Efficacy of preventive interventions for postoperative delirium in elderly patients undergoing spinal surgery: A network meta-analysis of randomized controlled trials

OBJECTIVE: To compare and rank preventive interventions for postoperative delirium (POD) in elderly spinal surgery patients via network meta-analysis. METHODS: We searched major databases (inception to March 2025) for relevant randomized controlled trials (RCTs). Methodological quality was assessed using the Cochrane RoB 2.0 tool. A frequentist random-effects network meta-analysis was performed. RESULTS: Thirty-two RCTs (enrolling 3454 patients) evaluating 19 interventions were included. Most studies (n = 25) demonstrated low risk of bias or raised only some concerns. Global inconsistency assessment indicated consistency (P = 0.44). Ten interventions significantly reduced POD incidence compared to control. Surface under the cumulative ranking curve (SUCRA) analysis ranked temperature protection combined with dexmedetomidine (OR = 0.11, 95% CI: 0.02-0.59, SUCRA = 81.7%) as the most effective intervention, followed by melatonin (OR = 0.20, 95% CI: 0.05-0.81, SUCRA = 70.3%) and goal-directed fluid therapy (OR = 0.25, 95% CI: 0.09-0.66, SUCRA = 63.6%). CONCLUSIONS: Dexmedetomidine monotherapy is the only intervention supported by moderate-certainty evidence (OR = 0.35) and should be the core POD prevention strategy. Other top-ranked interventions (temperature protection+DEX, melatonin, GDFT) showed promise but are based on low-certainty evidence, often from single trials, and require confirmation. All 32 trials were from China, limiting generalizability; international validation is needed. REGISTRATION: PROSPERO CRD420251014832.