Early Peri-operative Outcomes Were Unchanged in Patients Undergoing Spine Surgery During the COVID-19 Pandemic in New York City

A Longitudinal Evaluation of Coronavirus Disease 2019 and Its Effects on Spinal Decompressions With or Without Fusion

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

The objectives were to (1) compare the safety of spine surgery before and after the emergence of coronavirus disease 2019 (COVID-19) and (2) determine whether patients with a history of COVID-19 were at increased risk of adverse events.

SUMMARY AND BACKGROUND DATA

The COVID-19 pandemic had a tremendous impact on several health care services. In spine surgery, elective cases were canceled and patients received delayed care due to the uncertainty of disease transmission and surgical outcomes. As new coronavirus variants arise, health care systems require guidance on how to provide optimal patient care to all those in need of our services.

PATIENTS AND METHODS

A retrospective review of patients undergoing spine surgery between January 1, 2019 and June 30, 2021 was performed. Patients were split into pre-COVID or post-COVID cohorts based on local government guidelines. Inpatient complications, 90-day readmission, and 90-day mortality were compared between groups. Secondary analysis included multiple logistic regression to determine independent predictors of each outcome.

RESULTS

A total of 2976 patients were included for analysis with 1701 patients designated as pre-COVID and 1275 as post-COVID. The pre-COVID cohort had fewer patients undergoing revision surgery (16.8% vs 21.9%, P < 0.001) and a lower home discharge rate (84.5% vs 88.2%, P = 0.008). Inpatient complication (9.9% vs 9.2%, P = 0.562), inpatient mortality (0.1% vs 0.2%, P = 0.193), 90-day readmission (3.4% vs 3.2%, P = 0.828), and 90-day mortality rates (0.8% vs 0.8%, P = 0.902) were similar between groups. Patients with positive COVID-19 tests before surgery had similar complication rates (7.7% vs 6.1%, P = 1.000) as those without a positive test documented.

CONCLUSIONS

After the emergence of COVID-19, patients undergoing spine surgery had a greater number of medical comorbidities, but similar rates of inpatient complications, readmission, and mortality. Prior COVID-19 infection was not associated with an increased risk of postsurgical complications or mortality.

LEVEL OF EVIDENCE

Level III.

COVID-19 and Elective Spine Surgery: The Older Persons' Experience of Going It Alone

ABSTRACT

BACKGROUND: Older people with debilitating degenerative spine disease may benefit from surgery. However, recovery is described as a circuitous process. In general, they describe feeling powerless and receiving depersonalized care during hospitalization. Institution of hospital no-visitor policies to reduce COVID-19 spread may have caused additional negative consequences. The purpose of this secondary analysis was to understand experiences of older people who underwent spine surgery during early COVID-19. METHODS: Grounded theory guided this study of people 65 years or older undergoing elective spine surgery. Fourteen individuals were recruited for 2 in-depth interviews at 2 time points: T1 during hospitalization and T2, 1 to 3 months post discharge. All participants were affected by pandemic-imposed restrictions with 4 interviews at T1 with no visitors, 10 with a 1-visitor policy, and 6 interviews at T2 rehabilitation setting with no visitors. Discriminate sampling of data in which participants described their experiences with COVID-19 visitor restrictions was used. Open and axial coding (consistent with grounded theory) was used for data analysis. RESULTS: Three categories, worry and waiting , being alone , and being isolated , emerged from the data. Participants had delays ( waiting ) in getting their surgery scheduled, which produced worry that they would lose more function, become permanently disabled, have increased pain, and experience more complications such as falls. Participants described being alone during their hospital and rehabilitation recovery, without physical or emotional support from family and limited nursing staff contact. Being isolated often occurred from institution policy, restricting participants to their rooms leading to boredom and, for some, panic. CONCLUSIONS: Restricted access to family after spine surgery and during recovery resulted in emotional and physical burden for participants. Our findings support neuroscience nurses advocating for family/care partner integration into patient care delivery and investigation into the effect of system-level policies on patient care and outcomes.

Minimally Invasive Procedures, Perioperative Telemedicine, and Decreased Hospital Stays Following Covid-19 Surgical Restrictions: Spinal Surgery

The 2019 severe acute respiratory syndrome coronavirus 2 pandemic had devastating impacts on healthcare system operations. Disruption of this delicate system led to international healthcare challenges with new policy changes that affected all specialties, including the global spine surgery community. The pandemic disrupted normal spine surgery proceedings, restricting, and postponing elective procedures, which comprise a large proportion of spine surgeries. This disruption may have contributed to significant economic losses for providers and resulted in the prolonged impairment of patients who were forced to postpone their procedures. However, response to the pandemic precipitated new procedural guidelines and practices that prioritize health outcomes and satisfaction. These new changes and innovations are positioned to provide lasting economic and procedural impacts in favor of both providers and patients. Thus, the objective of our review is to explore how spinal surgical practices and post-op recovery changed following COVID-19 and highlight some lasting impacts the pandemic created for future patients.

A Retrospective Study of the Impact of COVID-19 Pandemic Related Administrative Restrictions on Spine Surgery Practice and Outcomes in an Urban Healthcare System

The study objective is to characterize the impact of COVID-19 related hospital administrative restrictions on patient demographics, surgical care, logistics, and patient outcomes in spine surgery. This was a retrospective study of 331 spine surgery patients at UCSD conducted during 1 March 2019-31 May 2019 (pre-COVID-19) and 1 March 2020-31 May 2020 (first COVID-19 surge). All variables were collected through RedCap and compared between pre- and during-COVID groups. There were no significant differences in patient demographics, operating room duration, and skin-to-skin time. However, length of stay was 4.7 days shorter during COVID-19 (p = 0.03) and more cases were classified as 'urgent' (p = 0.04). Preoperative pain scores did not differ between groups (p = 0.51). However, pain levels at discharge were significantly higher during COVID (p = 0.04) and trended towards remaining higher in the short- (p = 0.05) but not long-term (p = 0.17) after surgery. There was no significant difference in the number of post-operative complications, but there was an increase in the use of the emergency room and telemedicine to address complications when they arose. Overall, the pandemic resulted in a greater proportion of 'urgent' spine surgery cases and shorter length of hospital stay. Pain levels upon discharge and at short-term timepoints were higher following surgery but did not persist in the long term.

Changes in Surgical Volume and Outcomes During the Coronavirus Disease 2019 Pandemic at Two Tertiary Hospitals in Ethiopia: A Retrospective Cohort Study

BACKGROUND

Limited data exist concerning how the coronavirus disease 2019 (COVID-19) pandemic has affected surgical care in low-resource settings. We sought to describe associations between the COVID-19 pandemic and surgical care and outcomes at 2 tertiary hospitals in Ethiopia.

METHODS

We conducted a retrospective observational cohort study analyzing perioperative data collected electronically from Ayder Comprehensive Specialized Hospital (ACSH) in Mekelle, Ethiopia, and Tibebe Ghion Specialized Hospital (TGSH) in Bahir Dar, Ethiopia. We categorized COVID-19 exposure as time periods: "phase 0" before the pandemic (November 1-December 31, 2019, at ACSH and August 1-September 30, 2019, at TGSH), "phase 1" starting when elective surgeries were canceled (April 1-August 3, 2020, at ACSH and March 28-April 12, 2020, at TGSH), and "phase 2" starting when elective surgeries resumed (August 4-August 31, 2020, at ACSH and April 13-August 31, 2020, at TGSH). Outcomes included 28-day perioperative mortality, case volume, and patient district of origin. Incidence rates of case volume and patient district of origin (outside district yes or no) were modeled with segmented Poisson regression and logistic regression, respectively. Association of the exposure with 28-day mortality was assessed using logistic regression models, adjusting for confounders.

RESULTS

Data from 3231 surgeries were captured. There was a decrease in case volume compared to phase 0, with adjusted incidence rate ratio (IRR) of 0.73 (95% confidence interval [CI], 0.66-0.81) in phase 1 and 0.90 (95% CI, 0.83-0.97) in phase 2. Compared to phase 0, there were more patients from an outside district during phase 1 lockdown at ACSH (adjusted odds ratio [aOR], 1.63 [95% CI, 1.24-2.15]) and fewer patients from outside districts at TGSH (aOR, 0.44 [95% CI, 0.21-0.87]). The observed 28-day mortality rates for phases 0, 1, and 2 were 1.8% (95% CI, 1.1-2.8), 3.7% (95% CI, 2.3-5.8), and 2.9% (95% CI, 2.1-3.9), respectively. A confounder-adjusted logistic regression model did not show a significant increase in 28-day perioperative mortality during phases 1 and 2 compared to phase 0, with aOR 1.36 (95% CI, 0.62-2.98) and 1.54 (95% CI, 0.80-2.95), respectively.

CONCLUSIONS

Analysis at 2 low-resource referral hospitals in Ethiopia during the COVID-19 pandemic showed a reduction in surgical case volume during and after lockdown. At ACSH, more patients were from outside districts during lockdown where the opposite was true at TGSH. These findings suggest that during the pandemic patients may experience delays in seeking or obtaining surgical care. However, for patients who underwent surgery, prepandemic and postpandemic perioperative mortalities did not show significant difference. These results may inform surgical plans during future public health crises.

COVID-19 pandemic and elective spinal surgery cancelations - what happens to the patients?

BACKGROUND CONTEXT

The COVID-19 pandemic caused nationwide suspensions of elective surgeries due to reallocation of resources to the care of COVID-19 patients. Following resumption of elective cases, a significant proportion of patients continued to delay surgery, with many yet to reschedule, potentially prolonging their pain and impairment of function and causing detrimental long-term effects.

PURPOSE

The aim of this study was to examine differences between patients who have and have not rescheduled their spine surgery procedures originally cancelled due to the COVID-19 pandemic, and to evaluate the reasons for continued deferment of spine surgeries even after the lifting of the mandated suspension of elective surgeries.

STUDY DESIGN/SETTING

Retrospective case series at a single institution PATIENT SAMPLE: Included were 133 patients seen at a single institution where spine surgery was canceled due to a state-mandated suspension of elective surgeries from March to June, 2020.

OUTCOME MEASURES

The measures assessed included preoperative diagnoses and neurological dysfunction, surgical characteristics, reasons for surgery deferment, and PROMIS scores of pain intensity, pain interference, and physical function.

METHODS

Patient electronic medical records were reviewed. Patients who had not rescheduled their canceled surgery as of January 31, 2021, and did not have a reason noted in their charts were called to determine the reason for continued surgery deferment. Patients were divided into three groups: early rescheduled (ER), late rescheduled (LR), and not rescheduled (NR). ER patients had a date of surgery (DOS) prior to the city's Phase 4 reopening on July 20, 2020; LR patients had a DOS on or after that date. Statistical analysis of the group findings included analysis of variance with Tukey's honestly significant difference (HSD) post-hoc test, independent samples T-test, and chi-square analysis with significance set at p≤.05.

RESULTS

Out of 133 patients, 47.4% (63) were in the ER, 15.8% (21) in the LR, and 36.8% (49) in the NR groups. Demographics and baseline PROMIS scores were similar between groups. LR had more levels fused (3.6) than ER (1.6), p= .018 on Tukey HSD. NR (2.1) did not have different mean levels fused than LR or ER, both p= >.05 on Tukey HSD. LR had more three column osteotomies (14.3%) than ER and (1.6%) and NR (2.0%) p=.022, and fewer lumbar microdiscectomies (0%) compared to ER (20.6%) and NR (10.2%), p=.039. Other surgical characteristics were similar between groups. LR had a longer length of stay than ER (4.2 vs 2.4, p=.036). No patients in ER or LR had a nosocomial COVID-19 infection. Of NR, 2.0% have a future surgery date scheduled and 8.2% (4) are acquiring updated exams before rescheduling. 40.8% (20; 15.0% total cohort) continue to defer surgery over concern for COVID-19 exposure and 16.3% (8) for medical comorbidities. 6.1% (3) permanently canceled for symptom improvement. 8.2% (4) had follow-up recommendations for non-surgical management. 4.1% (2) are since deceased.

CONCLUSION

Over 1/3 of elective spine surgeries canceled due to COVID-19 have not been performed in the 8 months from when elective surgeries resumed in our institution to the end of the study. ER patients had less complex surgeries planned than LR. NR patients continue to defer surgery primarily over concern for COVID-19 exposure. The toll on the health of these patients as a result of the delay in treatment and on their lives due to their inability to return to normal function remains to be seen.