Targeting malnutrition with preoperative immunonutrition in major spine surgery: a current concepts review

BACKGROUND: Immunonutrition (IMN) consists of perioperative oral formulas enriched with arginine, omega-3 fatty acids, nucleotides, and antioxidants to modulate inflammatory and immune responses. In recent years, perioperative IMN has gained an increased relevance in major spine surgery, as a key component of the Enhanced Recovery After Surgery (ERAS), to improve perioperative clinical outcomes and prevent complications. The present review aims to summarize the current evidence on preoperative IMN and related nutritional strategies in major spine surgery, and to outline a pragmatic, ERAS-aligned optimization pathway.METHODS: A comprehensive literature search was conducted across Ovid-MedLine®, Embase, Scopus, Web of Science, Google Scholar, and PubMed, covering the period from January 2018 to December 2025, to identify studies relevant for inclusion. The primary search terms included: “malnutrition,” “preoperative nutritional optimization,” “preoperative immunonutrition,” combined with “major spine surgery,” “spine posterior decompression and fusion,” “lumbar spine fusion,” and “scoliosis surgery.” Reference lists were hand-searched and authors contacted for unavailable full texts. One reviewer screened titles/abstracts and retrieved full texts. Thirty-five studies met inclusion criteria.RESULTS: Across observational cohorts and registry studies, preoperative malnutrition prevalence ranged 15-50% and was consistently associated with higher surgical site infection (SSI), medical morbidity, readmission, and longer length of stay. Screening with Nutritional Risk Screening-2002 (NRS-2002) followed by Global Leadership Initiative on Malnutrition (GLIM) diagnostic criteria supported risk stratification; albumin and prealbumin, interpreted alongside inflammatory markers, correlated with adverse outcomes. Imaging-based assessment documented that paraspinal sarcopenia predicts complications and mechanical failure in deformity surgery. Evidence for IMN in spine is limited but suggestive of reduced in-hospital events and 90-day wound-healing complications after elective lumbar procedures. Extrapolated data from orthopedic and gastrointestinal surgery support biologic plausibility and potential reductions in infectious complications. Within ERAS, maltodextrin-based carbohydrate loading and early postoperative feeding are feasible adjuncts to preoperative IMN.CONCLUSIONS: Nutritional optimization should be routine and structured in major spine surgery. IMN appears safe and reasonable as a targeted strategy for nutritionally at-risk patients and high-complexity procedures when embedded in ERAS. High-quality, adequately powered randomized trials in spine populations are needed to better define the incremental benefit of IMN beyond standard protein-energy supplementation and other ERAS elements.