GLP-1 receptor agonists in elective spine surgery: a systematic review of fusion outcomes, perioperative safety, and procedure-specific risk.

Background: Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are increasingly used in patients with obesity and type 2 diabetes mellitus undergoing elective spine surgery. Although these agents may improve metabolic risk profiles, their associations with spinal fusion, perioperative complications, and procedure-specific outcomes remain incompletely defined. Methods: We conducted a systematic review and qualitative synthesis of comparative clinical studies evaluating adults undergoing spine surgery with documented preoperative or perioperative GLP-1 RA exposure. Eligible studies assessed fusion-related outcomes, perioperative medical complications, surgical site infection, readmission, length of stay, healthcare utilization or costs, and musculoskeletal outcomes. The review was conducted in accordance with PRISMA 2020 principles, with eligibility criteria defined using a PICOS framework. Results: Twenty-three studies were included, consisting predominantly of retrospective cohort studies and propensity-matched database analyses. Lumbar fusion studies generally reported favorable or neutral associations between GLP-1 RA exposure and pseudarthrosis, infection, readmission, and healthcare utilization, although some transforaminal lumbar interbody fusion cohorts reported adverse associations. Cervical fusion outcomes were more heterogeneous and appeared to vary by surgical approach. Anterior cervical fusion studies generally reported neutral or favorable outcomes, whereas posterior cervical fusion studies yielded conflicting findings. Gastrointestinal safety data were sparse, no included study reported postoperative pancreatitis, and preoperative treatment duration and longitudinal BMI or weight change were incompletely characterized. Conclusions: Current evidence suggests that GLP-1 RA exposure is associated with procedure-specific differences in outcomes after elective spine surgery. Because the available evidence is predominantly observational, these findings should be interpreted as associations rather than evidence of direct causal benefit or harm. Perioperative GLP-1 RA management should be individualized according to surgical procedure, metabolic status, gastrointestinal symptoms, renal and hydration risk, and nutritional or sarcopenia-related vulnerability.