Changes in the management of myelopathy during the COVID- 19 pandemic in a nationwide hospital network in Germany

Introduction: The Covid-19 pandemic has negatively impacted the management of spinal pathologies. Since, so far, the pandemic's effects specifically on the management of myelopathy in Germany have not been examined, we aim to do so in this analysis. Method(s): We used administrative data from a nationwide Network of 76 hospitals for this retrospective analysis and compared the first 5 pandemic waves (Jan 1, 2020 - May 17, 2022) to corresponding periods from the last year prior to the pandemic (2019). We included all patients hospitalized with the main diagnosis "myelopathy" (ICD-10-Codes: M47.11-15, G95.2, G99.2) and examined baseline characteristics and rates of different treatment types and in-hospital mortality. Result(s): We included 4,167 cases with myelopathy: 2,001 hospitalized during the pandemic, and 2,166 in 2019. Compared to pre-pandemic levels, the mean daily admissions for myelopathy decreased only in wave 1 (from 2.8 auf 1.7;p<0.01), while no changes in admissions were registered in any of the later waves. There were no alterations in patient age (range: 64.5-66.1 years), distribution of sex (female, range: 39.3%-50.4%), or rates of comorbidities, measured by the Elixhauser Comorbidity Index (range: 4.3-6.5). In contrast, we observed significant changes in the analysis of treatment modalities. Except in wave 1, there was a significant increase in rates of spinal decompression procedures throughout the pandemic, from a range of 43.3-47.0% before the pandemic to 55.6%-62.5% (p<0.01). Also, compared to prepandemic levels, the rates of disc hernia resections increased during waves 4 and 5 from a range of 29.8-30.4% to 37.1-41.1% (p<0.01). Furthermore, the rates of spinal fusion procedures increased in waves 3, 4, and 5 from a range of 32.7-40.5% to 45.0- 50.4% (p<0.01). No changes were observed throughout the pandemic for rates of kyphoplasty (0.2-1.0%), transfer to intensive care unit (22.9-30.7%), and in-hospital mortality (1.1-2.7%). Discussion(s): We present the largest analysis, to date, on the effects of the COVID-19 pandemic on the management of myelopathy in Germany. Our findings suggest that, in subjects with myelopathy, the pandemic did not lead to a selection for older or sicker patients. The fact that hospital admissions for myelopathy dropped off only during the wave 1 suggests a certain normalization over time. This is why it is worth discussing why rates of surgery increased in later phases of the pandemic, both for fusion and non-fusion procedures.

Changes in frailty among patients with spinal pathologies during the first 5 waves of the COVID-19 pandemic in a nationwide hospital network in Germany

Introduction: In patients with degenerative spinal disease, higher degrees of fraily, as measured by the Hospital Frailty Risk Score (HFRS), are associated with poor treatment outcomes. The COVID-19 pandemic has led to significant increases in frailty among hospitalized patients. We present the first nationwide analysis of the impact the COVID-19 pandemic has been having on frailty among spine patients. Method(s): In this retrospective study we examined administrative data from a nationwide network of 76 hospitals in Germany with emphasis on HFRS, types of treatment and outcomes. We compared data from the last year prior to the pandemic (2019) to the first 5 waves of the pandemic (Jan 1, 2020 - May 17, 2022). All patients with a primary diagnosis of degenerative, traumatic or infectious spinal disease were included. The following HFRS groups were compared to each other: low (< 5 points), intermediate (5-15 points), and high (>15 points). Result(s): Of the 379,910 included cases with spine pathologies 168,481 were hospitalized during the pandemic, and 194,722 in 2019. Compared to pre-pandemic levels, hospital admissions for spinal pathologies decreased significantly during all 5 waves of the pandemic and the proportion of spine patients with high HFRS increased from a range of 5.8-6.1% to 6.5-8.8% (p<0.01). Analogously, during all 5 waves, there was a significant increase in patient age (from 65.3-65.5 years to 65.8-66.5 years;p<0.01). The rate of comorbidities increased significantly, as well, with a rise in the Elixhauser Comorbidity Index from a range of 4.2-4.3 to 4.7- 5.9 (p<0.01). Throughout the pandemic, there was a significant increase in the rate of spinal fusion procedures among patients with low HFRS (from a range of 6.4-6.8% to 8.4-10.3%;p<0.01), as well as in the intermediate HFRS group (from 5.8-6.0% to 6.9- 7.8%;p<0.01). No changes in rates were observed for decompressive spine procedures, disc hernia resections, or kyphoplasty. Throughout all 5 pandemic waves, patients of the high HFRS group displayed significantly higher in-hospital mortality rates (8.6-13.6%) compared to patients in the low HFRS group (0.1-0.4%;p<0.01). Discussion(s): We present the largest study, to date, on frailty among patients with spinal pathologies in Germany. Our findings suggest that the COVID-19 pandemic has led to decreased numbers of hospital admissions for spinal pathologies but increased frailty among those hospitalized. This type of "negative selection" may be due to younger and healthier spine patients avoiding hospitalization out of fear of hospital-acquired COVID-19 infection. Among hospitalized spine patients with low or intermediate levels of frailty, the rate of spinal fusion procedures increased during the pandemic, while rates of non-fusion procedures were not impacted.