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.

Decompressive craniectomy for intracranial hypertension in vaccine-induced immune thrombotic thrombocytopaenia: a case series.

BACKGROUND: Vaccines have been key in preventing COVID-19 infections and the AstraZeneca (AZ) vaccine has been widely used. However, increased rates of thromboembolic events were identified in recipients and, subsequently, a syndrome of vaccine-induced immune thrombotic thrombocytopaenia (VITT) was described whereby recipients presented with venous sinus thromboses, haemorrhagic infarctions, and - consequently - raised intracranial pressure. National guidance recommended decompressive craniectomies for refractory intracranial hypertension. We describe our neurosurgical experience in managing a cohort of patients with VITT. CLINICAL PRESENTATION: Four patients were included (three females and one male); median age was 46 years. All patients presented with a constellation of headache, focal neurological deficit(s), altered consciousness, and/or seizure at a median 11 d post-vaccine. Pre-operatively, median GCS was 7 and the median platelet count was 28 × 109/L. Mean craniectomy size was 13 cm × 10 cm. All four cases tested positive for anti-PF4 antibodies. Median length of stay was 9 d (range: 2-25). Of the four who were operated upon, two survived to hospital discharge, and one of these subsequently died at a peripheral hospital. CONCLUSIONS: VITT-related sinus thromboses and associated infarcts are rare complications of the AZ vaccine. Neurosurgical management involves treating intracranial hypertension however survival outcomes in our cohort were poor. In our series, decompression was performed in deteriorating patients however prophylactic decompression, in the presence of extensive venous sinus thrombosis, should be considered on a case-by-case basis. As vaccination programmes accelerate across the world, neurosurgeons are likely to be increasingly involved in managing intracranial hypertension in patients with VITT-related sinus thromboses.

A Tale of Two Cities: Residents' Operative Experience in the United Kingdom and Germany During the Coronavirus Disease 2019 Pandemic.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has had a detrimental effect on residents' operative training. Our aim was to identify the proportion of procedures performed by residents across 2 neurosurgical centers (1 in the United Kingdom and 1 in Germany) during the pandemic-affected months of March 2020-May 2020, inclusive, compared with March 2019-May 2019, inclusive. METHODS: All neurosurgical procedures performed at the United Kingdom and German institutions, between March 1, 2019 and May 31, 2019 (pre-COVID months) and March 1, 2020 and May 31, 2020 (COVID months), were extracted and operative notes evaluated. Statistical analysis was performed on SPSS version 22. RESULTS: There was a statistically significant reduction in operative volume in the United Kingdom center from the pre-COVID months to the COVID months (χ2(5) = 84.917; P < 0.001) but no significant difference in the operative volume in the German center (P = 0.61). A Mann-Whitney U test showed a statistically significant difference in the volume of residents operating in the COVID months compared with pre-COVID months in both United Kingdom and German centers (P < 0.001). The average number of procedures performed by residents in the United Kingdom center as the primary surgeon decreased from 82 to 72 per month (pre-COVID vs. COVID months), whereas German residents' operating volume increased from 68 to 89 per month (pre-COVID vs. COVID months). CONCLUSIONS: The COVID-19 pandemic has significantly reduced the volume of operating by neurosurgical residents in the United Kingdom center, whereas residents in the German center performed more procedures compared with 2019. This finding may reflect variations in national practice on maintaining surgical activities and provision of critical care beds during the first wave of the pandemic.

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.

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.