Henry Knox, MS¹; John Schwartz, MD²; Gabrielle Aluisio, MBA¹; Ciara Ostrander, BS³; Philip Zitser, BS⁴; Brendan Jones, BGS⁵; Ciara Ostrander, BS³; Keziah Crossley, MS⁶; Ashwathy Cini, BS³
1Edward Via College of Osteopathic Medicine – Carolinas Campus
2Valley Consortium for Medical Education
3Touro College of Osteopathic Medicine – Middletown
4New York Institute of Technology College of Osteopathic Medicine, Old Westbury, NY
5Kansas City University
6SUNY Upstate Medical University

Abstract

Introduction
Spine surgery addresses a wide range of degenerative, traumatic, and deformity-related conditions. Postoperative care is critical to outcomes but challenged by complications, adherence barriers, and limited access. Telemedicine, rapidly expanded during the COVID-19 pandemic, has demonstrated feasibility across surgical specialties and offers a potential solution to improve access, reduce follow-up barriers, and enhance recovery. However, its role in spine surgery follow-up remains incompletely defined.

Methods
A systematic review was conducted of PubMed, Embase, Scopus, Cochrane Library, and Google Scholar (2000–2025) to identify English-language studies evaluating telemedicine interventions in spine surgery care. Eligible designs included randomized controlled trials, cohort studies, case series, and systematic reviews. Primary outcomes included surgical site infections (SSI), readmissions, reoperations, and adherence. Secondary outcomes included emergency utilization and patient satisfaction. Data were extracted and synthesized narratively. Two reviewers independently screened and extracted data, resolving discrepancies by consensus.

Results
In spine-specific cohorts, no differences were found in operative complications, reoperations, or six-month readmissions. Improved functional outcomes were reported with telemedicine patients showing greater Functional Independence Measure (FIM) score gains. Patient satisfaction was consistently high, with most spine patients reporting satisfaction. However, only a majority of patients preferred telemedicine for follow-up. Video-based encounters were rated significantly higher than audio-only visits. Integration of digital tools, including wearable accelerometers and mobile health applications, enhanced adherence, enabled early complication detection, and demonstrated a high retention rate with preliminary improvements in pain and disability scores. Reported barriers included the inability to conduct comprehensive neurological examinations, socioeconomic disparities, limited digital literacy, and variability in institutional protocols.

Conclusion
Collectively, the current literature warrants a conservative interpretation, when inspecting the promise of telemedicine in both preoperative and postoperative spinal care. Despite increasing utilization, challenges remain, including physical exam limitations, disparities in digital access, and heterogeneity in study design. While early findings suggest telemedicine outcomes comparable to traditional care, larger multicenter trials with adequate power are required to clarify timing, implementation, and patient selection, and to establish evidence-based recommendations for broader adoption.

Keywords: Spine surgery, telemedicine, telehealth, postoperative management, postoperative outcomes  

Introduction
Spine surgery indications span a wide spectrum of spinal pathologies, including herniated intervertebral discs, degenerative disc disease, fractures, spinal stenosis, spondylolisthesis, and spinal deformities. The burden of spine disease is large. Degenerative lumbar disease affects an estimated 266 million elderly individuals globally, and over 4.8 million spine surgeries are performed annually worldwide [1,2]. While surgical interventions can yield functional and symptomatic improvements when well indicated, postoperative care remains a critical determinant of long-term outcomes. Complications such as persistent postoperative pain, surgical site infections (SSI), hospital readmissions, and reoperations are not uncommon and can be influenced by inadequate follow-up, poor adherence to rehabilitation protocols, and loss to follow-up.

Over the past decade, telemedicine has emerged as a transformative tool in healthcare delivery, gaining particular traction during the COVID-19 pandemic when in-person visits were limited [3]. Telehealth has since become a routine component of chronic disease management and acute care follow-up in fields such as stroke neurology, cardiology, and oncology. Despite this shift, its integration into surgical specialties, particularly spine surgery, remains underexplored. While early studies in other surgical fields suggest comparable outcomes with telemedicine-based postoperative follow-up, the translation of these findings to the unique demands of spine surgery is not straightforward. 

Given the rising demand for spine surgery and the logistical challenges associated with postoperative follow-up, including travel burden, time constraints, and resource allocation, telemedicine offers a potentially efficient and patient-centered solution [4]. This systematic review aims to compare outcomes between in-person and telemedicine follow-up after spine surgery, with an emphasis on clinical endpoints such as complication rates, emergency visits, and readmissions, as well as measures of patient adherence and satisfaction. Additionally, the review explores the utility of digital tools—including wearable technologies and mobile health applications—in enhancing remote postoperative monitoring and promoting patient engagement.

Methods
A comprehensive literature search was conducted using the following databases: Pubmed, Scopus, Embase, Cochrane Library, and Google Scholar. The search identified studies evaluating the use of telemedicine in spine surgery, with an emphasis on the postoperative period. Search terms included combinations of keywords and Boolean operators, such as: “telemedicine AND spine surgery” “telehealth AND postoperative outcomes” “virtual care AND spinal fusion” “remote monitoring AND postoperative complications” “infection rates AND telehealth” “postoperative follow-up AND telemedicine” “video visit OR phone visit AND spine”. These terms attempted to capture telemedicine implementation in spine surgery recovery, including direct comparisons to in-person follow-up and assessments of clinical outcomes, patient adherence, and satisfaction. Studies published between 2000 and 2025 were included to reflect the increased adoption of telemedicine, especially in the post-COVID-19 era. Only peer-reviewed studies published in English were considered.

Eligible studies addressed postoperative care in spine surgery or other relevant surgical specialties where telehealth interventions were analogous and described the use of telemedicine in the study. These studies also reported on at least one or more of the following outcomes: clinical outcomes pertaining to surgical site infections, emergency room visits, readmissions or reoperations, comparative analysis between in-person and telemedicine follow-up, patient adherence to postoperative instructions, and measures of patient engagement or satisfaction.

Study types included randomized controlled trials, prospective and retrospective cohort studies, systematic reviews, meta-analysis, observational studies, and case series limited to the context of spine surgery. Studies were excluded if they focused on non-spine surgeries, did not involve a postoperative follow-up period, were non-human studies, consisted of commentaries, editorials or conference abstracts, or those that were not peer-reviewed or published in English. 

For each study, the data extracted included: study design, type of surgery, follow-up modality, duration of follow-up, and various outcomes SSI rates, emergency room visits, readmissions, reoperations, adherence to treatment, and patient satisfaction. Studies were categorized based on key outcomes and a results table was created to summarize and compare studies based on these outcomes. Narrative synthesis highlighted recurring themes including variability in telemedicine implementation, clinical effectiveness of telemedicine follow-up, patient satisfaction and engagement with virtual care.

Results

Clinical Outcomes and Implications 
The 2020 COVID-19 pandemic expedited the advancement of telemedicine in all facets of surgical care delivery including preoperative consultations. Garg and Walecha et al. performed a cross-sectional study during the COVID-19 pandemic, surveying a total of 6,306 patients who used telemedicine to minimize viral transmission in order to assess satisfaction and analyze the influence of telemedicine [5]. Statistically significant clinical endpoints reported were emergency department utilization (P= 0.000714), readmission rates (P= 0.00001) and medication adherence (P=0.000781), underscoring effective implementation of telehealth. Since the COVID-19 pandemic, the widespread adoption of telemedicine has radically changed the method of patient intake, highlighting a potentially sustainable way to efficiently practice medicine in versatile settings. 

Greven and McGinley et al. conducted a retrospective study comparing 138 telemedicine preoperative spine consults with 138 in-person controls at Emory Spine Center. Comparison between telemedicine pre-op and historical pre-op groups was made by collecting data on type of surgery, spine segment, age, sex, body mass index (BMI), American Society of Anesthesiology (ASA) score, comorbidities, and changes in Visual Analogue Scale (VAS) scores before and after the procedure. Virtual preoperative assessments in 138 spine surgery patients showed no statistical difference in objective measures such as surgical time, estimated blood loss and length of stay compared to historical in-person controls [6]. Additionally, there was no significant increased risk for intraoperative complications, with reported values of 0.7% for telemedicine pre-op and 1.4% for in-person pre-op visits, with P-value of 0.558. Additionally, this study reports a trend of increased readmission within six months of operation in the telemedicine pre-op group, but this did not reach statistical significance (P= 0.091). Furthermore, the study was powered to detect a difference in mean change in VAS score of 1.5 points or larger between the two groups. Although the telemedicine group had a slightly higher preoperative VAS score than the in-person group (6.2 ± 2.6 vs. 5.4 ± 2.8, P = 0.017), this 0.8-point difference is below both the pre-specified 1.5-point threshold and the 20% change considered clinically meaningful, suggesting it is unlikely to be of clinical significance [6]. There were no significant differences between intraoperative complication rates (0.7% telemedicine preop vs 1.4% in-person preop, P=0.558), reoperation rates within 6 months (7.9% vs 4.3%, P= 0.208), or readmission rates within 6 months postoperatively (10.1% vs 5.1%, P= 0.091) [6].  Since the study showed no significant differences in operative complications, readmission rates or reoperation rates between the telemedicine and in-person groups, telemedicine surgical evaluation may not increase the risk of complications or reoperation based on preliminary data. 

A multicenter randomized controlled trial by Dallolio and Menarini et al. compared the number of complications and readmissions of in-person versus telemedicine postoperative follow up for spinal surgery patients. Across 4 spinal cord units, a total of 137 participants were recruited who sustained spinal cord injury (SCI); 62 received telemedicine follow-up and 65 participants received in-person follow up. Over a 6 month period, there were 4 readmissions to the spinal cord unit from the control group and 1 in the telemedicine group, although this did not prove statistically significant (P= 0.19) [7]. The Functional Independence Measure (FIM) and Spinal Cord Independence Measure (SCIM) are two assessment scales used to objectively measure improvement postoperatively. At month six postoperative follow up, data revealed a significantly higher gain in FIM scores among the telemedicine group at the Italian spinal center. The difference in mean total FIM gain was 4.31 (95% CI, 1.27–7.35; t test=–2.84, df=56, P<.05), and the difference in mean FIM motor gain was 4.31 (95% CI, 1.24–7.38; t test=2.81, df=56, P<.05) [7]. These findings suggest that telemedicine may be a safe alternative for postoperative follow-up in spinal surgery patients, although larger, adequately powered studies are necessary to confirm its impact on complication and readmission rates. 

Totala and Janu et al. evaluated the role and success rate of spinal surgery telemedicine follow-up consultations among 84 patients, reporting that success rates were higher in patients from high socioeconomic status. In an attempt to overcome barriers in patient health literacy, the provider gave each patient a dermatomal pain diagram at the time of surgery and demonstrated the exam technique at the time of the call to assess sensation and pain. Unsuccessful consultations were often due to lack of device ownership or poor internet connectivity, exacerbating the financial and geographical disparities of various demographics. This study was conducted in India where telemedicine is being explored as a potential solution to mitigate physician shortages and improve access to care in underserved rural regions [4]. These findings indicate that remote consultation may not be suitable for all patients, especially those without access to technology. It has been shown that both providers and patients have had broadly positive experiences, however the in-person neurological examination is the gold standard for optimal care [8]. Furthermore, an in-person physical exam is vital to detect deficits in sensory function, nociception and motor strength indicative of acute spinal pathologies.

The prevalence of surgical site infections (SSI) is another important aspect of clinical outcomes. A previous multicenter cohort study including 15,358 patients undergoing abdominal surgery found frequently that there is not an increase in SSI or reoperations when comparing telemedicine follow up between in-person visits (telemedicine 11.1% vs in-person 13.4% and adjusted odds ratio= 0.73, 95% CI: 0.63-0.84, p<.001), suggesting it may even marginally decrease SSI [9]. The same paper included results from a meta-analysis of 9 nonrandomized studies which found that patients who had follow-up visits through telemedicine were about one-third less likely to develop surgical site infections compared to those seen in person (odds ratio 0.67, meaning a 33% lower risk; confidence interval 0.47–0.94). The results were consistent across the studies (I² = 45%, P = 0.12) [9]. While this data was drawn from abdominal surgery patients, the findings are relevant to spin surgery, where SSI remains one of the most feared complications due to its association with reoperation, prolonged antibiotic use, and significant morbidity. 

Telehealth has allowed patients undergoing spine and orthopedic surgery to prepare for surgery, adhere to their rehabilitation protocols, and decrease recovery times with real-time monitoring of patients and aimed behavior change strategies [10]. Examples include message reminders to increase physical activity. Such behaviors have increasingly been shown to improve post-operative outcomes for wound healing. In addition, digital interventions for behavior change have preliminarily been found to improve physical function, reduce pain and anxiety, reduce smoking and promote physical and mental health post spine surgery. These behaviors have been increasingly shown to improve postoperative outcomes such as better bone healing and wound healing, faster recovery, and decreased pain [10]. 

A recent pilot study by Master and Coronado et al. investigated the feasibility of combining wearable activity monitors with telehealth counseling to support physical activity after lumbar spine surgery. The intervention was delivered through remote physical therapist sessions paired with Actigraph monitoring. This randomized pilot study connects spine surgery follow-up to wearable activity monitors and telehealth physical therapy consultation (exercise prescription) which showed increased patient activity towards their daily step goals, high retention (88%), satisfaction, adherence, and no associated adverse events [11]. This study demonstrates that telehealth-based rehabilitation strategies incorporating wearable technology can engage patients in their recovery and lays the groundwork for larger trials to determine their effectiveness in improving postoperative spine outcomes.

Objective outcome measures obtained through wearable sensors are showing promise in spine surgery by providing continuous, quantifiable data on patient recovery. One such case report involving a wearable Oura ring accurately tracked step count, gait velocity, and step length which have all been shown to decline in lumbar spine pathology and improve postoperatively, making them reliable markers of function. Continuous monitoring of sleep duration and quality, as well as heart rate variability, may also serve as early indicators of disc herniation or psychological stress [12]. Unlike PROMs, which are influenced by patient perception and mental distress, objective metrics offer consistent, real-time insights that can track long-term recovery and detect complications such as recurrent herniation. These data suggest that remote, objective monitoring could enhance postoperative assessment and complement traditional follow-up in spine surgery.

Another case study by Mobbs and Katsinas et al. highlights the potential role of wearable accelerometers in early detection of adverse recovery after spine surgery. In this case, post L5/S1 microdiscectomy improvements were clearly captured in the first month, while a sudden decline at day 57 signaled a recurrent disc herniation—an issue not detected by standard self-reported scores [13]. The wearable device enabled early complication detection and timely intervention, underscoring its value as a complement to traditional measures. This evidence suggests that a wearable device in tandem with telemedicine follow-up protocol is not associated with SSI, ED visits, readmissions, and reoperations when compared to standard in-person care. In summary, wearable monitoring and telehealth post-operative follow-up monitoring during rehabilitation may aid in adherence and convenience for patients after surgery. 

Patient engagement and satisfaction
Telemedicine has been used in some capacity since 1879, with evidence that physicians made diagnoses via telephone [14]. Since then, technology use has skyrocketed and telemedicine has become an integral part of healthcare by providing greater access for patients with geographic and physical barriers to still receive adequate care from various physicians, including those in spine surgery [14]. Cui and Sedney et al. studied the effects of telemedicine triage in spinal care and found that initial review was often completed by a spine surgeon within 48 hours, compared to several months historically. Additionally, wait times for surgeon clinic visits decreased from eight months to as little as half a week with some providers [15]. By cutting wait times, patient satisfaction may increase as their needs are addressed promptly. This may also allow specialists to effectively triage patients and reserve face-to-face consultation for the most crucial discussions. Moreover, it was found that telemedicine in neurosurgical care significantly reduced wait times to see a specialist, while mitigating travel time and economic loss due to missed work time or gas money. It also allows physicians to see patients without traveling into the office or hospital [16,17]. 

In one study published in Spine, using a survey-based approach, Lightsey and Crawford et al. assessed the use of telemedicine in routine spine care. This study found that patients did have a strong preference for an in-person visit for their first appointment, however when it came to follow-up appointments, this difference decreased, indicating that telemedicine may be preferred for follow-up appointments. This study also demonstrates that when patients used telemedicine they were generally satisfied and did not find it difficult to use. On average, patients rated care received during their telemedicine visit as 8.7 (SD 1.7) on a scale of 1 to 10 [18]. Thus, virtual visits provide convenience for both the patient and physician, and patients still rate the quality of care received via telemedicine high. 

When patients attend virtual visits with specialists, they are generally satisfied. One cross-sectional study looked at telemedicine visits with a spine surgeon at two practices in 2020; overall 87.7% of patients were satisfied with their telemedicine visit and 45% indicated that they preferred telemedicine visits over in-person visits if given the choice [19]. Although a majority of patients still preferred in-person visits, nearly half opted for telemedicine indicating its effectiveness and importance to provide patients the option since many patients would potentially utilize it and benefit equally [19]. Video-based visits are preferred as physicians are able to evaluate and indicate patients for surgery with conditions such as lumbar stenosis, lumbar radiculopathy, and cervical radiculopathy [20]. Telemedicine may be indicated for typical post-operative checks and interventions, as well as initial evaluations when individuals may not be able to  travel for an in-person visit. 

Kolcun et al. examined the utilization of telemedicine for spine surgery and found that patients who utilized telemedicine for preoperative instructions and notifications were less likely to cancel surgery due to patient noncompliance than the comparison group [21]. Additionally, postoperative care was compared in patients that underwent lumbar discectomy in patients that had access to a mobile app with daily questionnaires (pain, temperature, neurological symptoms, wound status) versus those that followed traditional care protocols. Many patients reported high average satisfaction with its use and were able to receive quick intervention after using the app to alarm the neurosurgeon’s office of their status relating to pain management, fever, voiding delays and dressing issues [21]. The speed at which a patient’s pain can be addressed likely leads to more positive long-term outcomes and satisfaction. This is supported by Hou and Yang et al., where primary outcomes including Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) were utilized to assess those that used mobile app notifications versus standard instructions at discharge immediately after elective spine surgery and two years postoperatively. The telemedicine cohort had significantly greater improvements in both ODI and pain severity after two years [22]. This finding is likely due to an increased adherence to rehabilitation protocols among the telemedicine cohort because they felt supported and motivated during their healing process and they received prompt communication when needed. 

Another study highlighted the effectiveness of a custom smart phone application called SPINEhealthie app. For 3 months after elective spine surgery 60 patients were enrolled and instructed how to submit postoperative Patient-Reported Outcome Measures (PROMs) through the app interface. A majority of the patients provided 5 or more PROMs within 1 week from surgery and nearly two-thirds of patients used the applications chat function to skip the in-person clinic visit. The most common use for the chat function was to ask about postoperative symptoms such as paresthesia, radiculopathy, numbness, tingling, or muscle soreness. Many patients also inquired about their pain medication and return to activity. After 40 days of app usage 80% of users had a neutral or positive experience regarding the usefulness of the app [23]. The use of technology and monitoring apps can allow patients to skip the line for in-person care and to receive help from the comfort of their home which may influence patients perceived outcome. 

Challenges and Limitations

Surgeon Approach to Telehealth
When to use telemedicine versus in-person visits remains unclear. Although telemedicine shows promise in patient reported outcomes, it is unlikely to completely replace in-person care as some subsets of the population may never be amenable to a telehealth intervention. Additionally, the determination of offering in-person versus a telehealth visit is also provider dependent and based on their ability to decide its use in routine versus complex cases based upon their own experience and confidence. There is a consensus among providers that exam-based tasks (e.g. assessing neurologic deficits) should be done in-person when available, and communication-based aspects (e.g. history taking) can be done equivalently via telemedicine. Ultimately, many providers were confident in the ability of telemedicine to make an accurate diagnosis compared to in-person visits [24]. Another study found that surgical plans for 31 out of 33 spine patients did not change after they first underwent a telemedicine visit and then an in-person evaluation. The two that did change, only extended the operative site by one adjacent level, and it was noted that this would have been done regardless of the initial visit setting [25]. This realm of telemedicine capabilities remains largely unknown and seemingly subjective at this point in time as spine surgery as a field still has many gray areas, however it is clear telemedicine has the potential to alter the landscape of spine surgery in both routine visits and specialized surgeries by strongly complementing standard surgical protocols. 

Physical Exam Discrepancies
Limitations to telemedicine in postoperative spine surgery care to the standard in-person care include an inability to perform detailed physical exams during virtual visits, reliance on patient self-reporting, and limitations in remote assessment tools, which may lead to potential misdiagnosis or delayed intervention. Additional limitations in the literature include inconsistencies in study design, such as a lack of randomized controlled trials (RCTs) in spine surgery telehealth, variability in the implementation of telemedicine, and limited data on long-term outcomes beyond 30-day or 90-day follow-up.

A major limitation of virtual care is the inability to perform physical exams. An international review of spine surgeon perceptions regarding telehealth reported that 38.6% of surgeons cited a decrease in their ability to perform physical exams using telemedicine, while also citing medicolegal, reimbursement, and connectivity issues [26]. The inconsistent effectiveness of telemedicine leads surgeons to often rely on patient self-reporting. When utilizing patient self-reporting, the physician must rely on the patient’s word instead of an objective assessment [27]. This inability to objectively assess a patient leads to difficulties in establishing effective treatment plans. It has been shown that a virtual spine exam can be done with an assistant present in the room with the patient to test essential reflexes, such as the Babinski and Hoffmann reflexes [28]. These assistants could improve objective assessments, as patients often struggle to test these reflexes independently. Delays and discrepancies in correctly assessing patients can lead to potential misdiagnosis or delayed intervention in complex post-op cases. In addition to difficulty in assessing neurological conditions when using a video call, other factors such as poor internet connection can lead to additional difficulty when assessing patients through telemedicine [4]. These repeated concerns highlight the potential for misdiagnosis of patients due to difficulties in communication and examination, as well as the risk of complications if patients fail to report significant symptoms to their physician. Furthermore, a higher socioeconomic status is associated with better outcomes, which could undermine the purpose of telemedicine in rural communities that lack access to resources [4].

Condition-specific studies are increasingly showcasing the importance of tailoring telemedicine strategies to the unique recovery requirements of different spine procedures. For example, Brintz and Connors et al. studied a mindfulness-based telehealth intervention consisting of eight one-on-one virtual sessions delivered postoperatively to specifically lumbar spinal fusion and laminectomy patients—the intervention was well-received, with high satisfaction, strong adherence, and improvements in pain, disability, and psychosocial outcomes [29]. Debono and Bousquet et al. focused on postoperative monitoring following ambulatory lumbar discectomy using a mobile application, finding high patient satisfaction and reduced need for in-person follow-up—suggesting that app-based tracking may be most appropriate for less invasive procedures like discectomies [30]. These findings support the idea that surgical complexity and provider judgement should largely guide the telemedicine approach—where more intensive, behavioral interventions may benefit recovery from major surgeries like spinal fusion, while streamlined digital monitoring may suffice for less invasive procedures like discectomies. As such, future telemedicine strategies should take into consideration procedure-specific recovery demands to optimize outcomes and patient experience. 

Future Directions
The integration of telemedicine into spine surgery is shifting from a pandemic-driven necessity to a sustainable, evidence-based complement to in-person care. Future work should focus on large, multicenter RCTs with standardized protocols to assess long-term outcomes, complication detection, and patient-reported measures. Refinement of virtual neurological exams—via trained assistants, haptic tools, or augmented reality—and validation of wearable monitors and digital rehabilitation platforms could enhance assessment, adherence, and recovery. Policy efforts must address technological and socioeconomic barriers through broadband expansion, device access, and digital literacy programs. Cost-effectiveness analyses incorporating reduced travel, lost work time, and complication avoidance will be key to guiding reimbursement and adoption.

Conclusion
Collectively, all the studies discussed in the present paper warrant a conservative interpretation, when inspecting the promise of telemedicine in both preoperative and postoperative spinal care. Existing studies provide preliminary evidence that telemedicine may be applicable in both preoperative and postoperative spinal care; however, its role remains incompletely defined. While early results suggest comparable outcomes to standard in-person care in certain contexts, small sample sizes and heterogeneous patient populations limit definitive conclusions. Larger, adequately powered studies are required to determine whether significant differences exist and to establish evidence-based recommendations regarding timing, implementation, and patient selection for telemedicine. A clear understanding of telemedicine’s clinical efficacy will depend on its ability to deliver safe, equitable, satisfactory, and quality outcomes in postoperative spine care in order to shape evidence-based practice and policy of patient-centered care. 

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