Tak Kyu Oh, Saeyeon Kim, In‐Ae Song
BACKGROUND: Given propofol's antioxidant and anti‑inflammatory properties compared with volatile/inhalational agents, we aimed to evaluate the association between anesthetic technique and both in‑hospital mortality and postoperative complications following spinal surgery. METHODS: In this retrospective, population‑based cohort study, we used South Korea's National Health Insurance Service database to identify adult patients (≥ 18 years) who underwent spinal surgery between January 1, 2016 and December 31, 2021. Primary outcomes were in‑hospital mortality and postoperative complications. Propensity score (PS) matching (1:1) was employed to balance baseline characteristics between the total intravenous anesthesia (TIVA) and volatile/inhalational anesthesia (INH) groups. RESULTS: Among 708,387 patients, 264,728 (37.4%) received TIVA and 443,659 (62.6%) received INH. After PS matching, 460,654 patients remained (230,327 per group). In the PS‑matched cohort, TIVA was associated with significantly lower odds of in‑hospital mortality (OR 0.85; 95% CI 0.80-0.89; P = 0.004) and postoperative complications (11.8% vs. 14.2%; OR 0.81; 95% CI 0.80-0.82; P < 0.001) compared with INH. In the full cohort, multivariable logistic regression confirmed these findings: TIVA remained linked to reduced in‑hospital mortality (OR 0.74; 95% CI 0.63-0.87; P < 0.001) and fewer postoperative complications (OR 0.71; 95% CI 0.70-0.73; P < 0.001). CONCLUSIONS: In this nationwide cohort, propofol‑based TIVA was associated with lower in‑hospital mortality and fewer postoperative complications than volatile/inhalational anesthesia in adult spinal surgery patients. Prospective trials are warranted to confirm these findings. TRIAL REGISTRATION: Not applicable.