Journal of Pediatric Orthopaedics - 2026-09-02 - Journal Article
Cell Saver Use is Not Associated With Increased Morbidity But Reflects Transfusion Burden in Pediatric Spinal Deformity Surgery: A Retrospective Cohort Study.
Ortega DA, Levin-Carrion Y, Reyes JL, Geraghty E, Shi T, Peterson H, Purdie T, Fliginger D, Lenke LG, Lombardi JM, Eisler L, Sardar ZM
Topics
Key Takeaway
After IPTW adjustment in 20,376 pediatric spinal deformity patients, cell saver use was not associated with increased 30-day all-cause morbidity, but high CS volume (≥3.5 mL/kg) was associated with 83% higher odds of intraoperative allogeneic transfusion (OR=1.83) while low CS volume reduced transfusion odds by 38% (OR=0.62).
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Summary
This study used the ACS NSQIP-Pediatric database (2021–2023) to evaluate whether cell saver exposure was associated with postoperative morbidity in pediatric spinal deformity surgery, stratifying patients into no CS, low CS (<3.5 mL/kg), and high CS (≥3.5 mL/kg) groups with IPTW balancing. After weighting, all-cause morbidity did not differ across groups (P=0.75), nor did respiratory, renal, infectious complications, or reoperation rates. High CS volume was associated with increased neurological complication odds (OR=1.60 vs. no CS, P=0.015) and higher allogeneic transfusion rates, interpreted as a marker of surgical complexity and bleeding burden rather than a causal CS effect.
Key Limitation
Residual confounding is the dominant limitation: despite IPTW, the high CS group's elevated neurological complication rate (OR=1.60) most likely reflects unmeasured intraoperative bleeding severity and case complexity rather than a true CS effect, which the database cannot distinguish.
Original Abstract
STUDY DESIGN
Retrospective cohort study.
INTRODUCTION
Cell saver (CS) is widely used in spinal fusion to reduce exposure to allogeneic transfusion, which carries risks such as infection and prolonged hospitalization. Pediatric spinal fusion is frequently associated with significant intraoperative blood loss. Concerns persist that reinfused blood could increase morbidity. We therefore evaluated the association between CS exposure and postoperative outcomes after pediatric spinal fusion using the American College of Surgeons National Surgical Quality Improvement Program Pediatric database.
METHODS
Among patients who underwent spinal fusion surgery for pediatric spinal deformity between 2021 and 2023, CS exposure was categorized as none, low (<3.5 mL/kg), or high (≥3.5 mL/kg). Inverse probability of treatment weighting (IPTW) was used to balance demographics, comorbidities, and surgical complexity across groups. Logistic regression assessed outcomes, with global tests followed by Tukey-adjusted pairwise contrasts. The primary outcome was all-cause morbidity; secondary outcomes included reoperation rates, discharge to home, allogeneic transfusion, and other system-based complications.
RESULTS
There were 20,376 patients included in this study (no CS: 6967; low CS: 6811; high CS: 6598). High CS patients had more complex baseline profiles, including higher ASA III-IV status (42.4% vs. 28.6% no CS, 26.3% low CS), neuromuscular scoliosis (27.4% vs. 15.9% and 11.6%), and ≥13 levels fused (52.8% vs. 26.3% and 33.6%; all P<0.001). After IPTW, all-cause morbidity did not differ significantly between groups (P=0.75). Respiratory, renal, and infectious complications, discharge to home, and reoperation were also not significantly different (all P>0.05). Neurological complications varied significantly (P=0.013), but only the high CS versus no CS comparison was significant (OR=1.60; P=0.015). Intraoperative allogeneic transfusion rates differed (P<0.001), with low CS associated with reduced rates (OR=0.62; P<0.001) and high CS with increased rates (OR=1.83; P<0.001).
CONCLUSIONS
CS use was not associated with increased overall morbidity within 30 days. High CS volume identified a subgroup with higher odds of neurological complications and greater transfusion rates, likely reflecting residual confounding or bleeding severity rather than a direct CS effect. Low CS exposure was associated with reduced allogeneic transfusions.
LEVEL OF EVIDENCE
Level III.