title: Reliability of smartphone-based teleradiology for evaluating thoracolumbar spine fractures.
abstract: Timely interpretation of computed tomography (CT) scans is of paramount importance in diagnosing and managing spinal column fractures, which can be devastating. Out-of-hospital, on-call spine surgeons are often asked to evaluate CT scans of patients who have sustained trauma to the thoracolumbar spine to make diagnosis and to determine the appropriate course of urgent treatment. Capturing radiographic scans and video clips from computer screens and sending them as instant messages have become common means of communication between physicians, aiding in triaging and transfer decision-making in orthopedic and neurosurgical emergencies.
  
  
  
  The present study aimed to compare the reliability of interpreting CT scans viewed by orthopedic surgeons in two ways for diagnosing, classifying, and treatment planning for thoracolumbar spine fractures: (1) captured as video clips from standard workstation-based picture archiving and communication system (PACS) and sent via a smartphone-based instant messaging application for viewing on a smartphone; and (2) viewed directly on a PACS.
  
  
  
  Reliability and agreement study.
  
  
  
  Thirty adults with thoracolumbar spine fractures who had been consecutively admitted to the Division of Orthopedic Surgery of a Level I trauma center during 2014.
  
  
  
  Intraobserver agreement.
  
  
  
  CT scans were captured by use of an iPhone 6 smartphone from a computer screen displaying PACS. Then by use of the WhatsApp instant messaging application, video clips of the scans were sent to the personal smartphones of five spine surgeons. These evaluators were asked to diagnose, classify, and determine the course of treatment for each case. Evaluation of the cases was repeated 4 weeks later, this time using the standard method of workstation-based PACS. Intraobserver agreement was interpreted based on the value of Cohen's kappa statistic. The study did not receive any outside funding.
  
  
  
  Intraobserver agreement for determining fracture level was near perfect (κ=0.94). Intraobserver agreement for AO classification, proposed treatment, neural canal penetration, and Denis classification were substantial (κ values, 0.75, 0.73, 0.71, and 0.69, respectively). Intraobserver agreement for loss of vertebral height and kyphosis were moderate (κ values, 0.55 and 0.45, respectively) CONCLUSIONS: Video clips of CT scans can be readily captured by a smartphone from a workstation-based PACS and then transmitted by use of the WhatsApp instant messaging application. Diagnosing, classifying, and proposing treatment of fractures of the thoracic and lumbar spine can be made with equal reliability by evaluating video clips of CT scans transmitted to a smartphone or by the standard method of viewing the CT scan on a workstation-based PACS. Evaluating video clips of CT scans transmitted to a smartphone is a readily accessible, simple, and inexpensive method. We believe that it can be reliably used for consultations between the emergency physicians or orthopedic or neurosurgical residents with offsite, on-call specialists. It might also enable rural orcommunity emergency department physicians to communicate more efficiently and effectively with surgeons in tertiary referral centers.
authors.affiliation: Division of Orthopedic Surgery, Rambam Healthcare Campus, POB 9602, Haifa 31096, Israel. Electronic address: stahl.ido@gmail.com.
authors.forename: Ido
authors.initials: I
authors.lastname: Stahl
authors.affiliation: Division of Orthopedic Surgery, Rambam Healthcare Campus, POB 9602, Haifa 31096, Israel.
authors.forename: Daniel
authors.initials: D
authors.lastname: Dreyfuss
authors.affiliation: Division of Orthopedic Surgery, Rambam Healthcare Campus, POB 9602, Haifa 31096, Israel.
authors.forename: Dror
authors.initials: D
authors.lastname: Ofir
authors.affiliation: Division of Orthopedic Surgery, Rambam Healthcare Campus, POB 9602, Haifa 31096, Israel.
authors.forename: Lior
authors.initials: L
authors.lastname: Merom
authors.affiliation: Division of Orthopedics, Emek Medical Center, 21 Yitzhak Rabin Blvd, POB 1834111, Afula, Israel.
authors.forename: Michael
authors.initials: M
authors.lastname: Raichel
authors.affiliation: Division of Orthopedic Surgery, Rambam Healthcare Campus, POB 9602, Haifa 31096, Israel.
authors.forename: Nir
authors.initials: N
authors.lastname: Hous
authors.affiliation: Division of Orthopedic Surgery, Rambam Healthcare Campus, POB 9602, Haifa 31096, Israel.
authors.forename: Doron
authors.initials: D
authors.lastname: Norman
authors.affiliation: Division of Orthopedic Surgery, Rambam Healthcare Campus, POB 9602, Haifa 31096, Israel.
authors.forename: Elias
authors.initials: E
authors.lastname: Haddad
mesh_terms: D000328:Adult; D005260:Female; D006801:Humans; D008159:Lumbar Vertebrae / Q000000981:diagnostic imaging* / Q000293:injuries; D008297:Male; D015588:Observer Variation; D015203:Reproducibility of Results; D000068997:Smartphone / Q000592:standards*; D016103:Spinal Fractures / Q000145:classification / Q000000981:diagnostic imaging*; D019112:Teleradiology / Q000295:instrumentation / Q000592:standards*; D013904:Thoracic Vertebrae / Q000000981:diagnostic imaging* / Q000293:injuries; D014057:Tomography, X-Ray Computed / Q000379:methods* / Q000592:standards
keywords: Intraobserver agreement; Out-of-hospital consultation; PACS; Smartphone; Spine fractures; Teleradiology