Objectives Computed tomography (CT) is employed to evaluate surgical outcome after spinal interventions. Here, we investigate the potential of multispectral photon-counting computed tomography (PC-CT) on image quality, diagnostic confidence, and radiation dose compared to an energy-integrating CT (EID-CT). Methods In this prospective study, 32 patients underwent PC-CT of the spine. Data was reconstructed in two ways: (1) standard bone kernel with 65-keV (PC-CT std ) and (2) 130-keV monoenergetic images (PC-CT 130 keV ). Prior EID-CT was available for 17 patients; for the remaining 15, an age–, sex–, and body mass index–matched EID-CT cohort was identified. Image quality (5-point Likert scales on overall, sharpness, artifacts, noise, diagnostic confidence) of PC-CT std and EID-CT was assessed by four radiologists independently. If metallic implants were present ( n  = 10), PC-CT std and PC-CT 130 keV images were again assessed by 5-point Likert scales by the same radiologists. Hounsfield units (HU) were measured within metallic artifact and compared between PC-CT std and PC-CT 130 keV . Finally, the radiation dose (CTDI vol ) was evaluated. Results Sharpness was rated significantly higher ( p  = 0.009) and noise significantly lower ( p  < 0.001) in PC-CTstd vs. EID-CT. In the subset of patients with metallic implants, reading scores for PC-CT 130 keV revealed superior ratings vs. PC-CT std for image quality, artifacts, noise, and diagnostic confidence (all p  < 0.001) accompanied by a significant increase of HU values within the artifact ( p  < 0.001). Radiation dose was significantly lower for PC-CT vs. EID-CT (mean CTDI vol : 8.83 vs. 15.7 mGy; p  < 0.001). Conclusions PC-CT of the spine with high-kiloelectronvolt reconstructions provides sharper images, higher diagnostic confidence, and lower radiation dose in patients with metallic implants. Key Points • Compared to energy-integrating CT, photon-counting CT of the spine had significantly higher sharpness and lower image noise while radiation dose was reduced by 45%. • In patients with metallic implants, virtual monochromatic photon-counting images at 130 keV were superior to standard reconstruction at 65 keV in terms of image quality, artifacts, noise, and diagnostic confidence.