
Baseline characteristics and perioperative outcomes according to intraoperative cell salvage use.
Postoperative transfusion rates did not differ significantly between patients treated with and without cell salvage (22.8% vs 11.1%, respectively; P = 0.32).
Subgroup Analysis by Etiology
When stratified by scoliosis etiology, no significant differences in transfusion rates were identified between groups in any of the analyzed subgroups (Table 2; Figure 1).
Postoperative transfusion rate according to scoliosis etiology and intraoperative cell salvage use. ns, not significant.
Postoperative transfusion rate according to scoliosis etiology and intraoperative cell salvage use.
In patients with idiopathic and syndromic scoliosis, transfusion rates were comparable regardless of cell salvage use. In neuromuscular scoliosis, a higher proportion of transfused patients was observed in the cell salvage group (57.1% vs 0%), though this difference did not reach statistical significance (P = 0.06).
No postoperative transfusions were recorded in patients with congenital or other etiologies; therefore, these cases were excluded from the comparative subgroup analysis.
Reinfused Volume and Transfusion Risk
Among patients treated with cell salvage, the mean reinfused blood volume was 366 ± 221 mL (interquartile range 230–470 mL).
No reinfusion threshold associated with a reduction in transfusion risk was identified. On the contrary, stratified analysis using clinically relevant cutoffs showed a significantly higher probability of transfusion at greater reinfusion volumes. Patients with reinfused volumes ≤400 mL had a transfusion rate of 15.0%, whereas those with volumes >400 mL showed a rate of 41.2% (P = 0.04; Table 3).
Reinfused blood volume and risk of postoperative transfusion (cell salvage group).
Patients with reinfused volumes >400 mL had significantly higher EBL than those with reinfused volumes ≤400 mL (1380 ± 360 mL vs 760 ± 210 mL; P < 0.001), indicating that greater reinfusion volumes mainly reflected greater intraoperative blood loss.
Similarly, patients who required postoperative transfusion had significantly higher EBL than those who did not (1490 ± 420 mL vs 790 ± 260 mL; P < 0.001).
Intraoperative allogeneic transfusion was required in 8 patients (10.7%). Seven of these patients belonged to the cell salvage group (12.3%), whereas 1 patient (5.6%) underwent surgery without cell salvage. Among patients receiving more than 400 mL of reinfused blood, 6 of 17 (35.3%) required intraoperative allogeneic transfusion, compared with 1 of 40 (2.5%) among those receiving 400 mL or less.
Factors Associated With Transfusion
Preoperative hemoglobin levels were similar between transfused and nontransfused patients. However, patients who required postoperative transfusion had significantly lower postoperative hemoglobin levels compared with those who did not (8.97 ± 1.31 g/dL vs 10.43 ± 1.19 g/dL; P = 0.01).
Postoperative transfusion was associated with increased hospital resource utilization. Transfused patients had a significantly longer ICU stay (2.33 ± 1.50 vs 1.31 ± 1.14 days; P = 0.05) and a longer total hospital stay (9.13 ± 3.96 vs 7.80 ± 2.73 days; P = 0.04) compared with nontransfused patients (Figure 2).
Length of stay according to postoperative transfusion status.
Cost-Benefit Analysis
From the hospital perspective, the estimated cost of a transfusion episode was calculated by combining the cost of red blood cell units with the additional hospital resource utilization associated with transfusion. Based on official regional health care tariffs, the cost of pediatric ICU stay was estimated at approximately €1400 per day and standard ward hospitalization at €450 per day, while the cost of 1 unit of packed red blood cells ranged between €250 and €350.
Considering an average increase of 1.5 ICU days and 3 additional ward days, along with the use of 2 units of red blood cells per episode, the estimated total cost per transfusion episode was approximately €4754. The direct cost of intraoperative cell salvage was €250 per procedure. Cell salvage was used in 57 patients, resulting in a total direct cost of €14,250.
No significant reduction in postoperative transfusion rates or hospital stay was observed with the use of cell salvage. The break-even analysis showed that 1 transfusion would need to be avoided for every 19 procedures to achieve cost neutrality. This threshold was not reached in the analyzed cohort. Overall, the routine use of intraoperative cell salvage was associated with increased costs without demonstrated clinical benefit (Table 4).
Cost-effectiveness analysis of intraoperative cell salvage use.
Sensitivity Analysis
A sensitivity analysis was performed using 1:1 propensity score matching based on clinically relevant preoperative variables, including age, preoperative hemoglobin level, Cobb angle, number of instrumented levels, and planned osteotomies. After matching, baseline characteristics were adequately balanced between groups.
In the matched cohort, the use of cell salvage was not associated with a reduction in postoperative transfusion rates, maintaining the direction of effect observed in the unadjusted analysis (Table 5).
Sensitivity analysis using PSM.
Discussion
Our findings indicate that the routine use of intraoperative cell salvage was not associated with a significant reduction in overall postoperative transfusion rates, nor with improvements in hemoglobin levels or length of stay in the ICU and hospital ward. These results are consistent with those reported by Miao et al,10 who, in a multicenter study of 247 pediatric and adolescent scoliosis patients, observed that although cell salvage significantly reduced intraoperative transfusion requirements, it did not decrease total perioperative allogeneic transfusions and was not cost-effective when overall costs were considered.
Several studies13 have evaluated the efficacy of intraoperative cell salvage in scoliosis surgery with heterogeneous results.14,15 In a meta-analysis16 including multiple patient series, the use of cell salvage was associated with reductions in transfusion requirements, in some cases decreasing the use of allogeneic blood by approximately 1 unit per patient. However, this effect was primarily observed in the intraoperative setting and did not consistently translate into a reduction in total perioperative transfusion requirements, which limits the clinical relevance of these findings. Earlier studies, such as the study by Weiss et al,11 similarly concluded that cell salvage did not significantly reduce transfusion needs when all perioperative periods were considered.
The analysis of reinfused blood volume in our cohort further supports this interpretation. No reinfusion threshold associated with a protective effect against postoperative transfusion was identified. On the contrary, patients with reinfused volumes >400 mL had significantly greater EBL than those with reinfused volumes ≤400 mL (1380 ± 360 mL vs 760 ± 210 mL; P < 0.001), and patients requiring postoperative transfusion also had significantly greater EBL than those who did not (1490 ± 420 mL vs 790 ± 260 mL; P < 0.001). These findings support the interpretation that reinfused volume mainly reflects greater intraoperative blood loss and surgical complexity rather than representing an independent factor influencing postoperative transfusion risk.17 This observation is consistent with previous studies indicating that the benefit of cell salvage is closely linked to the magnitude of intraoperative bleeding rather than to a reduction in overall transfusion requirements.5 Similarly, the higher frequency of intraoperative allogeneic transfusion among patients with greater reinfused blood volumes further supports the interpretation that cell salvage was preferentially used in procedures with greater hemorrhagic complexity.
From a resource utilization perspective, our results demonstrate that patients requiring postoperative transfusion had longer ICU and hospital stays.18 The use of cell salvage did not mitigate this increase, as transfused patients exhibited prolonged hospitalization regardless of its use. This finding aligns with previous literature identifying allogeneic transfusion as an independent factor associated with increased health care resource utilization following spinal deformity surgery, reinforcing its clinical and economic impact.19
When stratified by scoliosis etiology, no reduction in transfusion rates associated with cell salvage use was observed in any subgroup. Notably, in neuromuscular scoliosis, a higher proportion of transfused patients was observed in the cell salvage group, although this difference did not reach statistical significance. This finding is consistent with previous reports indicating that neuromuscular scoliosis is associated with greater blood loss, increased surgical complexity, and a higher likelihood of transfusion, independent of cell salvage use.20,21 In this subgroup, cell salvage is typically employed in cases with higher anticipated bleeding, which may explain the absence of benefit and the apparent reversal of effect. Large database studies and subgroup analyses have similarly shown that in neuromuscular and syndromic scoliosis, cell salvage does not consistently reduce overall transfusion requirements and may function primarily as a marker of high-risk procedures, in contrast to some findings reported in idiopathic scoliosis.
Methodological differences may partially explain discrepancies across studies, including heterogeneity in the definition of major blood loss, variability in transfusion protocols, and differences in the use of multimodal blood management strategies. These factors suggest that the potential benefits of cell salvage may be context-dependent and more pronounced under specific conditions. Some reports have suggested that in patients with high intraoperative blood loss, cell salvage may reduce exposure to allogeneic transfusion during surgery; however, this effect is not consistently maintained when total perioperative transfusion requirements are considered.22
From an economic standpoint, previously published data are also inconsistent. While Miao et al10 did not demonstrate a reduction in overall transfusion-related costs, Oliveira et al8 reported that in patients with idiopathic scoliosis, intraoperative autotransfusion reduced both allogeneic blood use and associated costs, even achieving net savings when total transfusion-related expenses were considered.
In our cohort, the cost analysis showed that the routine use of cell salvage was associated with increased direct hospital costs without a significant reduction in transfusion rates or length of stay. The break-even analysis indicated that 1 transfusion would need to be avoided for every 19 procedures to achieve cost neutrality, a threshold that was not reached. These findings are conceptually consistent with the lack of conclusive evidence supporting the economic efficiency of cell salvage in general pediatric populations. Although its use may provide benefit in selected cases with high intraoperative blood loss, its routine application does not appear to translate into economic savings when device costs, hospitalization, and postoperative management are considered.
However, this economic analysis may underestimate the potential value of cell salvage because the number of intraoperative allogeneic transfusions that might have been required in its absence could not be determined. Consequently, the potential benefit associated with reduced exposure to allogeneic blood and its related complications was not fully captured by an analysis based primarily on postoperative transfusion and available direct costs.
The inclusion of a sensitivity analysis using propensity score matching strengthens the validity of these findings by reducing potential indication bias, such as the preferential use of cell salvage in more complex or higher bleeding-risk cases. After matching, postoperative transfusion rates remained unchanged, maintaining the direction of effect observed in the unadjusted analysis. This suggests that the absence of an observed benefit is unlikely to be explained solely by baseline differences or case selection, although residual confounding inherent to the retrospective design cannot be excluded.
From a clinical perspective, our findings are in line with systematic reviews indicating that high-quality randomized controlled trials evaluating the effectiveness of cell salvage in scoliosis surgery are scarce. Although some benefits have been demonstrated in reducing intraoperative transfusion, current evidence does not consistently support its routine use to decrease total transfusion requirements or generate clear economic advantages. This finding is particularly relevant in real-world tertiary care settings, where transfusion protocols often incorporate multiple blood conservation strategies.23
Overall, the available evidence suggests that while intraoperative cell salvage may have a role in highly complex procedures or for patients at high risk of significant blood loss, its effectiveness and cost-effectiveness as a routine strategy in pediatric scoliosis surgery remain uncertain. Based on our findings, these results support a more selective use of intraoperative cell salvage, particularly in patients with a high anticipated risk of blood loss, rather than its routine application in all pediatric scoliosis procedures.
This study has several limitations that should be acknowledged. First, its retrospective design limits the ability to establish causal relationships and introduces the potential for selection bias. Second, the single-center nature of the study may limit the generalizability of the findings. Third, the sample size, particularly in subgroup analyses, may have reduced statistical power and increased the risk of type II error, potentially obscuring clinically relevant differences between groups.
Conclusion
Intraoperative cell salvage in pediatric scoliosis surgery was not associated with a reduction in postoperative transfusion rates or hospital stay. Its routine use increased hospital costs without demonstrating cost-effectiveness. These findings support a selective rather than systematic use based on surgical complexity and bleeding risk.
Footnotes
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests The authors report no conflicts of interest in this work.
Ethical Considerations The institutional review board and ethics committee approved the project (code number COT26.RSI).
- This manuscript is generously published free of charge by ISASS, the International Society for the Advancement of Spine Surgery. Copyright © 2026 ISASS. To see more or order reprints or permissions, see http://ijssurgery.com.
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