Applications of acellular dermal matrix in spine surgery: A systematic review

Acellular dermal matrix (ADM) is a tissue-engineered biological scaffold widely adopted in plastic reconstructive surgery, yet its application in spine surgery remains largely underexplored. No prior systematic review has synthesized the available evidence. A systematic search of PubMed, Embase, Cochrane CENTRAL, Web of Science, and Scopus was performed from inception through 31 July 2026, following PRISMA 2020 guidelines (PROSPERO: CRD420261326660). Studies were stratified a priori into three evidence tiers: direct spine surgery evidence, craniovertebral/neuraxis evidence, and indirect cranial evidence. Risk of bias was assessed with ROBINS-I and JBI checklists; certainty was rated using GRADE. Ten studies comprising 385 enrolled patients met inclusion criteria: 172 patients in seven studies providing direct spine surgery evidence, 13 patients in two craniovertebral/neuraxis studies, and 200 patients in one predominantly cranial duraplasty series. Five application categories were identified. The single comparative study-a propensity score-matched cohort of 108 patients undergoing ACDF-reported lower Swallowing Impairment Scores at the pre-specified three-month endpoint (0.26 ± 0.16 vs. 0.68 ± 0.27, p = 0.01, significant after Bonferroni correction), although the observed difference (Δ = 0.42) fell below the suggested minimal clinically important difference, and adhesion scores did not differ between groups. All remaining studies were uncontrolled. GRADE certainty was very low across all outcomes. Efficacy of ADM in spine surgery cannot be determined from the current evidence base. Reported adverse events were infrequent, but ascertainment was neither standardized nor prospective, and these data are insufficient to establish safety. Findings are product- and indication-specific and should not be generalized across ADM formulations or clinical applications.