The Eclipse of Degenerative Spine Pathology During COVID-19 Pandemic

Trends in degenerative lumbar spinal surgery during the early COVID-19 pandemic in Republic of Korea: A national study utilizing the national health insurance database

During the first year of the COVID-19 pandemic, the Republic of Korea (ROK) experienced three epidemic waves in February, August, and November 2020. These waves, combined with the overarching pandemic, significantly influenced trends in spinal surgery. This study aimed to investigate the trends in degenerative lumbar spinal surgery in ROK during the early COVID-19 pandemic, especially in relation to specific epidemic waves. Using the National Health Information Database in ROK, we identified all patients who underwent surgery for degenerative lumbar spinal diseases between January 1, 2019 and December 31, 2020. A joinpoint regression was used to assess temporal trends in spinal surgeries over the first year of the COVID-19 pandemic. The number of surgeries decreased following the first and second epidemic waves (p<0.01 and p = 0.34, respectively), but these were offset by compensatory increases later on (p<0.01 and p = 0.05, respectively). However, the third epidemic wave did not lead to a decrease in surgical volume, and the total number of surgeries remained comparable to the period before the pandemic. When compared to the pre-COVID-19 period, average LOH was reduced by 1 day during the COVID-19 period (p<0.01), while mean hospital costs increased significantly from 3,511 to 4,061 USD (p<0.01). Additionally, the transfer rate and the 30-day readmission rate significantly decreased (both p<0.01), while the reoperation rate remained stable (p = 0.36). Despite the impact of epidemic waves on monthly surgery numbers, a subsequent compensatory increase was observed, indicating that surgical care has adapted to the challenges of the pandemic. This adaptability, along with the stable total number of operations, highlights the potential for healthcare systems to continue elective spine surgery during public health crises with strategic resource allocation and patient triage. Policies should ensure that surgeries for degenerative spinal diseases, particularly those not requiring urgent care but crucial for patient quality of life, are not unnecessarily halted.

Healthcare burden changes by restricted physical activities in lumbar spinal stenosis and spondylolisthesis: a retrospective large cohort study during the COVID-19 pandemic

BACKGROUND

Lumbar spinal stenosis (LSS) and spondylolisthesis (SPL) are characterized as degenerative spinal pathologies and share considerable similarities. However, opinions vary on whether to recommend exercise or restrict it for these diseases. Few studies have objectively compared the effects of daily physical activity on LSS and SPL because it is impossible to restrict activities ethnically and practically. We investigated the effect of restricting physical activity due to social distancing (SoD) on LSS and SPL, focusing on the aspect of healthcare burden changes during the pandemic period.

METHODS

We included first-visit patients diagnosed exclusively with LSS and SPL in 2017 and followed them up for two years before and after the implementation of the SoD policy. As controls, patients who first visited in 2015 and were followed for four years without SoD were analyzed. The common data model was employed to analyze each patient's diagnostic codes and treatments. Hospital visits and medical costs were analyzed by regression discontinuity in time to control for temporal effects on dependent variables.

RESULTS

Among 33,484 patients, 2,615 with LSS and 446 with SPL were included. A significant decrease in hospital visits was observed in the LSS (difference, -3.94 times/month·100 patients; p = 0.023) and SPL (difference, -3.44 times/month·100 patients; p = 0.026) groups after SoD. This decrease was not observed in the data from the control group. Concerning medical costs, the LSS group showed a statistically significant reduction in median copayment (difference, -$45/month·patient; p < 0.001) after SoD, whereas a significant change was not observed in the SPL group (difference, -$19/month·patient; p = 0.160).

CONCLUSION

Restricted physical activity during the SoD period decreased the healthcare burden for patients with LSS or, conversely, it did not significantly affect patients with SPL. Under circumstances of physical inactivity, patients with LSS may underrate their symptoms, while maintaining an appropriate activity level may be beneficial for patients with SPL.

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.

Appropriateness of specialized care referrals for LBP: a cross-sectional analysis

Background

Low back pain (LBP) accounts for a significant proportion of primary care visits. Despite the development of evidence-based guidelines, studies point to the inefficient use of healthcare resources, resulting in over 60.0% of patients with LBP being referred to spine surgeons without any surgical indication. Centralized waiting lists (CWLs) have been implemented to improve access to specialized care by managing asymmetry between supply and demands. To date, no study has provided data on patients' clinical profiles and referral patterns to medical specialists for LBP in the context of a publicly funded healthcare system operating a prioritization model. The objective of this study was to evaluate the appropriateness of specialized care referrals for LBP after the implementation of a CWL.

Methods

A retrospective cross-sectional analysis of 500 randomly selected electronic health records of patients who attended the outpatient neurosurgery clinic of the administrative Mauricie-et-Centre-du-Québec region was performed. Inclusion criteria were neurosurgery consultation referrals for adults ≥18 years suffering from a primary complaint of LBP, and performed between September 1st, 2018, and September 1st, 2021. Data relevant for drawing a comprehensive portrait of patients referred to the neurosurgery service and for judging referrals appropriateness were manually extracted.

Results

Of the 500 cases analyzed, only 112 (22.4%) were surgical candidates, while 221 (44.2%) were discharge from the neurosurgery service upon initial assessment. Key information was inconsistently documented in medical files, thus preventing the establishment of a comprehensive portrait of patients referred to the neurosurgery service for LBP. Nevertheless, over 80.0% of referrals made during the study period were deemed inappropriate. Inappropriate referrals were characterized by higher proportion of patients symptomatically improved, presenting a back-dominant chief complaint, exhibiting no objective neurological symptoms, and diagnosed with non-specific LBP.

Conclusion

This study reveals a significant proportion of inappropriate referrals to specialized care for LBP. Further research is needed to better understand the factors that prompt referrals to medical specialists for LBP, and the criteria considered by neurosurgeons when selecting the appropriate management strategy. Recent studies suggest that triaging approaches led by musculoskeletal experts may improve referral appropriateness to specialized care.

Surgical decompressions for cauda equina syndrome during COVID-19

BACKGROUND

The novel coronarvirus disease (COVID-19) has had a major impact on provision of spinal neurosurgery across the world, especially in the UK, with a significant fall in operating and patient volumes, and elective clinical activities. It is unclear whether the pandemic has affected the volume of urgent spinal procedures in the UK, especially surgical decompressions for cauda equina syndrome (CES).

METHODS

Therefore, we conducted a retrospective analysis of theatre records and electronic operation notes at our institution to identify all procedures performed for CES before (December 2019 to February 2020) and during (March 2020 to May 2020) the COVID-19 pandemic. Statistical analyses were performed on SPSS v22 (IBM).

RESULTS

Forty-four patients underwent surgical decompressions during the study period. Over half (54.5%) were female and the median age was 45 years (range = 22-78 years). Three in four procedures were performed at L4-5 and L5-S1 levels (79.5%). There was no statistically significant difference in the number of decompressions performed each month [χ²(5)=1.818; p = 0.874]. On the other hand, the number of referrals for suspected or confirmed CES fell by 81.8% between December 2019 and April 2020.

CONCLUSIONS

Our results did not show any statistically significant decline in the volume of surgical decompressions performed for CES despite the considerable fall in electronic referrals for CES and degenerative spinal conditions. This suggests that patients with critical neurological symptoms continued to present and were treated appropriately despite the restrictions imposed on spinal surgeons during the pandemic.

Lumbar Spine Surgery and What We Lost in the Era of the Coronavirus Pandemic: A Survey of the Lumbar Spine Research Society

STUDY DESIGN

This was a survey of the surgeon members of the Lumbar Spine Research Society (LSRS).

OBJECTIVE

The purpose of this study was to assess trends in surgical practice and patient management involving elective and emergency surgery in the early months of the coronavirus pandemic.

SUMMARY OF BACKGROUND DATA

The novel coronavirus has radically disrupted medical care in the first half of 2020. Little data exists regarding the exact nature of its effect on spine care.

METHODS

A 53-question survey was sent to the surgeon members of the LSRS. Respondents were contacted via email 3 times over a 2-week period in late April. Questions concentrated on surgical and clinical practice patterns before and after the pandemic. Other data included elective surgical schedules and volumes, as well as which emergency cases were being performed. Surgeons were asked about the status of coronavirus disease 2019 (COVID-19) virus testing. Circumstances for performing surgical intervention on patients with and without testing as well as patients testing positive were explored.

RESULTS

A total of 43 completed surveys were returned of 174 sent to active surgeons in the LSRS (25%). Elective lumbar spine procedures decreased by 90% in the first 2 months of the pandemic, but emergency procedures did not change. Patients with "stable" lumbar disease had surgeries deferred indefinitely, even beyond 8 weeks if necessary. In-person outpatient visits became increasingly rare events, as telemedicine consultations accounted for 67% of all outpatient spine appointments. In total, 91% surgeons were under some type of confinement. Only 11% of surgeons tested for the coronavirus on all surgical patients.

CONCLUSIONS

Elective lumbar surgery was significantly decreased in the first few months of the coronavirus pandemic, and much of outpatient spine surgery was practiced via telemedicine. Despite these constraints, spine surgeons performed emergency surgery when indicated, even when the COVID-19 status of patients was unknown.

LEVEL OF EVIDENCE

Level IV.

The Impact of the Coronavirus Disease 2019 Pandemic on Neurosurgical Practice and Feasibility of Safe Resumption of Elective Procedures During this Era in a Large Referral Center in Tehran, Iran: An Unmatched Case-Control Study

Objective

The coronavirus disease 2019 (COVID-19) pandemic has considerably affected surgical practice. The present study aimed to investigate the effects of the pandemic on neurosurgical practice and the safety of the resumption of elective procedures through implementing screening protocols in a high-volume academic public center in Iran, as one of the countries severely affected by the pandemic.

Methods

This unmatched case-control study compared 2 populations of patients who underwent neurosurgical procedures between June 1, 2019 and September 1, 2019 and the same period in 2020. In the prospective part of the study, patients who underwent elective procedures were tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection postoperatively to evaluate the viability of our screening protocol.

Results

Elective and emergency procedures showed significant reduction during the pandemic (59.4%, n = 168 vs. 71.3%, n = 380) and increase (28.7%, n = 153 vs. 40.6%, n = 115, respectively; P = 0.003). The proportional distribution of neurosurgical categories remained unchanged during the pandemic. Poisson regression showed that the reduction in total daily admissions and some categories, including spine, trauma, oncology, and infection were significantly correlated with the pandemic. Among patients who underwent elective procedures, 0 (0.0%) and 26 (16.25%) had positive test results on days 30 and 60 postoperatively, respectively. Overall mortality was comparable between the pre–COVID-19 and COVID-19 periods, yet patients with concurrent SARS-CoV-2 infection showed substantially higher mortality (65%).

Conclusions

By implementing safety and screening protocols with proper resource allocation, the emergency care capacity can be maintained and the risk minimized of hospital-acquired SARS-CoV-2 infection, complications, and mortality among neurosurgical patients during the pandemic. Similarly, for elective procedures, according to available resources, hospital beds can be allocated for patients with a higher risk of delayed hospitalization and those who are concerned about the risk of hospital-acquired infection can be reassured.

COVID-19 and Changes in Neurosurgical Workload in the United Kingdom

BACKGROUND

Cessation of elective procedures and lower bed capacity during the COVID-19 pandemic have led to a rise in the waiting lists for surgery, but it is unclear if workload has recovered sufficiently to account for this backlog. We describe the change in neurosurgical workload at a tertiary neurosciences center in the United Kingdom after the first pandemic wave in comparison with the months before and during the first wave.

METHODS

A retrospective review of theatre records and electronic referrals-between December 1, 2019, and August 31, 2020-was performed. The months of December 2019-February 2020 were designated as pre-COVID months and March-May 2020 were designated as COVID months. The time period from June to August 2020 was designated as post-wave months. Statistical analyses were performed on SPSS v22 (IBM).

RESULTS

Referrals declined from 572 in January to a nadir of 352 in April before a steady rise to August. Referral volumes for degenerative spinal disease and traumatic brain injuries showed a statistically significant change during the year. On average, 212 procedures per month were performed in the pre-COVID months, 167 procedures per month during COVID months, and 232 procedures per month in the post-wave months. The number of patients on the waiting list for scheduled operations rose from March (785 patients) onward to a peak of 997 patients in July.

CONCLUSIONS

In the aftermath of COVID-19, higher referral volumes and operative procedures were apparent in the post-wave months as services returned to normal. With the expectation of a second wave of infections, it is unclear whether this will be sustainable.

Neurosurgeons on the front line: experience from the center of the storm in Italy

In this tumultuous time, the entire world has been shaken up by the COVID-19 outbreak. Italy has had one of the highest infection-related mortality rates. Bergamo, a city in eastern Lombardy, was among the most affected. Here, the authors describe the main healthcare actions taken at their institution to stem the crisis, with particular concern regarding the fate of their neurosurgery department. Among the different topics, the authors particularly focus on the retraining of neurosurgeons, organization of activities, and what should be the role of neurosurgeons during a pandemic.

Neurosurgical Referral Patterns During the Coronavirus Disease 2019 Pandemic: A United Kingdom Experience

BACKGROUND

Coronavirus disease 2019 (COVID-19) is a severe respiratory viral illness that has spread rapidly across the world. However, the United Kingdom has been particularly affected. Evidence has suggested that stroke, cardiac, and spinal presentations decreased during the pandemic as the public avoided seeking care. The effect on neurosurgical presentations and referrals during COVID-19 is unclear. Our aim, therefore, was to describe the referral patterns to a high-volume neurosurgical department in the United Kingdom during the COVID-19 pandemic.

METHODS

Electronic referrals were identified from the referrals database from January 1, 2020 to May 31, 2020, inclusive, with January used as the baseline. The demographic data and referral diagnoses were captured on Excel (Microsoft, Redmond, Washington, USA). Statistical analyses were performed using SPSS, version 22 (IBM Corp., Armonk, New York, USA). Differences between referral volumes were evaluated using χ2 goodness-of-fit tests.

RESULTS

A total of 2293 electronic referrals had been received during the study period. The median age was 63 years. Overall, the referrals had decreased significantly in volume during the study period [χ2(4) = 60.95; P < 0.001]. We have described the patterns in the daily referrals as the pandemic progressed. The reduction in the volume of referrals for degenerative spine cases and traumatic brain injuries was statistically significant (P < 0.001).

CONCLUSIONS

The referrals for degenerative spine and traumatic brain injuries decreased significantly during the pandemic, which can be explained by the lower vehicular traffic and patient avoidance of healthcare services, respectively. The risk of neurological deterioration and increased morbidity and mortality, as a consequence, is of concern, and neurosurgeons worldwide should consider the optimal strategies to mitigate these risks as the pandemic eases.