RCT-based meta-analysis of povidone-iodine irrigation in spinal surgery: clarifying efficacy and safety

Surgical site infections (SSIs) remain a significant complication in spinal surgery, particularly in instrumented procedures, contributing to increased morbidity, prolonged hospitalization, and healthcare costs. Intraoperative wound irrigation (IWI) using antiseptic solutions such as povidone-iodine (PI) has been proposed as a preventive strategy. This systematic review and meta-analysis evaluate the efficacy of PI irrigation against control interventions, in reducing postoperative SSIs and examines its effect on spinal fusion outcomes.

Following PRISMA guidelines, a comprehensive search of Ovid MEDLINE, EMBASE, Web of Science, and the Cochrane Library was conducted through March 2025. Only randomized controlled trials (RCTs) comparing PI irrigation to control interventions (saline or no irrigation) in adult spinal surgery were included. The primary outcome was overall SSI rate. Secondary outcomes included superficial and deep SSI rates, fusion rates, and adverse events. Data were pooled using a random-effects model, and heterogeneity was assessed using the I² statistic.

Six RCTs involving 1,804 patients (901 PI group, 903 control group) were included. Pooled analysis demonstrated a significant reduction in overall SSI with PI irrigation (0.77% vs. 6.0%; RR = 0.16, 95% CI: 0.08-0.34; P < 0.00001; I² = 0%). Subgroup analyses showed significant reductions in both superficial (RR = 0.19; 95% CI: 0.07-0.52; P < 0.001) and deep SSIs (RR = 0.21; 95% CI: 0.08-0.52; P = 0.0009), with absolute infection rates reduced from 2.9 to 0.33% and from 3.2 to 0.4%, respectively. Fusion rates were comparable between groups (RD = 0.03; 95% CI: 0.00-0.06; P = 0.10).

PI irrigation significantly lowers the risk of both superficial and deep SSIs in spinal surgery without negatively impacting fusion outcomes. These findings are based on Level I evidence and support the integration of PI irrigation into routine perioperative protocols as a low-cost, effective adjunct for infection prevention.