BACKGROUND CONTEXT:Insurance prior authorization (PA), initially intended to curb healthcare costs and wasteful spending, has become a growing regulatory barrier to timely spine surgery. Yet, the process of PA and drivers of coverage denials remain elusive. PURPOSE:We present a one-year review of insurance referrals for spine surgery at a single academic, tertiary care center to identify predictors of PA and ultimately coverage approval and denial. STUDY DESIGN:We retrospectively reviewed 740 adult patients referred for spine surgery between June 2023 and March 2025 at our single academic medical center in Florida. METHODS:Data analyzed included demographics, insurance type (private vs public), insurance provider, clinical severity (eg, myelopathy, cord compression), and authorization outcomes. Univariate and Multivariate statistical analysis identified predictors of denial both with and without PA. RESULTS:Mean patient age was 66.8 years (54% male) with 40.4% of patients having public (Medicare) and 59.6% having private insurance. A majority of patients required PA (499, 67.4%). Of the total cohort, 45 (6.1%) of patients were ultimately denied coverage. Presence of neurologic deficit, myelopathic signs, cord compression or cord signal change on imaging, and prior trial of conservative management did not significantly predict need for PA or insurance coverage. Payor type (public vs private and type of private insurer) was significantly associated with need for PA and insurance outcome. Need for PA resulted in an average 14-day delay to final insurance decision and 11-day delay to spine surgery compared to patients who did not require PA (p<.001). CONCLUSION:This single institution study suggests there may be other factors payors consider when making insurance decisions that are not directly tied to traditional clinical indicators of surgical necessity. Public versus private insurance as well as type of payor amongst patients with private insurance appear to be correlated with need for PA and insurance denial. Need for PA does significantly increase time to surgery for patients who must first undergo that process.

Study Design: Retrospective analysis of patients from the prospective Quality Outcomes Database Spine CORe ® Spondylolisthesis cohort to assess the prevalence of sleep dysfunction and factors associated with improved sleep after surgery. Objective: To characterize the prevalence of sleep disruption and identify factors associated with improved sleep among patients undergoing surgery for Meyerding grade I degenerative lumbar spondylolisthesis. Summary of Background Data: Improved sleep after surgery for lumbar spinal stenosis has been reported in several studies but not in patients with spondylolisthesis. Methods: A total of 608 patients from the prospective Quality Outcomes Database Spine CORe ® Spondylolisthesis cohort were retrospectively analyzed. Patients were included in this study if they responded to the sleep subitem of the Oswestry Disability Index (ODI) at baseline and 24-month follow-up. The level of sleep dysfunction was assessed and compared at baseline and 24-month follow-up using univariable and multivariable statistics. Results: Overall, 526 of the 608 patients met the inclusion criteria. At baseline, 455 patients (86.5%) had sleep disruption. At 24 months or greater, 325 patients (71.4% of the 455 impaired) had improved sleep, with 184 patients (40.4%) reporting no disruption of sleep postoperatively. In multivariable analyses, improvement in sleep was predicted by a higher baseline ODI (OR=1.01, 95% CI: 1.001–1.01, P <0.001). Following subgroup analysis by age, improvement in sleep was predicted by a higher baseline ODI (OR=1.01, 95% CI: 1.001–1.01, P =0.002) and higher ASA grade (OR=1.15, 95% CI: 1.02–1.30, P =0.03) in the 65 years or younger cohort, while minimally invasive techniques (OR=1.14, 95% CI: 1.01–1.30, P =0.04) were significant in the 65 years of age or older cohort. Conclusion: Most patients (86.5%) presenting for surgery for low-grade degenerative spondylolisthesis have impaired sleep. However, 24 months after surgery, over 70% of patients with baseline dysfunction reported improvements with 40.4% reporting no sleep dysfunction.

OBJECTIVE:The authors aimed to evaluate the prevalence of sleep disturbance in patients with grade 2 lumbar spondylolisthesis and assess postoperative trajectories and predictors of improvement at 5 years. They hypothesized that surgical treatment of grade 2 spondylolisthesis would result in high rates of long-term improvement in sleep disturbance. METHODS:Patients with grade 2 lumbar spondylolisthesis were identified from the 14-site Spine CORe™ study group within the Quality Outcomes Database (QOD). Sleep disturbance was measured using the sleep item of the Oswestry Disability Index (ODI) at baseline and 3, 12, 24, and 60 months postoperatively. The prevalence of baseline sleep disturbance was determined. Clinically meaningful improvement was defined using minimal clinically important difference thresholds. Predictors of improvement were analyzed using multivariate Firth's logistic regression, and associations with pain, disability, quality of life, and satisfaction were assessed. RESULTS:A total of 328 patients underwent surgery for grade 2 spondylolisthesis. At baseline, 300 of 328 patients (91.5%) reported sleep disturbance. The 60-month follow-up rate in this subgroup was 81% (21 died within 5 years of surgery of unrelated causes and 223 of the 300 patients followed up at 5 years). Improvement in sleep disturbance was observed in 165 patients (74.0%), while 58 patients (26.0%) continued to report sleep disturbance at 60 months. Those with improved sleep were more likely to achieve clinically meaningful gains in back pain (80.5% vs 50.0%, p < 0.001), leg pain (83.6% vs 53.4%, p < 0.001), EQ-5D (31.1% vs 7.3%, p < 0.001), and ODI (62.8% vs 5.3%, p < 0.001) scores, with a trend toward higher satisfaction in patients with improved sleep (88.5% vs 77.8%; risk difference 10.7%, 95% CI -0.01 to 0.23). On multivariate analysis, only private insurance (OR 2.20, 95% CI 1.03-4.78; p = 0.041) was associated with greater odds of 60-month sleep improvement. CONCLUSIONS:Sleep disturbance was highly prevalent in 91.5% of patients with grade 2 spondylolisthesis, and 74.0% experienced meaningful improvement by 3 months and this was sustained for 5 years following surgery. Sleep recovery was closely tied to gains in pain, disability, and quality of life. These results demonstrate that surgery for grade 2 spondylolisthesis not only improves mechanical symptoms but also substantially alleviates sleep disturbance.

OBJECTIVE:Surgery for cervical spondylotic myelopathy (CSM) aims to halt disease progression. However, some patients will also ultimately note relief from their myelopathic symptoms. This study aimed to identify factors that predict improvement from moderate or severe myelopathy to mild or no myelopathy through an analysis of preoperative clinical and demographic data. Predictive models were developed to identify patients likely to achieve durable relief from myelopathy 24 months after surgery for CSM. METHODS:Data were obtained from the Quality Outcomes Database (QOD) CSM dataset, a prospective registry cohort of 1085 patients from the 14 Spine CORe™ sites. Patients were excluded if they were younger than 18 years, were missing baseline or 24-month modified Japanese Orthopaedic Association scale (mJOA) scores, or had baseline mJOA score > 14. The remaining patients were partitioned into a training (n = 467) or test (n = 117) set. Logistic regression and random forest models, with and without principal component analysis, were trained to predict whether patients achieved mild/no myelopathy at 24 months, which was defined as an mJOA score of 15 or greater. RESULTS:Overall, 584 patients (47.1% female) with moderate to severe myelopathy met the prespecified inclusion criteria, with a mean ± SD age of 61.7 ± 11.2 years, body mass index (BMI) 30.3 ± 6.3 kg/m2, and preoperative mJOA score 11.2 ± 2.4. At 24 months, 45% of patients (n = 263) had mJOA score > 14. There were no significant differences in performance between models with area under the receiver operating characteristic curve (AUROC) near 0.63 and area under the precision-recall curve (AUPRC) near 0.56. Significant positive predictors of postoperative relief from myelopathy in both the models and sensitivity analysis were symptom duration ≤ 12 months (OR 1.88, 95% CI 1.20-2.94, p < 0.01) and participation in activities outside the home (OR 2.19, 95% CI 1.12-4.27, p = 0.02). CONCLUSIONS:In a large prospective registry cohort of patients operated on for CSM, consistent factors associated with myelopathic symptom relief at 24 months were symptom duration ≤ 12 months and participation in activities outside the home. The finding that longer symptom duration was associated with a decreased propensity for relief from myelopathic symptoms suggests that earlier surgery may be beneficial for patients with moderate to severe myelopathy.

OBJECTIVE:Insurance status is known to influence access to spine surgery, but its role in cervical spondylotic myelopathy (CSM) remains underexplored. The authors hypothesized that government insurance payor status would be associated with delayed care access, evidenced by prolonged symptom duration and greater baseline symptom severity relative to those with private insurance. METHODS:This was a prospective observational cohort study of 1085 patients enrolled in the Quality Outcomes Database CSM module of the 14-site Spine CORe™ study group. Patients were included if they had complete data for insurance, symptom duration, and baseline patient-reported outcomes (PROs). Insurance status was categorized as private, Medicare, Medicaid, or Veterans Affairs (VA)/federal. Primary outcomes included surrogates of access to care, assessed by symptom duration (> 12 months) and baseline PROs, i.e., the Neck Disability Index (NDI) and EQ-5D. Associations were evaluated using multivariable logistic regression analysis. RESULTS:A total of 1085 patients with CSM who underwent surgery were enrolled, with more than 80% completing 5-year follow-up. Patients were excluded if they were uninsured or did not report baseline symptom duration, EQ-5D score, or NDI score, leaving a cohort of 977 patients for analysis. The proportion of patients reporting symptom duration > 12 months differed by insurance status (p < 0.001): highest in VA/federal (18/24, 75%), followed by Medicaid (45/70, 64%), Medicare (206/375, 55%), and private insurance (228/508, 45%). Compared to those who had private insurance, patients covered by VA/federal insurance (OR 3.85, 95% CI 1.56-10.89), Medicaid (OR 2.05, 95% CI 1.18-3.61), and Medicare (OR 1.98, 95% CI 1.39-2.82) had symptom duration > 12 months. Of patients with government insurance payors, Medicaid insurance status was independently associated with worse baseline disability (NDI: β = 7.35, 95% CI 2.35-12.35; p = 0.004) and lower quality of life (EQ-5D: β = -0.12, 95% CI -0.18 to -0.07; p < 0.001). CONCLUSIONS:Compared to patients with private insurance, patients covered by government insurance payors (VA/federal insurance, Medicare, and Medicaid) had significantly longer symptom duration before undergoing surgery. Patients with VA/federal insurance coverage had the longest symptom duration of the government payors. Of the government insurance payor types, Medicaid was the only one independently associated with significantly worse baseline disability (NDI) and quality of life (EQ-5D). After controlling for other factors, patients with government insurance coverage, and more specifically Medicaid, have difficulty accessing surgical care in a timely fashion to treat CSM compared to patients with private insurance.

STUDY DESIGN:Retrospective analysis of prospectively collected database. OBJECTIVE:Adult spinal deformity (ASD) has increasingly been treated with minimally invasive surgical (MIS) techniques. The authors sought to identify factors associated with delayed deterioration of ODI between 1 and 2 years postoperatively following minimally invasive surgery (MIS) for adult spinal deformity (ASD). SUMMARY OF BACKGROUND DATA:Coronal malalignment is known to be associated with patient disability but the extent to which coronal alignment is associated with delayed deterioration after circumferential MIS surgery for ASD is unknown. METHODS:A retrospective analysis of prospectively collected data from the Minimally Invasive Surgery International Spine Study Group (MIS-ISSG) was conducted, including 67 patients who underwent circumferential MIS for ASD with one and two-year follow-ups. The patient cohort was dichotomized by identifying patients who reported higher ODI scores at 2 years than 1 year (somewhat improved) and compared with patients who reported stable or improved ODI over the same time course (very improved). Preoperative and postoperative factors influencing ODI changes were analyzed, focusing on radiographic outcomes and complications. RESULTS:Of the 67 patients, 31 reported an increase in ODI at two years compared with one year but these patients continued to show an improvement in ODI compared to preoperative baseline. Statistical analyses revealed no significant differences in baseline demographic, surgical, or preoperative characteristics between the "somewhat improved" (2-year ODI>1-year ODI) and "very improved" (2 y ODI≤1 y ODI) cohorts (P>0.05). However, the somewhat improved group had a significantly higher mean central sacral vertical line (CSVL) at all follow-up intervals (6-week CSVL mean 36.26 mm in the Somewhat improved group versus 22.8 mm in the very improved group, P=0.01). CONCLUSION:Early post-operative coronal malalignment is associated with delayed changes in functional outcomes following MIS for ASD.

BACKGROUND AND OBJECTIVES:Minimum clinically important differences (MCIDs) for patient-reported outcome metrics (PROMs) in patients with cervical spondylotic myelopathy (CSM) lack consensus on the most appropriate calculation method. This retrospective study aimed to identify the optimal MCIDs for commonly used PROMs in CSM. METHODS:The CSM database from the Quality Outcomes Database SpineCORe Study Group was analyzed. Baseline, 3-month, and 24-month PROM values for Neck Disability Index (NDI), 5-dimension Euro-quality of life (EQ-5D) in quality-adjusted life years, modified Japanese Orthopaedic Association (mJOA) score, and neck/arm pain numeric rating scale (NRS) were collected. MCIDs were calculated for each PROM using previously validated techniques. MCID values were compared using the area under the curve (AUC) with the North American Spine Society satisfaction scale as an anchor. RESULTS:A total of 1141 patients with CSM undergoing surgery were included in this analysis. Improvement of ≥30% from baseline was the optimal MCID for NDI and neck/arm NRS. At 24 months, the optimal percentage cutoff MCID for these instruments resulted in AUCs of 0.76, 0.72, and 0.67, similar to the 30% improvement method, with AUCs of 0.73, 0.71, and 0.67, respectively. Numeric cutoffs (0.065 at 3 months; 0.149 at 24 months) were the superior MCIDs for EQ-5D. For mJOA score, a severity-adjusted MCID outperformed other methods, yielding an AUC of 0.67 at 24 months. MCIDs were achieved in 63% of patients for NDI, 59% for neck pain NRS, 61% for arm pain NRS, 52% for EQ-5D, and 59% for mJOA score at 24 months. CONCLUSION:Using the Quality Outcomes Database SpineCORe data set, we defined optimal MCIDs for key PROMs in CSM. A ≥30% improvement from baseline was optimal in NDI and arm/neck NRS. An absolute numeric cutoff was superior for EQ-5D (0.149 at the 24-month follow-up). A severity-adjusted MCID performed best for mJOA score. These redefined benchmarks better capture the treatment impact and guide care decisions for patients with CSM.

Awake spine surgery, under regional or local anesthesia, is an emerging alternative to general anesthesia (GA). This narrative review consolidates current evidence and proposes an implementation framework. Key components include multidisciplinary collaboration, patient selection, multimodal anesthesia, minimally invasive techniques, and integration with Enhanced Recovery After Surgery (ERAS) pathways. Evidence shows reduced operative time, blood loss, opioid use, length of stay, and GA-related complications. Cost savings and high patient satisfaction are consistently reported. Awake spine surgery is a safe, effective, and scalable approach that improves outcomes and efficiency when implemented through structured, protocol-driven programs.

OBJECTIVE:The purpose of this study was to evaluate patients undergoing surgery for cervical spondylotic myelopathy who presented with severe arm pain to determine which factors are associated with persistent and improved postoperative arm pain. METHODS:Of the patients with CSM included from 14 Spine CORe™ study group sites participating in the Quality Outcomes Database, those who presented with severe arm pain preoperatively (numeric rating scale [NRS] scores 7-10) were selected for analysis. Within this subset, patients who reported persistent severe arm pain (NRS scores 7-10) postoperatively were compared with patients who had moderate and improved/mild arm pain (NRS scores 4-6 and 0-3, respectively) postoperatively. NRS scores for arm pain were recorded at baseline and postoperatively at 3 months, 1 year, 2 years, and 5 years. Demographics, comorbidities, and patient-reported outcome measures (Neck Disability Index [NDI], quality-adjusted life years [QALY], modified Japanese Orthopaedic Association [mJOA] scale, and EuroQol visual analog scale [EQ-VAS]) were evaluated. These factors were compared between patients with persistent and those with improved arm pain at the 5-year follow-up using the Wilcoxon rank-sum test. RESULTS:Of 1085 patients with CSM, 458 reported severe arm pain (NRS scores 7-10) preoperatively. Of these, 60.7% of patients reported mild arm pain (NRS scores 0-3), 20.4% reported moderate arm pain (NRS scores 4-6), and 18.9% reported persistent severe arm pain (NRS scores 7-10) at the 5-year follow-up. Patients with persistent severe pain had significantly higher NDI scores (p = 0.001) and lower mJOA (p = 0.04), QALY (p = 0.02), and EQ-VAS (p < 0.00001) scores at baseline. Patients with mild/improved arm pain were significantly more likely to have postgraduate education (p = 0.04). Patients with early postoperative improvement in arm pain (at 3 months, p < 0.0001) had sustained improvement through the 5-year postoperative time point. However, patients with persistent severe pain at 5 years had consistently higher pain at all postoperative time points (3 months, 1 year, and 2 years), which significantly worsened between the 2- and 5-year time points (mean NRS scores from 4.8 to 8, p < 0.001). CONCLUSIONS:Among patients who underwent surgery for CSM who presented with severe radicular arm pain (NRS scores 7-10), 81.1% reported improvement (NRS scores 0-6), and 18.9% reported persistent severe arm pain 5 years after surgery. Persistent arm pain was associated with increased preoperative disability (mJOA, NDI, QALY, and EQ-VAS), while postgraduate education was associated with improved arm pain. Patients with early postoperative improvement in arm pain demonstrated a durable result through 5 years of follow-up, which could improve further. Conversely, those with severe postoperative arm pain had persistent pain at 2 years, which further deteriorated between 2 and 5 years, thus warranting careful long-term surveillance.

OBJECTIVE:Surgical management of cervical spondylotic myelopathy (CSM) aims to improve neurological deterioration. However, long-term predictors of outcome are unknown. The present study examined highest and lowest patient-reported satisfaction at the 5-year follow-up. The authors hypothesized that the most satisfied patients experience durable long-term improvement and have distinct characteristics compared to the least satisfied patients. METHODS:Prospectively collected data from the Spine CORe™ study group of the Quality Outcomes Database cervical spine module were retrospectively reviewed. Patients were stratified by North American Spine Society (NASS) satisfaction scores of 1 (most satisfied) and 4 (least satisfied). Demographics, surgical characteristics, and patient-reported outcome measures (PROMs) were compared between cohorts at baseline and 24 and 60 months of follow-up. A mixed-effects logistic regression assessed independent predictors of those who were most and least satisfied at 60 months. Univariate and multivariable analyses were repeated in the subsample of most satisfied patients at 2 years. Univariate analysis was completed for the subsample of least satisfied patients at 2 years. RESULTS:Of 1085 patients with CSM, 895 (82%) completed the 60-month follow-up. Of these 895 patients, 106 died within 5 years of surgery of unrelated causes, and 785 provided satisfaction scores at 60 months of follow-up. Of the 785 patients, 621 patients met inclusion criteria of reporting an NASS score of 1 or 4 at 60 months: 560 (90.2%) were most satisfied and 61 (9.8%) were least satisfied. The most satisfied cohort included more patients with bachelor's degrees (25% vs 13%, p = 0.043), more anterior cervical discectomies and fusions (61% vs 48%, p = 0.038), shorter hospitalizations (1.7 ± 1.8 vs 2.8 ± 2.6 days, p = 0.002), fewer laminectomies (23% vs 39%, p = 0.004), and fewer smokers (p = 0.036). Most satisfied patients reported higher baseline EuroQol visual analog scale (EQ-VAS) scores (60.8 ± 21.3 vs 51.5 ± 24.8, p = 0.008), but other baseline PROMs were similar. In multivariable analysis, college education (OR 2.54, p = 0.004), preoperative depression (OR 2.75, p = 0.043), higher baseline EQ-VAS score (OR 1.02, p = 0.009), and shorter hospitalization (OR 0.81, p = 0.003) independently predicted the most satisfaction at 60 months. Among 60-month least satisfied patients, 28% were most satisfied at 24 months. Among 60-month most satisfied patients, 2.9% were least satisfied at 24 months. Among 24-month most satisfied patients, maintenance of most satisfaction at 60 months was independently predicted by older age (OR 1.09, p = 0.045), preoperative pain (OR 9.28, p = 0.013), and higher 24-month neck pain numeric rating scale (NP-NRS) score (OR 1.58, p = 0.047). Neck Disability Index- and modified Japanese Orthopaedic Association (mJOA)-based independence measures correlated with a bidirectional satisfaction shift between 2 and 5 years. CONCLUSIONS:Highest NASS satisfaction scores at 5 years after surgery for CSM are predicted by college education of the patients, preoperative depression, higher baseline EQ-VAS scores, and shorter hospital length of stay. Younger age, lack of preoperative pain, and lower 2-year NP-NRS scores predict movement from most satisfied to least satisfied. After surgery for CSM, the majority of patients report the highest satisfaction NASS rating at 5 years, but delayed satisfaction reversals exist and warrant monitoring.

OBJECTIVE:Unemployment following surgery incurs significant societal costs. The authors aimed to identify predictors of return to work (RTW) following surgery for patients with grade 1 lumbar spondylolisthesis. METHODS:This Spine CORe™ study is a post hoc analysis of prospectively collected data from the Quality Outcomes Database (QOD) grade 1 lumbar spondylolisthesis module. Patients were divided into 2 groups: employed preoperatively and unemployed preoperatively. Univariate and multivariate instruments were used to identify predictors of RTW/employment within 5 years postoperatively. RESULTS:Across the 12 highest enrolling QOD sites (Spine CORe™ group), 608 patients were enrolled with 81% having Oswestry Disability Index (ODI) follow-up data. Of these 608 patients, 604 patients had baseline employment status recorded. Of 275 patients who were employed preoperatively, 249 had RTW follow-up data. Of the 329 patients unemployed preoperatively, 218 had RTW follow-up data. The study cohort follow-up for RTW was 77%. By 5 years postoperatively, 87.1% (n = 217) of those employed preoperatively and 22.0% (n = 48) of those unemployed preoperatively returned to work. In each cohort, there were no differences in age, sex, BMI, and American Society of Anesthesiologists class between those who did and those who did not RTW. These results remained consistent in the subgroup analysis of patients younger than 65 years at baseline. However, the only difference observed in this age group was within the preoperatively unemployed cohort, where the RTW group had a lower BMI (28.4 ± 5.5 vs 32.8 ± 9.0, p = 0.001). On multivariate analysis for the preoperatively employed cohort, college degree (OR 3.6, 95% CI 1.3-12.2) and active employment (OR 6.0, 95% CI 1.9-19.8) remained independent predictors of returning to work. For those preoperatively unemployed, a college degree (OR 2.2, 95% CI 1.1-4.4) independently predicted RTW. CONCLUSIONS:Approximately 87% of patients employed preoperatively RTW, and 22% of patients unemployed preoperatively returned to the workforce within 60 months after surgery for grade 1 spondylolisthesis. College-level education independently predicted RTW for both preoperatively employed and preoperatively unemployed patients.

OBJECTIVE:Cervical spondylotic myelopathy (CSM) is a leading cause of spinal cord dysfunction requiring surgical intervention. Prolonged length of stay (LOS) after CSM surgery is associated with worse outcomes, increased complications, greater financial burden, and inefficient resource utilization. This study aimed to develop machine learning models to predict prolonged LOS after CSM surgery and to improve patient counseling, perioperative optimization, and discharge planning. METHODS:The authors analyzed prospectively collected data from 14 high-accruing Spine CORe™ sites in the Quality Outcomes Database (QOD) of adult patients who underwent elective surgery for CSM. Patients with missing data were excluded. Machine learning models were trained to predict prolonged LOS, defined as ≥ 3 days. Models incorporated a wide range of preoperative demographic, clinical, and surgical variables. Model performance was evaluated using area under the receiver operating characteristic curve (AUROC) analysis, and significant predictors were extracted from the logistic regression model. RESULTS:Of the 1141 patients identified as having undergone elective surgery for CSM, 1020 were included. Logistic regression, XGBoost, and random forest models demonstrated excellent performance with mean ± standard deviation AUROC values of 0.88 ± 0.02, 0.89 ± 0.02, and 0.89 ± 0.02, respectively. Prior shoulder surgery (OR 2.33, 95% CI 2.16-2.51, p = 0.04), greater total fused levels (OR 1.89, 95% CI 1.83-1.95, p < 0.001), and diabetes (OR 1.75, 95% CI 1.66-1.83, p = 0.049) were predictors of prolonged LOS. In contrast, anterior surgical approach (OR 0.14, 95% CI 0.12-0.17, p < 0.001), radicular motor deficit (OR 0.49, 95% CI 0.45-0.54, p = 0.030), and greater baseline modified Japanese Orthopaedic Association (mJOA) score (OR 0.87, 95% CI 0.86-0.88, p = 0.007) were associated with a lower likelihood of prolonged LOS. Subgroup analyses revealed that patients with radicular motor deficit and prior shoulder surgery differed demographically, clinically, and surgically compared to those without. CONCLUSIONS:In this large cohort of patients operated on for CSM, prior shoulder surgery, greater number of levels fused, and diabetes were significant positive predictors of prolonged LOS, while anterior approach surgery, radicular motor deficit, and higher baseline mJOA scores were predictive of a shorter inpatient stay. Patients with prior shoulder surgery and those with radicular motor deficit may represent distinct and clinically important subgroups within the broader CSM population. Machine learning models demonstrated excellent performance for predicting prolonged LOS from purely preoperative variables. The findings of this study may help enhance preoperative counseling, perioperative care, and resource utilization for CSM surgery.

OBJECTIVE:Minimally invasive surgery (MIS) is a reasonable treatment option for lumbar spondylolisthesis, but its long-term cost-effectiveness is not well established. Herein, the authors describe the 5-year cost-effectiveness of posterior MIS using prospective data from the multicenter Quality Outcomes Database (QOD). METHODS:Patients from the Spine COReTM study group's multicenter, prospectively collected QOD grade 1 lumbar spondylolisthesis dataset who had undergone single-stage posterior surgery were included. Gains in quality-adjusted life years (QALYs) were quantified using EQ-5D scores across 60 months. Costs from index surgeries and related reoperations were estimated using Medicare rates for inpatient care and Current Procedural Terminology rates for outpatient care. Validation was achieved via price transparency diagnosis-related group (DRG) charges and charge/cost ratios (CCRs). The cost per QALY gained was ultimately calculated. RESULTS:Of the 608 patients identified as having undergone single- or multiple-stage surgery, 559 underwent single-stage posterior surgery, 242 via MIS (mean age 64.3 ± 11.7 years, 71.1% arthrodesis rate) and 317 via open surgical approaches (mean age 61.3 ± 12.2 years, 78.5% arthrodesis rate). Length of stay (LOS) was 2.3 ± 1.9 days for patients in the MIS group and 3.1 ± 1.7 days for those in the open surgery group (p < 0.0001). Operative duration was similar between the groups (171.7 ± 93.3 vs 174.2 ± 72.3 minutes, p = 0.739), whereas estimated blood loss was 108.3 ± 102.2 mL for the MIS group and 251.9 ± 230.6 mL for the open surgery group (p < 0.0001). Moreover, 6.2% of patients in the MIS group and 7.9% in the open surgery group underwent related reoperations; 5.0% and 7.6% of patients, respectively, had complications. Thirty-day readmission was required in 1.2% of patients in the MIS group and 2.5% in the open surgery group. DRG costs were stable between our model and the CCR-based model, providing external validation. The mean QALY gain was 1.06 (95% CI 0.92-1.20) for MIS and 0.94 (95% CI 0.83-1.05) for open surgery (p = 0.191); the mean QALY gain was 1.09 (95% CI 0.92-1.25) versus 0.95 (95% CI 0.82-1.08), respectively, among those who underwent arthrodesis (p = 0.193) and 0.99 (95% CI 0.71-1.28) versus 0.90 (95% CI 0.64-1.16) among those who underwent decompression only (p = 0.628). The mean cost of MIS was significantly lower ($31,822) than that of open surgery ($39,151; p = 0.001). Among those who underwent arthrodesis, the mean cost was $41,916 for MIS versus $46,626 for open surgery (p = 0.031). Among patients who underwent decompression only, the mean respective cost was $7021 versus $11,780 (p = 0.004). The mean cost per QALY gained was $29,995 for MIS and $41,635 for open surgery (p = 0.0017), $38,501 versus $48,998 among those who underwent arthrodesis (p = 0.0193), and $7073 versus $13,100 among those who underwent decompression only (p = 0.0123). CONCLUSIONS:MIS for grade 1 lumbar spondylolisthesis demonstrated a 60-month cost per QALY gained of $29,995, which was significantly lower than open surgery's $41,635. Differences were driven by LOS, complications, and reoperations, and MIS remained more cost-effective even after stratification for arthrodesis. However, both surgical approaches remained below the $100,000 willingness-to-pay threshold, highlighting overall long-term cost-effectiveness.

Complications from spine surgery are not just devastating because they happen, or because we believe that complications can be avoided, but are magnified because many of the complications occur in elective cases. Catastrophic outcomes in surgeries that are intended to improve lifestyle and comfort do not fit our sensibility. In the first Neurosurgical Focus issue on complications published in October 2024, most of the complications shared involved cranial neurosurgery. Many of these complications occurred in cases in which there was no acceptable option except to operate, such as cases involving extensive arteriovenous malformations, tumors, and aneurysms. In life-threatening diseases, the existence of challenged outcomes is often considered the trade-off. In spine surgery, however, we face risks of worse functional outcomes in patients who often have other options. We roll stochastic dice with each surgery. A 2% risk of a certain complication occurs with random precision and strikes with 100% completeness. This makes complications in spine surgery hard to express to patients in their full reality, hard to process for the surgeon when they do occur, and sometimes hard to bring to light, because the presence of a serious complication in an elective case horrifies. This issue of Neurosurgical Focus, like the laudable issue before, attempts to grapple with these challenges by presenting spinal complications in all of their attendant difficulties. These case illustrations were all written by esteemed and senior neurosurgeons who share hundreds of years of experience among them. The authors have a track record of sound judgment and technical excellence but are laying bare the challenges they have faced, primarily because they recognize the benefits of awareness and of the personal lessons they learned. A layer of anonymity is created by disassociating individual work from the authors. Videos were narrated by an individual who was not involved in video or case preparation.

OBJECTIVE:Patient satisfaction is an important outcome to measure quality of care. The hypothesis of this study was that more severe baseline neck disability (Neck Disability Index [NDI] scores 70-100) is associated with less frequent postoperative satisfaction in cervical spondylotic myelopathy. METHODS:This study used the 14-site Spine CORe™ study group's cervical dataset module from the Quality Outcomes Database, which included 1085 patients. Baseline demographics, clinical variables, and surgical parameters were collected. Patient-reported outcomes (PROs) collected include EQ-5D, NDI, and numeric rating scale for neck pain and arm pain scores. Heat maps were created to demonstrate the association of NDI scores with postoperative satisfaction. RESULTS:There were 1085 patients in this study with a 5-year follow-up rate of 83% for the NDI. PROs significantly improved 1 and 5 years postoperatively. Multivariate regression models found baseline NDI scores to be associated with 1- and 5-year satisfaction (OR 0.98 [95% CI 0.97-0.99], p = 0.004). Heat maps were created to determine the significance of baseline, 1-year, and 5-year NDI scores on satisfaction rates. The level of satisfaction decreased with increasing 1- and 5-year NDI scores. Additionally, patients with higher baseline NDI scores required a more significant change in NDI to achieve satisfaction with surgery. CONCLUSIONS:Patients with more severe disability measured by the NDI require a greater change in postoperative NDI scores to meet satisfaction. Despite the importance of postoperative satisfaction, failure to achieve satisfaction should not be assumed to be due to lack of clinical benefit. Discussing a patient's goals and expectations preoperatively is essential to maximize the probability of achieving satisfaction.

OBJECTIVE:Prolonged hospital length of stay (LOS) is an increasingly important quality metric among regulators and payers that has been associated with worse patient outcomes and decreased patient satisfaction. The aim of this study was to identify predictors of prolonged hospital LOS after surgery for Meyerding grade 2 spondylolisthesis using a multicenter prospectively collected registry. METHODS:The prospectively collected Spine CORe™ Quality Outcomes Database (QOD) study group cohort, which consisted of 328 patients from 14 sites, was used to identify all patients who underwent single-stage lumbar fusion for Meyerding grade 2 lumbar spondylolisthesis. Prolonged LOS was defined as ≥ 4 days (75th percentile). An array of demographic, comorbidity, and perioperative factors known to impact LOS were collected for each patient. Bivariate tests, including the chi-square goodness of fit and independent t-test, were used to identify variables associated with prolonged LOS. Multivariable logistic regression analysis was conducted to determine independent predictors of prolonged LOS. RESULTS:The QOD cohort comprised 328 patients with a follow-up rate of > 80%. After excluding patients with an anterior or lateral surgical approach and missing LOS data, the final cohort included 268 patients, of whom 52 (19.4%) experienced a prolonged LOS. In the univariate analysis, older age, dependent ambulation, insurance status, depression, greater estimated blood loss, longer operative duration, multilevel fusion (2 or more levels), perioperative complications (e.g., incidental durotomy and urinary tract infection), and nonhome discharge were associated with prolonged LOS. In the adjusted model, multilevel arthrodesis independently increased the odds of prolonged LOS (OR 2.11, 95% CI 1.07-4.18; p = 0.03), whereas private insurance (vs Medicare/Medicaid/government) was associated with lower odds (OR 0.42, 95% CI 0.20-0.87; p = 0.02). Patient-reported outcomes at 60 months did not differ between the groups with and without prolonged LOS. CONCLUSIONS:In this multicenter Spine CORe™ QOD study, multilevel lumbar fusion and noncommercial insurance were the principal independent predictors of prolonged LOS after surgery for grade 2 spondylolisthesis. These findings are valuable for patient informed consent, as well as to identify higher-risk patients who could benefit from earlier inpatient resource allocation (social work and counseling) to facilitate timely discharge.

OBJECTIVE:Minimal clinically important difference (MCID) thresholds are widely used to evaluate outcomes after surgery for cervical spondylotic myelopathy (CSM), but they may not fully reflect patient satisfaction. The authors hypothesized that discordance exists between MCID achievement in Neck Disability Index (NDI) score and satisfaction at long-term follow-up in a minority of patients after surgery for CSM. METHODS:The 14-site Spine CORe™ study group performed a post hoc analysis of their prospectively collected data from the Quality Outcomes Database, which included 1085 patients who underwent surgery for CSM. Patients with complete baseline and 5-year NDI scores as well as 5-year satisfaction data were included. Satisfaction was assessed using the North American Spine Society (NASS) satisfaction index, and the MCID was defined for the NDI score. Baseline characteristics and patient-reported outcomes were compared between satisfied and dissatisfied patients within the cohort who met the MCID for NDI score. Multivariate logistic regression identified predictors of dissatisfaction despite the MCID. RESULTS:In total, 1085 patients underwent surgery for CSM. The 5-year follow-up rate was 82% (106 died within 5 years, and 782 had both 5-year satisfaction and NDI data). At 5 years postoperatively, 497 patients (63.6%) achieved the MCID in NDI score. Among MCID achievers, 463 (93%) were satisfied and 34 (7%) were not satisfied. On univariate analysis, of those who met the MCID, dissatisfied patients were more likely to be current smokers (32.4% vs 15.8%, p = 0.029) and less likely to participate in outside activities (58.8% vs 85.1%, p < 0.001). They also presented with greater baseline disability (NDI score: 47.9 ± 18.2 vs 41.1 ± 19.5, p = 0.021), lower quality of life (EQ-5D score: 0.50 ± 0.19 vs 0.58 ± 0.22, p = 0.029), and lower preoperative functional status (mJOA score: 11.2 ± 2.8 vs 12.3 ± 2.7, p = 0.025) compared with satisfied patients. On multivariate analysis, of those who met the MCID, smoking showed a trend toward higher odds of dissatisfaction (OR 2.12, p = 0.065), while participation in outside activities was protective (OR 0.28, p < 0.001). CONCLUSIONS:In this study, only 7% of patients were dissatisfied despite achieving the MCID for NDI score. Participation in outside activities was independently associated with greater satisfaction, whereas smoking showed a trend toward increased dissatisfaction despite meeting the MCID for NDI score. The MCID and satisfaction capture distinct yet complementary aspects of recovery and should be jointly considered during preoperative counseling and postoperative outcome assessment.