Battle-Tested Guidelines and Operational Protocols for Neurosurgical Practice in Times of a Pandemic: Lessons Learned from COVID-19

Lessons learned during COVID-19 pandemic, a worldwide survey: evolution of global neurosurgical practice

BACKGROUND

During the COVID-19 pandemic, a multitude of surveys have analyzed the impact virus spreading on the everyday medical practice, including neurosurgery. However, none have examined the perceptions of neurosurgeons towards the pandemic, their life changes, and the strategies they implemented to be able to deal with their patients in such a difficult time.

METHODS

From April 2021 to May 2021 a modified Delphi method was used to construct, pilot, and refine the questionnaire focused on the evolution of global neurosurgical practice during the pandemic. This survey was distributed among 1000 neurosurgeons; the responses were then collected and critically analyzed.

RESULTS

Outpatient department practices changed with a rapid rise in teleservices. 63.9% of respondents reported that they have changed their OT practices to emergency cases with occasional elective cases. 40.0% of respondents and 47.9% of their family members reported to have suffered from COVID-19. 56.2% of the respondents reported having felt depressed in the last 1 year. 40.9% of respondents reported having faced financial difficulties. 80.6% of the respondents found online webinars to be a good source of learning. 47.8% of respondents tried to improve their neurosurgical knowledge while 31.6% spent the extra time in research activities.

CONCLUSIONS

Progressive increase in operative waiting lists, preferential use of telemedicine, reduction in tendency to complete stoppage of physical clinic services and drop in the use of PPE kits were evident. Respondents' age had an impact on how the clinical services and operative practices have evolved. Financial concerns overshadow mental health.

The impact of COVID-19 on clinical outcomes in people undergoing neurosurgery: a systematic review and meta-analysis

BACKGROUND

The coronavirus disease-2019 (COVID-19) pandemic has created a global crisis unique to the healthcare system around the world. It also had a profound impact on the management of neurosurgical patients. In our research, we investigated the effect of the COVID-19 pandemic on clinical outcomes in people undergoing neurosurgery, particularly vascular and oncological neurosurgery.

METHOD

Two investigators independently and systematically searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrail.Gov, and Web of Science to identify relevant studies respecting the criteria for inclusion and exclusion published up to June 30, 2022. The outcomes of our research included mortality rate, length of stay, modified Rankin Score, delay in care, Glasgow outcome scale, and major complications. The risk of bias was assessed using the Methodological Index for Non-randomized Studies (MINORS) checklist.

RESULTS

Two investigators independently and systematically searched 1378 results from MEDLINE, EMBASE, Cochrane database, ClinicalTrail.Gov, and Web of Science and extracted the detailed data from 13 studies that met the review's eligibility criteria. Two articles reported on patients with intracerebral hemorrhages, five on patients with subarachnoid hemorrhages, four on patients undergoing surgery for neuro-oncology, and in two studies the patients' conditions were unspecified. A total of 26,831 patients were included in our research. The number who died was significantly increased in the COVID-19 pandemic group (OR 1.52, 95% CI 1.36-1.69, P < 0.001). No significant difference was found between the two groups in terms of length of stay (SMD - 0.88, 95% CI - 0.18-0.02, P = 0.111), but it differed between regions, according to our subgroup analysis.

CONCLUSION

Compared to the pre-pandemic group, the number who died was significantly increased in the COVID-19 pandemic group. Meanwhile, the effect of the pandemic on clinical outcomes in people undergoing neurosurgery might differ in different regions, according to our subgroup analysis.

Task appeared in COVID-19 pandemic when tele-healthcare saved neurosurgical lives in rural area - A case reports and literature review

In rural areas, the medical resources are extremely limited not only pandemic but non-pandemic period. Tele-healthcare system using digital technology-based telemedicine is widely used across various medical specialties. To solve limitation of medical resources in hospital located in remote isolated areas, telehealthcare system using smart application has been applied to access expert opinions in pre-coronavirus disease (COVID-19) era since 2017. The COVID-19 has spread also in this island during COVID-19 period. We have experienced three consecutive neuroemergency patients. Their ages and final diagnoses were: 98 years with subdural hematoma (case 1), 76 years with post-traumatic subarachnoid hemorrhage (case 2), and 65 years with cerebral infarction (case 3), respectively. The tele-counseling could save two of three transportations to tertiary hospital and also save 6,000 US dollars per case for transportation by helicopter. From these three cases counseled through smart app which has been started to use 2 years before COVID-19 emerged in 2020, what this case series would report are the following two viewpoints: (1) medicoeconomic benefits exist in tele-healthcare system in COVID-19 era and (2) developing telehealthcare systems must be prepared that is available even when the electricity system has been shut down, for instance solar system that could. This system must be developed when non-disaster period for disaster days of natural disasters and human-related disasters including wars and terrorisms.

COVID-19 and Parkinsonism: A Critical Appraisal

A few cases of parkinsonism linked to COVID-19 infection have been reported so far, raising the possibility of a post-viral parkinsonian syndrome. The objective of this review is to summarize the clinical, biological, and neuroimaging features of published cases describing COVID-19-related parkinsonism and to discuss the possible pathophysiological mechanisms. A comprehensive literature search was performed using NCBI’s PubMed database and standardized search terms. Thirteen cases of COVID-19-related parkinsonism were included (7 males; mean age: 51 years ± 14.51, range 31–73). Patients were classified based on the possible mechanisms of post-COVID-19 parkinsonism: extensive inflammation or hypoxic brain injury within the context of encephalopathy (n = 5); unmasking of underlying still non-symptomatic Parkinson’s Disease (PD) (n = 5), and structural and functional basal ganglia damage (n = 3). The various clinical scenarios show different outcomes and responses to dopaminergic treatment. Different mechanisms may play a role, including vascular damage, neuroinflammation, SARS-CoV-2 neuroinvasive potential, and the impact of SARS-CoV-2 on α-synuclein. Our results confirm that the appearance of parkinsonism during or immediately after COVID-19 infection represents a very rare event. Future long-term observational studies are needed to evaluate the possible role of SARS-CoV-2 infection as a trigger for the development of PD in the long term.

Practice Patterns in Surgical Neuro-Oncology Among Low- and Middle-Income Countries During the Coronavirus Disease 2019 Pandemic: A Scoping Review and Situational Report from the Philippines

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has negatively affected the outcomes of surgical neuro-oncology patients worldwide. We aimed to review the practice patterns in surgical neuro-oncology in low- and middle-income countries (LMICs). We also present a situational report from our own country.

METHODS

A scoping review was performed following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines.

RESULTS

Twelve studies were included in the review. Most of the studies were from Asia (India, China, Iran, and Turkey), and 1 was from Brazil. Quantitative reports showed a decrease in the number of surgical neuro-oncology operations between pre-COVID-19 and post-COVID-19 time frames, but similar proportions of neuro-oncology procedures. Qualitative review showed similar practice patterns between LMICs and high-income countries, except for limitations in resources such as negative-pressure operating rooms and intensive care units, and maintenance of face-to-face consults despite the adoption of telemedicine. Limited data on adjuvant therapy were available in LMICs.

CONCLUSIONS

In our review, we found that the practice patterns in surgical neuro-oncology in LMICs during the COVID-19 pandemic are similar to those in high-income countries, except for a few modifications because of resource limitation and patient preferences.

Effects of the COVID-19 Pandemic on Treatment Efficiency for Traumatic Brain Injury in the Emergency Department: A Multicenter Study in Taiwan

The coronavirus disease 2019 (COVID-19) pandemic has impacted emergency department (ED) practice, including the treatment of traumatic brain injury (TBI), which is commonly encountered in the ED. Our study aimed to evaluate TBI treatment efficiency in the ED during the COVID-19 pandemic. A retrospective observational study was conducted using the electronic medical records from three hospitals in metropolitan Taipei, Taiwan. The time from ED arrival to brain computed tomography (CT) and the time from ED arrival to surgical management were used as measures of treatment efficiency. TBI treatment efficiencies in the ED coinciding with a small-scale local COVID-19 outbreak in 2020 (P1) and large-scale community spread in 2021 (P2) were compared against the pre-pandemic efficiency recorded in 2019. The interval between ED arrival and brain CT was significantly shortened during P1 and P2 compared with the pre-pandemic interval, and no significant delay between ED arrival and surgical management was found, indicating increased treatment efficiency for TBI in the ED during the COVID-19 pandemic. Minimizing viral spread in the community and the hospital is vital to maintaining ED treatment efficiency and capacity. The ED should retain sufficient capacity to treat older patients with serious TBI during the COVID-19 pandemic.

Simultaneous bilateral mechanical thrombectomy in a patient with COVID-19

Owing to systemic inflammation and widespread vessel endotheliopathy, SARS-CoV-2 has been shown to confer an increased risk of cryptogenic stroke, particularly in patients without any traditional risk factors. In this report, we present a case of a 67-year-old female who presented with acute stroke from bilateral anterior circulation large vessel occlusions, and was incidentally found to be COVID-positive on routine hospital admission screening. The patient had a large area of penumbra bilaterally, and the decision was made to pursue bilateral simultaneous thrombectomy, with two endovascular neurosurgeons working on each side to achieve a faster time to recanalization. Our study highlights the utility and efficacy of simultaneous bilateral thrombectomy, and this treatment paradigm should be considered for use in patients who present with multifocal large vessel occlusions.

Covid-19 Infection and Parkinsonism: Is There a Link?

Severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) is an opportunistic pathogen that infects the upper respiratory tract in humans and causes serious illness, including fatal pneumonia and neurological disorders. Several studies have reported that SARS‐CoV‐2 may worsen the symptoms of Parkinson's disease (PD), with the potential to increase mortality rates in patients with advanced disease. The potential risk of SARS‐CoV‐2 to induce PD has also been suggested because the virus can enter the brain, where it can trigger cellular processes involved in neurodegeneration. In this review, we will discuss the potential of SARS‐CoV‐2 to exacerbate and cause certain neurological disorders, including PD. We will then elucidate its impact on the brain while examining its pathways and mechanisms of action. © 2021 International Parkinson and Movement Disorder Society

Spine surgeon perceptions of the challenges and benefits of telemedicine: an international study

Introduction

While telemedicine usage has increased due to the COVID-19 pandemic, there remains little consensus about how spine surgeons perceive virtual care. The purpose of this study was to explore international perspectives of spine providers on the challenges and benefits of telemedicine.

Methods

Responses from 485 members of AO Spine were analyzed, covering provider perceptions of the challenges and benefits of telemedicine. All questions were optional, and blank responses were excluded from analysis.

Results

The leading challenges reported by surgeons were decreased ability to perform physical examinations (38.6%), possible increased medicolegal exposure (19.3%), and lack of reimbursement parity compared to traditional visits (15.5%). Fewer than 9.0% of respondents experienced technological issues. On average, respondents agreed that telemedicine increases access to care for rural/long-distance patients, provides societal cost savings, and increases patient convenience. Responses were mixed about whether telemedicine leads to greater patient satisfaction. North Americans experienced the most challenges, but also thought telemedicine carried the most benefits, whereas Africans reported the fewest challenges and benefits. Age did not affect responses.

Conclusion

Spine surgeons are supportive of the benefits of telemedicine, and only a small minority experienced technical issues. The decreased ability to perform the physical examination was the top challenge and remains a major obstacle to virtual care for spine surgeons around the world, although interestingly, 61.4% of providers did not acknowledge this to be a major challenge. Significant groundwork in optimizing remote physical examination maneuvers and achieving legal and reimbursement clarity is necessary for widespread implementation.