To the Editor:Clinics around the world are adapting to the novel coronavirus 2019 (COVID-19) pandemic employing telemedicine to serve the needs of their patients. Traditionally, telemedicine has been driven by providing healthcare to rural, underserved populations and has involved medical specialties that are thought to be more suitable for remote consultation, like psychiatry and dermatology. 1 During the COVID-19 pandemic, surgeons have started to implement remote clinic visits to meet the needs of their patients while practicing social distancing. Our aim is to discuss the unique challenges of caring for neurosurgical spine patients via telemedicine during the COVID-19 pandemic, and to define the opportunities for telemedicine as an outpatient care adjunct in the post-COVID-19 world.Neurosurgical telemedicine literature is sparse and primarily relates to triaging trauma in rural settings, 2 managing routine follow-up patients, 3 and analyzing the socioeconomic benefit for patients traveling long distances. 4 To meet the needs of the spine patient population, we must learn how to best incorporate telemedicine into spine care by (1) defining regulatory requirements, (2) implementing system-wide protocols centered around appropriate telemedicine technology, (3) structuring the clinic visit to best optimize telemedicine technology, and (4) understanding the benefits and limitations of telemedicine. REGULATORY REQUIREMENTSKey changes have been made to pre-COVID-19 telemedicine regulatory requirements in an effort to facilitate rapid implementation of telemedicine clinic visits across all medical specialties (see Table 1). Prior to the pandemic, healthcare providers had to be licensed in the state where the patient was located and Medicare/Medicaid covered only remote patient visits that occurred from eligible sites, which included offices, clinics, and hospitals, but not homes. 5 Currently, emergency waivers from governmental agencies now allow healthcare providers to see patients from out of state (though not all), telemedicine visits from home are now reimbursable, videoconferencing with non-Health Insurance Portability and Accountability Act (HIPAA)-compliant applications (such as FaceTime and Facebook Messenger) is acceptable, and prescriptions for controlled substances are now possible without a prior in-person evaluation. 5 Most private insurers have followed suit with the government and are allowing reimbursement for telemedicine visits.

Objective: Magnetic resonance imaging (MRI)-guided laser interstitial thermal therapy (MRg-LITT) is an alternative to open epilepsy surgery. We assess safety and effectiveness of MRg-LITT for extratemporal lobe epilepsy (ETLE) in patients who are considered less favorable for open resection. Methods: We retrospectively reviewed sequential cases of patients with focal ETLE who underwent MRg-LITT between 2012 and 2019. Epileptogenic zones were determined from standard clinical and imaging data ± stereoelectroencephalography (SEEG). Standard stereotactic techniques, MRI thermometry, and a commercial laser thermal therapy system were used for ablations. Anatomic MRI was used to calculate ablation volumes. Clinical outcomes were determined longitudinally. Results: Thirty-five patients with mean epilepsy duration of 21.3 ± 12.2 years underwent MRg-LITT for focal ETLE at a mean age 36.4 ± 12.7 years. A mean 2.59 ± 1.45 trajectories per patient were used to obtain ablation volumes of 8.8 ± 7.5 cm 3. Mean follow-up was 27.3 ± 19.5 months. Of 32 patients with >12 months of follow-up, 17 (53%) achieved good outcomes (Engel class I + II) of whom 14 (44%) were Engel class I. Subgroup analysis revealed better outcomes for patients with lesional ETLE than for those who were nonlesional, multifocal, or who had failed prior interventions (P = .02). Of 13 patients showing favorable seizure-onset patterns (localized low voltage fast activity or rhythmic spiking on SEEG) prior to ablation, 9 (69%) achieved good outcomes, whereas only 3 of 11 (27%) who show other slower onset patterns achieved good outcomes. Minor adverse events included six patients with transient sensorimotor neurologic deficits and four patients with asymptomatic hemorrhages along the fiber tract. Major adverse events included one patient with a brain abscess that required stereotactic drainage and one patient with persistent hypothalamic obesity. Three deaths-two seizure-associated and one suicide-were unrelated to surgical procedures.

OBJECTIVESeveral small series have described stereotactic MRI-guided laser interstitial thermal therapy for partial callosotomy of astatic and generalized tonic-clonic (GTC) seizures, especially in association with Lennox-Gastaut syndrome. Larger case series and comparison of distinct stereotactic methods for stereotactic laser corpus callosotomy (SLCC), however, are currently lacking. The objective of this study was to report seizure outcomes in a series of adult patients with epilepsy following anterior, posterior, and complete SLCC procedures and to compare the results achieved with a frameless stereotactic surgical robot versus direct MRI guidance frames.METHODSThe authors retrospectively reviewed sequential adult epilepsy surgery patients who underwent SLCC procedures at a single institution. They describe workflows, stereotactic errors, percentage disconnection, hospitalization durations, adverse events, and seizure outcomes after performing anterior, posterior, and complete SLCC procedures using a frameless stereotactic surgical robot versus direct MRI guidance platforms.RESULTSThirteen patients underwent 15 SLCC procedures. The median age at surgery was 29 years (range 20–49 years), the median duration of epilepsy was 21 years (range 9–48 years), and median postablation follow-up was 20 months (range 4–44 months). Ten patients underwent anterior SLCC with a median 73% (range 33%–80%) midsagittal length of callosum acutely ablated. Following anterior SLCC, 6 of 10 patients achieved meaningful (> 50%) reduction of target seizures. Four patients underwent posterior (completion) SLCC following prior anterior callosotomy, and 1 patient underwent complete SLCC as a single procedure; 3 of these 5 patients experienced meaningful reduction of target seizures. Overall, 8 of 10 patients in whom astatic seizures were targeted and treated by anterior and/or posterior SLCC experienced meaningful improvement. SLCC procedures with direct MRI guidance (n = 7) versus a frameless surgical robot (n = 8) yielded median radial accuracies of 1.1 mm (range 0.2–2.0 mm) versus 2.4 mm (range 0.6–6.1 mm; p = 0.0011). The most serious adverse event was a clinically significant intraparenchymal hemorrhage in a patient who underwent the robotic technique.CONCLUSIONSThis is the largest reported series of SLCC for epilepsy to date. SLCC provides seizure outcomes comparable to open surgery outcomes reported in the literature. Direct MRI guidance is more accurate, which has the potential to reduce the risks of SLCC. Methodological advancements and larger studies are needed.

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