At The Oregon Clinic in Portland, neurosurgeon Aqib Zehri, MD, is building a high-acuity spine program with a premise that runs counter to much of modern healthcare: the operating room is not where spine care begins.
His practice spans the full continuum, from minimally invasive and endoscopic techniques to spinal oncology and complex deformity surgery, much of it performed at Providence St. Vincent Medical Center. But the defining feature of his approach is not technical range. It is restraint.
Before any surgical plan takes shape, the central question is more fundamental: should this patient have surgery at all?
“Having access to spine care is the most important point that I want to make about improving spine care overall,” Dr. Zehri said.
In a system still shaped by procedural volume, that philosophy is quietly disruptive.
Redesigning the front door of spine care
Much of the inefficiency in spine care, Dr. Zehri believes, begins long before a patient reaches a surgeon. Referrals often arrive too early, too late or without the foundational work needed to make surgical decisions.
To address that, his team has rebuilt the intake process around structured triage. Patients are guided through a standardized screening, supported in part by AI, that assesses whether they have exhausted nonoperative treatments such as physical therapy, chiropractic care and injections. It also captures key risk factors, including BMI and smoking status, that can directly affect outcomes.
“We can easily screen patients who have done nonoperative treatments, and then they can be adequately triaged to see us in clinic, or they can refer back to their primary care doctor,” Dr. Zehri said.
The result is a more disciplined pipeline: patients who arrive for surgical evaluation are more likely to need it, and more likely to be optimized if they do.
Just as importantly, the model shifts accountability upstream, asking referring providers to play a more active role in preparing patients before escalation.
The tradeoff between access and complexity
As access improves, another challenge emerges: complexity rises with it. “The biggest challenge I’m seeing is balancing timely access with increasing case complexity,” Dr. Zehri said.
Programs that succeed in attracting referrals, particularly from other surgeons or institutions, often see a disproportionate share of high-acuity patients. These cases require more time, coordination and resources, placing new demands on both clinical teams and infrastructure.
Dr. Zehri’s response has been to standardize the patient journey without oversimplifying the care itself. From clinic intake to preoperative optimization, surgery, postoperative coordination and the critical first three months of recovery, patients move through a structured pathway designed to reduce variability.
Efficiency, in this context, is not speed. It is coherence.
Reframing the minimally invasive debate
Few areas of spine surgery have generated as much momentum, and misunderstanding, as minimally invasive techniques. For Dr. Zehri, the conversation has become too focused on the tools themselves, rather than the outcomes they are meant to achieve. “It’s not necessarily about the surgical technique,” he said. “It’s all about how to improve outcomes, how to make a spine program sustainable.”
Minimally invasive approaches can reduce blood loss, shorten operative time and accelerate recovery. In many cases, they also lower the overall cost of care. But they are not universally appropriate, and applying them indiscriminately can create new inefficiencies.
“There just needs to be a fine balance,” Dr. Zehri said, “between what’s most effective in treating the patient, but also not putting every patient in a single category.”
In practice, that means aligning surgical approach with pathology, not trend, and resisting the impulse to standardize where nuance is required.
The growing importance of preoperative discipline
If there is a quiet shift underway in spine surgery, it may be happening before the first incision. Dr. Zehri points to a growing emphasis on detailed preoperative planning, not just identifying pathology, but mapping spinal alignment, selecting implants in advance and anticipating the full trajectory of the procedure.
“I think we need to go in with a clear understanding of the implants and biologics we plan to use, and make sure they’re cost-conscious as well,” he said.
This level of preparation reflects a broader reality: sustainability in spine care increasingly depends on precision, clinical and financial. Using the right resources, in the right cases, at the right time is no longer just good practice. It is a necessity.
Building a system, not just a practice
Underlying each of these changes is a larger transformation. Spine care, once defined by individual surgeons, is becoming increasingly system-driven. For Dr. Zehri, that means tighter alignment across disciplines, from primary care and physical therapy to anesthesia, ICU teams and hospital operations, as well as stronger communication between clinic and hospital settings.
“It’s important to have collaboration across multiple disciplines to improve safety and ensure better outcomes,” he said. That coordination is not incidental. It is built through workflows, relationships and shared expectations around quality and accountability.
Looking ahead
Despite the pressures facing healthcare, Dr. Zehri is optimistic about the future of spine care. Demand continues to grow as patients live longer, remain active later in life and expect higher quality of life. At the same time, the field is evolving, technically and operationally, in how care is delivered.
“The need for spine care isn’t going anywhere,” he said.
The opportunity ahead, he suggests, lies in bringing greater consistency, efficiency and intentionality to that care, without compromising standards.
In spine surgery’s next chapter, the differentiator may not be who operates the most, but who knows when not to operate at all.
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