Neurosurgical Outcomes, Protocols, and Resource Management During Lockdown: Early Institutional Experience from One of the World's Largest COVID 19 Hotspots

The Hitchhiker's Guide to Spine Awake Surgery. The Oxford SAS Protocol and Early Outcomes

OBJECTIVE

Spine awake surgery (SAS) aims to achieve faster recovery times, better outcomes, and a lesser economic impact on society. Our drive to establish SAS was to improve patient outcomes and health economics during the COVID-19 pandemic. After a systematic review and to the best of our knowledge, SAS, the Oxford Protocol, is the first protocolized pathway that aims to train bespoke teams performing SAS safely, efficiently, and in a standardized repeatable fashion. A pilot study was designed around newly derived protocols and simulated training to determine if SAS is a safe and implementable pathway to improve patient outcomes and health economics.

METHODS

We assessed a cohort of 10 patients undergoing one-level lumbar discectomies and decompressions, analyzing the related costs, length of stay, complications, pain management, and patient satisfaction.

RESULTS

The age range of our patients was 46-84 years. Three discectomies and 7 central canal stenosis decompressions were performed. Eight patients were discharged on the same day. All patients gave positive feedback about their experience of SAS. A significant cost saving was made compared to a general anesthesia (GA) overnight stay across the group. No on day cancellations occurred due to lack of bed availability. No patient needed analgesia in the recovery room or needed additional analgesia over and above the SAS e-prescription take home package.

CONCLUSIONS

Our early experience and journey reinforce our drive to push forward and expand on this process. It aligns with the international literature which highlights this approach as safe, efficient, and economical.

The Effect of COVID-19 in a University Hospital Neurosurgery Clinic Comparison to Prepandemic Period: A Retrospective Study with 6 months of Data

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic affected all countries' health systems and people's lifestyles. In this study, we aimed to investigate its effects in a university hospital neurosurgery clinic.

METHODS

The 2019 year's 6 months' data as a prepandemic period compared to the 2020 year's same period as a pandemic date. Demographic data were collected. Operations were divided into seven groups: tumor, spinal, vascular, cerebrospinal fluid disorders, hematoma, local, and minor surgery, respectively. We classified the hematoma cluster into subgroups to evaluate the etiology: epidural, acute subdural, subarachnoid hemorrhage, intracerebral hemorrhage, depressed skull fractures, and others. Patients' COVID-19 test results were collected.

RESULTS

Total operations decreased from 972 to 795 (Δ18.2%) during the pandemic. All groups, except minor surgery cases, decreased compared to the prepandemic period. Also, vascular procedures for females increased during the pandemic period. While focusing on the hematoma subgroups, there was decreasing in epidural and subdural hematomas, depressed skull fractures, and total case numbers; an increase in subarachnoid hemorrhage and intracerebral hemorrhage. Overall mortality significantly increased to 9.6% from 6.8% during the pandemic (P = 0.033). Eight (1.0%) of 795 patients were COVID-19-positive; three of them died. Neurosurgery residents and academicians were unsatisfied with decreased number of operations, training, and research productivity.

CONCLUSIONS

The pandemic and restrictions affected negatively the health system and people's access to healthcare. Our retrospective observational study aimed to evaluate these effects and take lessons for the next similar situations. People's access to health care should be considered when lockdown restrictions.

A look at the global impact of COVID-19 pandemic on neurosurgical services and residency training

Background

The COVID-19 pandemic has left an indelible effect on healthcare delivery and education system, including residency training. Particularly, neurosurgical departments worldwide had to adapt their operating model to the constantly changing pandemic landscape. This review aimed to quantify the reduction in neurosurgical operative volume and describe the impact of these trends on neurosurgical residency training.

Methods

We performed a comprehensive search of PubMed and EMBASE between December 2019 and October 2022 to identify studies comparing pre-pandemic and pandemic neurosurgical caseloads as well as articles detailing the impact of COVID-19 on neurosurgery residency training. Statistical analysis of quantitative data was presented as pooled odds ratio (OR) and 95% confidence intervals (CI).

Results

A total of 49 studies met the inclusion criteria, of which 12 (24.5%) were survey-based. The case volume of elective surgeries and non-elective procedures decreased by 70.4% (OR=0.296, 95%CI 0.210-0.418) and 68.2% (OR=0.318, 95%CI 0.193-0.525), respectively. A significant decrease was also observed in functional (OR=0.542, 95%CI 0.394-0.746), spine (OR=0.545, 95%CI 0.409-0.725), and skull base surgery (OR=0.545, 95%CI 0.409-0.725), whereas the caseloads for tumor (OR=1.029, 95%CI 0.838-1.263), trauma (OR=1.021, 95%CI 0.846-1.232), vascular (OR=1.001, 95%CI 0.870-1.152), and pediatric neurosurgery (OR=0.589, 95%CI 0.344-1.010) remained relatively the same between pre-pandemic and pandemic periods. The reduction in caseloads had caused concerns among residents and program directors in regard to the diminished clinical exposure, financial constraints, and mental well-being. Some positives highlighted were rapid adaptation to virtual educational platforms and increasing time for self-learning and research activities.

Conclusion

While COVID-19 has brought about significant disruptions in neurosurgical practice and training, this unprecedented challenge has opened the door for technological advances and collaboration that broaden the accessibility of resources and reduce the worldwide gap in neurosurgical education.

Non-COVID surgical load of operation theatre during COVID-19 pandemic in Armed Forces tertiary care centres: "Snapshot of two timelines"

Background

The global COVID-19 pandemic has led to major changes in the surgical caseloads in the operation theatres across the world. Elective surgeries have been curtailed to a great extent and the number of emergency surgeries has risen. We conducted a study to assess the changes in the surgical caseloads in two tertiary care hospitals in India during the pandemic and to assess the changes in anaesthesia techniques used.

Methods

A multicentre retrospective observational study conducted at two tertiary care centres located 1500 kms apart. Hospital A in a city with high incidence of COVID-19 and Hospital B with a lighter load of COVID-19 cases. Record of all major surgeries carried out between 01Jul 2020 and 31 Dec 2020 were compared with the surgeries carried out between 01 Jul 2019 and 31 Dec 2019.

Results

There was a decrease of almost 53% in elective surgical workload in hospital A and 71% in hospital B. The decrease in the cases was not similar across all specialities. There was a significant increase in the percentage of emergency surgeries from 11.1% to 24% in hospital A and from 22.1% to 29.8% in hospital B in the year 2020. A statistically significant increase in regional anaesthesia and neuraxial blockade was noted in the year 2020 in both the hospitals.

Conclusion

During the COVID-19 pandemic, the number of elective surgical cases has significantly decreased in specialities like ophthalmology whereas there was no change in the surgical workload in specialities like obstetrics, oncology, orthopaedics, and neurosurgery. There was significant increase in the use of regional and neuraxial techniques of anaesthesia.

Management of neurosurgical patients during coronavirus disease 2019 pandemics: The Ljubljana, Slovenia experience

The novel coronavirus disease 2019 (COVID-19) is an emerging disease, caused by severe acute respiratory syndrome coronavirus-2. It bears unique biological characteristics, clinical symptoms and imaging manifestations, therefore presenting an important and urgent threat to global health. As a result, a new public health crisis arose, threatening the world with the spread of the 2019 novel coronavirus. Despite the maximal worldwide public health responses aimed at containing the disease and delaying its spread, many countries have been confronted with a critical care crisis, and even more, countries will almost certainly follow. In Slovenia, the COVID-19 has struck the health system immensely and among all the specialities, neurosurgery has also been experiencing difficulties in the service, not only in regular, elective surgeries but especially during emergencies. The management of these neurosurgical patients has become more difficult than ever. We describe our protocol in the management of neurosurgical patients in the University Medical Centre Ljubljana, Slovenia and how neurosurgical pathology was tackled during the pandemics.

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.

Surgical Management During the COVID-19 Era at a Private Tertiary Care Hospital of Karachi, Pakistan: A Cross-Sectional Study

Background

The coronavirus disease 2019 (COVID-19), declared a pandemic in March 2020, has affected the entire healthcare system, including the surgical practice. Guidelines for the management of surgical patients during this COVID-19 era need to be established to provide timely yet safe surgical care. In this study, we aimed to evaluate the outcomes of the COVID-19 testing algorithm established for surgery patients presenting to a tertiary care hospital in Karachi, Pakistan, and to compare the outcomes among patients who underwent elective versus emergency surgery.

Methodology

This is a cross-sectional study conducted at a tertiary care hospital in Pakistan to apply and assess the outcomes of the COVID-19 testing algorithm established for patients presenting for surgery. We included all patients who underwent any surgery from May to October 2020. The total sample size was 6,846. The data were analyzed using SPSS version 23 (IBM Corp., Armonk, NY, USA). The categorical variables were assessed using the chi-square or Fisher’s exact test. A p-value of <0.05 was considered significant.

Results

A total of 6,846 surgeries were performed from May 1 to October 31, 2020. In total, 74% of the surgeries were elective procedures. We observed that a significantly higher proportion of emergency surgery patients tested positive for COVID-19 (4.2%) compared to elective surgery patients (25/5,063, 0.5%). A higher proportion of surgeries were performed in September (1,437, 21%) and October (1,445, 21%) while the lowest number of surgeries were performed in May (625, 9.1%). From week one to week five, a higher proportion of emergency surgeries were performed (32%) compared to elective surgeries (25%). Only 1.9% of the patients who were undergoing surgery were COVID-19 positive, with the highest number of COVID-19 cases presenting in June. Overall, 74 (4.2%) of the COVID-19-positive patients underwent emergency surgeries.

Conclusions

The timely establishment of well-defined guidelines for surgical management during the pandemic allowed us to provide timely and effective surgical care to patients with the priority of minimizing the spread of COVID-19 and preventing unnecessary deferral of surgeries.