Telemedicine in Nerve Surgery: An Effective Method to Determine Indications for Surgery

Abstract

Background:

The COVID-19 pandemic accelerated the adoption of telemedicine for surgical consultations. Although patient satisfaction has been well documented, limited research exists regarding telemedicine’s effectiveness in determining the ability to indicate for surgical care compared with in-office visits. We conducted a retrospective review comparing surgical decision-making via telemedicine versus in-person consultations, hypothesizing that in-office visits would be more effective in establishing a surgical plan than telemedicine.

Methods:

A retrospective review of the medical records of all new patients presenting to the senior author’s nerve surgery clinic at a high-volume quaternary referral center between June 2020 and January 2023 was performed. Surgical consultations were categorized as (1) surgery recommended, (2) surgery not recommended, (3) further screening required, or (4) surgery declined. The Fisher exact test compared the distribution of these categories between consultation types and the proportion of patients who underwent surgery after an initial recommendation.

Results:

Of the 809 patients, 283 (35%) had in-person and 526 (65%) had telemedicine consultations. Surgery was recommended in 49.5% of in-person consultations compared with 38% of telemedicine consultations (P = 0.03). Among those recommended for surgery at the initial visit, 77.9% of in-person and 77.8% of telemedicine patients ultimately underwent surgery (P = 0.10). Of the telemedicine patients subsequently seen in the office and offered surgery, 84.5% ultimately underwent that surgery.

Conclusions:

Our findings suggest that telemedicine and in-office visits are equally effective in establishing a surgical plan, suggesting that the expansion of telemedicine could be considered for a broader geographic patient base.

Takeaways

Question: Does this study evaluate whether telemedicine is as effective as in-person consultations in determining surgical candidacy for nerve surgery?

Findings: In a retrospective review of 809 patients at a high-volume, single-surgeon nerve surgery clinic, we found that the proportion of patients who ultimately underwent surgery was nearly identical between groups (77.9% in-person versus 77.8% telemedicine, P = 0.10). These findings suggest that telemedicine is a viable tool for surgical decision-making.

Meaning: Telemedicine and in-office visits are equally effective in establishing a surgical plan, supporting the expansion of telemedicine to a broader geographical patient population.

INTRODUCTION

Originally established in the late 1950s for psychiatric consultations, telemedicine experienced a dramatic resurgence during the COVID-19 pandemic.¹ Lockdowns and social distancing forced healthcare providers, including surgeons, to rapidly adopt telemedicine, which in turn revolutionized the delivery of healthcare across diverse settings.^2,3 Yet, despite its widespread implementation, relatively few studies have specifically assessed the effectiveness of virtual visits in evaluating patients for potential surgery, and the cost of obtaining broader state licensing is a financial barrier to expanding this service.^3–8 Understanding telemedicine’s efficacy in determining indications for surgical care, therefore, warrants further investigation.

METHODS

A retrospective review was conducted within a quaternary nerve surgical referral practice, comparing surgical rates with telemedicine versus in-person consultations. Electronic medical records for all new patients seen by the senior author (S.E.M.) between June 2020 and January 2023 were reviewed. Patients were excluded from this analysis if their referral reason was for nerve or muscle biopsy or if the chart had incomplete data (Fig. 1). All patients were prescreened by a clinic nurse and reviewed with the senior author as needed to ensure appropriateness based on the author’s clinical expertise and scope of practice. No patients were self-referred. Once accepted, patients had an initial consultation, conducted either in-person or virtually via video chat. Initially, due to COVID-19 restrictions, all consultations were conducted via telemedicine; however, as restrictions eased, patients were offered to choose their preferred format between telemedicine and in-person consultations. In-office visits were first permitted in February 2021 and did not stabilize to pre-COVID-19 numbers until February 2022. In 2020–2021, temporary COVID-19 licenses in several states (Kansas, Oklahoma, and Kentucky) were granted; however, by 2022, licensure was reduced to Missouri and Illinois. Each consultation included a shared decision-making discussion to reach a conclusion regarding whether to offer or proceed with surgery. Treatment courses were classified into 4 categories:

Fig. 1.

A flowchart outlining the patient selection process, including inclusion and exclusion criteria applied throughout the study.

1. “Yes surgery”: The patient was offered a surgical procedure, and they decided to undergo that procedure.

2. .“No surgery”: The patient was not offered a surgical procedure.

3. “Further screening”: More information was needed to decide if the patient was a surgical candidate. This could include imaging, electrodiagnostic studies, specialist consultation, or a trial of conservative management.

4. “Declined surgery”: The patient was offered surgery but, at the time of their consultation, declined to undergo said surgery due to individual circumstances (eg, associated risks, not interested in surgery for any reason).

Patients initially seen virtually and offered further workup or surgery were subsequently seen in the clinic. The date of the in-person visit was recorded, and their surgical candidacy was reassessed using the same 4 categories. This study’s primary endpoint was the determination of a surgical plan, defined as the proportion of patients who ultimately underwent surgery after an initial “yes surgery” classification at the first consultation by the senior author.

Other data collected include patient demographics, chief complaint, consultation type (virtual or in-person), diagnosis at the initial and subsequent consultations (if applicable), and whether nonsurgical management strategies had already been trialed. For patients who underwent surgery, the date and procedure performed were recorded.

The distance between each patient’s ZIP code and the surgical clinic was compared between groups to evaluate the potential impact of travel distance on patients’ decisions to choose telemedicine versus in-person consultations. Carbon emissions for the in-person consultation group were calculated using the Environmental Protection Agency’s emissions factor of 404 g of CO₂ per mile for a typical passenger vehicle, based on the round-trip distance for each patient and assuming travel by car.⁹ For the telemedicine consultation group, carbon emissions were estimated using data derived from existing literature.¹⁰ This study was approved by the Washington University School of Medicine institutional review board (no. 202309090).

Statistical Analysis

Descriptive statistics are presented as median and interquartile ranges for continuous variables with a nonnormal distribution. The Fisher exact test was used to compare the proportions of patients in each surgical decision-making category between telemedicine and in-person visits. Results were considered statistically significant if the P value was less than or equal to 0.05. This study was powered to detect a 10% difference in the proportions of patients undergoing surgery between the telemedicine and in-person groups, using a significance level (alpha) of 0.05 and power (1-beta) of 0.80. Statistical analysis was performed using IBM SPSS Statistics for Windows Version 29.0 (IBM Corp., Armonk, NY).

RESULTS

Between June 2020 and January 2023, 921 patients presented to the senior author’s clinic. A total of 809 of these patients met inclusion criteria, and 112 patients were excluded from the analysis due to being referred only for nerve or muscle biopsy (Fig. 1).

Patient demographics are summarized in Table 1. The average age of the study population was 53.6 years (SD 17.0 y). Fifty-two percent were women, and 48% were men. Among all patients, 42.5% resided within 50 miles of the campus, 9.8% lived between 50 and 100 miles away, and 47.7% lived more than 100 miles away. For patients initially seen in person, the median distance from the patient’s home ZIP code to the hospital was 182.7 miles (interquartile range: 42.9–324.8; Table 1), and for patients seen via telemedicine, it was 48.6 miles (interquartile range: 25.1–231.3; Table 1). Additionally, the carbon footprint for each consultation type was calculated, with in-person consultations producing approximately 148 kg CO₂ per visit compared with 0.04 kg CO₂ for telemedicine visits.

Table 1.

Demographics of Included Patients

Demographics
	In-person	Telemedicine	P
Age (SD), y	54.3 (17.9)	53.2 (16.6)	0.36
Sex, % (n)			0.46
Male	48.5 (133)	47.5 (248)
Female	51.5 (141)	52.5 (273)
Weight (SD), kg	82.4 (21.2)	86.2 (22.7)	0.601
Distance to hospital, median (interquartile range), miles	182.7 (42.9–324.8)	48.6 (25.1–231.3)	<0.001
Average carbon emission, kg CO2	148	0.04

Of the 809 patients identified, 35% (n = 283) of their initial consultations were conducted in-person, whereas 65% (n = 526) were conducted via telemedicine (Fig. 2 and Table 2). Of those patients whose initial consultation was in-person, 29% (n = 82) were not offered surgery, 49.5% (n = 140) were offered and accepted surgery, and 4.2% (n = 12) were offered surgery but declined surgical intervention. More information was needed before a determination could be made regarding surgery for 17.3% (n = 49) of patients who had an initial in-person consultation (Table 2).

Fig. 2.

A flowchart depicting the analyzed patient cohort and their corresponding clinical outcomes. *Further screening, declined, and no surgery.

Table 2.

Outcomes Between Telemedicine and In-person Consult Patients

	Telemedicine, % (n)	In-person, % (n)	P
	526	283
Recommendation at first visit
Recommended for surgery	38.6 (203)	49.5 (140)	<0.01
Underwent surgery	77.8 (158)	77.9 (109)	0.10
Further screening	36.4 (191)	17.3 (49)	<0.001
Declined surgery	1.9 (10)	4.2 (12)	0.05
No surgery	23 (121)	29 (82)	0.06
Secondary visit (in-person)	52 (168)	N/A
Underwent surgery	84.5 (60)	N/A
Underwent surgery (total)	43.9 (231)	44.2 (125)	0.96

N/A, not applicable.

For telemedicine visits, 23% (n = 121) of patients were not offered surgery, 38.6% (n = 203) were offered and accepted surgery, 1.9% (n = 10) declined the surgery they were offered, and further screening was needed for 36.4% (n = 191) of these patients (Table 2). Among the 323 patients who were not offered surgery at the initial telemedicine consultation, the majority (52%, n = 168) had a subsequent in-person examination. This follow-up visit occurred an average of 59.5 days after the initial telemedicine consultation.

Surgical rates were calculated for both telemedicine and in-person groups. Of the 203 telemedicine patients who accepted the offer of surgery at the time of their appointment, 77.8% (n = 158) ultimately underwent surgery. Similarly, of the 140 patients who were offered surgery at their initial in-person consultation, 77.8% (n = 109) proceeded to surgery (P = 0.10). Overall, 44% (n = 356) of all new patient consultations resulted in surgery.

A total of 27 different diagnoses were made across all patient visits (Table 3). The 3 most common diagnoses for the telemedicine group were “ulnar neuropathy” (n = 102, 19.4%), “common peroneal nerve compression/injury” (n = 85, 16.2%), and “carpal tunnel syndrome” (n = 78, 14.8%). For in-person consultations, the most common diagnoses were “ulnar neuropathy” (n = 51, 18%), “carpal tunnel syndrome” (n = 48, 17%), and “common peroneal nerve compression/injury” (n = 45, 15.9%). The diagnosis “other” refers to conditions that did not fall into the categories described and comprises 59 different diagnoses. (See table, Supplemental Digital Content 1, which displays a detailed list of all diagnoses included in the “other” primary diagnosis group, https://links.lww.com/PRSGO/E142.)

Table 3.

Most Common Diagnoses and Surgical Procedures Relative to Telemedicine or In-person Evaluations

Telemedicine	% (n)	In-person	% (n)
Most common diagnosis
Other	26.2 (138)	Other	26.1 (74)
Ulnar neuropathy	19.4 (102)	Ulnar neuropathy	18.0 (51)
Common peroneal nerve compression/injury	16.2 (85)	Carpal tunnel syndrome	17.0 (48)
Carpal tunnel syndrome	14.8 (78)	Common peroneal nerve compression/injury	15.9 (45)
Most common surgical procedures
Nerve transfer(s)/graft(s)	38.5 (89)	Carpal tunnel decompression	41.6 (52)
Carpal tunnel decompression	34.2 (79)	Guyon canal decompression	36.8 (46)
Guyon canal decompression	29.9 (69)	Nerve transfer(s)/graft(s)	36.8 (46)
Common peroneal nerve decompression	19.9 (46)	Common peroneal nerve decompression	23.2 (29)

A total of 17 different surgical procedures were performed, with the most common procedures and associated presentation groups shown in Table 3. In the telemedicine group, the most frequently performed procedures were “nerve transfer(s)/graft(s)” (n = 89, 38.5%), “carpal tunnel decompression” (n = 79, 34.2%), and the “Guyon canal decompression” (n = 69, 29.9%). Although for in-person patients, the most common procedures were “carpal tunnel decompression” (n = 52, 41.6%), the “Guyon canal decompression” (n = 46, 36.8%), and “nerve transfer(s)/graft(s)” (n = 46, 36.8%).

DISCUSSION

As telemedicine continues to reshape healthcare, assessing its effectiveness in triaging patients for surgical intervention is increasingly essential. A systematic review by Kruse et al¹¹ noted that patients report high satisfaction with telehealth due to factors such as improved health outcomes, convenience, affordability, and reduced travel. Furthermore, studies have shown an association between the use of telemedicine and fewer missed appointments, optimized visit lengths, and improved physician schedule adherence.^12,13 Although there are a few large studies showing long-term outcome measures with the use of telemedicine, the data presently available support the notion that telemedicine can, in some instances and specialties, be superior to in-person screening. For instance, a long-running, single-center, retrospective cohort study has shown that, over the course of more than a decade, telemedicine has led to faster diagnosis of stroke and better long-term outcomes.^14–16 These factors collectively contribute to the effectiveness of telehealth utilization throughout the surgical field.

In March 2020, when we started using telemedicine out of necessity, we were surprised to note the effectiveness of telemedicine in determining surgical candidacy and indicating patients for surgery. Results from this present study indicated that, during a 3-year period, there was no significant difference in the rates of surgical conversion (ie, undergoing surgery after it being offered at the initial visit) between patients who were initially evaluated via telemedicine versus those who had in-person consultations. This suggests that telemedicine can be a viable and effective tool for selecting appropriate patients for surgery, potentially offering significant advantages for both patients and healthcare providers, and further supporting the expanded use of telemedicine in clinical practice.

We report the largest study to date examining the surgical conversion rate between telemedicine and in-person consultation. Although this aspect of telemedicine is seldom reported, our findings are consistent with those previously reported.^3–8 Khalaf et al⁵ reported that of their 73 patients presenting with hand-specific complaints, they found no statistical difference in the conversion rates of 67% for in-person consultation versus 50% for virtual; however, the study’s findings are limited by the small number of patients in the telemedicine group, impacting its generalizability. The literature further supports similarity in conversion rates for several other surgical specialties, including facial cosmetic surgery,⁷ general plastic surgery,⁵ and neurosurgery.⁶

There is an apparent difference in rates of telemedicine surgical conversion between surgical specialties, with reported rates ranging from 33% for spine surgery⁶ to 79% for oncological plastic surgery.⁵ This study’s telehealth conversion rate of 78% is at the higher end of the reported range; we attribute this to the specialized nature of the senior author’s nerve surgery practice as well as the prescreening process implemented to ensure that the most appropriate patients “present” to the clinic. Of note, the senior author and staff are not compensated for the additional time spent reviewing records to determine the appropriateness of telemedicine consultations.

All patients who had an initial telemedicine consultation underwent an in-person office visit before proceeding with surgery. This allowed for a thorough physical examination and informed consent process. In our study, the planned surgical procedure remained unchanged between the initial telemedicine consultation and the subsequent in-person evaluation for all patients, suggesting that virtual assessments provided sufficient information to determine surgical candidacy. In some cases, we also purposefully used telemedicine to provide patients with an explanation of potential nonoperative options and to discuss any necessity for “further screening” when referral notes were inadequate. Notably, 36.4% of patients in the telemedicine group were categorized as requiring “further screening,” compared with only 17.3% in the in-person group (P ≤ 0.001). This underscores the potential of telemedicine to identify patients who may benefit from a more conservative approach before proceeding to surgery. This is also relevant in the context of patients with acute nerve injuries seen before 3 months postinjury to educate the patients regarding their anticipated clinical course, as it is not possible to determine surgical indication in the acute setting for many types of nerve injury.

Of particular note in this study, and in contrast to many other studies,^6,17,18 the median distance for patients to travel to get to the hospital was greater for the in-person group (183 miles) than the telemedicine group (49 miles). This difference can be attributed to licensure restrictions on the senior author’s practice, which only permits telemedicine consultations for patients residing in Illinois and Missouri. As a result, patients in other states who sought consultation were required to travel for in-person visits. The results of this study indicating comparable efficacy between the telemedicine and in-person consultations support the expansion of this service, especially in tertiary or quaternary surgical practices. Additionally, telemedicine visits were reimbursed using the same new patient evaluation codes as in-person consultations, reinforcing its practicality as a billing mechanism. Although clinical and personal considerations primarily dictated the choice of visit format rather than proximity, these findings indicate that telemedicine remains a viable option for initial consultations, regardless of a patient’s travel distance to the hospital. Although many advantages of telemedicine are specific to patients, telemedicine also provides advantages for providers, including improved clinic efficiency and time management.⁵

As an additional benefit, the implementation of telemedicine is an effective use of clinic space, and visits may decrease a clinic’s carbon footprint; for a patient living 30 miles away from the hospital, an in-person visit produces 25 times more greenhouse gasses than a virtual visit.¹⁹ For our patient population, in-person consultations produced, on average, 3700 times more carbon emissions than telemedicine visits. These findings, supported by existing literature, strongly emphasize the environmental advantages of telemedicine.^10,19

This study has inherent limitations due to its retrospective, single-surgeon, single-institution design. One limitation of this study is the assumption that proceeding with surgery is always the correct decision. Although the senior author’s expertise helps minimize this risk, the study does not account for cases where surgery may not have been the best option. This limitation applies to both telemedicine and in-person consultations. Future studies could explore the reasons why patients decline surgery when it is offered. Additionally, as this study was conducted at a highly specialized quaternary referral center for nerve surgery, the findings may not be representative of other surgical practices.

Selection bias, though unavoidable in this design, may influence our findings. Specifically, during the COVID-19 pandemic, hospital-mandated restrictions initially required all consultations to be conducted via telemedicine. As these restrictions were lifted, patients could choose between in-person or telemedicine consultations. All clinic visits between 2020 and 2023 were included in this study, presenting a potential source of selection bias. Future studies would include evaluations of patients from 2024 to 2025.

Ultimately, this study suggests that telemedicine can be as effective as in-person consultations for determining surgical candidacy in specific contexts, offering advantages such as increased convenience; reduced cost; and, with institutional support and expanded licensing, improved access to care. However, it remains crucial to recognize the importance of additional in-person examinations.²⁰ Further research will be essential in optimizing the integration of telemedicine within surgical care to enhance healthcare delivery and patient outcomes. Our study provided evidence that expanding licensing outside of the closest regions would not compromise surgical care and would instead improve access for patients for whom long-distance travel to the clinic is a significant cost burden.

DISCLOSURES

The authors have no financial interest to declare in relation to the content of this article. Funding was provided by the Barnes-Jewish Foundation.