A spine operation can go exactly as planned. The patient leaves the hospital, avoids a readmission and looks good at six weeks. Aqib Zehri, MD, does not think this fact tells him whether the surgery was successful.
Dr. Zehri, a neurosurgeon practicing in Portland, Ore., specializes in complex and revision spine surgery, spinal deformity and minimally invasive techniques. He now follows fusion patients for one to two years, or until a durable fusion is confirmed, a practice he said was not emphasized as heavily during his training.
“A patient can technically have a successful operation and look well at six weeks, but we don’t know how they’ll be doing one or two years later,” Dr. Zehri told Becker’s.
During training, much of the focus was on selecting the right indications, performing the operation correctly and preventing short-term complications. Length of stay, readmissions and outcomes within the 90-day global period were, and still are, important measures. But for spinal fusion, Dr. Zehri believes they capture only part of the outcome.
What shows up a year later
Following patients for one or two years allows Dr. Zehri to see whether decisions made in the operating room hold up.
Construct length, screw density in scoliosis surgery, biologics and surgical technologies can all influence durability, he said. Longer follow-up gives him a way to evaluate those choices by what happens months and years later rather than by the immediate postoperative course alone.
It has also changed how he thinks about cost. Hospitals may face pressure to limit expensive implants, technologies and biologics. Dr. Zehri said the upfront price can tell an incomplete story if an investment contributes to a more durable result and helps avoid a revision.
That thinking has influenced his approach to deformity surgery. He has incorporated sacroiliac joint fusion into long-segment constructs in his practice and said he has seen favorable outcomes among those patients at one- and two-year follow-ups. He also uses biologics that he said have data supporting long-term fusion rates.
“It’s important to minimize revision rates in these patients,” Dr. Zehri said. “I think that’s more important and valuable than trying to lower costs upfront for these surgeries.” The calculation, in other words, does not end when the first operation does.
Defining success beyond the scan
Longer follow-up raises a more fundamental question: What does a successful spine operation actually look like? Dr. Zehri tracks pain scores, walking distance and whether patients have returned to activities they value. He also uses CT imaging when appropriate to assess fusion.
But he places greater weight on what patients report about their recovery. That distinction can be practical as well as philosophical. Insurance authorization can make postoperative CT scans difficult to obtain for some patients, he said, leaving clinical outcomes as another important measure of progress.
Dr. Zehri compares those results with preoperative data to examine what worked and what he might change. The value of follow-up, then, extends beyond the patient in front of him: What he learns from one operation can influence how he approaches the next.
“I think that as surgeons, we should constantly collect our own data and see what is working and what is not,” he said.
That continuous evaluation becomes increasingly important as surgeons are asked to deliver complex spine care at a sustainable cost.
One of Dr. Zehri’s answers has been standardization. He has worked to create consistent approaches to preoperative optimization, imaging and laboratory testing, operating room equipment, perioperative pain management, mobilization and follow-up.
The goal is not to make difficult surgery routine. It is to remove unnecessary variability from everything surrounding it. When the team already knows the protocols and their individual roles, less attention is spent solving routine logistical problems during the most demanding portions of a case.
“Spine surgery, like any other surgery, is a team sport,” Dr. Zehri said.
More technology, more emphasis on judgment
Over the next decade, Dr. Zehri expects AI, advanced imaging, navigation and robotics to assume a larger role in surgical planning and execution.
As technology takes on more repetitive tasks, he believes the surgeon’s most consequential responsibilities will remain patient selection and judgment: determining who should undergo surgery, which operation is appropriate and when to intervene.
AI and other technologies may make those decisions better informed, but Dr. Zehri does not see them replacing the surgeon who makes them.
That future is closely connected to what he has already learned by following patients longer. More data can reveal whether a construct endured. Imaging can show whether fusion occurred. Patient-reported outcomes can show whether life actually improved. None of those measures matters much, however, unless surgeons use what they learn to make the next decision better.
A successful spine operation, then, cannot be defined by what happens in the operating room alone, or even by an uncomplicated first 90 days.
For Dr. Zehri, the harder test comes later: whether the result lasts.
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