Ninety-two patients undergoing prone-positioned spinal surgery were randomized to receive driving pressure-guided ventilation (n=46) or standard protective ventilation. The primary outcome of interest was the incidence of postoperative pulmonary complications, based on Lung Ultrasound Scores (LUS) and simplified Clinical Pulmonary Infection Scores (sCPIS). Secondary outcomes of interest included hemodynamic and intraoperative arterial blood outcomes, pain, drainage volume, hemoglobin levels, and length of stay. Follow-up was performed up to 3 days post-surgery. sCPIS on the first postoperative day and LUS scores at the end of surgery were significantly better in the pressure-guided group, indicating a lower risk of pulmonary complications. No differences in hemodynamic outcomes, intraoperative arterial blood outcomes, pain, drainage volume, hemoglobin or length of stay were observed.