Feasibility and Value of Telemedicine Neurosurgical Consultations in a Rural Health System

INTRODUCTION

Telemedicine has been available for more than 20 years and is playing an increasing role in clinical care. However, few studies have evaluated the value of telemedicine in neurosurgical consultations and in guiding neurosurgical care.

METHODS

In this prospective observational study, we examined our experience with emergency video telemedicine consultations for neurosurgical patients at a rural hospital system. Our system uses secure and HIPAA-compliant video conferencing to connect providers and patients to a remote neurosurgery consultant, and operates one out of two days.

RESULTS

During a ten-month period, 229 neurosurgical telemedicine consultations were performed. Two-thirds of the patients had intracranial pathology, 28% had spinal pathology and 3% of the consults were for patients who returned after care at our institution or required clearance for another procedure. Five patients required transfer within the hospital system and 12 out of the hospital system for a higher level of care (total 7.4%). Patients that required transfer most frequently had intracranial pathology (70%). The number of patients transferred out was less than in the year before telemedicine was available.

CONCLUSION

Telemedicine consultation for neurosurgery is feasible for a variety of neurosurgical pathologies, improves patient access to neurosurgery expertise, and facilitates appropriate transfers to a higher level of care when required. Our findings are especially relevant in light of the COVID-19 pandemic, which has highlighted the importance of delivering quality medical care when physical patient contact is not possible.

Future of convection-enhanced delivery in the treatment of brain tumors

Gliomas are one of the most lethal forms of cancer. The poor prognosis associated with these malignant primary brain tumors treated with surgery, radiotherapy and chemotherapy has led researchers to develop new strategies for cure. Interstitial drug delivery has been the most appealing method for the treatment of primary brain tumors because it provides the most direct method of overcoming the barriers to tumor drug delivery. By administering therapeutic agents directly to the brain interstitium and, more specifically, to tumor-infiltrated parenchyma, one can overcome the elevated interstitial pressure produced by brain tumors. Convection-enhanced delivery (CED) has emerged as a leading investigational delivery technique for the treatment of brain tumors. Clinical trials utilizing these methods have been completed, with mixed results, and several more are being initiated. However, the potential efficacy of these drugs may be limited by ineffective tissue distribution. The development of computer models/algorithms to predict drug distribution, new catheter designs, and utilization of tracer models and nanocarriers have all laid the groundwork for the advancement of CED. In this review, we summarize the recent past of the clinical trials utilizing CED and discuss emerging technologies that will shape future CED trials.

Novel drug delivery strategies in neuro-oncology

Treatment of malignant gliomas represents one of the most formidable challenges in oncology. Despite treatment with surgery, radiation therapy, and chemotherapy, the prognosis remains poor, particularly for glioblastoma, which has a median survival of 12 to 15 months. An important impediment to finding effective treatments for malignant gliomas is the presence of the blood brain barrier, which serves to prevent delivery of potentially active therapeutic compounds. Multiple efforts are focused on developing strategies to effectively deliver active drugs to brain tumor cells. Blood brain barrier disruption and convection-enhanced delivery have emerged as leading investigational delivery techniques for the treatment of malignant brain tumors. Clinical trials using these methods have been completed, with mixed results, and several more are being initiated. In this review, we describe the clinically available methods used to circumvent the blood brain barrier and summarize the results to date of ongoing and completed clinical trials.

Novel drug delivery strategies in neuro-oncology

Treatment of malignant gliomas represents one of the most formidable challenges in oncology. Despite treatment with surgery, radiation therapy, and chemotherapy, the prognosis remains poor, particularly for glioblastoma, which has a median survival of 12 to 15 months. An important impediment to finding effective treatments for malignant gliomas is the presence of the blood brain barrier, which serves to prevent delivery of potentially active therapeutic compounds. Multiple efforts are focused on developing strategies to effectively deliver active drugs to brain tumor cells. Blood brain barrier disruption and convection-enhanced delivery have emerged as leading investigational delivery techniques for the treatment of malignant brain tumors. Clinical trials using these methods have been completed, with mixed results, and several more are being initiated. In this review, we describe the clinically available methods used to circumvent the blood brain barrier and summarize the results to date of ongoing and completed clinical trials.