Triaging Spine Surgery and Treatment during the COVID-19 Pandemic

COVID-19 and Spontaneous Resolution of Lumbar Disk Prolapse: A Retrospective Cohort Study of Patients Awaiting Microdiscectomy

BACKGROUND

 Between individual patients with lumbar disk prolapse (LDP), the natural course of disease is significantly variable. Spontaneous resolution is reported to occur in up to 70% of cases. However, we currently cannot predict for whom and when this will occur. Neurosurgical intervention is indicated for LDP patients with nontolerable pain after at least 8 to 12 weeks of conservative management, or significant neurologic deficit. Channeling essential resources in the National Health Service (NHS) to fight the COVID-19 pandemic led to the postponement of most elective operations, including microdiskectomy. This left many LDP patients previously considered to be surgical candidates with conservative-only options in the interim. To our knowledge, we are the first center to report the specific impact of the peri- and postpandemic period on waiting list times, delayed elective microdiskectomy, and the incidence of spontaneous LDP resolution.

METHODS

 Retrospective case series of a prospectively collected electronic departmental database identified LDP patients who would have been impacted by the COVID-19 pandemic at some point in their care pathway (March 2020-February 2022). Further information was obtained from electronic patient records.

RESULTS

 In total, 139 LDP patients were listed for elective microdiskectomy at the time of postponement of elective surgery. Over a third of LDP patients (n = 47, 33.8%), in shared decision with the responsible neurosurgeon, had their rescheduled microdiskectomy canceled due to clinical improvement (14.1%), radiologic regression (6.5%), or both (12.2%).

CONCLUSION

 Our single-center retrospective analysis revealed that for over a third of LDP patients, the prolonged postpandemic waiting list times for elective microdiskectomy resulted in their surgery not taking place either due to spontaneous clinical improvement or proven radiologic regression. Considering this, a prolonged conservative approach to LDP may be appropriate in some patients, allowing time for natural resolution, while avoiding perioperative risks.

The Impact of the COVID-19 Pandemic on Ambulatory Lumbar Spine Decompression Surgery

Background Only a few studies have examined the impact of the coronavirus disease 2019 pandemic on spine ambulatory surgeries and changes in trends. Therefore, we investigated trends during the pre-pandemic period and three pandemic stages in patients undergoing lumbar decompression procedures in the ambulatory surgery (AMS) setting. Methodology A total of 2,670 adult patients undergoing one- or two-level lumbar decompression surgery were retrospectively reviewed. Patients were categorized into the following four groups: 1: pre-pandemic (before the pandemic from January 1, 2019, to March 16, 2020); 2: restricted period (when elective surgery was canceled from March 17, 2020, to June 30, 2020); 3: post-restricted 2020 (July 1, 2020, to December 31, 2020, before vaccination); and 4: post-restricted 2021 (January 1, 2021 to December 31, 2021 after vaccination). Simple and multivariable logistic regression analyses as well as retrospective interrupted time series (ITS) analysis were conducted comparing AMS patients in the four periods. Results Patients from the restricted pandemic period were younger and healthier, which led to a shorter length of stay (LOS). The ITS analysis demonstrated a significant drop in mean LOS at the beginning of the restricted period and recovered to the pre-pandemic levels in one year. Multivariable logistic regression analyses indicated that the pandemic was an independent factor influencing the LOS in post-restricted phases. Conclusions As the post-restricted 2020 period itself might be independently influenced by the pandemic, these results should be taken into account when interpreting the LOS of the patients undergoing ambulatory spine surgery in post-restricted phases.

[Translated article] Impact of COVID-19 pandemia on spine surgery in 2nd level hospital

INTRODUCTION

The consequences of COVID-19 pandemic, like in any other field of medicine, had such a massive effect in the activity of spine surgeons.

OBJECTIVES

The main purpose of the study is quantifying the number of interventions done between 2016 and 2021 and analyze the time between the indication and the intervention as an indirect measurement of the waiting list. As secondary objectives we focused on variations of the length of stay and duration of the surgeries during this specific period.

METHODS

We performed a descriptive retrospective study including all the interventions and diagnosis made during a period including pre-pandemic data (starting on 2016) until 2021, when we considered the normalization of surgical activity was achieved. A total of 1039 registers were compiled. The data collected included age, gender, days in waiting list before the intervention, diagnosis, time of hospitalization and surgery duration.

RESULTS

We found that the total number of interventions during the pandemic has significantly decreased compared to 2019 (32.15% less in 2020 and 23.5% less in 2021). After data analysis, we found an increase of data dispersion, average waiting list time and for diagnosis after 2020. No differences were found regarding hospitalization time or surgical time.

CONCLUSION

The number of surgeries decreased during pandemic due to the redistribution of human and material resources to face the raising of critical COVID-19 patients. The increase of data dispersion and median of waiting time, is the consequence of a growing waiting list for non-urgent surgeries during the pandemic as the urgent interventions also raised, those with a shorter waiting time.

Impact of COVID-19 pandemia on spine surgery in 2nd level hospital

INTRODUCTION

The consequences of COVID-19 pandemic, like in any other field of medicine, had such a massive effect in the activity of spine surgeons.

OBJECTIVES

The main purpose of the study is quantifying the number of interventions done between 2016 and 2021 and analyze the time between the indication and the intervention as an indirect measurement of the waiting list. As secondary objectives we focused on variations of the length of stay and duration of the surgeries during this specific period.

METHODS

We performed a descriptive retrospective study including all the interventions and diagnosis made during a period including pre-pandemic data (starting on 2016) until 2021, when we considered the normalization of surgical activity was achieved. A total of 1039 registers were compiled. The data collected included age, gender, days in waiting list before the intervention, diagnosis, time of hospitalization and surgery duration.

RESULTS

We found that the total number of interventions during the pandemic has significantly decreased compared to 2019 (32.15% less in 2020 and 23.5% less in 2021). After data analysis, we found an increase of data dispersion, average waiting list time and for diagnosis after 2020. No differences were found regarding hospitalization time or surgical time.

CONCLUSION

The number of surgeries decreased during pandemic due to the redistribution of human and material resources to face the raising of critical COVID-19 patients. The increase of data dispersion and median of waiting time, is the consequence of a growing waiting list for non-urgent surgeries during the pandemic as the urgent interventions also raised, those with a shorter waiting time.

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.

Management and Scheduling of Spine Surgery in a Level 1 Trauma Center in the Setting of the COVID-19 Pandemic: Feasibility and Considerations for Reimplementation of Elective Spine Surgery

Introduction

Determination of what constitutes necessary surgery in the setting of acute hospital resource strain during the COVID-19 pandemic is an unprecedented challenge for healthcare systems. Over the past two years during the COVID-19 pandemic, there have been many changes in reviews of medically necessary spine surgery. There continues to be no clear guidelines on recommendations and further discussion is necessary to continue to provide appropriate and high-level care during future pandemics.

Significance

This review critically appraises and evaluates current barriers to medically necessary spine surgery during the COVID-19 pandemic and evaluates future decision making to maintain spine surgery during future pandemics or limitations in medical care.

Results

Multiple studies included in this review have shown that while various orthopaedic surgeries may be considered elective, medically necessary spine surgery will need to continue during settings of limited medical care. This review discussed multiple methods and recommendations to limit transmission of virus from patients to providers and providers to patients.

Conclusion

Continued medically necessary spine surgery in the setting of the COVID-19 pandemic and future pandemics should continue while limiting risk of transmission to continue providing high-level medical care and allowing hospitals to maintain financial responsibility.

Global research hotspots and trends in the field of spine surgery during the COVID-19 pandemic: A bibliometric and visual analysis

Background

The Coronavirus disease-2019 (COVID-19) significantly affected the healthcare and research systems, including spine surgery, throughout the world. A bibliometric analysis allows graphical visualization of the development of an academic field and its frontiers. Since research concerning spine surgery during the COVID-19 pandemic is being constantly upgraded, we conducted a bibliometric analysis of this literature to investigate the current status, research hotspots, and trends in this field.

Methods

We searched the Web of Science database for literature published (from December 1, 2019, to March 24, 2022) using the terms “COVID-19” OR “2019-nCoV” OR “SARS-CoV-2” AND “spine surgery” OR “spinal surgery” OR “discectomy” OR “decompression” OR “laminectomy” OR “interbody fusion” OR “pedicle screws.” Detailed bibliometric and visual analysis of the number of publications, geographical distribution, institutions, journals, authors, and keywords was done using CiteSpace, VOSviewer, and R-Bibliometrix.

Results

Of the initially screened 173 articles, we included 84 relevant articles—62 original articles, 10 editorial materials, 8 reviews, and 4 others. The United States, China, Egypt, and Argentina were most actively publishing in the field of spine surgery and COVID-19. The AOSpine International community contributed 7 articles (24 citations). The Hospital for Special Surgery (13.1%) and Johns Hopkins University (13.1%) were institutions with the most publications. Using the Law of Bradford, we found that World Neurosurgery, Global Spine Journal, and European Spine Journal are the core journals in this field, with P. K. Louie being the most influential author. “Elective surgery,” “intensive care,” “telehealth,” “patient satisfaction,” and “follow-up” had the strongest citation bursts.

Conclusions

During the COVID-19 pandemic, spine surgeons were more concerned with surgical timing, care, treatment, and patient’s quality of life. Accordingly, research hotspots in spine surgery during the pandemic shifted from “early healthcare” to “virus management” and “experience and education.”

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.

COVID-19 pandemic: An update on the reaction attitude of the spine societies and their members worldwide

BACKGROUND

All surgical specialties have been influenced by the coronavirus disease 2019 (COVID-19) pandemic, and substantial changes have been determined in medical assistance, especially in elective surgery. Several spine societies have published recommendations to provide optimal care during this unique situation.

AIM

To discuss the recommendations by many spine societies for the management of spinal diseases during the COVID-19 pandemic.

METHODS

The present study was performed according to the PRISMA guidelines. A review of the MEDLINE database (PubMed - National Library of Medicine), Google, and Google Scholar was performed from March 2020 to date for articles published in the English Language.

RESULTS

Spine associations and societies worldwide were divided into three groups: Continental, specialty and country-based societies. A total of 27 spine associations were included in this review. There were eight major continental associations, but only one-third of these had published guidelines and recommendations on this topic. On the other hand, the specialty-based societies have not addressed the topic, except in two cases.

CONCLUSION

The national spine societies showed the deepest concern on this topic with several publications in scientific journals influenced by the local epidemiological severity. Contrarily, continental and specialty-based societies showed less interest in this topic.

COVID-19: Moral and Ethical Implications for Orthopaedic Spine Surgeons

The rapid spread of COVID-19 has made a significant impact on healthcare systems worldwide, with a large influx of patients prompting the cancellation of elective surgery in order to conserve resources and prevent the risk of exposure to the novel virus. In this case report, we present a 66-year-old male patient, with a history of cerebral palsy and developmental disabilities, exhibiting an increasing loss of function over the course of 10 days amid the COVID-19 pandemic. The patient was initially refused transport to the hospital by emergency medical services and later transported per independent request from his surgeon. Upon admittance to the hospital, the patient was found to have severe spinal cord compression with myelopathic symptoms and underwent an anterior cervical discectomy and fusion. This case highlights the need for more specific guidelines regarding the evaluation of a spinal injury by EMS and the hospital system amid a national crisis.

Surgical plans generated from telemedicine visits are rarely changed after in-person evaluation in spine patients

BACKGROUND CONTEXT

The role of telemedicine within the realm of spine surgery is evolving, catalyzed by the recent pandemic. Specifically, the capability of this technology to provide high-quality, cost-effective care without an in-person interaction and physical examination remains poorly defined.

PURPOSE

To characterize the impact of telemedicine on spine surgical planning by assessing whether surgical plans established in virtual visits changed following in-person evaluation.

STUDY DESIGN

Retrospective cohort study.

PATIENT SAMPLE

We evaluated the records of patients who were indicated for surgery with documented specific surgical plans during a virtual encounter (March-July 2020) and underwent subsequent in-person evaluation prior to surgery.

OUTCOME MEASURES

We determined whether surgical plans changed between the virtual encounter and the in-person interaction. Secondarily, we reviewed use of the virtual physical examination across surgeons.

METHODS

We reviewed virtual and in-person clinical encounters from a single academic spine division, evaluating those patients who were seen exclusively via telemedicine encounters and indicated for surgery with documented specific surgical plans. These plans were compared to the surgical plan after these same patients underwent in-person evaluation. Demographic data, patient primary complaint, and the type and extent of physical examination performed by the surgeon were recorded.

RESULTS

Of the 33 patients included, the surgical plan did not change among 31 individuals (94%) following in-person interaction. For the two patients where surgical plans were modified, multilevel fusions were increased by one level. There was notable inter- and intra-surgeon variability with regard to the use of virtual physical exams.

CONCLUSIONS

Our findings suggest that telemedicine evaluations are efficient means of preoperative assessment of spine patients and delineation of surgical plans. These results may support innovations that can optimize access to care for patients.

The Demand for Elective Neurosurgery at a German University Hospital during the First Wave of COVID-19

Background: Patients’ fear of the coronavirus disease 2019 (COVID-19) may delay inevitable treatment, putting potential benefits at risk. This single-center retrospective study aims to analyze temporal relationships of the first wave of the COVID-19 pandemic in Germany with the number of patients who sought and received elective neurosurgical treatment at a German university hospital. Methods: Daily outpatient numbers (ON) and elective procedures (EP) were recorded at our department between 1 January 2020 and 30 June 2020 (baseline: between 1 January 2019 and 30 June 2019). In patients who received EP, we recorded indication, outcome, and length of stay (LOS). Moving averages of ON (MAON) and of EP were calculated. Data on governmental action taken in response to the pandemic and on coronavirus-positive cases in Germany (CPCG) were superimposed. Exponential and arc tangent curves (ATC) were fitted to the absolute numbers of CPCG. Phase shifts were estimated, and Spearman’s rank correlation coefficient, rho, was calculated between the 2020 MAON and the derivative function of the fitted ATC (DFATC). Wilcoxon rank sum served as statistical test. Significance was assumed with p values of less than 0.05. Results: ON were significantly decreased in April 2020 as compared to April 2019 (p = 0.010). A phase shift between the German lockdown, the DFATC, and the decrease in MAON was not detected, while a phase shift of 10 days between the DFATC and the subsequent increase in MAON was detected. The DFATC was significantly negatively correlated (rho = −0.92, p < 0.0001) to the MAON until 31 March 2020, and, when shifted by 10 days, the DFATC was significantly negatively correlated (rho = −0.87, p < 0.0001) to the MAON from 01 April 2020. EP (p = 0.023), including the subset of non-oncological EP (p = 0.032), were significantly less performed in the first half of 2020 as compared to the first half of 2019. In March and April 2020, we conducted significantly more EP due to motor deficits (p = 0.0267, and less), visual disturbances (p = 0.0488), and spinal instability (p = 0.0012), and significantly less EP due to radicular pain (p = 0.0489), as compared to March and April 2019. LOS ranked significantly higher in patients who received cranial or spinal EP in March and April 2020 as compared to March and April 2019 (p = 0.0497). Significant differences in outcome were not observed. Conclusion: The beginning of the COVID-19 pandemic was correlated to an immediate and significant decrease in ON, and to a significant decrease in the number of EP performed. The subsequent increase in ON was delayed. Adequate measures to promote timely discharge of patients may become increasingly relevant as the pandemic proceeds. Although we observed a shift in the range of indications towards significantly more EP in patients with neurological deficiencies, care should be taken to avoid potentially deleterious delays of necessary elective treatment in future pandemic situations.