Spine surgery complications do not necessarily surface in the operating room. The conditions for breakdown are laid long before a patient ever reaches the table.
From the outside, the work looks straightforward: diagnose the problem, decide whether surgery is appropriate, operate and initiate recovery. Internally, however, the process is increasingly shaped by forces that have little to do with surgical judgment and everything to do with authorization, reimbursement and system design.
Sheeraz Qureshi, MD, co-chief of HSS Spine at New York City-based Hospital for Special Surgery and chief medical officer of West Palm Beach-based HSS Florida, sits at the intersection of it all.
He runs one of the busiest spine practices in the country while also operating in system leadership and business strategy roles — occupying a vantage point that makes the hidden pressures of spine care hard to ignore.
For most surgeons, he said, the biggest operational challenges begin well before a patient is ever scheduled.
“On the front end, it is getting harder and harder to get authorizations and approvals,” Dr. Qureshi said. “You’re fighting with insurance companies for simple things like imaging.”
That friction, he said, delays diagnosis and decision-making at the very moment clarity matters most. It also adds layers of administrative work that have quietly become part of routine spine care.
Once a patient is indicated for surgery, the difficulty only escalates.
“The challenges of getting surgery approved and authorized are unbelievably difficult right now,” he said. “We’re doing tons of peer-to-peers for simple things like laminectomy procedures for stenosis, things we’ve never really faced before.”
Those delays can push decisions to the last minute, contributing to same-day cancellations and operating room disruptions that ripple through already strained schedules.
What many people underestimate, Dr. Qureshi said, is how much infrastructure is required just to deliver a single operation.
“For the patient, it’s a one-to-one relationship: physician and patient,” he said. “But the operational challenges happening in the background just to take care of somebody are so numerous and involved at every part of the path.”
Without the right team and support systems in place, that burden can quickly snowball into professional dissatisfaction and burnout.
When innovation snarls economics
Advances in minimally invasive and motion-sparing techniques have expanded what spine surgeons can safely do in outpatient settings. Originally, that shift was in favor of patient recovery and efficiency, not reimbursement.
“For a long time, spine was seen as a cash cow for inpatient facility fee revenue,” Dr. Qureshi said. Minimally invasive techniques allowed some procedures to move safely out of the inpatient setting, whether to hospital outpatient departments or ASCs.
The intent, he emphasized, was never to make spine surgery uniformly ambulatory. “What payers have done is essentially say, ‘You’re doing more spine surgery in an ambulatory setting, so we’re just going to reimburse everything at a discount,’” he said.
That logic ignores how variable spine surgery actually is. At Dr. Quereshi’s institution, surgeons have developed a thoughtful, limited list of procedures appropriate for same-day discharge, a small subset of the dozens of operations that can be performed on the spine.
“Those probably represent seven or eight procedures out of about 50,” he said.
Insurers, however, often treat all 50 the same: “There are multilevel cervical and lumbar fusions where insurers are saying, ‘We’re only going to approve this as ambulatory.’ There’s no way that patient is going home.”
In those moments, the choice is not financial. It is clinical.
“As a surgeon and as a hospital, our duty and responsibility is to take care of our patients,” he said. “So we’re going to do it.”
The long-term concern, he said, is that spine surgery is becoming less financially viable, not because care is inappropriate, but because reimbursement no longer reflects complexity.
“It’s becoming less profitable, and the concern is that it could almost become a cost center,” he said.
That shift, he added, has implications far beyond individual practices. Historically, revenue from complex spine care helped support underinsured patients and emergency care. As margins erode, that balance becomes harder to sustain.
The danger of mistaking volume for value
When health systems evaluate spine programs, Dr. Qureshi said, they often make the mistake of focusing on volume as a proxy for value.
Spine surgery, he argued, is fundamentally different from more predictable orthopedic procedures.
“With a hip replacement, you have bad arthritis, you replace the hip, and the results are predictable,” he said. “In spine, there are often multiple pain drivers.”
Outcomes depend on careful patient selection, shared decision-making and honest assessment of risk — conversations that cannot be rushed or standardized without consequence.
“There are times when we don’t get it right,” he said. “Or we did everything we could, and it was just as good as it could get.”
When expectations are not set appropriately, patient dissatisfaction can follow, and with it, reputational and legal risk. That is why, he said, health systems should prioritize quality and ethics over sheer throughput when recruiting spine surgeons.
“Too many institutions continue to say, ‘Volume, volume, volume,’ whereas they should be saying, ‘Let me find the spine doctors that are of the highest quality and the most ethical.’”
Why leadership in spine is a team sport
For spine surgeons who want to shape system strategy, not just deliver strong clinical results, the most important leadership skill is a broad perspective, Dr. Qureshi said.
“The best outcomes come when you have a great multidisciplinary team,” he said, pointing to physiatry, neurology, pain management, physical therapy and rehabilitation.
That structure, he said, improves quality at scale and reduces unnecessary surgery by ensuring patients are routed to the right care at the right time.
“Spine, more than almost anything else, is a team sport,” he said. “Each facet is as important as another.”
