Kathleen Suzann Botterbush

BACKGROUND AND OBJECTIVES: Locum tenens refers to the professional activity of physicians who temporarily contract at hospitals or clinics to address staffing shortages, a practice that has grown substantially across all specialties, including neurosurgery, especially in the past few years due to events such as the COVID-19 pandemic. Neurosurgery carries one of the highest malpractice burdens of all medical specialties, yet no previous study has examined litigation specifically involving locum tenens neurosurgeons and spine surgeons. METHODS: A search of legal disputes (including malpractice claims and contract disputes) was performed in the legal database LexisNexis using terms related to neurosurgeons and spine surgeons acting as locum tenens or independent contractor physicians, with 2 independent reviewers screening all results. RESULTS: Of the 556 cases identified, 54 cases met the inclusion criteria, of which, 41 were malpractice, 8 were contract disputes, and 5 involved both. The cases spanned 27 states from 1980 to 2025. Defense verdicts comprised most outcomes (30/54, 55.6%), and the defense prevailed in 69% of cases where both a physician and hospital were named codefendants. Employment classification emerged as the most consequential legal variable regarding outcome of the litigation. When hospitals demonstrated a clear independent contractor status, they were frequently absolved of vicarious liability, shifting the legal burden toward the individual neurosurgeon. CONCLUSION: This is the first study to provide empirical data on the legal liability involving the practice of neurosurgery as locum tenens in the United States from 1980 to 2025. As locum tenens utilization continues to grow within neurosurgery, neurosurgeons must carefully review contracts, confirm malpractice coverage, and understand institutional liability frameworks before entering such a work model.

Grief is an under-recognized yet pervasive experience in neurosurgery, arising not only from the death of patients and loved ones but also from losses related to professional identity, health, and personal relationships. Despite its relevance, grief is often conflated with burnout or overlooked entirely within surgical culture. When personal adversity strikes, such as loss, illness, or major life upheaval, the intensity of neurosurgical practice can amplify these challenges, influencing professional identity, performance, and overall resilience. As the field continues to evolve and diversify, it is increasingly important to foster open dialogue about vulnerability, personal hardship, and life beyond the operating room. This perspective examines how neurosurgeons experience and process loss, distinguishing grief from burnout and resilience, and highlighting the need for institutional and cultural change.

BACKGROUND AND OBJECTIVES: Large Language Models (LLMs) are increasingly used by healthcare professionals and patients for medical information synthesis. Unfortunately, their tendency to generate fabricated information (“hallucinations”) poses a significant risk. This study quantifies and compares citation accuracy of 5 prominent LLMs for common neurosurgical spine topics. METHODS: Five LLMs (ChatGPT, Gemini, Claude, Microsoft Copilot, and OpenEvidence) were evaluated. Ten clinician-level questions derived from North American Spine Society guidelines were posed using a prompt instructing the LLM to act as an “ experienced spine surgeon .” Ten corresponding patient-level questions were posed using a “ patient ” persona prompt. Both prompts requested a concise answer and 3 to 5 peer-reviewed references. Each citation was manually verified and scored as 2 (accurate), 1 (real but misrepresented), or 0 (fabricated). RESULTS: Performance varied significantly across models and question types. OpenEvidence, which directly indexes PubMed and requires user verification as a healthcare professional, achieved perfect accuracy. Among general purpose LLMs, Claude demonstrated the highest accuracy (average score 1.67, 78.0% accurate citations). Gemini had the lowest accuracy (average score 0.97) and the highest rate of fabrications (26.2%). All general purpose LLMs performed worse on patient-level queries. ChatGPT's accuracy score dropped from 1.83 to 1.08 for patient questions while its fabrication rate increased from 2.1% to 20.0%. Error profiles differed by model. Copilot frequently misrepresented article metadata (55.1% score-1 citations) and cited non–peer-reviewed websites (31.6%), particularly for patient questions. CONCLUSION: General purpose LLMs exhibit substantial and variable citation errors when queried on spine surgery topics. Accuracy is substantially lower for patient-facing prompts, which often yield fabricated references or nonscientific sources. While specialized, access-restricted platforms such as OpenEvidence provide high accuracy, the performance of widely accessible models highlights the need for careful verification of all LLM-generated medical information to ensure patient safety.

Background: A 69-year-old male, who underwent a C5-T1 ACDF 5-years prior to arrival, presented with a ventral pharyngeal abscess and esophageal perforation warranting major gastro-esophageal surgery and instrumentation removal. Methods: The case of a patient who underwent a C5-T1 ACDF five years ago was reviewed. A review of past reports of cases of patients who experienced esophageal erosion or perforation following ACDF was conducted. Results: At the age of 69, the patient acutely developed disorientation/agitation and urinary/fecal incontinence. Lab studies showed leukocytosis, an elevated creatine phosphokinase (CPK), and lactic acidosis, while the EKG confirmed a non-ST-elevation myocardial infarction (NSTEMI) with increased troponins. An esophagram revealed esophageal perforation, and a prevertebral C5-C6 abscess, and neck/thoracic CT studies documented 8-9 mm anterior displacement of the right inferior C7 screw with extravasation extending inferiorly into the mediastinum. Surgery consisted of an esophagogastroduodenoscopy, gastric/jejunal tube placement, left neck exploration, and dissection of the esophagus off the anterior instrumentation that was subsequently removed. Despite emergent surgical intervention, the patient expired 5 days postoperatively. Conclusion: Neurosurgical follow-up is warranted in ACDF patients who newly present with findings indicative of with anterior retropharyngeal abscess or esophageal perforation.

Background: Depression is common in spine surgery candidates and may influence postoperative outcomes. Ecological momentary assessments (EMAs) can overcome limitations of existing depression screening methods (e.g., recall bias, inaccuracy of historical diagnoses) by longitudinally monitoring depression symptoms in daily life. In this study, we compared EMA-based depression assessment with retrospective self-report (a 9-item Patient Health Questionnaire [PHQ-9]) and chart-based depression diagnosis in lumbar spine surgery candidates. We further examined the associations of each depression assessment method with surgical outcomes. Methods: Adult patients undergoing lumbar spine surgery (n = 122) completed EMAs quantifying depressive symptoms up to 5 times daily for 3 weeks preoperatively. Correlations (rank-biserial or Spearman) among EMA means, a chart-based depression history, and 1-time preoperative depression surveys (PHQ-9 and Psychache Scale) were analyzed. Confirmatory factor analysis was used to categorize PHQ-9 questions as somatic or non-somatic; subscores were compared with a propensity score-matched general population cohort. The associations of each screening modality with 6-month surgical outcomes (pain, disability, physical function, pain interference) were analyzed with multivariable regression. Results: The association between EMA Depression scores and a depression history was weak (r_rb = 0.34 [95% confidence interval (CI), 0.14 to 0.52]). Moderate correlations with EMA-measured depression symptoms were observed for the PHQ-9 (r_s = 0.51 [95% CI, 0.37 to 0.63]) and the Psychache Scale (r_s = 0.68 [95% CI, 0.57 to 0.76]). Compared with the matched general population cohort, spine surgery candidates endorsed similar non-somatic symptoms but significantly greater somatic symptoms on the PHQ-9. EMA Depression scores had a stronger association with 6-month surgical outcomes than the other depression screening modalities did. Conclusions: A history of depression in the medical record is not a reliable indication of preoperative depression symptom severity. Cross-sectional depression assessments such as PHQ-9 have stronger associations with daily depression symptoms but may conflate somatic depression symptoms with spine-related disability. As an alternative to these methods, mobile health technology and EMAs provide an opportunity to collect real-time, longitudinal data on depression symptom severity, potentially improving prognostic accuracy. Level of Evidence: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND AND OBJECTIVES: Advanced diffusion-weighted MRI (DWI) modeling, such as diffusion tensor imaging (DTI) and diffusion basis spectrum imaging (DBSI), may help guide rehabilitation strategies after surgical decompression for cervical spondylotic myelopathy (CSM). Currently, however, postoperative DWI is difficult to interpret, owing to signal distortions from spinal instrumentation. Therefore, we examined the relationship between postoperative DTI/DBSI—extracted from the rostral C3 spinal level—and clinical outcome measures at 2-year follow-up after decompressive surgery for CSM. METHODS: Fifty patients with CSM underwent complete clinical and DWI evaluation—followed by DTI/DBSI analysis—at baseline and 2-year follow-up. Clinical outcomes included the modified Japanese Orthopedic Association score and comprehensive patient-reported outcomes. DTI metrics included apparent diffusion coefficient, fractional anisotropy, axial diffusivity, and radial diffusivity. DBSI metrics evaluated white matter tracts through fractional anisotropy, fiber fraction, axial diffusivity, and radial diffusivity as well as extra-axonal pathology through restricted and nonrestricted fraction. Cross-sectional Spearman's correlations were used to compare postoperative DTI/DBSI metrics with clinical outcomes. RESULTS: Twenty-seven patients with CSM, including 15, 7, and 5 with mild, moderate, and severe disease, respectively, possessed complete baseline and postoperative DWI scans. At 2-year follow-up, there were 10 significant correlations among postoperative DBSI metrics and postoperative clinical outcomes compared with 3 among postoperative DTI metrics. Of the 13 significant correlations, 7 involved the neck disability index (NDI). The strongest relationships were between DBSI axial diffusivity and NDI (r = 0.60, P < .001), DBSI fiber fraction and NDI (r_s = −0.58, P < .001), and DBSI restricted fraction and NDI (r_s = 0.56, P < .001). The weakest correlation was between DTI apparent diffusion coefficient and NDI (r = 0.35, P = .02). CONCLUSION: Quantitative measures of spinal cord microstructure after surgery correlate with postoperative neurofunctional status, quality of life, and pain/disability at 2 years after decompressive surgery for CSM. In particular, DBSI metrics may serve as meaningful biomarkers for postoperative disease severity for patients with CSM.

Cervical spinal cord injury (SCI) causes devastating loss of upper limb function and independence. Restoration of upper limb function can have a profound impact on independence and quality of life. In low-cervical SCI (level C5–C8), upper limb function can be restored via reinnervation strategies such as nerve transfer surgery. The translation of recovered upper limb motor function into functional independence in activities of daily living (ADLs), however, remains unknown in low cervical SCI (i.e., tetraplegia). The objective of this study was to evaluate the association of patterns in upper limb motor recovery with functional independence in ADLs. This will then inform prioritization of reinnervation strategies focused to maximize function in patients with tetraplegia. This retrospective study performed a secondary analysis of patients with low cervical (C5–C8) enrolled in the SCI Model Systems (SCIMS) database. Baseline neurological examinations and their association with functional independence in major ADLs—i.e., eating, bladder management, and transfers (bed/wheelchair/chair)—were evaluated. Motor functional recovery was defined as achieving motor strength, in modified research council (MRC) grade, of ≥ 3 /5 at one year from ≤ 2/5 at baseline. The association of motor function recovery with functional independence at one-year follow-up was compared in patients with recovered elbow flexion (C5), wrist extension (C6), elbow extension (C7), and finger flexion (C8). A multi-variable logistic regression analysis, adjusting for known factors influencing recovery after SCI, was performed to evaluate the impact of motor function at one year on a composite outcome of functional independence in major ADLs. Composite outcome was defined as functional independence measure score of 6 or higher (complete independence) in at least two domains among eating, bladder management, and transfers. Between 1992 and 2016, 1090 patients with low cervical SCI and complete neurological/functional measures were included. At baseline, 67% of patients had complete SCI and 33% had incomplete SCI. The majority of patients were dependent in eating, bladder management, and transfers. At one-year follow-up, the largest proportion of patients who recovered motor function in finger flexion (C8) and elbow extension (C7) gained independence in eating, bladder management, and transfers. In multi-variable analysis, patients who had recovered finger flexion (C8) or elbow extension (C7) had higher odds of gaining independence in a composite of major ADLs (odds ratio [OR] = 3.13 and OR = 2.87, respectively, p < 0.001). Age 60 years (OR = 0.44, p = 0.01), and complete SCI (OR = 0.43, p = 0.002) were associated with reduced odds of gaining independence in ADLs. After cervical SCI, finger flexion (C8) and elbow extension (C7) recovery translate into greater independence in eating, bladder management, and transfers. These results can be used to design individualized reinnervation plans to reanimate upper limb function and maximize independence in patients with low cervical SCI.

Pre-operative prediction of post-surgical recovery for patients is vital for clinical decision-making and personalized treatments, especially with lumbar spine surgery, where patients exhibit highly heterogeneous outcomes. Existing predictive tools mainly rely on traditional Patient-Reported Outcome Measures (PROMs), which fail to capture the long-term dynamics of patient conditions before the surgery. Moreover, existing studies focus on predicting a single surgical outcome. However, recovery from spine surgery is multi-dimensional, including multiple distinctive but interrelated outcomes, such as pain interference, physical function, and quality of recovery. In recent years, the emergence of smartphones and wearable devices has presented new opportunities to capture longitudinal and dynamic information regarding patients' conditions outside the hospital. This paper proposes a novel machine learning approach, Multi-Modal Multi-Task Learning (M3TL), using smartphones and wristbands to predict multiple surgical outcomes after lumbar spine surgeries. We formulate the prediction of pain interference, physical function, and quality of recovery as a multi-task learning (MTL) problem. We leverage multi-modal data to capture the static and dynamic characteristics of patients, including (1) traditional features from PROMs and Electronic Health Records (EHR), (2) Ecological Momentary Assessment (EMA) collected from smartphones, and (3) sensing data from wristbands. Moreover, we introduce new features derived from the correlation of EMA and wearable features measured within the same time frame, effectively enhancing predictive performance by capturing the interdependencies between the two data modalities. Our model interpretation uncovers the complementary nature of the different data modalities and their distinctive contributions toward multiple surgical outcomes. Furthermore, through individualized decision analysis, our model identifies personal high risk factors to aid clinical decision making and approach personalized treatments. In a clinical study involving 122 patients undergoing lumbar spine surgery, our M3TL model outperforms a diverse set of baseline methods in predictive performance, demonstrating the value of integrating multi-modal data and learning from multiple surgical outcomes. This work contributes to advancing personalized peri-operative care with accurate pre-operative predictions of multi-dimensional outcomes.

Study Design: Retrospective Case-Series. Objectives: Due to heterogeneity in previous studies, the effect of MI-TLIF on postoperative segmental lordosis (SL) and lumbar lordosis (LL) remains unclear. Therefore, we aim to identify radiographic factors associated with lordosis after surgery in a homogenous series of MI-TLIF patients. Methods: A single-center retrospective review identified consecutive patients who underwent single-level MI-TLIF for grade 1 degenerative spondylolisthesis from 2015-2020. All surgeries underwent unilateral facetectomies and a contralateral facet release with expandable interbody cages. PROs included the ODI and NRS-BP for low-back pain. Radiographic measures included SL, disc height, percent spondylolisthesis, cage positioning, LL, PI-LL mismatch, sacral-slope, and pelvic-tilt. Surgeries were considered “lordosing” if the change in postoperative SL was ≥ +4° and “kyphosing” if ≤ -4°. Predictors of change in SL/LL were evaluated using Pearson’s correlation and multivariable regression. Results: A total of 73 patients with an average follow-up of 22.5 (range 12-61) months were included. Patients experienced significant improvements in ODI (29% ± 22% improvement, P < .001) and NRS-BP (3.3 ± 3 point improvement, P < .001). There was a significant increase in mean SL (Δ3.43° ± 4.37°, P < .001) while LL (Δ0.17° ± 6.98°, P > .05) remained stable. Thirty-eight (52%) patients experienced lordosing MI-TLIFs, compared to 4 (5%) kyphosing and 31 (43%) neutral MI-TLIFs. A lower preoperative SL and more anterior cage placement were associated with the greatest improvement in SL (β = -.45° P = .001, β = 15.06° P < .001, respectively). Conclusions: In our series, the majority of patients experienced lordosing or neutral MI-TLIFs (n = 69, 95%). Preoperative radiographic alignment and anterior cage placement were significantly associated with target SL following MI-TLIF.