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Background Multilevel fusions and complex osteotomies to restore global alignment in adult spinal deformity (ASD) surgery can lead to increased operative time and blood loss. In this regard, we assessed factors predictive of perioperative blood product transfusion in patients undergoing long posterior spinal fusion for ASD. Methods A single-institution retrospective review was conducted on 909 patients with ASD, age 18 years, who underwent surgery for ASD with greater than 4 levels fused. Using conditional inference tree analysis,