Ninety-four patients undergoing major spinal surgery in the prone position were randomized to receive either remimazolam-based total intravenous anesthesia (TIVA) (n=47) or propofol-based TIVA (n=47). The primary outcome was the incidence of hypotension during the first hour after prone positioning. Secondary outcomes included incidence of severe hypotension, number of hypotensive episodes per patient, and total amount of vasopressors administered. Hemodynamic variables such as mean arterial pressure (MAP), heart rate, stroke volume, and cardiac output were monitored continuously. Overall, the results of the study revealed no significant difference in the incidence of hypotension or severe hypotension between groups. However, the remimazolam group had higher MAP in the initial 10 minutes post-positioning and required less ephedrine. These findings suggest remimazolam may offer marginal hemodynamic benefits in the immediate post-positioning period.