Tag: Telemedicine

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Pain alleviation and functional improvement: ultra-early patient-reported outcome measures after full endoscopic spine surgery

J Neurosurg Spine 40:465–474, 2024

Questions regarding anticipated pain improvement and functional recovery postsurgery are frequently posed in preoperative consultations. However, a lack of data characterizing outcomes for the first postoperative days only allows for anecdotal answers. Hence, the assessment of ultra-early patient-reported outcome measures (PROMs) is essential for patient-provider communication and patient satisfaction. The aim of this study was to elucidate this research gap by assessing and characterizing PROMs for the first days after full endoscopic spine surgery (FESS).

METHODS This multicenter study included patients undergoing lumbar FESS from March 2021 to July 2023. After informed consent was provided, data were collected prospectively through a smartphone application. Patients underwent either discectomy or decompression. Analyzed parameters included demographics, surgical details, visual analog scale scores for both back and leg pain, and the Oswestry Disability Index (ODI) score. Data were acquired daily for the 1st postoperative week, as well as after 2 weeks, 3 months, and 6 months.

RESULTS A total of 182 patients were included, of whom 102 underwent FESS discectomy and 80 underwent FESS decompression. Significant differences between the discectomy and decompression groups were found for age (mean 50.45 ± 15.28 years and 63.85 ± 13.25 years, p < 0.001; respectively), sex (p = 0.007), and surgery duration (73.45 ± 45.23 minutes vs 98.05 ± 46.47 minutes, p < 0.001; respectively). Patients in both groups reported a significant amelioration of leg pain on the 1st postoperative day (discectomy group VAS score: 6.2 ± 2.6 vs 2.4 ± 2.9, p < 0.001; decompression group: 5.3 ± 2.8 vs 1.9 ± 2.2, p < 0.001) and of back pain within the 1st postoperative week (discectomy group VAS score: 5.5 ± 2.8 vs 2.8 ± 2.2, p < 0.001; decompression group: 5.2 ± 2.7 vs 3.1 ± 2.4, p < 0.001). ODI score improvement was most pronounced at the 3-month time point (discectomy group: 21.7 ± 9.1 vs 9.3 ± 9.1, p < 0.001; decompression group: 19.3 ± 7.8 vs 9.9 ± 8.3, p < 0.001). For both groups, pain improvement within the 1st week after surgery was highly predictive of later benefits.

CONCLUSIONS Ultra-early PROMs reveal an immediate pain improvement after FESS. While the benefits in pain reduction plateaued within the 1st postoperative week for both groups, functional improvements developed over a more extended period. These results illustrate a biphasic rehabilitation process wherein initial pain alleviation transitions into functional improvement over time.

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Intraoperative confocal laser endomicroscopy: prospective in vivo feasibility study of a clinical-grade system for brain tumors

J Neurosurg 138:587–597, 2023

The authors evaluated the feasibility of using the first clinical-grade confocal laser endomicroscopy (CLE) system using fluorescein sodium for intraoperative in vivo imaging of brain tumors.

METHODS A CLE system cleared by the FDA was used in 30 prospectively enrolled patients with 31 brain tumors (13 gliomas, 5 meningiomas, 6 other primary tumors, 3 metastases, and 4 reactive brain tissue). A neuropathologist classified CLE images as interpretable or noninterpretable. Images were compared with corresponding frozen and permanent histology sections, with image correlation to biopsy location using neuronavigation. The specificities and sensitivities of CLE images and frozen sections were calculated using permanent histological sections as the standard for comparison. A recently developed surgical telepathology software platform was used in 11 cases to provide real-time intraoperative consultation with a neuropathologist.

RESULTS Overall, 10,713 CLE images from 335 regions of interest were acquired. The mean duration of the use of the CLE system was 7 minutes (range 3–18 minutes). Interpretable CLE images were obtained in all cases. The first interpretable image was acquired within a mean of 6 (SD 10) images and within the first 5 (SD 13) seconds of imaging; 4896 images (46%) were interpretable. Interpretable image acquisition was positively correlated with study progression, number of cases per surgeon, cumulative length of CLE time, and CLE time per case (p ≤ 0.01). The diagnostic accuracy, sensitivity, and specificity of CLE compared with frozen sections were 94%, 94%, and 100%, respectively, and the diagnostic accuracy, sensitivity, and specificity of CLE compared with permanent histological sections were 92%, 90%, and 94%, respectively. No difference was observed between lesion types for the time to first interpretable image (p = 0.35). Deeply located lesions were associated with a higher percentage of interpretable images than superficial lesions (p = 0.02). The study met the primary end points, confirming the safety and feasibility and acquisition of noninvasive digital biopsies in all cases. The study met the secondary end points for the duration of CLE use necessary to obtain interpretable images. A neuropathologist could interpret the CLE images in 29 (97%) of 30 cases.

CONCLUSIONS The clinical-grade CLE system allows in vivo, intraoperative, high-resolution cellular visualization of tissue microstructure and identification of lesional tissue patterns in real time, without the need for tissue preparation.

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Telemedicine in the Evaluation and Management of Neurosurgical Spine Patients

Spine 2021;46:472–477

Study Design. Retrospective questionnaire study of all patients seen via telemedicine during the COVID-19 pandemic at a large academic institution.

Objective. This aim of this study was to compare patient satisfaction of telemedicine clinic to in-person visits; to evaluate the preference for telemedicine to in-person visits; to assess patients’ willingness to proceed with major surgery and/or a minor procedure based on a telemedicine visit alone.

Summary of Background Data. One study showed promising utility of mobile health applications for spine patients. No studies have investigated telemedicine in the evaluation and management of spine patients.

Methods. An 11-part questionnaire was developed to assess the attitudes toward telemedicine for all patients seen within a 7- week period during the COVID-19 crisis. Patients were called by phone to participate in the survey. x2 and the Wilcoxon Rank-Sum Test were performed to determine significance.

Results. Ninety-five percent were ‘‘satisfied’’ or ‘‘very satisfied’’ with their telemedicine visit, with 62% stating it was ‘‘the same’’ or ‘‘better’’ than previous in-person appointments. Patients saved a median of 105 minutes by using telemedicine compared to inperson visits. Fifty-two percent of patients have to take off work for in-person visits, compared to 7% for telemedicine. Thirtyseven percent preferred telemedicine to in-person visits. Patients who preferred telemedicine had significantly longer patient reported in-person visit times (score mean of 171) compared to patients who preferred in-person visits (score mean of 137, P=0.0007). Thirty-seven percent of patients would proceed with surgery and 73% would proceed with a minor procedure based on a telemedicine visit alone.

Conclusion. Telemedicine can increase access to specialty care for patients with prolonged travel time to in-person visits and decrease the socioeconomic burden for both patients and hospital systems. The high satisfaction with telemedicine and willingness to proceed with surgery suggest that remote visits may be useful for both routine management and initial surgical evaluation for spine surgery candidates.

Level of Evidence: 3

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Interhospital Transfer of Neurosurgical Patients to a High-Volume Tertiary Care Center: Opportunities for Improvement

Interhospital Transfer of Neurosurgical Patients to a High-Volume Tertiary Care Center- Opportunities for Improvement

Neurosurgery 77:200–207, 2015

Neurosurgical indications for patient transfer include absence of local or available neurosurgical coverage, subspecialty or interdisciplinary requirements, and family preference. Transfer of patients to regional centers will increase with further centralization of medical care.

OBJECTIVE: To report the transfer records of a large tertiary care center to identify trends, failures, and opportunities to improve interhospital transfer of neurosurgical patients.

METHODS: All consecutive, prospectively documented requests for interhospital patient transfer to the adult neurosurgical service of Emory University Hospitals were retrospectively identified from a centralized transfer center database for a 1-year study period.

RESULTS: Requests for neurosurgical care constituted 1323 of the 9087 calls (14.6%); 81.1% of these requests were accepted, and a total of 984 patients (74.4%) arrived at our institutions. Patients arrived from 133 unique facilities throughout a catchment area of 66 287 sq miles. Although the median travel time for transfer patients was 36 minutes, the median interval between the request and patient arrival was 4 hours 2 minutes. The most frequent diagnoses were intracranial hemorrhage (31.8%), subarachnoid hemorrhage (31.2%), and intracranial tumor (15.2%). The overall diagnostic error rate was 10.3%. Only 42.5% of patients underwent neurosurgical intervention, and 57 patients admitted to intensive care were immediately transitioned to a lower level of care.

CONCLUSION: Interhospital transfer requires a coordinated effort among hospital administrators, physicians, and staff to make complex decisions that govern this important and costly process. These data suggest common failures and numerous opportunities for improvement in transfer efficiency, diagnostic accuracy, triage, and resource allocation.

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Telemedicine Through the Use of Digital Cell Phone Technology in Pediatric Neurosurgery: A Case Series

Neurosurgery. 66(5):999-1004, May 2010. DOI: 10.1227/01.NEU.0000368443.43565.2A

Advances in medicine have largely followed advances in technology. Medical strides have been made when physicians and researchers have adapted growing science to target specific problems. A new medical field, telemedicine, has emerged that links physicians with colleagues and patients. Cell phone technology is affordable for almost everyone, and basic models include digital photography.

OBJECTIVE: We present a case series exhibiting the utility of digital pictures taken with patients’ cell phones.

CLINICAL PRESENTATION: Our patients had wound infections requiring daily intravenous antibiotics and dressing changes. Previously, these patients would have required prolonged hospitalizations. Currently, patients with these infections are discharged from the hospital, but close outpatient observation is required to monitor the wound. Our patients lived up to 8 hours away from the hospital. Daily appointments for wound checks in the clinic were impractical. Wounds were monitored via cell phone images without the inconvenience of travel and the expense of a local hotel, and unnecessary appointments in the clinic.

INTERVENTION: Wound evaluations were conducted with the patients’ cell phone cameras. These images were transmitted to the surgeon by text messaging and emails.

CONCLUSION: This application of cell phone technology has been documented in other literature and could become a legitimate method for close outpatient observation by neurosurgeons if medicolegal issues are addressed.

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