Objective To design a novel fine-adjustment prone positioning cushion and apply it in patients undergoing spinal surgery and to reduce the incidence of intraoperatively acquired pressure injuries （IAPIs）.Methods A single-blind, prospective, randomized controlled trial was conducted.A convenience sample of 438 patients who underwent posterior spinal surgery during May through December 2024 was enrolled and randomized equally into a control group (n=219) and an intervention group (n=219).The control group was positioned using a spinal prone cushion combined with lower limb sponge pads, while the intervention group was positioned using a novel fine-adjustment prone positioning cushion.The incidence of IAPIs and the time required for positioning were compared between groups.Results The intervention group had a significantly lower incidence rate of IAPIs and a significantly shorter positioning time compared with the control group (both P＜0.05).Conclusion The use of the fine-adjustment prone positioning cushion reduces the incidence rate of IAPIs and shortens positioning time in patients undergoing spinal surgery.