A New Era of Practice: COVID-19 and Neurosurgical Care via Telemedicine

The COVID-19 pandemic has had an immense impact on neurosurgical practice in the past year. To control the spread of the virus, elective procedures were canceled, educational activities moved online, and there was an increase in the use of telemedicine. Virtual care has served as a valuable tool in the spectrum of neurosurgical subspecialties throughout the pandemic. There have been particularly valuable applications for the triage, assessment and follow-up of spine patients.

This article provides a brief commentary on the current literature about spine surgery and telemedicine in the COVID era. Pros and cons of telemedicine are discussed, along with recent guidelines to facilitate telemedicine visits for patients with spinal conditions. While the transition to telehealth provided some challenges, some positives can be adopted as part of routine care in the future.

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Pros of Telemedicine

Telemedicine carries the obvious benefit of reducing COVID-19 transmission between patients and providers, but also has several other benefits. This includes reducing travel expenses and travel time for patients who live far away and providing convenience to patients who can be examined from the comfort of their own homes.¹ For example, in one study, 7% of spine patients surveyed needed to take time off work for telemedicine visits, compared to 52% for in-person appointments.² Moreover, fewer in-person clinic visits can potentially lead to lower overhead costs for surgeons by reducing the demand for electricity, examination space and administrative staff.³ Changes to telemedicine regulatory requirements have also been implemented during the pandemic to improve access to virtual care. Patients can now use accessible commercial modalities such as Zoom, Facetime and Skype, and physicians are now able to prescribe certain controlled substances via telemedicine.³ The benefits of telemedicine during the pandemic have been recognized by spine surgeons internationally.

In a survey of 902 spine surgeons from 91 countries, 35.6% held over half of their clinic visits virtually and 50.3% used telehealth to conduct over 25% of their visits.4

Cons of Telemedicine

The transition to the virtual environment provides an opportunity to broaden multidisciplinary engagement through web-based platforms and hence improve patient care. In academic centers, virtual platforms can also be utilized to increase the follow-up rates for a clinical trial. Furthermore, telemedicine provides new opportunities to develop and utilize teaching tools, such as videos or modules, to inform patients about their condition and treatment options.

Telemedicine is not without its drawbacks. There are limitations to performing the physical exam virtually. This includes being unable to differentiate 4/5 strength from 5/5 strength and recognizing subtle sensory deficits on the exam.5 Additionally, in the absence of a trained professional at the patient’s location, physiologic or pathological reflexes cannot be elicited. Moreover, there is a loss of the subtleties of an in-person visit, such as the gait of a patient walking from the waiting area to the examination room. Beyond these limitations of the physical exam, patients’ lack of digital literacy, lack of access to devices compatible with telehealth programs and poor internet connection quality can create additional barriers to performing effective virtual clinic visits.4 These barriers fall disproportionately on older individuals and minority populations.4

In a survey involving 485 members of AO spine, the main challenges of telemedicine that were reported by spine surgeons included: difficulties with virtual physical exams (38.6%), the potential of increased legal liability (19.3%), and lower reimbursement compared to in-person visits (15.5%).6

Guidelines and Recommendations

In response to the increased use of telemedicine among spine surgeons during the pandemic, various groups have published strategies to have an effective virtual visit. These strategies include preparation before the clinical encounter, such as providing patients with instructions on how to position their camera and lighting for an optimal physical exam.3,5 Additionally, pictures and videos of common examination maneuvers can be sent to patients before their appointment to improve communication during the physical exam.5 Moreover, asking patients to have certain household objects available during the visit can facilitate the assessment.5,7 For example, the Spurling test can be performed by having the patient hold a folded towel over their head, holding each end.7 The patient then turns their head towards the affected side to elicit suspected radicular pain. These creative strategies enable providers to obtain additional clinical information from telemedicine visits. Furthermore, technological features, such as screen sharing and annotating patients’ MRIs or CT scans, are valuable tools to improve communication and enhance patient education.3,5,8 Several articles are available that provide detailed approaches to the virtual spine physical exam.5,7-10 Satin and Lieberman published a series of virtual examination techniques, including assessments of gait, the cervical and lumbar spine and adult spinal deformity, with written and visual descriptions available.5 However, additional research is necessary to validate the sensitivity and specificity of telemedicine examination techniques in diagnosing common spinal conditions.10,11

Patient Satisfaction

To understand the patient experience with telemedicine during the pandemic, many groups have administered surveys to their patients. Overall, the results from patients are positive. For example, in a study involving 772 patients who had telemedicine visits with a spine surgeon, 87.7% were ‘satisfied’ with their virtual care and if given a choice, 45% listed they would prefer a telemedicine visit over an in-person visit.12

In a survey of 346 spine patients who received virtual care, 95% were ‘satisfied’ or ‘very satisfied’ with telemedicine, with 62% indicating it was ‘the same’ or ‘better’ than in-person visits.2

In a study by Basil et al., 2020, the spine service demonstrated significant improvement in Press Ganey scores following the implementation of virtual care during the pandemic, with overall doctor ranking moving from the 29^th to 93^rd percentile.13 Although high patient satisfaction with telemedicine is documented in several other studies, a paper published recently surveyed 164 patients at a spine clinic and found only 15.3% of patients preferred telemedicine over traditional visits.14-17 Moreover, with regards to patients consenting to spine surgery, one survey indicated 37% of patients would consent to surgery and 73% would consent to minor procedures based on the assessment of a virtual visit alone.2 Additionally, certain procedures are more amenable to consent virtually, such as lumbar laminectomies and microdiscectomy, where typical presentations from conditions like lumbar stenosis can facilitate diagnosis via telemedicine.13 Therefore, certain spinal pathologies still require in-person examinations for the provider to make a confident diagnosis and for the patient to feel comfortable consenting to an operation.

Equitable Care Delivery

The transition to electronic care combined with improved image sharing capabilities has enhanced equitable care delivery in certain populations. Our center has a broad referral network in Ontario, a province which spans a geographic area larger than France and Spain combined. With telemedicine, we have been able to enhance delivery to those living in remote or rural areas who do not have consistent access to specialty care. Furthermore, individuals who have severe mobilities issues (e.g., spinal cord injury patients) often face challenges physically presenting to the hospital.

There is, however, a “digital divide” that can impose challenges in equitable care delivery. To access care digitally, one needs internet access and the ability to use their device. Access to the internet and the appropriate technology is not present to all. In some places in rural Canada, the appropriate internet infrastructure is not present to access medical care virtually. People from low-income backgrounds also may not have the funds to access the appropriate technology required for telemedicine. For the elderly, new technologies may pose challenges to access. They often require assistance in setting up and using the technologies required for telemedicine. When transitioning to telemedicine it is essential that these barriers to care are acknowledged and efforts are made to provide care to those that are impacted by the digital divide.

Our Experience

Starting in March of 2020, we started implementing a virtual clinic protocol for the outpatient neurosurgery spine clinic at Toronto Western Hospital. The key to this approach is acknowledging that, despite all the strengths of the virtual clinic, some patients still require in-patient assessment. A triaging system is required to identify the select few patients who require an in-patient visit to allow for most of the patients to be safely assessed virtually. Patients that warranted in-patient assessment included those that required a neurological exam for the diagnosis of mild myelopathy and those being assessed for potential wound complications.

The next step in this approach involved enhancing the accessibility of the virtual clinic. We adopted commercial platforms, such as Zoom, that are geared toward accessibility and ease of use. Often, patients who think they do not have any video conferencing capabilities can be coached to use technology they already own (i.e. a smartphone). We drafted simple guides for patients to follow and test their systems before the appointment.

The third step was enhancing the efficacy of the virtual appointment. This was through adopting standardized physical examinations. We utilized functional strength and dexterity assessments, such as instructing patients to button up their shirts or lifting a phone book etc. We also took advantage of the technology to screen share the imaging and laboratory results.

Anecdotally, patients have been receptive to this change and some have expressed their desires to continue with virtual follow-up visits indefinitely. As a center that encompasses a wide geographical area, the ability to adopt virtual clinics as a routine part of follow-up will eliminate significant travel times in often dangerous driving conditions for patients.

Conclusion

Overall, the COVID-19 pandemic has demonstrated that telemedicine can be used as an effective alternative to in-person visits for a significant portion of spine patients. Moving forward, centers worldwide should consider adopting telemedicine into their practice post-COVID to offer the benefits of virtual care to patients. Refinement of the virtual physical exam and validation of virtual examination techniques will be an important step in improving the quality of telemedicine in the future.