Spinal surgery in the context of end-stage renal disease: Balancing risks and surgical strategies - A narrative review.

Spinal surgery in patients with chronic kidney disease and end-stage renal disease on hemodialysis presents unique challenges due to systemic comorbidities, poor bone quality, and high perioperative risks. This review aims to evaluate outcomes, complications, and optimal surgical strategies in this high-risk population that reveals significantly higher rates of perioperative mortality (up to 17.2%), intensive care unit admission, and implant failure compared to nonrenal cohorts due to uremic toxicity, renal osteodystrophy, and cardiovascular vulnerabilities. Posterolateral fusion and minimally invasive techniques demonstrated advantages over interbody fusion in reducing blood loss and operative time, while circumferential stabilization improved durability in destructive cervical pathologies. Adjacent segment disease developed in 43% of lumbar fusion cases, with younger age and multilevel constructs as risk factors. Renal transplantation emerged as a protective factor, reducing complications and mortality, though access barriers persist. Despite perioperative risks, surgical intervention achieved meaningful functional improvements, including pain relief and neurological recovery. This review underscores the need for tailored surgical planning, preoperative optimization of anemia and electrolyte imbalances, and multidisciplinary care to mitigate risks. Surgeons must balance the potential benefits of spinal surgery against the substantial morbidity and mortality inherent to this population, prioritizing minimally invasive approaches and cautious patient selection.