Intraoperative Pulsed Irrigation with PovidoneIodine and Hydrogen Peroxide in Spine Surgery: A Systematic Review on its Efficacy and Low Toxicity Advantages in Preventing Surgical Site Infections

background. surgical site infections (SSIs) are a significant complication following spine surgery, leading to increased morbidity, prolonged hospital stays, and higher healthcare costs. traditional methods to prevent SSIs, including perioperative antibiotics, have limited efficacy, necessitating innovative approaches. objective. this systematic review aims to evaluate the efficacy and low toxicity advantages of intraoperative irrigation combining three elements: povidone-iodine (PVPI), hydrogen peroxide (H2 O2), and pulsed irrigation technique in preventing SSIs in spine surgery. methods. a comprehensive literature search was conducted in MEDLINE, cochrane Library, and scopus databases, covering publications from 1980 to may 2024. articles were selected based on their relevance to the use of PVP-I and H2 O2 in pulsed irrigation during spine surgeries. while there are studies that use H2 O2 and PVP-I separately or in combination without pulsed irrigation, the combination of all three elements (pulsed irrigation, H2 O2, and betadine) has not been previously explored. the inclusion criteria focused on clinical trials, observational studies, case-control studies, cohort studies, review or case series that reported on SSI prevention with a minimum follow-up of three months. results. the review identified a significant gap in the literature concerning the combined use of PVP-I and H2 O2 in pulsed irrigation for spine surgeries. studies primarily investigated these agents individually or in combinations of two, but not all three together. the findings suggest that the combination of PVP-I and H2 O2 can enhance antimicrobial effects and reduce toxicity, potentially lowering SSI rates. conclusions. intraoperative pulsed irrigation with PVP-I and H2 O2 shows promise in reducing SSIs in spine surgery, with potential benefits over traditional methods. however, the risks associated with the use of H2 O2 require careful evaluation and prudent application, especially in the presence of dural tears. further large-scale clinical studies are needed to confirm these preliminary results and optimize protocols for the combined use of these agents.