Pre‐operative autologous blood donation (PAD) is increasingly used in spinal surgery because of the risk of substantial intraoperative blood loss. However, evidence on the effectiveness and safety of apheresis autologous red blood cell (RBC) technology remains limited. This study was conducted to evaluate whether this technology can reduce allogeneic transfusion in spinal surgery without adverse effects.

In this randomized, two‐group, unblinded clinical trial, participants undergoing spinal surgery between November 2018 and September 2023 were randomized 1:1 to receive apheresis autologous RBCs (auto‐RBC group, n = 30) or standard allogeneic transfusion (allo‐RBC group, n = 30). The two primary outcomes were allogeneic RBC transfusion and postoperative length of hospitalization. Twenty‐eight secondary outcomes and 12 safety indicators were also assessed.

Of the 60 randomized patients, 47 completed the trial. The allogeneic RBC transfusion rate was significantly lower in the auto‐RBC group than in the allo‐RBC group (39.1% vs. 70.8%, p = 0.041). Intraoperative allogeneic RBC transfusion volume was also significantly reduced (0.50 ± 1.16 vs. 1.50 ± 1.69 U, p = 0.023). No significant difference was found in postoperative hospitalization (7.48 ± 0.80 vs. 9.21 ± 2.41 d, p = 0.461). Of the 28 prespecified secondary outcomes, 25 showed no significant between‐group differences. Hemoglobin on postoperative day 3 was lower in the auto‐RBC group (91.09 ± 2.99 vs. 100.00 ± 2.91 g/L, p = 0.039). Hemoglobin in the auto‐RBC group also declined from pre‐apheresis to preoperative levels (144.65 ± 10.86 vs. 122.56 ± 14.60 g/L, p < 0.001).

Apheresis autologous RBC technology reduces the rate of allogeneic RBC transfusion in major spinal surgeries without increasing hospitalization or complications. These findings support its use in adult patients undergoing major spinal procedures.