To our knowledge, this is the first international study to assess physician-perceived challenges and benefits of telemedicine in spine surgery. Based on our survey, we found that telemedicine provides significant advantages in the current socially distanced environment. Recent evidence suggests that spine telemedicine is feasible [5, 11, 14], but there are doubts about whether telemedicine will continue to be a viable option once shelter-in-place demands subside due to provider preferences and patient demand . We found that 95.4% of our respondents required one in-person visit prior to surgery and overwhelmingly favored in-person visits, echoing the concerns over whether clinicians will continue to offer telemedicine in the future. Our results provide insight into the pros and cons of telemedicine, which we hope will aid payers, hospital systems, administrators, researchers, and surgeons in determining whether and how to best integrate effective telehealth care after the pandemic.
Prior to COVID-19, it was thought that factors hindering mass adoption of telemedicine in spine surgery included unfamiliar learning curves, large technology costs, reimbursement difficulty, increased liability, and difficulty performing virtual physical examinations . Our results showed that the most substantial challenge was the decreased ability to perform the physical examination, with nearly 40% of respondents highlighting this issue. Recent manuscripts have sought to address this challenge by publishing guidelines how to conduct effective virtual spine examinations [13, 16]. Additionally, efforts to enhance the telemedicine appointment—such as providing instructions for patients prior to the visit on camera/body positioning, clothing, and setting—have shown to increase telemedicine efficiency [17, 18]. While this inability to perform physical examinations was a major challenge faced by spine surgeons around the world, it is also interesting to note that 61.4% of survey respondents did not acknowledge the lack of physical examination to be a major challenge.
Regulatory frameworks had been confusing and rapidly changing at the outset of the pandemic. According to our survey, 10–20% of spine surgeons worried about increased medicolegal exposure or reimbursement parity. However, as time has elapsed, policies and laws around telemedicine have become more clear and standardized as more providers have shifted toward telemedicine [10, 19]. Additional guidelines and regulations are necessary as the field continues to evolve, as some of these in existence have only been temporary for the duration of the COVID-19 pandemic . Notably, few providers had issues with technology—less than 9.0% of respondents noted problems with Internet, computers, or phones. However, patients appeared to struggle more frequently; 24.1% of surgeons reported that patient “lack of technological literacy” was an issue. While some studies have found that technology is a significant barrier to the telemedicine clinical workflow , others have found strikingly high success rates; Eichberg et al.  analysis of 52 neurosurgery studies found that telemedicine was successful in an astonishing 99.6% of cases. Moreover, with the increasing integration of telemedicine into EMR systems, proper training, and standardization of practices, technological difficulties may not be a major hindrance to effective spine telemedicine use.
Our survey suggests that spine surgeons believed that telemedicine carried certain benefits. Providers agreed that telemedicine can provide societal cost savings, consistent with cost analyses showing telemedicine can increase savings and decrease the need for unnecessary travel [23, 24]. Additionally, respondents agreed that telemedicine can enhance access to care for patients—for example those living in rural, developing, or resource-limited areas . Interestingly, while surgeons slightly agreed that telemedicine increases patient and provider convenience, they were neutral to the statement that telemedicine increases patient satisfaction. Many studies have shown that telemedicine satisfaction is comparable to and sometimes exceeds that of in-person visits [22, 26, 27]. However, our data suggest that spine surgeons may not hold this view.
Prior telemedicine studies also examined the benefits of facilitating simultaneous communication between the patient and multiple providers during visits . However, our study showed that few spine surgeons had other physicians (17.1%) or trainees (22.0%) present during telemedicine visits, signifying that the majority of providers are not utilizing this proposed advantage (Fig. 2). The feasibility of the multidisciplinary examination (providing simultaneous provider perspectives—general practitioner, surgeon, etc.) is clearly improved with virtual consults; however, improved coordination and collaborative logistics are necessary to integrate such visits into routine clinical care. Additionally, in the future, it may be important for more surgeons to consider including trainees to teach new surgeons how to properly provide telemedicine visits.
Regional and respondent variation
North American providers encountered the most challenges, but also were the most optimistic about benefits. A multitude of North American studies has noted physical examinations, reimbursement parity, and unclear billing codes as barriers for telemedicine, but also has noted the potential benefits of increased patient/provider convenience and patient satisfaction [3, 8]; our study echoed this duality, underscoring the importance of addressing the shortcomings of telemedicine to sustain adoption. On the other hand, African respondents tended to downplay both challenges (billing codes, physical examination) and benefits (patient satisfaction/provider convenience). These providers may have a different perspective on telemedicine, prioritizing expansion of health access in rural settings and dealing with more underdeveloped settings [25, 29].
Although older individuals may be expected to experience more troubles with telemedicine , our study noted no differences in responses based on age-group. Providers who used audio-visual versus audio-only telemedicine had better opinions of telemedicine, understandably because the video component adds personalization and the ability to observe the patient. Surgeons that performed more visits (> 50 vs. ≤ 50) tended to also have higher opinions of telemedicine, noting fewer Internet and payment issues and appreciating the convenience of virtual visits more—reinforcing the idea that the more visits one performs, the more comfortable one becomes .
Our study represents an international perspective on the benefits and challenges of telemedicine. However, it has limitations inherent in a survey study. Approximately 12.5% of surgeons who were emailed responded, and because every question was optional, not every response had an answer. Additionally, each of the challenges and benefits were assessed from the provider perspective, as no patients were included in the survey. Finally, AO Spine may not be representative of all spine surgeons, either in its global or regional membership. Despite these limitations, 485 surgeons across the world responded to our survey, making this the largest international survey of spine surgeons that addressed the topic of telemedicine.