It has now been six months since COVID-19 was declared a pandemic by the World Health Organization. The impact of this disease has been immense, but not unprecendented; our society has gone through previous pandemics, as was the case with the Spanish Flu. In the face of this immense challenge, many neurosurgical centers have resorted to creative measures to allow for efficient delivery of surgical care and neurosurgical education. It is imperative that the lessons learned are published and used as references for other centers and in preparation for future health crises. It is now appropriate to reflect on the literature available and identify knowledge gaps that need further research. The literature on the impact of COVID-19 on surgical practice can broadly be divided into five categories:
- Neurosurgical Education;
- Telehealth;
- Provider Health;
- Status of Care; and
- Surgical Triaging.
This article highlights some key findings in each category from the currently available literature.
Status of Care
Neurosurgeons worldwide have reported significant changes to practice as a result of the COVID-19 pandemic. Many of these reports come from countries who have been most impacted by the virus, such as Italy and the U.S. Cancellation of elective procedures and an overall reduction in surgical volume have been reported in institutions worldwide. One center in Italy reported a 50% decrease in spinal surgery from March 2020 to June 2020, compared to the same time period in 2019.1 Additionally, a survey of 486 members of the Latin American Federation of Neurosurgical Societies reported a mean 79% reduction in neurosurgical practice.2 Not only are case volumes affected by COVID-19, but also patients are presenting differently. A center in Germany reported older patients with chronic subdural hematoma presented less often, with poorer disease profile (p=0.046) and had a lower likelihood of reaching a positive treatment outcome (p=0.003) compared to pre-COVID.3 Patients with spinal emergencies also presented later following symptom onset (median 72h in 2020 compared to median of 24h in 2019, p =0.001) during the pandemic.
Delivery of care has also changed by reducing time patients spend in the hospital by utilizing telemedicine and allowing for early discharge when possible. Changes in protocol at one site have allowed the mean time between admission and surgery to be reduced from 6.8 days in 2019 to 1.7 days (p<0.001) during the COVID-19 pandemic.4 Furthermore, during the pandemic, there has been a significant increase in the cases of abusive head trauma in the United Kingdom. Ten cases were reported in a one month period (March 23-April 23, 2020), compared to a mean of 0.67 cases per month in the same time frame over the last three years (1,493% increase in cases).5 A review of 18 studies that commented on changes in neurosurgical practice during the pandemic identified three main themes: cancellation of elective operations, reduction in outpatient services and pandemic rotas.6
Surgical Triaging
Triaging and managing surgical flow during the pandemic present neurosurgeons with challenging practical and ethical decisions. Neurosurgery departments have shared their experiences and offer recommendations on how to triage patients for different subspecialties. Several departments have split teams into groups operating independently to minimize transmission of infection. Multidisciplinary meetings are being held to decide which cases require surgery and which can be delayed. High-risk surgeries such as sinus and skull base procedures are being identified and additional precautions implemented because of potential aerosolization of COVID-19.7 The time gained from reduced surgical volume was utilized by several departments to assist in medical wards and COVID units. Furthermore, decision-making tools have been developed to facilitate triage. Rispoli et al. present a framework to assess the status of the health care system and subsequently clarify which spine surgeries should be prioritized.8 Sciubba et al. present a quantitative urgency scoring system to triage spine patients using neurologic status, underlying spine stability, presentation of high-risk postoperative complication, patient medical comorbidities, expected hospital course, expected discharge disposition, facility resource limitations and local disease burden.9 The literature also comments on the long-term impact of delaying operations deemed as “nonurgent” during the pandemic, such as for certain cases of idiopathic normal pressure hydrocephalus, degenerative spine disease and peripheral nerve pathologies.
There is also concern surrounding how delaying elective procedures will dramatically increase surgical volume post-COVID because of the backlog of cases. It is imperative that in the aftermath of the COVID-19 pandemic revamping of surgical care is done systematically to avoid disproportionate impact on underserved populations. Given shared resources, any priority setting has to be discussed with the greater surgical community and allied health representatives. It is recommended that revamping of surgical care is monitored to identify underserved populations that need focused attention.
Telehealth
To maintain continuity of care and reduce the spread of COVID-19, neurosurgery departments have increased the use of telemedicine. At one institution in the U.S., there was a 40-fold increase in telemedicine use amid shelter-in-place measures, with significant increases in average numbers of patients seen via telemedicine each week across all divisions of neurosurgery (4.5 ± 0.9 to 180.4 ± 13.9, P < 0.001).10 Additionally, reports show high levels of satisfaction with telemedicine among neurosurgeons and their patients.11 A systematic review found that telemedicine was successful in 99.6% of cases, with 81.5% of unsuccessful cases due to technological failure.12 Although telemedicine confers advantages during a pandemic, there are still challenges in performing physical exams online and adapting to the new format. In response to this need, guidelines and recommendations have been published to assist neurosurgeons in various disciplines, particularly spine surgery.13
In the aftermath of the pandemic, it will be interesting to see the expanded role of telemedicine in neurosurgical care. Lessons learned from the transfer to telehealth can be used to develop virtual clinics aimed at providing care to underserved populations. Furthermore, research meetings and conferences can shift towards virtual visits to improve outreach to centers in the developing world.
Neurosurgical Education
The COVID-19 pandemic has posed significant challenges to neurosurgical education. Trainees’ surgical experience has been reduced as departments cancel elective surgeries and limit numbers in the hospital and operating room (OR). In a survey administered to residents in the United States (US), 91% of respondents reported that their work responsibilities or hospital access reduced.14 Furthermore, changes to the OR environment pose additional challenges to learning neurosurgical techniques. To help combat the strain COVID-19 has put on resident education, neurosurgical departments have transitioned to online meetings to continue educational activities, had trainees continue gaining clinical experience through telehealth, and increased focus on resident research. One department has even created a microsurgical skills program for residents at home using basic suturing material and their smartphone, with results showing significant improvement in ability.15 In addition, resident education may also be limited due to redeployment from neurosurgery into a COVID-related area.16
The pandemic has also affected medical students interested in neurosurgery by limiting shadowing, clinical rotations and mentorship opportunities.17 The cancellation of sub-internships has also raised questions for the 2020-2021 residency cycle with regards to how applicants will be selected. To combat this, creative strategies are required. In a nationwide survey in the U.S., the most favourable educational interventions for first and second year medical students were virtual mentorships. For third and fourth year students the most favourable intervention was virtual surgical skills workshops.18 Research, which constitutes a significant portion of neurosurgical education, has also been impacted. Many labs were forced to shut down completely or operate with restricted hours. Given the importance of research on neurosurgical education, students can transition to projects that do not require phsycial lab space. Examples of such projects include systematic reviews and data analytical work.
Provider Health
Providing care during the COVID-19 pandemic puts neurosurgeons’ physical and mental health at risk. Strategies to mitigate risk include intubations and extubations being performed with only anesthesia staff present, OR staff only entering after the air has been cleared of particulate matter, limiting the use of general anesthesia when possible and additional personal protective equipment (PPE) precautions. Special focus is given to high-risk aerosol generating procedures, such as endonasal surgeries. Recommendations for these surgeries include irrigating power drills more often to reduce aerosolization, using nonpowered tools if possible, using powered-air-purifying respirators, and additional training for staff.
The effects of COVID-19 on the mental health of neurosurgeons has also been studied. A survey of spine surgeons worldwide revealed family health concerns to be the greatest stressor globally (76.0%) and PPE access to be an issue for surgeons as well, with 50.4% indicating inadequate PPE at their site.19 The availability of PPE appears relevant to mental health as the availability of N95 masks (47%) and disposable eye protectors or face shields (39.4%) was significantly associated with lower psychological stress.20 As the pandemic continues, it is critical to keep health care providers healthy and free from infection as they serve their communities.
Overall, the current COVID-19 pandemic has imposed immense challenges and barriers to neurosurgical practice. It is crucial for effective strategies to be shared in the literature for use for other centers and in preparation for future pandemics. It is plausible that we will be faced with another global pandemic in our life time and summary of key recommendations need to be available. Some changes, such as the increasing use of telemedicine, can also be adapted for use during routine care to enhance surgical care delivery.
References
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