Robotic-Assisted vs Nonrobotic-Assisted Minimally Invasive Transforaminal Lumbar Interbody Fusion: A Cost-Utility Analysis.

BACKGROUND: Management of degenerative disease of the spine has evolved to favor minimally invasive techniques, including nonrobotic-assisted and robotic-assisted minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF). Value-based spending is being increasingly implemented to control rising costs in the US healthcare system. With an aging population, it is fundamental to understand which procedure(s) may be most cost-effective. OBJECTIVE: To compare robotic and nonrobotic MIS-TLIF through a cost-utility analysis. METHODS: We considered direct medical costs related to surgical intervention and to the hospital stay, as well as 1-yr utilities. We estimated costs by assessing all cases involving adults undergoing robotic surgery at a single institution and an equal number of patients undergoing nonrobotic surgery, matched by demographic and clinical characteristics. We adopted a willingness to pay of $50 000/quality-adjusted life year (QALY). Uncertainty was addressed by deterministic and probabilistic sensitivity analyses. RESULTS: Costs were estimated based on a total of 76 patients, including 38 undergoing robot-assisted and 38 matched patients undergoing nonrobot MIS-TLIF. Using point estimates, robotic surgery was projected to cost $21 546.80 and to be associated with 0.68 QALY, and nonrobotic surgery was projected to cost $22 398.98 and to be associated with 0.67 QALY. Robotic surgery was found to be more cost-effective strategy, with cost-effectiveness being sensitive operating room/materials and room costs. Probabilistic sensitivity analysis identified robotic surgery as cost-effective in 63% of simulations. CONCLUSION: Our results suggest that at a willingness to pay of $50 000/QALY, robotic-assisted MIS-TLIF was cost-effective in 63% of simulations. Cost-effectiveness depends on operating room and room (admission) costs, with potentially different results under distinct neurosurgical practices.

Telemedicine Utilization in Neurosurgery During the COVID-19 Pandemic: A Glimpse Into the Future?

OBJECTIVE: To describe telemedicine utilization in neurosurgery at a single tertiary institution to provide outpatient care during the coronavirus disease 2019 (COVID-19) pandemic, with 315 telemedicine visits performed by the neurosurgery department. PATIENTS AND METHODS: In response to the COVID-19 pandemic national stay-at-home orders and postponed elective surgeries, we converted upcoming clinic visits into telemedicine visits and rescheduled other patients thought not to be markedly affected by surgical postponement. We reviewed the charts of all patients who had telehealth visits from April 1 through April 30, 2020, and collected demographic information, diagnosis, type of visit, and whether they received surgery; a satisfaction questionnaire was also administered. RESULTS: In March 2020, 94% (644 of 685) of the neurosurgery clinic visits were face-to-face, whereas in April 2020, 55% (315 of 573) of the visits were telemedicine (P<.001). In April, of the 315 telemedicine visits, 172 (55%) were phone consults and 143 (45%) video consults; 101 (32%) were new consults, 195 (62%) return visits, and 18 (6%) postoperative follow-up. New consults were more likely to be video with audio than return visits and postoperative follow-up (P<.001). Only 39 patients (12%) required surgery. Ninety-one percent of the questionnaire respondents were very likely to recommend telemedicine. CONCLUSION: Rapid implementation of telemedicine to evaluate neurosurgery patients became an effective tool for preoperative consultation, postoperative and follow-up visits during the COVID-19 pandemic, and decreased risks of exposure to severe acute respiratory syndrome coronavirus 2 to patients and health care staff. Future larger studies should investigate the cost-effectiveness of telemedicine used to triage surgical from nonsurgical patients, potential cost-savings from reducing travel burdens and lost work time, improved access, reduced wait times, and impact on patient satisfaction.

Path to Reopening Surgery in the COVID-19 Pandemic: Neurosurgery Experience.

OBJECTIVE: To test the efficacy of an innovative coronavirus disease 2019 (COVID-19) preoperative triage protocol as a way to gradually reopen and ramp-up elective surgeries. PATIENTS AND METHODS: We reviewed clinical, radiographic, and laboratory data for all patients who underwent surgery within the neurosurgery department from March 26 through April 22, 2020. We collected data on demographic information, comorbidities, preoperative COVID-19 test results, whether COVID-19 respiratory or other symptoms were developed during hospitalization, hospital length of stay, discharge disposition, and postoperative COVID-19 test results. RESULTS: Using a combination of both preoperative outpatient COVID-19 drive-through and inpatient testing to obtain surgical clearance with selected telemedicine evaluations, 103 nonelective neurosurgical procedures were performed in 102 patients. No patients tested positive for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) 48 hours before surgery. None of the patients developed any COVID-19 symptoms during their hospitalization or were readmitted to our emergency department postoperatively for COVID-19 symptoms. CONCLUSION: We describe a multifaceted preoperative triage protocol for safely performing nonelective neurosurgical procedures during the COVID-19 pandemic, which could help other neurosurgical departments and hospitals minimize coronavirus exposure for patients and health care workers. We believe this triage strategy could be implemented at other centers to gradually restart a process toward elective surgeries in a safe way.