The Impact of the COVID-19 Pandemic on Spine Surgery in Central Europe: A Questionnaire-Based Study.

OBJECTIVE: The severe acute respiratory coronavirus 2 (SARS-CoV2) crisis led to many restrictions in daily life and protective health care actions in all hospitals to ensure basic medical supply. This questionnaire-based study among spinal surgeons in central Europe was generated to investigate the impact of coronavirus disease 2019 (COVID-19) and consecutively the differences in restrictions in spinal surgery units. METHODS: An online survey consisting of 32 questions on the impact of the COVID-19 pandemic and the related restrictions on spinal surgery units was created. Surgical fellows and consultants from neurosurgical, orthopedic, and trauma departments were included in our questionnaire-based study with the help of Austrian, German, and Swiss scientific societies. RESULTS: In a total of 406 completed questionnaires, most participants reported increased preventive measurements at daily clinical work (split-team work schedule [44%], cancellation of elective and/or semielective surgeries [91%]), reduced occurrence of emergencies (91%), decreased outpatient work (45%) with increased telemedical care (73%) and a reduced availability of medical equipment (75%) as well as medical staff (30%). Although most physicians considered the political restrictive decisions to be not suitable, most considered the medical measures to be appropriate. CONCLUSIONS: The COVID-19 pandemic resulted in comparable restrictive measures for spinal surgical departments in central Europe. Elective surgical interventions were reduced, providing additional resources reserved for severe acute respiratory coronavirus 2-positive patients. Although similar restrictions were introduced in most participants' departments, the supply of personal protective equipment and the outpatient care remained insufficient and should be re-evaluated intensively for future global health care crises.

Using administrative data to determine rates of surgical site infections following spinal fusion and laminectomy procedures.

OBJECTIVE: Surgical site infections (SSIs) are a serious and costly post-op complication. Generating SSI rates often requires labor-intensive methods, but increasing numbers of publications reported SSI rates using administrative data. METHODS: Index laminectomy and spinal fusion procedures were identified using Canadian Classification of Health Interventions (CCI) procedure codes for inpatients and outpatients in the province of Alberta, Canada between 2008 and 2015. SSIs occurring in the year postsurgery were identified using the International Classification of Diseases, 10th Revision, Canada (ICD-10-CA) diagnosis and CCI procedure codes indicative of post-op infection. Rates of SSIs and case characteristics were reported. RESULTS: Over the 8-year study period, 21,222 index spinal procedures were identified of which 12,027 (56.7%) were laminectomy procedures, with 322 SSIs identified, an SSI rate of 2.7 per 100 procedures. Of the 9,195 (43.3%) fusion procedures, 298 were identified as an SSI, an SSI rate of 3.2 per 100 procedures. This study found SSI rates increased from 2008 and 2015, and rates were the highest in the 0-18 year age group. CONCLUSIONS: The rates reported in this study were similar to published SSI rates using traditional surveillance methods, suggesting administrative data may be a viable method for reporting SSI rates following spinal procedures. Further work is needed to validate SSIs identified using administrative data by comparing to traditional surveillance.

Interventional procedure plans generated by telemedicine visits in spine patients are rarely changed after in-person evaluation.

BACKGROUND AND OBJECTIVES: The role of telemedicine in the evaluation and treatment of patients with spinal disorders is rapidly expanding, brought on largely by the COVID-19 pandemic. Within this context, the ability of pain specialists to accurately diagnose and plan appropriate interventional spine procedures based entirely on telemedicine visits, without an in-person evaluation, remains to be established. In this study, our primary objective was to assess the relevance of telemedicine to interventional spine procedure planning by determining whether procedure plans established solely from virtual visits changed following in-person evaluation. METHODS: We reviewed virtual and in-person clinical encounters from our academic health system's 10 interventional spine specialists. We included patients who were seen exclusively via telemedicine encounters and indicated for an interventional procedure with documented procedural plans. Virtual plans were then compared with the actual procedures performed following in-person evaluation. Demographic data as well as the type and extent of physical examination performed by the interventional spine specialist were also recorded. RESULTS: Of the 87 new patients included, the mean age was 60 years (SE 1.4 years) and the preprocedural plan established by telemedicine, primarily videoconferencing, did not change for 76 individuals (87%; 95% CI 0.79 to 0.94) following in-person evaluation. Based on the size of our sample, interventional procedures indicated solely during telemedicine encounters may be accurate in 79%-94% of cases in the broader population. CONCLUSIONS: Our findings suggest that telemedicine evaluations are a generally accurate means of preprocedural assessment and development of interventional spine procedure plans. These findings clearly demonstrate the capabilities of telemedicine for evaluating spine patients and planning interventional spine procedures.

Personal protective equipment usage, recycling and disposal among spine surgeons: An Asia Pacific Spine Society survey.

PURPOSE: In this study we investigated on the personal protective equipment (PPE) usage, recycling, and disposal among spine surgeons in the Asia Pacific region. METHODS: A cross-sectional survey was carried out among spine surgeons in Asia Pacific. The questionnaires were focused on the usage, recycling and disposal of PPE. RESULTS: Two hundred and twenty-two surgeons from 19 countries participated in the survey. When we sub-analysed the differences between countries, the provision of adequate PPE by hospitals ranged from 37.5% to 100%. The usage of PPE was generally high. The most used PPE were surgical face masks (88.7%), followed by surgical caps (88.3%), gowns (85.6%), sterile gloves (83.3%) and face shields (82.0%). The least used PPE were powered air-purifying respirators (PAPR) (23.0%) and shoes/boots (45.0%). The commonly used PPE for surgeries involving COVID-19 positive patients were N95 masks (74.8%), sterile gloves (73.0%), gowns (72.1%), surgical caps (71.6%), face shields (64.4%), goggles (64.0%), shoe covers (58.6%), plastic aprons (45.9%), shoes/boots (45.9%), surgical face masks (36.5%) and PAPRs (21.2%). Most PPE were not recycled. Biohazard bins were the preferred method of disposal for all types of PPE items compared to general waste. CONCLUSIONS: The usage of PPE was generally high among most countries especially for surgeries involving COVID-19 positive patients except for Myanmar and Nepal. Overall, the most used PPE were surgical face masks. For surgeries involving COVID-19 positive patients, the most used PPE were N95 masks. Most PPE were not recycled. Biohazard bins were the preferred method of disposal for all types of PPE.

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.

An Analysis of Public Interest in Elective Neurosurgical Procedures During the COVID-19 Pandemic Through Online Search Engine Trends.

OBJECTIVE: In the wake of the COVID-19 pandemic, the Centers for Medicare & Medicaid Services (CMS) has recommended the temporary cessation of all elective surgeries. The effects on patients' interest of elective neurosurgical procedures are currently unexplored. METHODS: Using Google Trends, search terms of 7 different neurosurgical procedure categories (trauma, spine, tumor, movement disorder, epilepsy, endovascular, and miscellaneous) were assessed in terms of relative search volume (RSV) between January 2015 and September 2020. Analyses of search terms were performed for over the short term (February 18, 2020, to April 18, 2020), intermediate term (January 1, 2020, to May 31, 2020), and long term (January 2015 to September 2020). State-level interest during phase I reopening (April 28, 2020, to May 31, 2020) was also evaluated. RESULTS: In the short term, RSVs of 4 categories (epilepsy, movement disorder, spine, and tumor) were significantly lower in the post-CMS announcement period. In the intermediate term, RSVs of 5 categories (miscellaneous, epilepsy, movement disorder, spine, and tumor) were significantly lower in the post-CMS announcement period. In the long term, RSVs of nearly all categories (endovascular, epilepsy, miscellaneous, movement disorder, spine, and tumor) were significantly lower in the post-CMS announcement period. Only the movement disorder procedure category had significantly higher RSV in states that reopened early. CONCLUSIONS: With the recommendation for cessation of elective surgeries, patient interests in overall elective neurosurgical procedures have dropped significantly. With gradual reopening, there has been a resurgence in some procedure types. Google Trends has proven to be a useful tracker of patient interest and may be used by neurosurgical departments to facilitate outreach strategies.

Response to the Coronavirus Disease 2019 Pandemic by the Spine Division at a Level-I Academic Referral Center.

Coronavirus disease 2019 (COVID-19) is a ubiquitous health concern and a global pandemic. In an effort to slow the disease spread and protect valuable healthcare resources, cessation of nonessential surgery, including many orthopaedic procedures, has become commonplace. This crisis has created a unique situation in the care of spine patients as we must balance the urgency of patient evaluation, surgical intervention, and continued training against the risk of disease exposure and resource management. The spine division of an orthopaedic surgery department has taken an active role in enacting protocol changes in anticipation of COVID-19. In the initial 4 weeks of the COVID-19 pandemic the spine division went from an average of 60.4 cases to 10 cases during the same timeframe. Clinic visits decreased from 417.4 to 322 with new patient visits decreasing from 28% to 20%. Three hundred eighteen of the 322 (98.7%) clinic visits were performed via telehealth. Although these changes have been forced upon us by necessity, we feel that our division and department will emerge in a more responsive, agile, and stronger state. As we look to the coming months and beyond, it will be important to continue to adapt to the changing landscape during unprecedented times.

Telemedicine in the Evaluation and Management of Neurosurgical Spine Patients: Questionnaire Assessment of 346 Consecutive Patients.

STUDY DESIGN: Retrospective questionnaire study of all patients seen via telemedicine during the COVID-19 pandemic at a large academic institution. OBJECTIVE: This aim of this study was to compare patient satisfaction of telemedicine clinic to in-person visits; to evaluate the preference for telemedicine to in-person visits; to assess patients' willingness to proceed with major surgery and/or a minor procedure based on a telemedicine visit alone. SUMMARY OF BACKGROUND DATA: One study showed promising utility of mobile health applications for spine patients. No studies have investigated telemedicine in the evaluation and management of spine patients. METHODS: An 11-part questionnaire was developed to assess the attitudes toward telemedicine for all patients seen within a 7-week period during the COVID-19 crisis. Patients were called by phone to participate in the survey. χ2 and the Wilcoxon Rank-Sum Test were performed to determine significance. RESULTS: Ninety-five percent were "satisfied" or "very satisfied" with their telemedicine visit, with 62% stating it was "the same" or "better" than previous in-person appointments. Patients saved a median of 105 minutes by using telemedicine compared to in-person visits. Fifty-two percent of patients have to take off work for in-person visits, compared to 7% for telemedicine. Thirty-seven percent preferred telemedicine to in-person visits. Patients who preferred telemedicine had significantly longer patient-reported in-person visit times (score mean of 171) compared to patients who preferred in-person visits (score mean of 137, P = 0.0007). Thirty-seven percent of patients would proceed with surgery and 73% would proceed with a minor procedure based on a telemedicine visit alone. CONCLUSION: Telemedicine can increase access to specialty care for patients with prolonged travel time to in-person visits and decrease the socioeconomic burden for both patients and hospital systems. The high satisfaction with telemedicine and willingness to proceed with surgery suggest that remote visits may be useful for both routine management and initial surgical evaluation for spine surgery candidates.Level of Evidence: 3.

Safe Spine Surgery During the COVID-19 Pandemic.

Safe spine surgery is possible during the COVID-19 pandemic. Certain urgent procedures must still be performed during this challenging time to prevent permanent long-term disability or death for patients. Precautions must be taken in the operating room to optimize safety, including the use of personal protective equipment and appropriate room setup and anesthesia and equipment optimization. Evidence-based guidelines to create a safe operative paradigm for use in future viral outbreaks are paramount.

Spine Surgery in Italy in the COVID-19 Era: Proposal for Assessing and Responding to the Regional State of Emergency.

In December 2019, coronavirus disease 2019 (COVID-19) was discovered in Wuhan, Hubei province, from where it spread rapidly worldwide. COVID-19 characteristics (increased infectivity, rapid spread, and general population susceptibility) pose a great challenge to hospitals. Infectious disease, pulmonology, and intensive care units have been strengthened and expanded. All other specialties have been compelled to suspend or reduce clinical and elective surgical activities. The profound effects on spine surgery call for systematic approaches to optimizing the diagnosis and treatment of spinal diseases. Based on the experience of one Italian region, we draw an archetype for assessing the current and predicted level of stress in the health care system, with the aim of enabling hospitals to make better decisions during the pandemic. Further, we provide a framework that may help guide strategies for adapting surgical spine care to the conditions of epidemic surge.

Tracking the Volume of Neurosurgical Care During the Coronavirus Disease 2019 Pandemic.

OBJECTIVE: In the present study, we quantified the effect of the coronavirus disease 2019 (COVID-19) on the volume of adult and pediatric neurosurgical procedures, inpatient consultations, and clinic visits at an academic medical center. METHODS: Neurosurgical procedures, inpatient consultations, and outpatient appointments at Vanderbilt University Medical Center were identified from March 23, 2020 through May 8, 2020 (during COVID-19) and March 25, 2019 through May 10, 2019 (before COVID-19). The neurosurgical volume was compared between the 2 periods. RESULTS: A 40% reduction in weekly procedural volume was demonstrated during COVID-19 (median before, 75; interquartile range [IQR], 72-80; median during, 45; IQR, 43-47; P < 0.001). A 42% reduction occurred in weekly adult procedures (median before, 62; IQR, 54-70; median during, 36; IQR, 34-39; P < 0.001), and a 31% reduction occurred in weekly pediatric procedures (median before, 13; IQR, 12-14; median during, 9; IQR, 8-10; P = 0.004). Among adult procedures, the most significant decreases were seen for spine (P < 0.001) and endovascular (P < 0.001) procedures and cranioplasty (P < 0.001). A significant change was not found in the adult open vascular (P = 0.291), functional (P = 0.263), cranial tumor (P = 0.143), or hydrocephalus (P = 0.173) procedural volume. Weekly inpatient consultations to neurosurgery decreased by 24% (median before, 99; IQR, 94-114; median during, 75; IQR, 68-84; P = 0.008) for adults. Weekly in-person adult and pediatric outpatient clinic visits witnessed a 91% decrease (median before, 329; IQR, 326-374; median during, 29; IQR, 26-39; P < 0.001). In contrast, weekly telehealth encounters increased from a median of 0 (IQR, 0-0) before to a median of 151 (IQR, 126-156) during COVID-19 (P < 0.001). CONCLUSIONS: Significant reductions occurred in neurosurgical operations, clinic visits, and inpatient consultations during COVID-19. Telehealth was increasingly used for assessments. The long-term effects of the reduced neurosurgical volume and increased telehealth usage on patient outcomes should be explored.