COVID-19: Initiating the Expansion of Telemedicine in Neurosurgery

Objective: As COVID-19 spreads around the world, so does telemedicine across many medical specialties including neurosurgery. Given the unique patient population in neurosurgery, arising opportunities for integration and expansion of telemedicine into neurosurgery practice come with challenges for both the patient and the provider. Methods: A literature review has been performed, and a survey has been sent out to neurosurgery providers in Texas to determine if providers are satisfied with the current state of telemedicine in their clinical practice. Results: Patients who live far away from a medical center have cited increased convenience when routine postoperative visits have been converted to telemedicine. For providers, challenges have arisen in performing physical exams, especially when performing detailed neurological exams in the diagnosis of a spine disorder. Survey results of neurosurgery providers have revealed mixed opinions since the initiation of telemedicine. Conclusion: Although it is unclear what role telemedicine will have after the social distancing restrictions are lifted, many providers surveyed have expressed interest in keeping telemedicine in their clinical practice.


Copy@ Jason H Huang
Some smartphone applications can display the results of the CT angiogram with similar accuracy to a hospital-based work station [2]. On the other hand, as telemedicine continues to expand during the COVID-19 crisis, certain subspecialties of neurosurgery are experiencing telemedicine for the first time. Consequently, new opportunities and challenges are being discovered by the patient and the provider with the expansion of telemedicine into this field. With the intention to determine if patients and providers are satisfied with the expansion of telemedicine, a survey has been sent out to neurosurgery providers in the state of Texas, and a literature review has been performed. The opportunities, challenges, and the prospect of telemedicine in neurosurgery have been discussed.

Methods
A questionnaire has been sent out to the nation's secondlargest organized group of neurosurgeons, the Texas Association of Neurological Surgeons (TANS) ( Table 1). The questionnaire consists of five questions of interest. First, neurosurgery practices have been put into four categories, i.e., hospital/health system employed or academic practice, group practice with more than two partners, solo practice, and other. Second, we asked the surveyed providers the proportion of patients seeking help for a spine issue as this group of disorders requires a more complex physical examination.
Third, the surveyed neurosurgeons scaled the level of complexity in transitioning clinic practice to telemedicine. Then the satisfaction of reimbursement in telemedicine was scaled. The second to the fourth questions are matrix types with a scale from one to five, with one being the least and five being the most. For matrix types of survey questions, the mean of the scale has been obtained, which was then divided by 5 to obtain the percentage in the corresponding question category. Finally, the surveyed surgeons responded with whether they would be interested in converting a portion of clinic visits to telemedicine. With the results of responses in hand, we performed a literature review and examined the opportunities, challenges, and the prospect of telemedicine in neurosurgery. Copy@ Jason H Huang

Discussion
Neurosurgery clinic consists of a wide range of encounters, from initial neurosurgical evaluation, preoperative visit, to postoperative wound care and follow-up. Inevitably, the complexity of each visit is contingent on the specific scenario. Nonetheless, a physical examination with a neurological focus is essential to each neurosurgery visit. As telemedicine separates patient and provider physically, neurological exam becomes unreliable and even impossible for certain assessments. Meanwhile, technical infrastructure demanded by telemedicine calls for professional information technology (IT) support on both ends of healthcare service. These all hinder the transition of traditional neurosurgery clinic visit to a telemedicine platform. The low satisfaction rate in reimbursement for telehealth visit could be a reflection of the limitation of telemedicine in neurosurgery, as a virtual visit prevents a comprehensive evaluation including a thorough physical examination. Intriguingly, the majority of the surveyed neurosurgeons favored converting a portion of their clinic practice to telemedicine. This might be contributed to the flexibility of conducting a telepresence visit.

Opportunities of telemedicine in neurosurgery
A crisis is an opportunity in disguise. The dreadful COVID-19 has been such an opportunity for telemedicine. The COVID-19 pandemic has posed both patients and healthcare providers in great threat through traditional in-person clinic visit. With social distancing being imposed nationwide, many patients and providers have turned to telemedicine for certain outpatient visits, as it efficiently keeps patients and providers connected while maintaining a safe physical distance.
Emergency stroke evaluations via telemedicine have been established and proven to be non-inferior to traditional evaluation.
Telemedicine is often well-suited for routine postoperative visits where the patient can report progress, and a simple video wound check can be conducted easily. Thakar et al. [3] found telemedicine to be more cost-effective as measured by patient-perceived utility scores, especially for patients traveling long distances to the medical center in routine postoperative visits after elective spine surgery [3]. Telemedicine postoperative visit was a safe and even desirable alternative by patients in the first ninety days after elective cranial surgeries, including aneurysm clipping, arteriovenous malformation resection, brain tumor resection, and various forms of microvascular decompression [4]. The time and cost savings attributed to telemedicine visits are the major contributing factors leading to higher patient satisfaction scores in regards to routine postoperative or post-hospital discharge follow-up visits [5].
Other types of neurosurgical patients may be well-suited for telemedicine-based initial consultations or follow-up visits.
For example, patients harboring small, unruptured intracranial aneurysms that simply need to establish care or schedule an outpatient angiogram with a neurosurgeon may find it ideal to The area of neurosurgery that might be most hindered by telemedicine is spine disorder since imaging findings may not directly correlate with the patient's presenting complaints. The physical exam is crucial to patients presenting with severe low back pain to differentiate a spine pathology such as a compressive myelopathy or radiculopathy from an intrinsic hip, sacroiliac joint, or peripheral nerve pathology [9]. Additionally, patients presenting with cauda equina syndrome, a surgical emergency, can accurately be diagnosed only after a detailed physical exam is performed with a careful assessment of a patient's rectal tone, perineal sensation, and lower extremity strength [10].
Aside from certain aspects of the neurological exam, providers may struggle with obtaining other critical pieces of a patient's overall health to include current weight, gait, posture, and vital signs. The collection of certain vital signs using over-the-counter equipment may be commonplace for patients with chronic respiratory disease, cardiac conditions, or diabetes, but this requires a purchase that patients seeking an initial consultation with a neurosurgeon may be unable to perform [11]. The coding, billing, and reimbursement process could be perfected to better serve telehealth visits. These are all challenges that limit the broad adoption of telemedicine in neurosurgery.

Future of telemedicine in neurosurgery
Telemedicine closes the physical gap between providers and patients, among specialists, between educators and students. We already have access to medical resources at our fingertips through smartphones. Soon, in a rural area, we may see a local clinic with a designated room in which a patient can be comprehensively evaluated by a neurosurgeon via telemedicine while assisted by a trained examiner present with the patient. With the advancement of communicating technology and improvement of a robotic surgery system, remote neurosurgery might become the new norm of neurosurgery practice. As augmented reality being introduced into the medical field, patient-physician interaction will become more effective and efficient. Additionally, students from underdeveloped regions can learn advanced neurosurgical knowledge and technique even from thousands of miles away under the establishment of telemedicine. Without a doubt, telemedicine will advance and greatly mobilize limited medical resources and upraise medical education.

Limitations
The survey sample size is small and targeted neurosurgeons that are members of the TANS. This inevitably created selection bias, and the small sample size limit the generalization of the Copy@ Jason H Huang findings. Not all neurosurgeons responded to the surveys.
Those who did not respond may present a different picture of telemedicine in neurosurgery. The matrix-type of survey question requests responders to scale from 1 to 5. Responses generated in this way are more subjective; therefore, objective parameters and measurements are warranted in further study.

Conclusion
The COVID-19 outbreak has set the stage for a potential new practice model with telemedicine as an integral part to neurosurgical care instead of an alternative means during times of social distancing. At this time, it is unclear if certain restrictions that the Centers for Medicare and Medicaid Services have lifted such as the ability for practitioners to practice across state lines or equal reimbursement for a telehealth visit when compared to an in-person visit of equal complexity level will continue to hold true once the pandemic is over [12].