OBJECTIVES: Awareness to blood loss and transfusions in spine surgery is important to reduce patient risk of morbidity and mortality. We aim to assess blood loss and transfusions for patients with spine deformities characterized by heavy blood loss. METHODS: A search is performed in Embase and Medline from 2007 to 2018. Spine deformity patients undergoing ≥4 level spine surgery, both pediatric (<18 years) and adult (≥18 years) are included. Studies with <10 patients, interventions that limit blood loss and other spine diseases such as but not limited to degenerative disc disease and trauma are excluded. RESULTS: Out of 372 articles identified, 37 full-text articles are included. Most studies include ≥50% female patients (74%) and <18 years old (71%). The mean intraoperative blood loss reported across studies is 1274mL. Higher mean intraoperative blood loss is linked to more peri-operative transfusions(P=0.02) and total complications (P=0.03). With an increase in number of spine levels operated so does the mean intraoperative blood loss(P=0.01). Lower peri-operative transfusion is observed when a blood management strategy is used (55%) versus not used (88%)(P<0.001). However, implementation of a blood management strategy with cell saver results in higher mean intraoperative blood loss when compared to different antifibrinolytic drugs (cell saver, mean 2092mL; tranexamic acid or the like, mean 877mL) (P=0.02). In addition, fewer peri-operative transfusions are observed with the use of antifibrinolytic drugs (74%) versus medical devices (80%)(P=0.03). Patient pathology of AIS versus neuromuscular scoliosis demonstrate a lower mean intraoperative blood loss (AIS, mean 792mL; neuromuscular scoliosis, mean 1917mL) (P=0.01). Peri-operative transfusions are lower for AIS patients and higher for neuromuscular scoliosis patients when compared to all indications for scoliosis surgery (P<0.001). CONCLUSIONS: This literature review substantiates existing evidence on blood loss and transfusions in spine surgery. Even with current management strategy, blood loss and transfusions remain a challenge in spine surgery.