BACKGROUND:Split cord malformations (SCMs) are uncommon congenital anomalies that are usually detected in children, but can present in adulthood with signs and symptoms of spinal cord tethering. SCMs rarely occur in association with a lipoma and a defect in the posterior elements. OBSERVATIONS:A 37-year-old man presented with 6 months of new-onset leg weakness, urinary urgency, and reduced sensation in his feet. He developed pain radiating from his low back into his legs, worsened by bending forward and walking. Prior to this presentation, he had not noticed any symptoms. MRI revealed a congenital fusion from L2 to L4 with a type I SCM and a lipoma extending through a dorsal bony defect and terminating at the duplicated spinal cord. A posterior L2-4 lumbar laminectomy was performed to excise the bony spur, resect the spinal cord lipoma, and section the fatty filum terminale. LESSONS:Removal of the bony or fibrous septum and intradural lipoma and sectioning of the fatty filum terminale are required for effective detethering. Careful lipoma debulking, which can be facilitated with a CO2 laser, must be performed while developing surgical planes and minimizing tension on the tethered cord. https://thejns.org/doi/10.3171/CASE25691.

OBJECTIVE:This study assessed whether social media involvement correlated with higher physician rating website (PRW) ratings and academic productivity. METHODS:This retrospective study (November 2022-June 2023) reviewed all spine neurosurgeons in the American Association of Neurological Surgeons database. Neurosurgeon names were searched on Twitter/X, Instagram, and LinkedIn; number of followers was recorded. Healthgrades ratings and number of reviewers were collected. h-index was searched in Scopus. Statistical analysis included t-tests, Mann-Whitney U test, χ2 test, and analysis of variance. RESULTS:A total of 1031 neurosurgeons were included (mean age, 61 years; 96.6% male). Median (interquartile range) Healthgrades rating was 4.20 (1.00), and median h-index was 5.0 (1.0). Surgeons with a presence on LinkedIn (528; 51.2%), Twitter/X (113; 11.0%), and Instagram (38; 3.7%) were younger than those without social media (P < 0.001). Median Healthgrades rating was 4.2 for those without and 4.55 for those with an Instagram account (P = 0.005). The median number of reviewers was 16.0 for surgeons without and 19.0 for surgeons with a LinkedIn account (P = 0.004). Surgeons with LinkedIn and Twitter/X accounts had a higher median h-index than surgeons not on these platforms (P < 0.001). CONCLUSIONS:Spine neurosurgeons involved in social media are typically younger than surgeons with no social media presence. Social media involvement was associated with higher ratings on PRWs (Instagram), more PRW reviews (LinkedIn), and higher h-index (LinkedIn and Twitter). These findings should be interpreted with care because the analyses are correlative rather than causal, and voluntary response bias is inherent to PRW data.

BACKGROUND CONTEXT Preoperative lower extremity neurologic deficits may affect outcomes in adult spinal deformity surgery. PURPOSE To evaluate the impact of preoperative motor deficits on perioperative outcomes, complications, and patient-reported outcomes. STUDY DESIGN/SETTING Retrospective analysis of a prospective multicenter study. PATIENT SAMPLE ASD patients undergoing surgery between 2009–2018. OUTCOME MEASURES Perioperative morbidity, complications, reoperation, and 2-year PROMs (ODI, SF-36 PF, SRS-22r). METHODS Multivariable regression controlling for demographic and surgical variables. RESULTS Among 1,290 patients, 25% had preoperative motor deficits. These were associated with longer operative time (β=17.3, p=0.044), higher rates of new deficits (OR=1.9, p=0.018), major complications (OR=1.6, p=0.006), worse ODI (β=4.5, p=0.003), and worse SF-36 PF (β=-2.0, p=0.018). 52.4% recovered motor function by 6 weeks, but recovery did not correlate with 2-year outcomes. CONCLUSIONS Preoperative motor deficits are associated with worse perioperative and long-term outcomes. Early intervention and patient counseling are critical. FDA Device/Drug Status This abstract does not discuss or include any applicable devices or drugs.

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.

BACKGROUND AND OBJECTIVES:Circumferential minimally invasive surgery (cMIS) techniques in adult spinal deformity (ASD) surgery may reduce physiological burden compared with open technique, but their utility in octogenarians has not been previously assessed. METHODS:Operative ASD patients aged 80 years or older with complete baseline (BL) and 2-year postoperative radiographic and health-related quality of life data were assessed and compared by surgical technique: open vs cMIS. Propensity score matching aligned groups by BL Charlson Comorbidity Index (CCI), C7-S1 sagittal vertical axis, pelvic incidence minus lumbar lordosis mismatch, and C7 plumb line. BL and peri/postoperative factors were assessed using analysis of variance and Bonferroni-adjusted analysis of covariance while controlling for BL CCI and posterior fusion length. RESULTS:Thirty-four octogenarian ASD patients met inclusion criteria, of whom 29.4% underwent cMIS and 70.6% underwent open correction. cMIS patients were less likely to require surgical intensive care unit (10% vs 75%, P < .001) and had shorter hospital stays (4.6 vs 10.1 days, P = .013). Open patients reported higher Scoliosis Research Society-22 Appearance and Mental domain scores (both P < .005) and more frequently reached minimal clinically important difference in both domains by 2 years (P = .025, .024). cMIS patients more often required reoperation for radiographic sagittal imbalance by 2 years when controlling for CCI and levels fused (20.0% vs 8.3%, P < .001). No deaths occurred in either group by 2 years. CONCLUSION:In octogenarians undergoing ASD surgery, cMIS reduced physiological burden but had higher reoperation rates, whereas open surgery showed greater durability.

Background Rosai-Dorfman Disease (RDD) is a rare histiocytic disorder typically affecting lymph nodes. Extranodal RDD is uncommon, and isolated central nervous system (CNS) or spinal disease is particularly rare, limiting guidance on diagnosis and management. Methods We report a patient treated at our institution and conducted a systematic review of all published cases of extranodal RDD isolated to the thoracic spine. Patient demographics, clinical presentation, imaging and histopathologic findings, treatments, and outcomes were extracted. Results A 21-year-old woman presented with progressive back pain and bilateral lower extremity paresthesia. MRI revealed an enhancing extradural lesion at T3 causing spinal cord compression. Surgical resection confirmed RDD. Despite postoperative steroids and radiotherapy, recurrence occurred within months, necessitating repeat surgery. Subsequent imaging revealed further progression with unresectable extension. She was treated with corticosteroids and cobimetinib, resulting in gradual radiographic and symptomatic improvement. Our review identified 41 cases of thoracic spinal RDD, including this case. Most patients were male (80%) with median age of 40 years. Common symptoms included lower extremity weakness (83%) and sensory deficits (64%). Lesions were typically T1 isointense and contrast-enhancing. Histopathology consistently showed S100+ and CD68+ histiocytes with emperipolesis. Surgical resection was the primary treatment (98%). Despite recurrence in 21% of cases, all patients showed clinical improvement at last follow-up. Conclusions Thoracic spinal RDD is a rare and diagnostically challenging entity requiring multimodal treatment. Surgical decompression remains the mainstay of therapy for cord compression, while adjunctive medical treatments—including corticosteroids, radiation, and targeted agents—may be necessary for long-term disease control.

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.

BACKGROUND CONTEXT Complications beyond 2-years after adult spinal deformity (ASD) surgery remain poorly characterized. PURPOSE In patients undergoing ASD surgery, we sought to: 1) report the incidence of complications and reoperations beyond 2 years and 2) identify risk factors for late complications. STUDY DESIGN/SETTING Retrospective analysis of prospective multicenter study. PATIENT SAMPLE A retrospective cohort study (2009-18) was performed of patients who underwent ASD surgery. Patients undergoing ASD surgery with ≥5 years of follow-up were included. OUTCOME MEASURES Primary outcome was mechanical complication beyond 2-years, including proximal junctional kyphosis/failure (PJK/F), rod fracture, and pseudarthrosis, reoperation, and patient-reported outcomes at >2 years. Secondary analysis evaluated specific predictors of late-onset mechanical complications. Sagittal alignment parameters were evaluated as T4-L1 within 4°, or L1-pelvic angle (L1PA) within 5° of target [(0.5 × pelvic incidence)-21°]. METHODS Bivariate analyses were performed. RESULTS Of 664 patients with ≥5-year follow-up (age:59±15 years; 76% females), late mechanical complications occurred in 40 (6%) patients, and 35/40 (88%) required reoperation. The most common complications were rod fractures (58%), proximal junctional kyphosis (PJK) (28%) and pseudarthrosis (13%). A history of prior complications was not associated with late complications (3% vs 7%, p=0.230). Despite no significant predictors of late complications or reoperations, patients with T4-L1PA mismatch >4° trended towards a higher rate of PJF (1% vs 0%, p=0.060). Regarding ODI, patients with mechanical complications (35 vs 27, p=0.015) and T4-L1PA mismatch (30 vs 25, p=0.043) had a higher ODI at 3 years. Patients with late mechanical complications continued to have higher ODI at last follow-up (35 vs 27, p=0.019). CONCLUSIONS Mechanical complications occurring beyond 2 years after ASD surgery affected approximately 1 in 20 patients, and 88% of these cases required reoperation. T4–L1 PA mismatch may predispose patients to PJF during the 2-5-year postoperative period. Patients who experienced late mechanical complications demonstrated sustained functional impairment, reflected by persistently higher ODI scores. These findings underscore the importance of long-term follow-up beyond 2-years and ongoing monitoring to optimize outcomes. FDA Device/Drug Status This abstract does not discuss or include any applicable devices or drugs.

OBJECTIVE:Stand-alone lateral lumbar interbody fusion (SA-LLIF) without posterior instrumentation is increasingly being performed for various spine pathologies. There are few studies regarding clinical and radiographic outcomes in patients who underwent multilevel SA-LLIF. In this study, the authors aimed to explore these outcomes. METHODS:This is a retrospective review of patients who underwent multilevel SA-LLIF without posterior instrumentation between August 2017 and October 2021. Demographic information, comorbidities, and complications were collected. Clinical outcomes were measured using the Oswestry Disability Index (ODI) and visual analog scale (VAS). Spinopelvic parameters, subsidence rates, and repeat operations were recorded. RESULTS:Forty-three patients met the inclusion criteria. The mean age was 70.1 years, and 31 (72.1%) patients were male. The mean BMI was 28.2. Patients often had multiple indications for surgery, with 39 (90.7%), 28 (65.1%), and 9 (20.9%) patients undergoing surgery for adult spinal deformity, degenerative disc disease, and adjacent segment disease, respectively. The mean number of levels treated was 2.42 (range 2-4 levels, total 104 levels treated). The mean time to follow-up imaging was 2.01 years (range 30 days-4.95 years). There were significant differences in pre- and postoperative lumbar lordosis (LL) (+4.9°, p = 0.001), pelvic incidence-LL mismatch (-4.5°, p = 0.003), and segmental LL at treated levels (+4.0°, p = 0.002). Fifteen (35%) patients had coronal Cobb angles > 20° preoperatively; 11 (73%) showed improvement in Cobb angle postoperatively (mean change -5.4°, p = 0.02). Fifteen (35%) patients experienced grade 1 or higher subsidence at 23 of 104 (22%) levels. Five (12%) patients required repeat operations for failure of indirect decompression, progressive deformity, symptomatic subsidence, or a combination thereof. Three (7%) of these patients had symptomatic subsidence. Subsidence was more common in patients with polyetheretherketone implants (n = 13) versus titanium implants (n = 2) (p = 0.002). Significant improvements were seen in median (IQR) pre- and postoperative ODI (38 [28-48.5] vs 25 [17.5-38.5], p = 0.001), VAS back (7.0 [4.8-8.0] vs 3.5 [0.8-6.2], p = 0.002), and VAS leg (6.0 [2.5-8.0] vs 0.0 [0.0-4.2], p = 0.001) scores. CONCLUSIONS:In this small cohort, multilevel SA-LLIF was a safe and clinically effective surgical option for patients who required a shorter operative duration. Multilevel SA-LLIF had good clinical and radiographic outcomes but had a 7% reoperation rate for symptomatic subsidence. Further studies with longer clinical and radiographic follow-up are necessary to determine the durability of multilevel SA-LLIF.

OBJECTIVE:The substantial financial implications of minimally invasive surgery for adult spinal deformity (ASD) necessitate a thorough assessment of its inherent value and efficacy. Factors contributing to protracted cost-effectiveness (CE) have not been examined in the context of minimally invasive spine surgery (MIS) for ASD (MIS-ASD). Investigating these determinants can yield pivotal insight to optimize the efficacy of such surgical interventions while concurrently moderating associated expenditures. METHODS:MIS-ASD patients who underwent fusion > 2 levels with lateral lumbar interbody fusion or anterior lumbar interbody fusion and 4-year (4Y) follow-up were included. Published methods were used to determine the costs based on the Centers for Medicare & Medicaid Services definitions and average diagnosis-related group (DRG) reimbursement rates. Utility was calculated using quality-adjusted life years (QALYs), with a 3% discount applied for decline with life expectancy. Cost-utility (CU) was determined by dividing costs by total utility gained. Those who met CE at 4 years (CE4+) were evaluated relative to those who did not (CE4-). RESULTS:Eighty-six patients were included. Revision surgery occurred in 27% of patients. The overall mean cost was $73,000. CU at 4 years was $233,000, with 44% meeting CE4+ and a cumulative mean ± SD QALY gain of 0.8 ± 0.7. Among patients without revision, 54% met CE4+, while 76% met CE at life expectancy. There were no differences in length of stay, ICU admission rates, or time in ICU. Those with greater baseline disability (OR 1.1, p < 0.05) and frailty (OR 1.8, p < 0.05) had a higher likelihood of achieving CE4+. Lower comorbidity burden (i.e., lower Charlson Comorbidity Index score) was associated with increased odds of achieving CE4+ (OR 1.8, p < 0.05). Improved correction of pelvic incidence-lumbar lordosis mismatch was associated with achieving CE4+ (OR 3.8, p < 0.05). Those patients with major complications had 6× higher odds of failure to achieve CE4+, whereas those who underwent reoperation had 12× odds (both p < 0.05). CONCLUSIONS:MIS-ASD achieves CE in a significant subset of patients, particularly those with higher baseline disability, lower comorbidity burden, and better correction of spinal deformities. However, major complications and reoperations significantly hinder CE, underscoring the importance of optimizing patient selection and surgical techniques.

BACKGROUND CONTEXT Larger and more caudal lumbar pedicle subtraction osteotomies (PSOs) are associated with an increased risk of neurological deficits after adult spinal deformity (ASD) surgery. PURPOSE In patients undergoing lumbar PSO, we evaluated the impact of PSO level and size on postoperative motor deficits. STUDY DESIGN/SETTING Retrospective analysis of a prospective multicenter study. PATIENT SAMPLE Patients in a prospective multicenter database, including patients undergoing L2-L5 PSOs. Primary exposures were: 1) PSO level: upper lumbar (L2/3) and lower lumbar (L4/5), and 2) PSO size (angle). OUTCOME MEASURES Primary outcomes were new motor deficits. METHODS Bivariate and multivariable comparisons were performed, controlling for age, sex, body mass index, operative times, and a PSO level/size interaction term. RESULTS Of 162 patients undergoing L2-L5 PSOs, mean age was 63 years, and 66% were female. Overall rate of new motor deficits was 8.6%. Level 62.3% of PSOs were upper lumbar (L2/3), while 37.7% were lower lumbar (L4/5). PSO level was not significantly associated with development of new motor deficit (10.9% vs 4.9%, p=0.190). Size Mean PSO size was 29.8°±11.3°, with upper lumbar PSOs being significantly larger than lower lumbar PSOs (31.2°±10.6° vs 27.3°±12.1°, p=0.033). As a continuous variable, PSO size was not associated with new motor deficits (p>0.05). Interaction A larger, caudal PSO was independently associated with decreased odds of new motor deficits (OR 0.85, 95% CI 0.74-0.97, p=0.020). CONCLUSIONS In ASD patients undergoing lumbar PSO, neither osteotomy level nor size alone was associated with postoperative motor deficits. However, when accounting for the interaction between level and size, larger and lower (L4/L5) PSOs were significantly associated with a reduced likelihood of developing motor deficits. FDA Device/Drug Status This abstract does not discuss or include any applicable devices or drugs.

OBJECTIVE:The aim of this study was to assess whether the severity of systemic illness affects outcomes following surgery for grade 2 spondylolisthesis by using prospectively collected data from the Quality Outcomes Database (QOD) spondylolisthesis database. METHODS:This retrospective analysis of patients who underwent surgery for grade 2 degenerative lumbar spondylolisthesis used a prospective national longitudinal registry of data collected from 14 sites. The American Society of Anesthesiologists (ASA) physical classification system was used to assess systemic illness and compare patients categorized as ASA classes I and II with patients categorized as ASA classes III and IV. Baseline demographics, comorbidities, and clinical variables were collected for comparison. Primary outcomes were Oswestry Disability Index (ODI) and EQ-5D scores 3, 12, 24, and 60 months after surgery, and multiple linear regression was used to determine whether ASA class significantly predicted postoperative change in patient-reported outcome measures. RESULTS:Of the 328 patients in the grade 2 spondylolisthesis QOD cohort, 172 (52.4%) were categized as having a low ASA class (ASA class I or II) and 156 (47.6%) with a high ASA class (ASA class III or IV). There was a > 80% follow-up rate 5 years after surgery. Compared with patients in the low ASA class group, those in the high ASA class group were older (mean age 64.1 [SD 10.1] years vs 57.3 [SD 13.2] years, p < 0.001), had a higher BMI (mean 31.9 [SD 7.2] vs 28.8 [SD 5.9], p < 0.001), and had higher rates of comorbidities (diabetes, coronary artery disease, chronic obstructive pulmonary disease, and chronic kidney disease). The hospital length of stay and readmission rate did not differ significantly between the two groups. At baseline, ODI scores were significantly higher in the high ASA class group (mean 23.8 [SD 7.2] vs 21.5 [SD 8.3], p = 0.01), but there was not a significant difference in the ODI score 3, 12, 24, and 60 months after surgery. There were no significant differences in the mean EQ-5D score between the two groups at all time points. Multiple linear regression showed that ASA class was not a significant predictor of change in the ODI or EQ-5D score from baseline to 60 months postoperatively. CONCLUSIONS:Patients with higher systemic illness, categorized as ASA classes III or IV, had a higher baseline ODI score compared with those with low ASA classes (I or II), but had similar ODI scores 3, 12, 24, and 60 months postoperatively. There were no significant differences in the length of stay or readmission rate between groups. These findings suggest that patients with high ASA classes benefit from surgery for grade 2 spondylolisthesis and experience significant improvements in disability status.

OBJECTIVE:The objective of this study was to evaluate predictors of patient satisfaction following surgical treatment of Meyerding grade 2 lumbar spondylolisthesis. The authors hypothesized that postoperative improvements in patient-reported outcomes (PROs) would be the primary determinants of satisfaction. METHODS:Patients with grade 2 lumbar spondylolisthesis were identified from the Spine CORe™ study group of the Quality Outcomes Database, a multicenter consortium of 14 participating sites. This cohort comprises 328 patients with a 60-month follow-up rate of 81%. Demographic, clinical, and surgical characteristics were collected. PROs included the Oswestry Disability Index (ODI), numeric rating scale (NRS) for back (NRS-BP) and leg pain (NRS-LP), and EQ-5D, measured at baseline and at 60 months. The primary outcome was satisfaction at 60 months, assessed using the North American Spine Society patient satisfaction index. Satisfaction was defined as a score of 1 ("surgery met my expectations") or 2 ("I did not improve as much as I had hoped, but I would undergo the same surgery again"). Minimal clinically important difference (MCID) thresholds were ≥ 14.3 for the ODI, ≥ 0.2 for the EQ-5D, ≥ 1.7 for the NRS-LP, and ≥ 1.6 for the NRS-BP. Univariate comparisons and logistic regression were performed to identify predictors of satisfaction. RESULTS:A total of 328 patients underwent surgery for grade 2 spondylolisthesis. At 5 years, follow-up data was complete in 266 patients (81%). Of these patients, 25 died within 5 years of surgery of unrelated causes and 241 had complete satisfaction scores at 5 years. At 60 months, 208 of the 241 patients were satisfied with surgery. Baseline demographic, comorbidity, and operative characteristics were similar between groups. Lower rates of 90-day readmissions were observed in satisfied patients (1.6% vs 19.4% p < 0.001). At 60 months, satisfied patients reported lower mean NRS-BP (2.6 vs 5.3, p < 0.001), NRS-LP (2.3 vs 5.2, p < 0.001), and ODI scores (8.9 vs 19.5, p < 0.001). MCID achievement was higher in satisfied patients for NRS-BP (78.3% vs 54.5%, p = 0.008), NRS-LP (79.8% vs 54.5%, p = 0.003), ODI (53.4% vs 15.2%, p < 0.001), and EQ-5D (30.0% vs 3.0%, p < 0.001) scores. In multivariable analysis, greater 5-year improvements in ODI (OR 0.88, p = 0.010) and NRS-LP (OR 0.74, p = 0.010) scores, as well as lower baseline NRS-LP scores (OR 0.54, p = 0.001) were independently associated with higher odds of satisfaction. No baseline demographic, comorbidity, or surgical factor predicted satisfaction. CONCLUSIONS:Eighty-six percent of patients with grade 2 lumbar spondylolisthesis were satisfied with results 5 years after surgery. Satisfaction was primarily associated with improvements in disability (ODI), while baseline and perioperative characteristics were not predictive.

Aims:Proximal junctional kyphosis (PJK) remains a major complication after surgery for adult spinal deformity (ASD). While postoperative alignment is a recognized modifiable risk factor, objective methods for selecting the upper instrumented vertebra (UIV), a key modifiable factor, are lacking. We aimed to determine whether preoperative sagittal alignment, specifically cervicothoracic alignment, predicts the risk of PJK, and whether this risk can be mitigated by UIV selection, focusing on factors available at the time of surgical planning. Methods:From a multicentre, prospective ASD registry, we identified patients who had undergone fusion to the sacrum or pelvis and had an upper (T1-T5) or lower thoracic (T9-L1) UIV, with a two-year or more radiological follow-up, excluding those with a previous fusion over more than four levels. The primary outcome was PJK within two years. Multivariable logistic regression modelled the risk of PJK by UIV region, preoperative C2-T9 pelvic angle (PA), age, sex, and pelvic incidence, testing for interaction between UIV region and C2-T9 PA. Adjusted absolute risk reduction (ARR) and number needed to be exposed (NNEB) were calculated. Multivariable linear regression estimated two-year patient-reported outcome measures, adjusting for baseline scores, age, UIV, and PJK. Results:A total of 627 patients across 20 centres were included (median age 66 years (IQR 59 to 70); 483 (77%) female). The UIV was lower thoracic in 380 (61%) and upper thoracic in 247 (39%) patients. PJK occurred in 149 (39%) lower thoracic and 38 (15%) upper thoracic UIV patients. There was a significant interaction (p = 0.028) between preoperative C2-T9 PA and UIV region. At a preoperative C2-T9 PA of 14° (cohort median), an upper thoracic UIV had an adjusted ARR of 36% and NNEB was 2.8. Females had an adjusted odds ratio of 1.62 (95% CI 1.03 to 2.59; p = 0.042) for PJK. Conclusion:Worse preoperative sagittal malalignment, measured by C2-T9 PA, was associated with a higher risk of PJK and depended on UIV region. An upper thoracic UIV in patients with high preoperative C2-T9 PA may reduce PJK.

BACKGROUND AND OBJECTIVES: Physician rating websites (PRWs) are increasingly used by patients to find health care providers. This study explores spine neurosurgeon PRW ratings and their relationship with academic productivity. METHODS: A retrospective study was conducted from November 2022 to May 2023 that included 1990 neurological surgeons listed in the American Association of Neurological Surgeons database with a subspecialty in spine. Neurosurgeons were excluded if they had no reviews on Healthgrades or if no citation data were available on Scopus or Google Scholar. Surgeon demographic data were collected. Ratings and the number of reviewers were collected for Healthgrades, Vitals, Google reviews, and physician institutional websites. The h-index, number of publications, and number of citations were found on Scopus or Google Scholar. RESULTS: A total of 1031 spine neurosurgeons met the inclusion criteria (mean age [range], 61 [34-94] years; male sex, 996 of 1031 [96.6%]). The mean (SD) Healthgrades, Vitals, Google reviews, and institutional ratings were 4.08 (0.70), 4.06 (0.65), 4.34 (0.79), and 4.70 (0.25), respectively. Median (IQR) h-index, number of publications, and number of citations were 5.0 (1.0), 8.0 (26), and 205 (684), respectively. For all PRWs, the average PRW rating decreased as age increased. Academic productivity as measured by h-index, number of publications, and number of citations were not significantly associated with PRW rating. CONCLUSION: Overall, spine neurosurgeon ratings on PRWs were favorable. Ratings were found to decrease with increasing surgeon age, and academic productivity was not correlated with better ratings.