Mounting evidence suggests that both socioeconomic status (SES) and healthy lifestyle play beneficial roles in spine surgical outcomes. However, their combined influence on patient satisfaction remains insufficiently understood in patients with adult spinal deformity (ASD).To evaluate the association between SES and healthy lifestyle on patient satisfaction in patients undergoing corrective surgery.Retrospective review of a single-institution cohort.A total of 263 patients undergoing corrective surgery between January 2017 and November 2022.Completion of the North American Spine Society Satisfaction Questionnaire (NASS) questionnaire 2 year postoperatively.This was a retrospective review of patients who underwent primary thoracolumbar fusion surgery ≥ 4 spinal levels between January 2017 and November 2022 with a 2-year follow-up. SES was constructed by latent class analysis using education level, total household income and wealth. An Overall healthy lifestyle was identified using information on the top tertile of physical activity, active social contact and appropriate body mass index (BMI) at the 2-year follow-up based on well-organized questionnaire. A mediation effect analysis was performed to explore whether healthy lifestyle mediated the association between SES and patient dissatisfaction. Additionally, a joint analysis of SES and healthy lifestyle with patient dissatisfaction was investigated.Among 263 patients included in the final analysis, 68 (25.8%) had high SES, 134 (51.0%) had medium SES and 61 (23.2%) had low SES. Compared with patients with high SES, the odds ratio (OR) for dissatisfaction among patients with medium and low SES were 1.32 [95% confidence interval (CI), 1.06-1.76) and 3.01 (95%CI 1.79-4.46), respectively, and the proportion of dissatisfaction mediated by healthy lifestyle was 11.3% (7.9%-25.8%) for patients with medium SES and 17.1% (8.6%-21.9%) for those with low SES. The combined effect of low SES and unhealthy lifestyle showed a progressive increase in the risk of dissatisfaction. Compared with patients with high SES and healthy lifestyle, those with low SES and unhealthy lifestyle had a higher risk of dissatisfaction, with an OR of 3.37 (95% CI 2.74-5.17).While healthy lifestyle factors partially mediate the association between SES and patient satisfaction, broader measures beyond lifestyle interventions may be necessary to address disparities in surgical outcomes. These findings underscore the importance of integrating socioeconomic considerations into clinical strategies to improve outcomes for patients with ASD.Copyright © 2025 Elsevier Inc. All rights reserved.