The magnitude and potential duration of the current coronavirus disease 2019 (COVID-19) pandemic is something that most doctors currently in practice have yet to experience. While considerable information regarding COVID-19 is being published every day, it is challenging to filter out the most relevant or appropriate information for our individual practice. The Spine Society of Singapore convened via a teleconference on April 24, 2020 to collaborate on a national level and share collective wisdom in order to tackle the ongoing crisis. In the teleconference, 13 spine surgeons from across various hospitals in Singapore constituted the panel of experts. The following topics were discussed: repurposing of surgeons, continuity of spine services, introduction of telemedicine, triaging of spinal surgeries, preoperative testing, new challenges in performing spine surgery, and preparing for the post-pandemic era. While some issues required only the sharing of best practices, the Delphi panel method was adopted to form a consensus on others. Existing spine specific triage guidelines were debated and a locally accepted set of guidelines was established. Although preoperative testing is currently not performed routinely, the panel voted in favor of its implementation because they concluded that it is vital to protect themselves, their colleagues, and their patients. Solutions to operating room specific concerns were also discussed. This article reflects the opinions and insights shared during this meeting and reviews the evidence relevant to the issues that were raised. The rapid consensus reached during the teleconference has enabled us to be concerted, and thus stronger, in our national efforts to provide the best standard of care via our spine services in these challenging times. We believe that this article will provide some guidance for addressing COVID-19 in spine surgery and encourage other national/regional societies to conduct similar discussions that would help their navigation of this pandemic.

Methods: We reviewed the evidence behind telemedicine and described our clinical protocol, patient selection criteria, and workflow for telemedicine. We discussed a simple methodology to convert pre-existing traditional clinic resources into telemedicine tools, along with future challenges. Results: Our methodology was successfully and easily applied in our clinical practice, with a streamlined workflow allowing our spine surgery service to implement telemedicine as a consultation modality in line with the national recommendations of social distancing. Conclusions Telemedicine was well incorporated into our outpatient practice using the above workflow. We believe that the use of telemedicine via videoconferencing can become part of the new normal and a safe strategy for healthcare systems as both a medical and an economic countermeasure against COVID-19.

Methods: We reviewed the evidence behind telemedicine and described our clinical protocol, patient selection criteria, and workflow for telemedicine. We discussed a simple methodology to convert pre-existing traditional clinic resources into telemedicine tools, along with future challenges. Results: Our methodology was successfully and easily applied in our clinical practice, with a streamlined workflow allowing our spine surgery service to implement telemedicine as a consultation modality in line with the national recommendations of social distancing. Conclusions Telemedicine was well incorporated into our outpatient practice using the above workflow. We believe that the use of telemedicine via videoconferencing can become part of the new normal and a safe strategy for healthcare systems as both a medical and an economic countermeasure against COVID-19.

BACKGROUNDSpine surgery using computer-assisted navigation (CAN) has been proven to result in low screw misplacement rates, low incidence of radiation exposure and excellent operative field viewing versus the conventional intraoperative image intensifier (CIII). However, as we know, few previous studies have described the learning curve of CAN in spine surgery.

METHODSWe performed two consecutive case cohort studies on pedicel screw accuracy and operative time of two spine surgeons with different experience backgrounds, A and B, in one institution during the same period. Lumbar pedicel screw cortical perforation rate and operative time of the same kind of operation using CAN were analyzed and compared using CIII for the two surgeons at initial, 6 months and 12 months of CAN usage.

RESULTSCAN spine surgery had an overall lower cortical perforation rate and less mean operative time compared with CIII for both surgeon A and B cohorts when total cases of four years were included. It missed being statistically significant, with 3.3% versus 4.7% (P = 0.191) and 125.7 versus 132.3 minutes (P = 0.428) for surgeon A and 3.6% versus 6.4% (P = 0.058), and 183.2 versus 213.2 minutes (P = 0.070) for surgeon B. In an attempt to demonstrate the learning curve, the cases after 6 months of the CAN system in each surgeon's cohort were compared. The perforation rate decreased by 2.4% (P = 0.039) and 4.3% (P = 0.003) and the operative time was reduced by 31.8 minutes (P = 0.002) and 14.4 minutes (P = 0.026) for the CAN groups of surgeons A and B, respectively. When only the cases performed after 12 months using the CAN system were considered, the perforation rate decreased by 3.9% (P = 0.006) and 5.6% (P < 0.001) and the operative time was reduced by 20.9 minutes (P < 0.001) and 40.3 minutes (P < 0.001) for the CAN groups of surgeon A and B, respectively.

CONCLUSIONSIn the long run, CAN spine surgery decreased the lumbar screw cortical perforation rate and operative time. The learning curve showed a sharp drop after 6 months of using CAN that plateaued after 12 months; which was demonstrated by both perforation rate and operative time data. Careful analysis of the data showed CAN is especially useful for less experienced surgeon to reduce perforation rate and intraoperative time, although further comparative studies are anticipated.

Cohort Studies ; Humans ; Spine ; surgery ; Surgery, Computer-Assisted ; methods