Abstract
Whether perioperative transfusion worsens survival after spinal osteotomy (SO) remains unclear. Using the Korean National Health Insurance Service database (2002–2018), we analyzed 912 adults aged ≥ 50 years who had undergone SO. Transfusion occurred in 72.6% of the patients (mean ± SD, 1324 ± 1120 mL). In the unmatched cohort, Female sex independently increased the transfusion risk (adjusted odds ratio 1.48, 95% CI 1.23–1.77; p < 0.0001). this associations disappeared after propensity matching. A 1:1 propensity score-matched cohort was created (232 pairs, all standardized mean differences ≤ 0.11). In this balanced sample, transfusion was not associated with all-cause mortality at 3 months, 6 months, 1 year, 3 years, 5 years, or 10 years (all p > 0.05). Mortaility rates observed before matching appeared to reflect the clinical condition necessitating transfusion rather than the transfusion itself. Given the high exposure rate, comprehensive patient blood management— preoperative anemia correction, tranexamic acid, meticulous hemostasis, and restrictive thresholds—remains essential to minimize unnecessary transfusion and optimize outcomes after SO. Level of evidence: III. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1038/s41598-025-17515-y.