The coronavirus disease 2019 (COVID-19) pandemic has developed into the greatest crisis in the modern world since its emergence from Wuhan in December 2019 [1]. As of October 3rd, 2020, the number of confirmed cases has surpassed 34 million, with more than 1,026,000 deaths [2]. Based on multiple epidemiological studies and simulation models, the key to successfully containing the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2: COVID-19) is early detection, early isolation, and early intervention by means of social distancing and the reduction of non-essential human contact [3,4]. These steps are paramount for keeping the COVID-19 incidence curve flat until an effective vaccine is developed. Even after the curve has been flattened, avoiding a second or third wave of disease depends on the avoidance of unnecessary human exposure to SARS-CoV-2 in this new normal state, until herd immunity against the virus has been obtained.

The aim of this paper is to call for the use of telemedicine to reduce human exposure to SARS-CoV-2 in an outpatient setting. We describe our university spine clinic protocol, established methodology, and workflow considerations for the easy and rapid adoption of telemedicine in this extraordinary time.

Telemedicine has already been applied in the field of orthopedics with encouraging results. In the year 2000, Haukipuro et al. [5] performed the first orthopedic telemedicine randomized controlled trial (RCT) in Finland and found that, despite the inability to perform physical examinations, patients were satisfied with the videoconferencing nature of the consultation. In addition, Harno et al. [6] showed a 45% cost saving in orthopedic telemedicine consultations compared with traditional face-to-face consultations. Moreover, in 2019, Buvik et al. [7,8] reported two RCTs of telemedicine in remote orthopedic consultations. The studies found no difference in patient-reported satisfaction and health outcomes between video-assisted and standard consultations, with a significantly high proportion of patients being keen to continue with video-assisted consultations for their repeat consultation. Sultan et al. [9] studied 189 telemedicine virtual visits for pediatric patients with spinal deformity and found that the patients who underwent telemedicine consultations received faster care, with shorter waiting times to appointments and high patient satisfaction scores comparable to those of standard visits. Similar positive results with telemedicine have been reported in patients suffering spinal cord injuries [10] and chronic spinal pain [11].

In the era of the COVID-19 pandemic, reducing patient density in clinics by adopting telemedicine via videoconferencing is an important strategy that must be deployed as a matter of urgency. It has been reported that, among those infected with SARS-CoV-2, the asymptomatic carrier rate is up to 80% [12,13], with a prolonged period of viral shedding via the respiratory and fecal routes for up to 37 and 47 days, respectively, after the onset of symptoms [12,13]. These concerns add extra weight to the need to reduce patient density in clinics.

The additional advantages of telemedicine use during the COVID-19 pandemic include the following [14–16]: (1) providing continued medical care to patients whose condition is not deemed to be medically urgent for elective hospital admission; (2) protecting healthcare workers and patients from the risk of SARS-CoV-2 exposure and transmission; (3) reducing patient backlog during social distancing measures; (4) reducing demands on administrative staff for continuous rescheduling of appointments via contacting patients and re-bookings on the system during periods of partial or complete lockdown; (5) maintaining financial viability of outpatient practice to cover hospital overhead costs.

The construction of a comprehensive, customized telemedicine videoconferencing platform may take a long time and be expensive. A few quick and simple steps can be used to convert traditional clinic aids into telemedicine tools, as shown in Table 2. One of the difficulties with the use of telemedicine is confirmation of patients’ symptoms. This is especially so if the patient complains of back pain and sciatica, as the videoconferencing display only captures the face and upper torso of the patient, and it would be difficult for the patient to show the exact location of the pain on his or her back and legs in order for the surgeon to locate the dermatome of the nerve root pathology. To facilitate this, we scan a clinical body diagram with anterior and posterior views that can be charted by the clinician after ascertaining the symptoms of the patient (Fig. 1), and can be shown to the patient for telemedicine confirmation on the computer via the share-screen function on video conferencing software (Fig. 2). Different colors are used to illustrate symptoms (e.g., red for pain, blue for numbness, and green for paresthesia). The diagrams are later scanned as electronic records into our patient records system. In our hospital, this body diagram is part of our electronic history and physical examination template for patient symptoms. The use of a standardized electronic template during video conferencing can further reduce errors occurring during the transcription of medical information.

Another simple step made to quantify the severity of the patient’s symptoms is by scanning a copy of the Visual Analog Scale for pain as part of the telemedicine illustrative tool. This is shown on the shared screen during video consultation and allows the patient to effectively rank the severity of the symptoms.

In addition, we recommend scanning all pre-existing brochures for patient education and using spine models with and without implants available in the clinic as illustration tools during telemedicine consultation. These steps do not cost money and provide on-point information required for that specialty in the clinic. Information such as explanations of common pathologies (e.g., prolapsed intervertebral disc, scoliosis, and spinal stenosis), back care physiotherapy, and core strengthening exercises can be provided to patients during a videoconference and electronic copies of these reading materials can be emailed to them after the consultation. The use of these brochures, which are often written by and familiar to clinic specialists, may aid the surgeon in giving a better illustration during consultation and shortening clinicians’ telemedicine proficiency learning curve.

In our hospital, like many others, to maintain strict cybersecurity, the majority of hospital network computers do not have internet access. To circumvent this, an HDMI (high-definition multimedia interface) cable is used to connect the hospital network computer with the electronic medical records (EMR) system to a hospital-approved laptop with a webcam and internet access for videoconferencing. The operator should be trained to ensure cybersecurity and protect patient privacy. Headphones with a microphone are recommended to ensure privacy of communication and to avoid shouting at the patient in a noisy clinical environment due to poor internet reception. We advise consulting the hospital’s information technology (IT) department and using only hospital-approved videoconferencing software (e.g., Zoom Pro [Zoom Video Communications Inc., San Jose, CA, USA] or Microsoft Teams [Microsoft Corp., Redmond, WA, USA]).

During partial lockdown where the spine surgery division is segregated into separate teams, this telemedicine consultation platform is also set up in the office block where surgeons who are not scheduled in the clinic block can also review patients. After the COVID-19 curve is flattened, and in the new normal state, we expect that telemedicine consultation will remain and be integrated as part of the service provided during our normal clinic sessions. The clinic will provide two to three rooms for consultation, and approximately 50% of the booked patients (e.g., first-visit cases) will experience a traditional face-to-face consultation with physical examination, while the remaining 50% of patients in the same clinic session will be consulted via telemedicine videoconferencing to avoid overcrowding of the clinic.

There are several challenges that may be encountered during the implementation of teleconsultations.

Teleconsultations require a patient with a clinical condition suitable to be followed up in a virtual setting, and basic knowledge of and access to teleconferencing platforms. Some elderly patients may not be technologically literate, while others may not have access to computers. However, those with access to a phone that can support teleconferencing applications can still participate in telemedicine. For elderly patients who are not technologically literate, a younger, more technologically savvy family member can assist in the set up.