Appropriate Telemedicine Utilization in Spine Surgery

Results From a Delphi Study

Sravisht Iyer, MD; Patawut Bovonratwet, MD; Dino Samartzis, DSc; Andrew J. Schoenfeld, MD, MSc; Howard S. An, MD; Waleed Awwad, MD; Scott L. Blumenthal, MD; Jason P.Y. Cheung, MBBS; Peter B. Derman, MD, MBA; Mohammad El-Sharkawi, MD; Brett A. Freedman, MD; Roger Hartl, MD; James D. Kang, MD; Han Jo Kim, MD; Philip K. Louie, MD; Steven C. Ludwig, MD; Marko H. Neva, MD, PhD; Martin H. Pham, MD; Frank M. Phillips, MD; Sheeraz A. Qureshi, MD, MBA; Kris E. Radcliff, MD; K. Daniel Riew, MD; Harvinder S. Sandhu, MD; Daniel M. Sciubba, MD; Rajiv K. Sethi, MD; Marcelo Valacco, MD; Hasan A. Zaidi, MD; Corinna C. Zygourakis, MD; Melvin C. Makhni, MD, MBA


Spine. 2022;47(8):583-590. 

In This Article

Abstract and Introduction


Study Design: Delphi expert panel consensus.

Objective: To obtain expert consensus on best practices for appropriate telemedicine utilization in spine surgery.

Summary of Background Data: Several studies have shown high patient satisfaction associated with telemedicine during the COVID-19 peak pandemic period as well as after easing of restrictions. As this technology will most likely continue to be employed, there is a need to define appropriate utilization.

Methods: An expert panel consisting of 27 spine surgeons from various countries was assembled in February 2021. A two-round consensus-based Delphi method was used to generate consensus statements on various aspects of telemedicine (separated as video visits or audio visits) including themes, such as patient location and impact of patient diagnosis, on assessment of new patients. Topics with ≥75% agreement were categorized as having achieved a consensus.

Results: The expert panel reviewed a total of 59 statements. Of these, 32 achieved consensus. The panel had consensus that video visits could be utilized regardless of patient location and that video visits are appropriate for evaluating as well as indicating for surgery multiple common spine pathologies, such as lumbar stenosis, lumbar radiculopathy, and cervical radiculopathy. Finally, the panel had consensus that video visits could be appropriate for a variety of visit types including early, midterm, longer term postoperative follow-up, follow-up for imaging review, and follow-up after an intervention (i.e., physical therapy, injection).

Conclusion: Although telemedicine was initially introduced out of necessity, this technology most likely will remain due to evidence of high patient satisfaction and significant cost savings. This study was able to provide a framework for appropriate telemedicine utilization in spine surgery from a panel of experts. However, several questions remain for future research, such as whether or not an in-person consultation is necessary prior to surgery and which physical exam maneuvers are appropriate for telemedicine.

Level of Evidence: 4


The COVID-19 pandemic introduced the necessity for remote work in a variety of occupational settings including orthopedic surgery.[1–4] Spine care similarly witnessed a rapid increase in utilization of telemedicine,[5] with usage rising from <10% to approximately 40% of all visits, with the greatest adoption in North America.[1] These telemedicine encounters comprised of various types including audio only or video-based visits.[1] Other than aiding physical distancing efforts, other reported benefits of telemedicine include providing greater access to care for patients and decreasing healthcare costs.[6,7]

In the United States, the adoption of telemedicine was aided greatly by several waivers granted by the Centers for Medicare and Medicaid Services and subsequently adopted by a majority of private payers. These allowed remote care to be practiced across state lines and improved coverage for telehealth phone and video services.[8] While the majority of these waivers were issued on a temporary basis, the use of telehealth has proven to be popular with patients and providers, including those within the field of spine surgery.[1–3] Spine patients have generally been very satisfied with telemedicine visits and have rated them highly for the clarity of communication, formulation of treatment plans, and the ability to ask questions.[9–11]

Due to such rapid introduction of the technology as well as changing medical, political, and legal landscapes, several uncertainties surrounding the optimal utilization of telemedicine in spine surgery persist.[12] Previous studies have shown considerable differences in the definition of telemedicine across geographic regions (e.g., telephone visits vs. video visits).[3] Such variation has contributed to regulatory and clinical uncertainties and inconsistencies. For example, which visit types are appropriate for telemedicine? Should patients be seen in person prior to surgery? Therefore, the purpose of the current study was to use a consensus-based Delphi method surveying a panel of spine surgery experts to attempt to achieve agreement on these and other important practical considerations regarding best practices in telemedicine utilization for spine surgery. We believe that a consensus obtained from spine surgery experts could serve as a framework for appropriate telemedicine use criteria in other sub-specialties in orthopedic surgery as well as a basis for policy change for telemedicine utilization in regions or countries where such practice has yet to be adopted.