Letter: The Coronavirus Disease 2019 Global Pandemic: A Neurosurgical Treatment Algorithm

Increased time to surgery and worse perioperative outcome in benign brain tumor patients with COVID-19

BACKGROUND

The COVID-19 pandemic caused significant disruptions to healthcare systems around the world, due to both high resource utilization and concern for disease spread. Delays in non-emergent surgeries have also affected chronic disease management, including that of benign brain tumors such as meningiomas and pituitary adenomas. To evaluate the effect of COVID-19 infection on benign brain tumor resection rates and subsequent perioperative and inpatient outcomes, this study utilized the 2020 National Inpatient Sample (NIS) to investigate rates of surgical resection, time to surgery, and mortality among benign brain tumor patients with and without COVID-19.

METHODS

Patient data from April 2020 to December 2020 was extracted from the NIS. Confirmed COVID-19 diagnosis was identified using the ICD-10 diagnosis code U07.1. Patients with benign neoplasms of the cerebral meninges, cranial nerves, pituitary gland, craniopharyngeal duct, and brain were included in the study. Patient socio-demographics, hospital characteristics, and clinical comorbidities were obtained. Outcome variables included rates of surgical resection, time to surgery, in-hospital mortality, length of stay, and discharge disposition.

RESULTS

The study analysis consisted of 13,053 patients with benign intracranial neoplasms who met inclusion criteria; 597 (4.6%) patients were COVID-19 positive. Patients with COVID-19 were more likely to be older and male than COVID-19 negative patients. Patients with COVID-19 had increased overall likelihood of mortality (OR 2.36, 95% CI 1.72-3.25, p < 0.0001). Even when controlling for sociodemographic/hospital factors and comorbidities, COVID-19 positive patients had a significantly longer time to surgery (8.7 days vs. 0.9 days, p < 0.0001) than COVID negative patients, and were associated with a decreased likelihood of undergoing surgery on index admission overall (OR 0.17, 95% CI 0.10-0.29, p < 0.0001).

CONCLUSIONS

As expected, COVID-19 infection was associated with worse inpatient outcomes in effectively all measured categories, including longer time to surgery, decreased likelihood of receiving surgery on index admission, and increased likelihood of in-hospital mortality. These findings emphasize the effect that COVID-19 has on other aspects of patient care and highlight the importance of appropriate avenues of care for patients who are COVID-19 positive. Although the COVID-19 pandemic is no longer a public health emergency, understanding the pandemic's impact on outcome for these patients is essential in efficient triage and optimizing treatment for these patients in the future. Further study is needed to elucidate causal relationships on the outcomes of benign brain tumor patients.

COVID-19 and Surgical Practice in Slovenia: Managing the Crisis in Neurosurgery during the COVID-19 Pandemic

Worldwide, the novel coronavirus disease 2019 (COVID-19) has become a significant threat to global health. Worldwide, COVID-19 has affected the health service also in Slovenia. During this time, neurosurgery is facing difficulties in its service, both in emergency and elective surgeries. In the article, we describe the anti-COVID-19 measures taken at our neurosurgical department in a medical centre in Ljubljana, Slovenia, and analysed and compared the number of emergency and elective neurosurgical procedures during the time of the pandemic.

Neurosurgical care for patients with high-grade gliomas during the coronavirus disease 2019 pandemic: Analysis of routine billing data of a German nationwide hospital network

Background

Little is known about delivery of neurosurgical care, complication rate and outcome of patients with high-grade glioma (HGG) during the coronavirus disease 2019 (Covid-19) pandemic.

Methods

This observational, retrospective cohort study analyzed routine administrative data of all patients admitted for neurosurgical treatment of an HGG within the Helios Hospital network in Germany. Data of the Covid-19 pandemic (March 1, 2020-May 31, 2022) were compared to the pre-pandemic period (January 1, 2016-February 29, 2020). Frequency of treatment and outcome (in-hospital mortality, length of hospital stay [LOHS], time in intensive care unit [TICU] and ventilation outside the operating room [OR]) were separately analyzed for patients with microsurgical resection (MR) or stereotactic biopsy (STBx).

Results

A total of 1763 patients underwent MR of an HGG (648 patients during the Covid-19 pandemic; 1115 patients in the pre-pandemic period). 513 patients underwent STBx (182 [pandemic]; 331 patients [pre-pandemic]). No significant differences were found for treatment frequency (MR: 2.95 patients/week [Covid-19 pandemic] vs. 3.04 patients/week [pre-pandemic], IRR 0.98, 95% CI: 0.89-1.07; STBx (1.82 [Covid-19 pandemic] vs. 1.86 [pre-pandemic], IRR 0.96, 95% CI: 0.80-1.16, P > .05). Rates of in-hospital mortality, infection, postoperative hemorrhage, cerebral ischemia and ventilation outside the OR were similar in both periods. Overall LOHS was significantly shorter for patients with MR and STBx during the Covid-19 pandemic.

Conclusions

The Covid-19 pandemic did not affect the frequency of neurosurgical treatment of patients with an HGG based on data of a large nationwide hospital network in Germany. LOHS was significantly shorter but quality of neurosurgical care and outcome was not altered during the Covid-19 pandemic.

Coronavirus disease-19 is associated with decreased treatment access and worsened outcomes in malignant brain tumor patients

Background

The global coronavirus disease-19 (COVID-19) pandemic has resulted in procedural delays around the world; however, timely and aggressive surgical resection for malignant brain tumor patients is essential for outcome optimization. To investigate the association between COVID-19 and outcomes of these patients, we queried the 2020 National Inpatient Sample (NIS) for differences in rates of surgical resection, time to surgery, mortality, and discharge disposition between patients with and without confirmed COVID-19 infection.

Methods

Patient data were taken from the NIS from April 2020 to December 2020. COVID-19 diagnosis was determined with the International Classification of Diseases, Tenth Revision, Clinical Modification code U07.1.

Results

A total of 30,671 malignant brain tumor patients met inclusion criteria and 738 (2.4%) patients had a confirmed COVID-19 diagnosis. COVID-19-positive patients had lower likelihood of receiving surgery (Odds ratio [OR] 0.43, 95% confidence interval [CI] 0.29-0.63, P < 0.0001), increased likelihood of mortality (OR 2.18, 95% CI 1.78-2.66, P < 0.0001), and increased likelihood of non-routine discharge (OR 1.25, 95% CI 1.13-1.39, P < 0.0001). Notably, COVID patients receiving surgery were not associated with surgical delay (P = 0.17).

Conclusion

COVID-19 infection was associated with worse patient outcome in malignant brain tumor patients, including decreased likelihood of receiving surgery, increased likelihood of mortality, and increased likelihood of non-routine discharge. Our study highlights the need to balance the risks and benefits of delaying surgery for malignant brain tumor patients with COVID-19. Although the COVID-19 pandemic is no longer a public health emergency, understanding the pandemic's impact on outcome provides important insight in effective triage for these patients in the situations where resources are limited.

Network analysis of neurosurgical literature: an increased focus on training during the COVID-19 pandemic

The COVID-19 pandemic led to stringent guidelines to restrict the conduct of non-emergent surgical procedures. Consequently, neurosurgery departments experienced a decline in case volumes and greater educational time being spent on virtual research projects. In our report, we reveal how neurosurgical research has changed during the pandemic compared to the pre-pandemic phase. The WebOfScience database was searched for neurosurgical articles published between 2012-2019 (pre-pandemic) and 2020-2022 (pandemic). From this data, the keywords, terms, and countries were analyzed using networks formed by the VOS Viewer software. In addition, the analysis was repeated for neurosurgical articles specific to COVID-19. Network analyses of terms and keywords revealed an increased popularity of virtual research projects, including case reports, meta-analyses, reviews, surveys, and database studies. Additionally, there was increased interest in research pertaining to neurosurgical education during the post-pandemic era, including topics regarding virtual training modalities, mental health, and telemedicine. Our bibliometrics analysis suggests that the impact of COVID-19 restrictions on hospital systems affected neurosurgical training programs. Future investigations should explore the effects of the trainee experience during the COVID-19 pandemic on the outlook for neurosurgical education.

The Korean Society for Neuro-Oncology (KSNO) Guideline for the Management of Brain Tumor Patients During the Crisis Period: A Consensus Recommendation Using the Delphi Method (Version 2023.1)

BACKGROUND

During the coronavirus disease 2019 (COVID-19) pandemic, the need for appropriate treatment guidelines for patients with brain tumors was indispensable due to the lack and limitations of medical resources. Thus, the Korean Society for Neuro-Oncology (KSNO), a multidisciplinary academic society, has undertaken efforts to develop a guideline that is tailored to the domestic situation and that can be used in similar crisis situations in the future.

METHODS

The KSNO Guideline Working Group was composed of 22 multidisciplinary experts on neuro-oncology in Korea. In order to reach consensus among the experts, the Delphi method was used to build up the final recommendations.

RESULTS

All participating experts completed the series of surveys, and the results of final survey were used to draft the current consensus recommendations. Priority levels of surgery and radiotherapy during crises were proposed using appropriate time window-based criteria for management outcome. The highest priority for surgery is assigned to patients who are life-threatening or have a risk of significant impact on a patient's prognosis unless immediate intervention is given within 24-48 hours. As for the radiotherapy, patients who are at risk of compromising their overall survival or neurological status within 4-6 weeks are assigned to the highest priority. Curative-intent chemotherapy has the highest priority, followed by neoadjuvant/adjuvant and palliative chemotherapy during a crisis period. Telemedicine should be actively considered as a management tool for brain tumor patients during the mass infection crises such as the COVID-19 pandemic.

CONCLUSION

It is crucial that adequate medical care for patients with brain tumors is maintained and provided, even during times of crisis. This guideline will serve as a valuable resource, assisting in the delivery of treatment to brain tumor patients in the event of any future crisis.

Tailoring of neurosurgical practice during COVID-19 in a developing country: Insights gained and a way forward

Background:

The coronavirus disease-19 pandemic has aggravated the already neglected neurosurgical specialty in developing countries with a mounting shortage of specialists, long queues of operative patients, and a lack of adequate critical care units.

Methods:

We have reviewed the innovative strategies adopted for maintaining an optimal surgical practice while ensuring team safety at the Aga Khan University Hospital, Karachi Pakistan.

Results:

There is already a scarcity of resources in developing countries. The international guidelines had to be tailored to the context of the developing world. A multimodal strategy that focused on infection control, continuum of care, and the well-being of staff was adopted at Aga Khan University. Patients were screened and seen either in person or through telemedicine, depending on the severity of the disease. All educational activities for residents were shifted online, and this helped in preventing overcrowding.

Conclusion:

Optimal surgical practice while ensuring team safety can be achieved through a multimodal strategy focusing on infection control, continuum of care, and the well-being of staff.

Problematics of neurosurgical service during the COVID-19 pandemic in Slovenia

The novel coronavirus disease 2019 (COVID-19) is an ongoing disease caused by severe acute respiratory syndrome coronavirus-2 that still poses an important and urgent threat to global health. In Slovenia, the epidemic was declared on March 12^th, 2020, and since then COVID-19 has had a great impact on our health system. The field of neurosurgery in particular has been experiencing difficulties in both elective and emergency service. In this article, we described epidemiologic protocols and the effect that the COVID-19 pandemic had on the surgical practice and workflow of the Department of Neurosurgery at the University Medical Centre Ljubljana. We analyzed and compared the number of elective and emergency neurosurgical procedures in a 2-year period before and during the pandemic. We recorded a drop in cases mostly on account of elective procedures whilst emergency service remained relatively unaffected.

Impact of the COVID-19 Pandemic and Lockdown on Non-COVID Neurosurgical Patients: Lessons Learned

Objective The COVID-19 pandemic has challenged the basic functioning of the health care system. There has been an adverse impact on non-COVID-19 patients due to a shift in healthcare delivery, which is underreported. This study aims to explore the impact of the pandemic on various aspects of non-COVID neurosurgical patients.

Methods This descriptive cross-sectional study was conducted with a structured questionnaire to assess the physical, economic, and psychological impacts of the COVID-19 pandemic and lockdown measures on neurosurgical patients presenting to our hospital after a nationwide lockdown.

Results Among 203 patients, non-neurotrauma and neurotrauma cases were 175 (86%) and 28 (16%), respectively. Among non-neurotrauma patients, 130 (64%) patients had cranial pathology. All 56 (27.6%) preoperative patients experienced rescheduling of surgery. Among 52 postsurgical patients, 47 (90%) had their adjuvant therapy delayed. Forty patients experienced deterioration in their neurological symptoms. Seventy-six (37%) patients sought medical attention from private hospitals. A severe contraction of income (≥ 25% of the income before lockdown) was experienced by families of 29 (14.3%) patients. Severe and very severe stress have been experienced by 24 (11.8%) and 14 (6.9%) patients, respectively. Severe and very severe anxiety was experienced by 32 (15.8%) and 9 (4.4%) patients.

Conclusion The COVID-19 pandemic and nationwide lockdown had a tremendous impact on the physical, social, and psychological well-being of patients with non-COVID illnesses. We are yet to face the long-term implications of the delay due to this pandemic in scheduled surgical and adjuvant treatments of non-COVID neurosurgical patients.

Impact of the COVID-19 Pandemic on Neurosurgical Transfers: A Single Tertiary Center Study

OBJECTIVE

Interfacility transfers represent a large proportion of neurosurgical admissions to tertiary care centers each year. In this study, the authors examined the impact of the COVID-19 pandemic on the number of transfers, timing of transfers, demographic profile of transfer patients, and clinical outcomes including rates of surgical intervention.

METHODS

A retrospective review of neurosurgical transfer patients at a single tertiary center was performed. Patients transferred from April to November 2020 (the "COVID Era") were compared with an institutional database of transfer patients collected before the COVID-19 pandemic (the "Pre-COVID Era"). During the COVID Era, both emergent and nonemergent neurosurgical services had resumed. A comparison of demographic and clinical factors between the 2 cohorts was performed.

RESULTS

A total of 674 patients were included in the study (331 Pre-COVID and 343 COVID-Era patients). Overall, there was no change in the average monthly number of transfers (P = 0.66) or in the catchment area of referral hospitals. However, COVID-Era patients were more likely to be uninsured (1% vs. 4%), had longer transfer times (COVID vs. Pre-COVID Era: 18 vs. 9 hours; P < 0.001), required higher rates of surgical intervention (63% vs. 50%, P = 0.001), had higher rates of spine pathology (17% vs. 10%), and less frequently were admitted to the intensive care unit (34% vs. 52%, P < 0.001). Overall, COVID-Era patients did not experience delays to surgical intervention (3.1 days vs. 3.6 days, P = 0.2). When analyzing the subgroup of COVID-Era patients, COVID infection status did not impact the time of transfer or rates of operation, although COVID-infected patients experienced a longer time to surgery after admission (14 vs. 2.9 days, P < 0.001).

CONCLUSION

The COVID-19 pandemic did not reduce the number of monthly transfers, operation rates, or catchment area for transfer patients. Transfer rates of uninsured patients increased during the COVID Era, potentially reflecting changes in access to community neurosurgery care. Shorter time to surgery seen in COVID-Era patients possibly reflects institutional policies that improved operating room efficiency to compensate for surgical backlogs. COVID status affeted time to surgery, reflecting the preoperative care that these patients require before intervention.

Managing Traumatic Brain Injury During the Coronavirus Disease 2019 Pandemic-A Case-Matched Controlled Analysis of Immediate Outcomes

OBJECTIVE

The primary objective of this study was to evaluate the outcome of patients with traumatic brain injury (TBI) during the coronavirus disease 2019 (COVID-19) pandemic and to compare their outcome with case-matched controls from the prepandemic phase.

METHODS

This is a retrospective case-control study in which all patients with TBI admitted during COVID-19 pandemic phase (Arm A) from March 24, 2020 to November 30, 2020 were matched with age and Glasgow Coma Scale score-matched controls from the patients admitted before March 2020 (Arm B).

RESULTS

The total number of patients matched in each arm was 118. The length of hospital stay (8 days vs. 5 days; P < 0.001), transit time from emergency room to operation room (150 minutes vs. 97 minutes; P = 0.271), anesthesia induction time (75 minutes vs. 45 minutes; P = 0.002), and operative duration (275 minutes vs. 180 minutes; P = 0.002) were longer in arm A. Although the incidence of fever and pneumonia was significantly higher in arm A than in arm B (50% vs. 26.3%, P < 0.001 and 27.1% vs. 1.7%, P < 0.001, respectively), outcome (Glasgow Outcome Scale-Extended) and mortality (18.6% vs. 14.4% respectively; P = 0.42) were similar in both the groups.

CONCLUSIONS

The outcome of the patients managed for TBI during the COVID-19 pandemic was similar to matched patients with TBI managed at our center before the onset of the COVID-19 pandemic. This finding suggests that the guidelines followed during the COVID-19 pandemic were effective in dealing with patients with TBI. This model can serve as a guide for any future pandemic waves for effective management of patients with TBI without compromising their outcome.

Neurosurgery Subspecialty Practice During a Pandemic: A Multicenter Analysis of Operative Practice in 7 U.S. Neurosurgery Departments During Coronavirus Disease 2019

OBJECTIVE

Changes to neurosurgical practices during the coronavirus disease 2019 (COVID-19) pandemic have not been thoroughly analyzed. We report the effects of operative restrictions imposed under variable local COVID-19 infection rates and health care policies using a retrospective multicenter cohort study and highlight shifts in operative volumes and subspecialty practice.

METHODS

Seven academic neurosurgery departments' neurosurgical case logs were collected; procedures in April 2020 (COVID-19 surge) and April 2019 (historical control) were analyzed overall and by 6 subspecialties. Patient acuity, surgical scheduling policies, and local surge levels were assessed.

RESULTS

Operative volume during the COVID-19 surge decreased 58.5% from the previous year (602 vs. 1449, P = 0.001). COVID-19 infection rates within departments' counties correlated with decreased operative volume (r = 0.695, P = 0.04) and increased patient categorical acuity (P = 0.001). Spine procedure volume decreased by 63.9% (220 vs. 609, P = 0.002), for a significantly smaller proportion of overall practice during the COVID-19 surge (36.5%) versus the control period (42.0%) (P = 0.02). Vascular volume decreased by 39.5% (72 vs. 119, P = 0.01) but increased as a percentage of caseload (8.2% in 2019 vs. 12.0% in 2020, P = 0.04). Neuro-oncology procedure volume decreased by 45.5% (174 vs. 318, P = 0.04) but maintained a consistent proportion of all neurosurgeries (28.9% in 2020 vs. 21.9% in 2019, P = 0.09). Functional neurosurgery volume, which declined by 81.4% (41 vs. 220, P = 0.008), represented only 6.8% of cases during the pandemic versus 15.2% in 2019 (P = 0.02).

CONCLUSIONS

Operative restrictions during the COVID-19 surge led to distinct shifts in neurosurgical practice, and local infective burden played a significant role in operative volume and patient acuity.

Patients awaiting surgery for neurosurgical diseases during the first wave of the COVID-19 pandemic in Spain: a multicentre cohort study

OBJECTIVES

The large number of infected patients requiring mechanical ventilation has led to the postponement of scheduled neurosurgical procedures during the first wave of the COVID-19 pandemic. The aims of this study were to investigate the factors that influence the decision to postpone scheduled neurosurgical procedures and to evaluate the effect of the restriction in scheduled surgery adopted to deal with the first outbreak of the COVID-19 pandemic in Spain on the outcome of patients awaiting surgery.

DESIGN

This was an observational retrospective study.

SETTINGS

A tertiary-level multicentre study of neurosurgery activity between 1 March and 30 June 2020.

PARTICIPANTS

A total of 680 patients awaiting any scheduled neurosurgical procedure were enrolled. 470 patients (69.1%) were awaiting surgery because of spine degenerative disease, 86 patients (12.6%) due to functional disorders, 58 patients (8.5%) due to brain or spine tumours, 25 patients (3.7%) due to cerebrospinal fluid (CSF) disorders and 17 patients (2.5%) due to cerebrovascular disease.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was mortality due to any reason and any deterioration of the specific neurosurgical condition. Second, we analysed the rate of confirmed SARS-CoV-2 infection.

RESULTS

More than one-quarter of patients experienced clinical or radiological deterioration. The rate of worsening was higher among patients with functional (39.5%) or CSF disorders (40%). Two patients died (0.4%) during the waiting period, both because of a concurrent disease. We performed a multivariate logistic regression analysis to determine independent covariates associated with maintaining the surgical indication. We found that community SARS-CoV-2 incidence (OR=1.011, p<0.001), degenerative spine (OR=0.296, p=0.027) and expedited indications (OR=6.095, p<0.001) were independent factors for being operated on during the pandemic.

CONCLUSIONS

Patients awaiting neurosurgery experienced significant collateral damage even when they were considered for scheduled procedures.

Impact of COVID-19 pandemic on epilepsy care in Japan: A national-level multicenter retrospective cohort study

OBJECTIVE

The impact of the coronavirus disease 2019 (COVID-19) pandemic on epilepsy care across Japan was investigated by conducting a multicenter retrospective cohort study.

METHODS

This study included monthly data on the frequency of (1) visits by outpatients with epilepsy, (2) outpatient electroencephalography (EEG) studies, (3) telemedicine for epilepsy, (4) admissions for epilepsy, (5) EEG monitoring, and (6) epilepsy surgery in epilepsy centers and clinics across Japan between January 2019 and December 2020. We defined the primary outcome as epilepsy-center-specific monthly data divided by the 12-month average in 2019 for each facility. We determined whether the COVID-19 pandemic-related factors (such as year [2019 or 2020], COVID-19 cases in each prefecture in the previous month, and the state of emergency) were independently associated with these outcomes.

RESULTS

In 2020, the frequency of outpatient EEG studies (-10.7%, p<0.001) and cases with telemedicine (+2,608%, p=0.031) were affected. The number of COVID-19 cases was an independent associated factor for epilepsy admission (-3.75*10-3 % per case, p<0.001) and EEG monitoring (-3.81*10-3 % per case, p = 0.004). Further, the state of emergency was an independent factor associated with outpatient with epilepsy (-11.9%, p<0.001), outpatient EEG (-32.3%, p<0.001), telemedicine for epilepsy (+12,915%, p<0.001), epilepsy admissions (-35.3%; p<0.001), EEG monitoring (-24.7%: p<0.001), and epilepsy surgery (-50.3%, p<0.001).

SIGNIFICANCE

We demonstrated the significant impact that the COVID-19 pandemic had on epilepsy care. These results support those of previous studies and clarify the effect size of each pandemic-related factor on epilepsy care.

Nosocomial COVID-19 infection mortality following surgery for severe progressive cervical myelopathy: a case report

Introduction

We present the unique case of a nosocomial COVID infection acquired after urgent surgical intervention for cervical myelopathy, as well as the sequelae that followed in the postoperative period.

Case presentation

An initially COVID-negative patient underwent urgent surgical intervention for cervical myelopathy with significant neurological deterioration. She underwent an uncomplicated staged anterior cervical discectomy and fusion with corpectomy, as well as a subsequent posterior cervical instrumented fusion within the same hospitalization. The patient would refuse to adhere to standard COVID precautions during her admission and demonstrated rapid decompensation following her particularly uneventful surgeries, ultimately leading to her expiration. A laboratory test confirmed that she had contracted COVID at the time of the patient’s death.

Discussion

This report highlights the repercussions of COVID-19 infection during the perioperative period and its implications on surgical outcomes. The stresses of surgery and the body’s immunosuppressive responses during this time place patients at particular risk for the contraction of this virus. The standard precautions should be followed and vaccination should be considered for surgical candidates prior to their operations, as they become more readily accessible.

Current Trends in Mild Traumatic Brain Injury

In this review, we provide an overview of the current research and treatment of all types of traumatic brain injury (TBI) before illustrating the need for improved care specific to mild TBI patients. Contemporary issues pertaining to acute care of mild TBI including prognostication, neurosurgical intervention, repeat radiographic imaging, reversal of antiplatelet and anticoagulation medications, and cost savings initiatives are reviewed. Lastly, the effect of COVID-19 on TBI is addressed.

Unequal Impact of COVID-19 on Private and Academic Neurosurgical Workforce: Results of an International Survey

Background: Since the COVID-19 outbreak several manuscripts regarding neurosurgical practice during this pandemic have been published. Qualitative studies on how the pandemic affected neurosurgeons, with additional focus on their practice, are still scarce. This study's objective was to investigate the impact of COVID-19 on various aspects of the professional and private life of a homogeneous group of international neurosurgeons affiliated to the European Association of Neurosurgical Societies (EANS). Methods: Neurosurgeons from Europe and abroad were invited to participate in an online survey endorsed by the Individual Membership Committee of the EANS. The survey captured a subjective snapshot of the impact of the first wave of the COVID-19 pandemic on EANS members and was advertised through its Institutional website. In addition to departmental data, personal feeling of safety, financial security, local precautions, number of surgeries performed, changes in daily routine, and other practice-related information were inquired. Differences among practice types were closely reviewed. Results: The survey was distributed between April and May 2020: 204 neurosurgeons participated. Participants were typically active EANS members (73%), consultants (57.9%), from university hospitals (64.5%). Elective surgical practice was still ongoing only for 15% of responders, whereas 18.7% of them had already transitioned to COVID-19 and emergency medical services. While 65.7% of participants thought their institutions were adequately prepared, lack of testing for SARS-CoV-2, and scarcity of personal protective equipment were still a matter of concern for most of them. Overall surgical activity dropped by 68% (cranial by 54%, spine by 71%), and even emergencies decreased by 35%. COVID-19 prompted changes in communication in 74% of departments, 44% increased telemedicine by >50%. While most neurosurgeons had concerns about personal and families' health, financial outlook appeared to be gloomy only for private practitioners. Conclusion: The lockdown imposed in many countries by the COVID-19 outbreak called for immediate modification of working routine and resulted in a dramatic decrease of elective surgical procedures. Neurosurgeons share common concerns but were not equally exposed to the personal health and financial dangers of the ongoing pandemic.

Top 100 Most Cited Neurologic and Neurosurgical Articles on COVID-19: A Bibliometric Analysis

Objective

With the exponential growth of literature on coronavirus disease 2019 (COVID-19), we aimed to identify and characterize the 100 most cited COVID-19–related articles in neurology and neurosurgery.

Methods

In March 2021, we performed a title-specific search of the Scopus database using (“neurology” or “neurologic” or “neurosurgery” or “neurosurgical”) and “COVID” as our search query term without date restrictions. The top 100 most cited English-language articles were obtained and reviewed.

Results

Our search yielded 9648 articles published from December 2019 to March 2021. Bibliometric analysis of the top 100 articles found that the most cited article had a citation count of 1741 and was the first to report on the detailed neurologic manifestations of the disease; Neurology had the most number of publications; the majority of the primary authors were neurologists, but 35% were from nonneuroscience specialties; the United States, Italy, the United Kingdom, China, and Germany were the top contributors, with a combined total of 77%; most of the publications were correspondence or editorial articles; and most articles discussed the neurologic manifestations and complications of patients with COVID-19.

Conclusions

This study identified the top 100 most cited neurologic or neurosurgical COVID-19–related articles published to date. This list can be used to identify high-impact studies that will help health care practitioners in clinical decision making and researchers in navigating key areas of study and guiding future research.

A National Survey Evaluating the Impact of the COVID-19 Pandemic on Students Pursuing Careers in Neurosurgery

Background: The COVID-19 pandemic has profoundly disrupted medical education and the residency application process. Methods: We conducted a descriptive observational study in April 2020 of medical students and foreign medical graduates considering or pursuing careers in neurosurgery in the United States to examine the impact of the pandemic. Results: A total of 379 respondents from 67 medical schools completed the survey. Across all participants, 92% (n = 347) stopped in-person didactic education, and 43% (n = 161) experienced basic science and 44% (n = 167) clinical research delays. Sixty percent (n = 227) cited a negative impact on academic productivity. Among first year students, 18% (n = 17) were less likely to pursue a career in neurosurgery. Over half of second year and third year students were likely to delay taking the United States Medical Licensing Examination Steps I and II. Among third year students, 77% (n = 91) reported indefinite postponement of sub-internships, and 43% (n = 53) were unsatisfied with communication from external programs. Many fourth-year students (50%, n = 17) were graduating early to participate in COVID-19-related patient care. Top student-requested support activities included access to student-focused educational webinars and sessions at upcoming conferences. Conclusions: Medical students pursuing careers in neurosurgery faced unique academic, career, and personal challenges secondary to the pandemic. These challenges may become opportunities for new initiatives guided by professional organizations and residency programs.

Perioperative Practices and Outcome of Neurosurgery during the COVID-19 Pandemic: Institutional Experience and Retrospective Observational Analysis

Introduction Surgery during the coronavirus disease 2019 (COVID-19) pandemic is a major concern due to possibility of infection transmission among health care workers (HCWs) and patients, and a worsened surgical outcome; most surgeries are thus being deferred. However, we continued with emergency neurosurgeries using our own Neurosurgical Standard Operating Procedures (NS-SOPs). We describe here our institutional neurosurgical experience and observations of a retrospective analysis done to determine the incidence of workplace-acquired COVID infection among the HCWs, and the outcome of neurosurgery performed during the early phase of the on-going pandemic.

Methods Our NS-SOPs included a Screening Proforma, and protocols for the conduct of neurosurgery, starting from the preoperative period till death or postdischarge follow-up of the patients. Protocols to ensure safety and mental well-being of the HCWs were also implemented. Patient and HCW data from April 1 to August 31, 2020 was collected and analyzed for the postsurgical patient outcome and for determining the level of workplace-transmitted COVID infection.

Results Neurosurgeries were performed on 169 patients during this 5-month period. We observed a cumulative mortality of 17/169 (10.1%), with 5 patients having unexplained postoperative respiratory manifestations and rapid deterioration suggestive of COVID illness. Nineteen HCWs (8.83%), mostly nurses, were infected, but only 3 (16.7%) had workplace-acquired infection. The infections were sporadic with no cluster of infections observed.

Conclusion Implementation of standard perioperative protocols and their continuous scrutiny, evaluation, and modification is important to contain infection in HCWs and to improve the neurosurgical outcome during this pandemic.

Analysis of Neurosurgical Cases Before and During the Coronavirus Disease 2019 Pandemic from a Tertiary-Care Centre in India

Objective

We present the unique administrative issues as well as specific patient-related and surgeon-related challenges and solutions implemented while treating neurosurgical patients during the coronavirus disease 2019 (COVID-19) pandemic vis-à-vis pre-COVID-19 times at our tertiary-care center.

Methods

This is a retrospective study comparing the outcome of the neurosurgical patients treated from the beginning of lockdown in India on March 25, 2020 to November 30, 2020 with that of same period in the previous year, 2019.

Results

There were 687 neurosurgery admissions during the study period compared with 2550 admissions in 2019. The total number of surgeries performed in neurosurgery also showed a similar trend, with only 654 surgeries in 2020 compared with 3165 surgeries in 2019. During COVID-19 times, 474 patients were operated on including both trauma and nontrauma cases. Of the 50 patients with suspected/indeterminate COVID-19 who were operated on, 5 turned out to be positive for COVID-19. Significant differences were seen in the mortality (P < 0.01) and morbidity (P < 0.01) among patients with trauma on comparing COVID and pre-COVID periods. Similarly, a significant difference was observed in the mortality (P < 0.001) and morbidity (P < 0.001) in patients who did not have trauma.

Conclusions

The higher mortality and morbidity during the COVID pandemic is primarily attributable to poorer baseline clinical status. Our experience from this COVID period might not only help us in tackling subsequent waves but also help other institutions in the developing world to be better prepared for similar circumstances.

Neurologic Manifestations of COVID-19

Neurological manifestations of novel coronavirus disease (COVID-19) are reported to occur in as much as 37% of the affected patients. These manifestations range from headache and dizziness to altered mental status and consciousness, anosmia, ageusia, sensory disturbances, and stroke. The mechanisms by which the neurological symptoms arise are not yet determined but may either proceed as an indirect consequence of systemic hyperinflammation or result from the direct invasion of the virus to neural and glial cells. The neural invasion can explain both the retrograde pathway of encephalitis and the early manifestation of anosmia by invading the olfactory bulb. Moreover, in the case of attacking the brain stem, it may take part in the early apnea manifestation reported by patients. Additionally, neurotropism of the virus could be the cause of acute hemorrhagic encephalitis. Hyperinflammation can have acute and prolonged effects in the nervous system, such as acute demyelination and predisposition to multiple sclerosis. Moreover, the pro-inflammatory state contributes to hypercoagulation, which in turn could result in cerebrovascular injuries in COVID-19 patients. This chapter would discuss that the neurologic manifestations of the COVID-19 are to be looked at as a multifactorial entangled phenomenon.

Orthopedic Department of Education Center and Service Provide During Coronavirus Disease-2019 Pandemic: An Experience from Single-Center Hospital

BACKGROUND: In the global pandemic of the 2019 coronavirus disease (COVID-19), many countries have reported a decrease in visits to hospitals, and health-care systems around the world are reshaping health protocols. Health service and education in orthopedics are also affected although not at the frontline in dealing COVID-19. METHODS: The data from this study collected from several official databases, including the Indonesian Ministry of Health, Central Java provincial government, general hospital, and orthopedic surgery cases. RESULTS: Pandemic COVID-19 started in March 2020 in Indonesia. Surakarta has become one of the epicenters. Health services in the orthopedic department also experienced a decrease cases on all divisions (outpatient clinics, emergency rooms, and inpatients). Mann–Whitney non-parametric comparative test showed significance result in p value operation of orthopedic cases and inpatients (p = 0.016 and p = 0.016; p < 0.05), meanwhile, outpatient visits did not show significance result with p = 0.0509 (p > 0.05). The decrease in the number of cases being treated in the orthopedic service also has an impact on education and training programs. The digital era is one of the choices in the field of education. However, digital resources cannot substitute for direct patient exposure. CONCLUSION: The average number of orthopedic patients during the pandemic period from January to December 2020 decreased compared to visits in the same period in 2019 so that orthopedic services at tertiary and academic referral hospitals experienced a significant decrease in cases. The education and services department must adapt to the policy on educational activities for residents and medical students. The education department and hospital institutions restructured and reorganized resident doctors to continue providing services. The digital era is an option that supports the education process during a pandemic.

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.

The Management and Outcomes of Coronavirus Disease 2019 Infection in a Series of Neurosurgical Patients

Background

The coronavirus disease 2019 (COVID-19) pandemic has impacted neurosurgical practice worldwide. In Iran, hospitals have halted their routine activities, and most hospital beds have been assigned to COVID-19 patients. Here, we share our experience with 10 neurosurgical cases with confirmed COVID-19.

Materials and Methods

From February 24, 2020 to April 20, 2020, we were able to obtain clinical data on ten neurosurgical patients with COVID-19 through a predefined electronic form.

Results

Of the 10 patients with COVID-19 on neurosurgical units, eight underwent surgical interventions. The age of the patients ranged from 21 to 75 years and 70% were males. The diagnosis of COVID-19 was based on chest imaging findings and reverse transcriptase-polymerase chain reaction for coronavirus and an infectious disease specialist and a pulmonologist confirmed the diagnoses. In two cases, there was a significant decrease in O2 saturation intraoperatively. Three patients in this series died during the assessment period. One death was due to respiratory failure induced by the coronavirus infection. The cause of death in other two patients was cardiovascular failure not related to COVID-19.

Conclusions

We hope we can provide a reference for future studies and help develop a clearer understanding of neurosurgical practice and outcomes in patients with COVID-19. In the time of COVID-19 pandemic when dealing with neurosurgical emergencies, a conservative approach is recommended. Using committed personal protective equipment, short-time operating procedures or minimally invasive surgery must be considered in the management of emergent patients. Resuming elective surgeries need defining measures needed to ensure patients and health-care providers' safety. Reorganizing the health-care system for telemonitoring released patients can lessen hospital visits.

Characteristics and operation outcomes of neuro-oncology patients after COVID-19 pandemic - A case series

Background

COVID-19 has been spreading worldwide at hitherto unknown speed, and the treatment of neuro-oncology patients without COVID-19 has been greatly affected.

Methods

To compare the medical records and surgical results of surgical patients before and after the pandemic. We collected a total of 80 patients form April 2020 to May 2020 after pandemic and from April 2019 to May 2019 before pandemic. The patient's demographics, past medical history, comorbidities, imaging, pathology, laboratory teat, and Karnofsky Performance Score (KPS) were analyzed.

Results

The most common presenting symptom was intracranial hypertension and neurological deficit. Hypertension and diabetes were the most common comorbid diseases. The pre-operation KPS were 83.21 ± 15.60, 80 ± 14.77, 78.57 ± 12.83 and 74.14 ± 12.72, respectively. The post-operation KPS were 94.64 ± 8.65, 95.45 ± 6.56, 91.43 ± 10.82 and 84.21 ± 22.55, respectively. The tumor volume was larger and the midline shift distance was greater after the pandemic than before. For pathological grade, meningiomas were mostly grade I, while gliomas were mainly grade III and IV.

Conclusion

Although affected by the COVID-19 pandemic, patients with glioma should be operated as soon as possible to obtain better surgical results, however, for patients with meningiomas, their operation can be postponed slightly when the patients are tolerable.

Is Elective Neurosurgery Justified During COVID-19 Pandemic?

Background

As the world faces a new viral pandemic, which has spread very rapidly, initial response from most countries was to suspend nonemergent health services so that available resources can be diverted to handle the large numbers of patients with COVID-19 infection. Many societies issued guidelines to suspend or postpone nonemergent surgeries.

Methods

We reviewed the emerging evidence regarding the impact of COVID-19 infection in neurosurgery and the postponement of elective surgeries.

Results and Observations

COVID-19 infection poses serious threat in hospitals in the form of cross-infection, hospital staff falling sick, with potential risk to overwhelm or paralyze the healthcare. In addition, we have come to realize the significant perioperative morbidity and mortality secondary to active COVID-19 infection. All these strongly favor suspension of elective neurosurgical services. However, these have to be weighed against the fallout due to prolonged postponement of neurosurgical treatment for conditions, which can progress and cause neurological deterioration.

Conclusion

This article discusses the contemporary published literature regarding the perioperative risk of COVID-19 infection, impact of postponed surgeries, challenges, risk assessment and guidelines for elective neurosurgery at this point of time.

Modification of neurosurgical practice during corona pandemic: Our experience at AIIMS patna and long term guidelines

BACKGROUND

First case of covid-19 was confirmed on 30th January 2020 in India. Our state, Bihar reported its first confirmed case of covid on 22nd march 2020 at AIIMS Patna. For safety, Electives surgeries and outpatient department was suspended temporary since 25th March. Standard operating procedure (SOP) was framed for covid suspected, covid positive and negative patients. Neurosurgery department formulated their own strategy for successful and covid free management of neurosurgical patients along with zero transmission rate among doctors and staff.

METHODS

All Neurosurgical patients who got attended, admitted and operated from 25th March to 30th June 2020 (Period of lockdown) were taken in this study. Categorizations of the patients were done according to the urgency and elective nature of pathology after corona screening and RT-PCR testing of covid-19. A proper training to all neurosurgical staff and residents were given for management of patients (admission to operation to discharge).

RESULTS

Total 133 patients were attended and 90 were admitted. We operated 76 cases (major - 52, minor - 24) during the lockdown period. Out of this 2 were corona positive (both eventually succumbed) and rest 74 was corona negative. One patient who was operated with corona negative report became positive after 10 days of surgery inward. All the residents, faculty and nursing staff remain asymptomatic throughout the lockdown period with zero infection rate and zero transmission rate.

CONCLUSION

Following a properly made standard operating procedure and strictly implementing it can avoid any type of misadventure in neurosurgery during corona pandemic.

Epilepsy and COVID-19: Updated evidence and narrative review

The coronavirus disease 2019 (COVID-19) outbreak started in Wuhan, China, in late 2019 and rapidly spread globally. Vaccines have recently been developed and are being administered in some countries, but their widespread use is not yet sufficient; the battle against COVID-19 is protracted and people need to adapt to living under the influence of this disease. Epilepsy is a common chronic neurological condition characterized by spontaneous recurrence of unprovoked seizures. Various effects of COVID-19 on epilepsy have been studied in recent months. As clinicians, we need to keep up with daily updates in the evidence regarding interactions between COVID-19 and epilepsy. This review article summarizes the current evidence. Prospective studies on epilepsy and COVID-19 remain lacking. Most articles have comprised case reports, case series, retrospective studies, and recommendations/opinions that do not include data. However, summarizing these articles can identify the demands for research into COVID-19 and epilepsy by clarifying what is known and what remains unclear from current research.

The impact of coronavirus 2019 (COVID-19) on neurosurgical practice and training: a review article

The 2019 coronavirus pandemic (COVID-19) has affected all of society at different levels. Similarly, COVID-19 has significantly impacted every medical field, including neurosurgery. By exposing scarcities in the healthcare industry and requiring the reallocation of available resources towards the priority setting and away from elective surgeries and outpatient visits, the pandemic posed new, unprecedented challenges to the medical community. Despite the redistribution of resources towards COVID-19 patients and away from elective surgeries, urgent and emergent surgeries for life-threatening conditions needed to be continued. The neurosurgical community, like other specialties not directly involved in the care of COVID-19 patients, initially struggled to balance the needs of COVID-19 patients with those of neurosurgical patients, residents, and researchers. Several articles describing the effect of COVID-19 on neurosurgical practice and training have been published throughout the COVID-19 pandemic. This article aims to provide a focused review of the impact COVID-19 has had on neurosurgical practice and training as well as describe neurological manifestations of the disease.

SARS-CoV-2 mediated neuroinflammation and the impact of COVID-19 in neurological disorders

SARS-CoV-2 is a novel coronavirus that severely affects the respiratory system, is the cause of the COVID-19 pandemic, and is projected to result in the deaths of 2 million people worldwide. Recent reports suggest that SARS-CoV-2 also affects the central nervous system along with other organs. COVID-19-associated complications are observed in older people with underlying neurological conditions like stroke, Alzheimer's disease, and Parkinson's disease. Hence, we discuss SARS-CoV-2 viral replication and its inflammation-mediated infection. This review also focuses on COVID-19 associated neurological complications in individuals with those complications as well as other groups of people. Finally, we also briefly discuss the current therapies available to treat patients, as well as ongoing available treatments and vaccines for effective cures with a special focus on the therapeutic potential of a small 5 amino acid peptide (PHSCN), ATN-161, that inhibits SARS-CoV-2 spike protein binding to both integrin α5β1 and α5β1/hACE2.

Algorithm of traumatic brain injury management at Indonesia in the COVID 19 pandemic ERA. Retrospective cohort study

OBJECTIVES

COVID-19, a global pandemic, affects neurosurgical care in Indonesia. This study has objective to propose guideline and algorithm recommendation for the management of TBI patients during this pandemic, which can be used flexibly at neurosurgery centers, both in Indonesia and throughout the world.

METHODS

We performed retrospective Cohort analysis from TBI database at tertiary public general hospitals. All neurotrauma cases from mid-February until mid-August 2020 was included in this study. The chronology of COVID-19 pandemics impact in Indonesia was defined by early period from mid-February until end of May 2020, and late period are latter. All subjects undergone the screening and perioperative measures that based on our proposes scoring system and algorithm as follows.

RESULTS

There are many guidelines that explain screening methods in neurosurgery patients in general, as well as neurotrauma in particular. But here, we proposed our own scoring and screening algorithm that has been developed based on conditions in Indonesia. In total of 757 neurotrauma cases data were collected from the pandemic starts in Indonesia.

DISCUSSION

Screening is a crucial initial step in this pandemic period, not only for COVID patients, but also all patients who enter the emergency room. The use of PPE is a necessity in several neurosurgery centers, especially with high COVID-19 case rates.

CONCLUSION

The management of neurotrauma patients with suspected and confirmed COVID-19 requires special attention, starting from admission of the patient in ER. Rapid scoring and screening are important and the highest level of PPE is mandatory during patient care.

Impact of a pandemic on surgical neuro-oncology-maintaining functionality in the early phase of crisis

Background

The Coronavirus disease 2019 (COVID-19) pandemic has extraordinarily impacted global healthcare. Neuro-oncological surgery units have peculiar features that make them highly relevant in the strategic reaction to the pandemic. In this Chinese Society of Neuro-Oncology (CSNO) initiated survey, we appraise the changes implemented in neuro-oncological surgery hospitals across different Asian countries and provide expert recommendations for responses at different stages of the pandemic.

Methods

We performed a 42-question survey of the early experience of neuro-oncological surgery practice in hospitals across different Asian countries on April 1, 2020, with responses closed on April 18, 2020.

Results

144 hospitals completed the questionnaire. Most were in WHO post-peak phase of the pandemic and reported a median reduction in neuro-oncological surgery volume of 25–50%. Most (67.4%) resumed elective surgery in only COVID-19 negative patients;11.1% performed only emergency cases irrespective of COVID-19 status;2.1% suspended all surgical activity. Ninety-one (63.2%) relocated personnel from neurosurgery to other departments. Fifty-two (36.1%) hospitals suspended post-operative adjuvant therapy and 94 (65.2%) instituted different measures to administer post-operative adjuvant therapy. Majority (59.0%) of the hospitals suspended research activity. Most (70%) respondents anticipate that current neurosurgery restrictions will continue to remain for > 1 month.

Conclusions

Majority of the respondents to our survey reported reduced neuro-oncological surgery activity, policy modification, personnel reallocation, and curtailment of educational/research activities in response to the COVID-19 pandemic. The persistent widespread interruption of surgical neuro-oncology in even post-peak phases of the pandemic raises serious concerns about the long-term impact of the pandemic on neuro-oncological patients and highlights the essence of timely measures for pandemic preparedness, patient triage, and workforce protection.

The effects of COVID-19 pandemic on pediatric neurosurgery practice and training in a developing country

PURPOSE

COVID-19 pandemic has influenced all aspects of societies, with the healthcare being the most affected field. All specialties including neurosurgery are involved, and due to resource limitations, the number of elective surgeries in subspecialized filed has substantially decreased. Herein, we report our practice experience in pediatric neurosurgery in a tertiary hospital during pandemic, and the effects of pandemic on educational issues.

METHODS

All the patients on whom any kind of neurosurgical operation was performed from March to June 2020 were retrospectively collected, and also from the same period in the previous year.

RESULTS

A total of 111 patients underwent surgery in this period. This figure was 159 patients during the same period in 2019. The total number of surgical cases reduced by 31% compared to the last year. While ventriculoperitoneal shunts and supratentorial tumor were more frequent, there was a considerable reduction in subspecialized educational surgeries like neural tube defects and craniosynostoses.

CONCLUSION

CVID-19 pandemic changed all scopes of medical practice and training. Considering the limitation in the available resources, the number of educational cases may decrease in subspecialized disciplines like pediatric neurosurgery. If pandemic continues, alternative measures should be taken to compensate for the shortcoming in technical and practical training.

A Systematic Review on the Impact of the COVID-19 Pandemic on Neurosurgical Practice and Indian Perspective

OBJECTIVE

The study objective was to systematically review the impact of the current pandemic on neurosurgical practice and to find out a safe way of practicing neurosurgery amid the highly infectious patients with COVID-19.

MATERIALS AND METHODS

A review of the PubMed and EMBASE databases was performed. The literature was systematically searched using keywords such as "COVID-19" and "Neurosurgery."

RESULTS

Among the 425 records, 128 articles were found to be eligible for analysis. These articles described the perspectives of the neurosurgical departments during the pandemic, departmental models, and organizational schemes for triaging emergent and nonemergent neurosurgical cases for the optimal utilization of limited resources, and solutions to continue academic and research activities. Triaging systems help us to optimally utilize the limited resources available. Guidelines have been developed for safe neurosurgical practice and for the continuation of clinical and academic activities during this pandemic by various national and international neurosurgical societies. Key changes in the telemedicine regulatory guidelines would help us to continue to provide neurosurgical care. Videoconferences, online education programs, and webinars could help us to overcome the disadvantages brought upon the neurosurgical education by the social-distancing norms.

CONCLUSION

In an unprecedented time like this, no single algorithm is going to clear the ethical dilemma faced by us. Individual patient triage is a way for maintaining our ethical practice and at the same time, for efficiently utilizing the limited resources. As the pandemic progresses, new guidelines and protocols will continue to evolve for better neurosurgical practice.

Early Effects of COVID-19 Pandemic on Neurosurgical Training in the United States: A Case Volume Analysis of 8 Programs

OBJECTIVE

To determine the impact of the 2019 novel coronavirus disease (COVID-19) pandemic on operative case volume in 8 U.S. neurosurgical residency training programs in early 2020 and to survey these programs regarding training activities during this period.

METHODS

A retrospective review was conducted of monthly operative case volumes and types for 8 residency programs for 2019 and January through April 2020. Cases were grouped as elective cranial, elective spine, and nonelective emergent cases. Programs were surveyed regarding residents' perceptions of the impact of COVID-19 on surgical training, didactics, and research participation. Data were analyzed for individual programs and pooled across programs.

RESULTS

Across programs, the 2019 monthly mean ± SD case volume was 211 ± 82; 2020 mean ± SD case volumes for January, February, March, and April were 228 ± 93, 214 ± 84, 180 ± 73, and 107 ± 45. Compared with 2019, March and April 2020 mean cases declined 15% (P = 0.003) and 49% (P = 0.002), respectively. COVID-19 affected surgical case volume for all programs; 75% reported didactics negatively affected, and 90% reported COVID-19 resulted in increased research time. Several neurosurgery residents required COVID-19 testing; however, to our knowledge, only 1 resident from the participating programs tested positive.

CONCLUSIONS

This study documents a significant reduction in operative volume in 8 neurosurgery residency training programs in early 2020. During this time, neurosurgery residents engaged in online didactics and research-related activities, reporting increased research productivity. Residency programs should collect data to determine the educational impact of the COVID-19 pandemic on residents' operative case volumes, identify deficiencies, and develop plans to mitigate any effects.

Management protocol for emergency aneurysm craniotomy clipping in non-major COVID-19 epidemic areas in Beijing, China

Background

An epidemic of COVID-19 broke out in Wuhan, China, since December 2019. The ordinary medical services were hindered. However, the emergency cases, including aneurysmal subarachnoid hemorrhage (aSAH), still required timely intervention. Thus, it provoked challenges to the routine management protocol. In this study, we summarized our experience in the emergency management of aSAH (Beijing Tiantan Protocol, BTP) in Beijing, China.

Methods

Demographic, clinical, and imaging data of consecutive emergency aSAH patients who underwent craniotomy clipping during the COVID-19 epidemic season were reviewed and compared with the retrospective period last year. Subgroup analysis was further performed to assess the outcomes of different screening results and several detailed protocols. Neurological outcomes were evaluated by the modified Rankin Scale (mRS).

Results

A total of 127 aSAH were referred to our emergency department, and 42 (33.1%) underwent craniotomy clipping between January 20, 2020, and March 25, 2020. The incidence of preoperative hospitalized adverse events and the perioperative outcomes were similar (− 0.1, 95% CI − 1.0 to 0.8, P = 0.779) to the retrospective period last year (January 2019–March 2019). After the propensity score matching (PSM), there were still no statistical differences in prognostic parameters between the two groups. Eight (19.0%) of the 42 individuals were initially screened as preliminary undetermined COVID-19 cases, in which 2 of them underwent craniotomy clipping in the negative pressure operating room (OR). The prognosis of patients with varied COVID-19 screening results was similar (F(2, 39) = 0.393, P = 0.678). Since February 28, 12 cases (28.6%) received COVID-19 nucleic acid testing (NAT) upon admission, and all showed negative. The false-negative rate was 0.0%. The preoperative hospitalized adverse events and postoperative prognosis were still similar between patients with and without COVID-19 NAT (− 0.3, 95% CI − 1.4 to 0.9, P = 0.653).

Conclusions

Our emergency surgery management protocol (BTP) is reliable for scheduling emergency aneurysm craniotomy clipping in non-major epidemic areas.

Preparedness and guidelines for neurosurgery in the COVID-19 era: Indian perspective from a tertiary care referral hospital

The COVID-19 pandemic has severely impacted healthcare systems globally. The need of the hour is the development of effective strategies for protecting the lives of healthcare providers (HCPs) and judicious triage for optimal utilization of human and hospital resources. During this pandemic, neurosurgery, like other specialties, must transform, innovate, and adopt new guidelines and safety protocols for reducing the risk of cross-infection of HCPs without compromising patient care. In this article, the authors discuss the current neurosurgical practice guidelines at a high-volume tertiary care referral hospital in India and compare them with international guidelines and global consensus for neurosurgery practice in the COVID-19 era. Additionally, the authors highlight some of the modifications incorporated into their clinical practice, including those for stratification of neurosurgical cases, patient triaging based on COVID-19 testing, optimal manpower management, infrastructure reorganization, evolving modules for resident training, and innovations in operating guidelines. The authors recommend the use of their blueprint for stratification of neurosurgical cases, including their protocol for algorithmic patient triage and management and their template for manpower allocation to COVID-19 duty, as a replicable model for efficient healthcare delivery.

Reconversion of neurosurgical practice in times of the SARS-CoV-2 pandemic: a narrative review of the literature and guideline implementation in a Mexican neurosurgical referral center

OBJECTIVE

The coronavirus disease 2019 (COVID-19) pandemic has forced the modification of surgical practice worldwide. Medical centers have been adapted to provide an efficient arrangement of their economic and human resources. Although neurosurgeons are not in the first line of management and treatment of COVID-19 patients, they take care of patients with neurological pathology and potential severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Here, the authors describe their institutional actions against the pandemic and compare these actions with those in peer-reviewed publications.

METHODS

The authors conducted a search using the MEDLINE, PubMed, and Google Scholar databases from the beginning of the pandemic until July 11, 2020, using the following terms: "Neurosurgery," "COVID-19/SARS-CoV-2," "reconversion/modification," "practice," "academy," and "teaching." Then, they created operational guidelines tailored for their institution to maximize resource efficiency and minimize risk for the healthcare personnel.

RESULTS

According to the reviewed literature, the authors defined the following three changes that have had the greatest impact in neurosurgical practice during the COVID-19 pandemic: 1) changes in clinical practices; 2) changes in the medical care setting, including modifications of perioperative care; and 3) changes in the academic teaching methodology.

CONCLUSIONS

The Instituto Nacional de Neurología y Neurocirugía "Manuel Velasco Suárez" is one of the major referral centers for treating highly complex neurosurgical pathologies in Mexico. Its clinical and neurosurgical practices have been modified with the implementation of specific interventions against the spread of COVID-19. These practical and simple actions are remarkably relevant in the context of the pandemic and can be adopted and suited by other healthcare centers according to their available resources to better prepare for the next event.

Neurosurgeons on the front line: experience from the center of the storm in Italy

In this tumultuous time, the entire world has been shaken up by the COVID-19 outbreak. Italy has had one of the highest infection-related mortality rates. Bergamo, a city in eastern Lombardy, was among the most affected. Here, the authors describe the main healthcare actions taken at their institution to stem the crisis, with particular concern regarding the fate of their neurosurgery department. Among the different topics, the authors particularly focus on the retraining of neurosurgeons, organization of activities, and what should be the role of neurosurgeons during a pandemic.

Neurosurgery at the epicenter of the COVID-19 pandemic in Indonesia: experience from a Surabaya academic tertiary hospital

OBJECTIVE

Global outbreak of the novel coronavirus disease 2019 (COVID-19) has forced healthcare systems worldwide to reshape their facilities and protocols. Although not considered the frontline specialty in managing COVID-19 patients, neurosurgical service and training were also significantly affected. This article focuses on the impact of the COVID-19 outbreak at a low- and/or middle-income country (LMIC) academic tertiary referral hospital, the university and hospital policies and actions for the neurosurgical service and training program during the outbreak, and the contingency plan for future reference on preparedness for service and education.

METHODS

The authors collected data from several official databases, including the Indonesian Ministry of Health database, East Java provincial government database, hospital database, and neurosurgery operative case log. Policies and regulations information was obtained from stakeholders, including the Indonesian Society of Neurological Surgeons, the hospital board of directors, and the dean's office.

RESULTS

The curve of confirmed COVID-19 cases in Indonesia had not flattened by the 2nd week of June 2020. Surabaya, the second-largest city in Indonesia, became the epicenter of the COVID-19 outbreak in Indonesia. The neurosurgical service experienced a significant drop in cases (50% of cases from normal days) along all lines (outpatient clinic, emergency room, and surgical ward). Despite a strict preadmission screening, postoperative COVID-19 infection cases were detected during the treatment course of neurosurgical patients, and those with a positive COVID-19 infection had a high mortality rate. The reduction in the overall number of cases treated in the neurosurgical service had an impact on the educational and training program. The digital environment found popularity in the educational term; however, digital resources could not replace direct exposure to real patients. The education stakeholders adjusted the undergraduate students' clinical postings and residents' working schemes for safety reasons.

CONCLUSIONS

The neurosurgery service at an academic tertiary referral hospital in an LMIC experienced a significant reduction in cases. The university and program directors had to adapt to an off-campus and off-hospital policy for neurosurgical residents and undergraduate students. The hospital instituted a reorganization of residents for service. The digital environment found popularity during the outbreak to support the educational process.

Impact of COVID-19 on Neurosurgical Training in Southeast Asia

OBJECTIVE

Neurosurgery departments worldwide have been forced to restructure their training programs because of the coronavirus disease 2019 (COVID-19) pandemic. In this study, we describe the impact of COVID-19 on neurosurgical training in Southeast Asia.

METHODS

We conducted an online survey among neurosurgery residents in Indonesia, Malaysia, Philippines, Singapore, and Thailand from May 22 to 31, 2020 using Google Forms. The 33-item questionnaire collected data on elective and emergency neurosurgical operations, ongoing learning activities, and health worker safety.

RESULTS

A total of 298 of 470 neurosurgery residents completed the survey, equivalent to a 63% response rate. The decrease in elective neurosurgical operations in Indonesia and in the Philippines (median, 100% for both) was significantly greater compared with other countries (P < 0.001). For emergency operations, trainees in Indonesia and Malaysia had a significantly greater reduction in their caseload (median, 80% and 70%, respectively) compared with trainees in Singapore and Thailand (median, 20% and 50%, respectively; P < 0.001). Neurosurgery residents were most concerned about the decrease in their hands-on surgical experience, uncertainty in their career advancement, and occupational safety in the workplace. Most of the residents (n = 221, 74%) believed that the COVID-19 crisis will have a negative impact on their neurosurgical training overall.

CONCLUSIONS

An effective national strategy to control COVID-19 is crucial to sustain neurosurgical training and to provide essential neurosurgical services. Training programs in Southeast Asia should consider developing online learning modules and setting up simulation laboratories to allow trainees to systematically acquire knowledge and develop practical skills during these challenging times.

COVID-19 Impact on Neurosurgical Practice: Lockdown Attitude and Experience of a European Academic Center

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic is an unprecedented challenge. Different models of reorganization have been described aiming to preserve resources and ensure optimal medical care. Limited clinical neurosurgical experience with patients with COVID-19 has been reported. We share organizational experience, attitudes, and preliminary data of patients treated at our institution.

METHODS

Institutional guidelines and patient workflow are described and visualized. A cohort of all neurosurgical patients managed during the lockdown period is presented and analyzed, assessing suspected nosocomial infection risk factors. A comparative surgical subcohort from the previous year was used to investigate the impact on surgical activity.

RESULTS

A total of 176 patients were admitted in 66 days, 20 of whom tested positive for COVID-19. Patients initially admitted to the neurosurgical ward were less likely to be suspected for a COVID-19 infection compared with patients admitted for critical emergencies, particularly with neurovascular and stroke-related diseases. The mortality of patients with COVID-19 was remarkably high (45%), and even higher in patients who underwent surgical intervention (77%). In addition to the expected decrease in surgical activity (-53%), a decrease in traumatic emergencies was noted.

CONCLUSIONS

By applying infection prevention and resource-sparing logistics measures shared by the international medical community, we were able to maintain essential neurosurgical care in a pandemic with controlled nosocomial infection risk. Special consideration should be given to medical management and surgical indications in patients infected with severe acute respiratory syndrome coronavirus 2, because they seem to show a problematic hemostatic profile that might result in an unfavorable clinical and surgical outcome.

Pediatric Neurosurgery After the COVID-19 Pandemic: Management Strategies from a Single Pediatric Hospital in Italy

BACKGROUND

Coronavirus disease-2019 (COVID-19) pandemic had a great impact over all elective neurosurgical activity and important implications in management of neurosurgical urgencies. During the pandemic, some pediatric hospitals reported their experiences. After the emergency phase of the COVID-19 pandemic, the health care system needs to be reorganized to again manage all nonurgent activities, while ensuring safety of both patients and health care workers.

METHODS

We developed preventive measures to limit any possibility of COVID-19 spread, according to the principles of epidemiologic prevention and suggestions from recent literature. To evaluate the efficacy of these measures, we retrospectively reviewed the neurosurgical activity at our institution from May 4 to July 15, 2020.

RESULTS

One hundred nineteen patients were admitted to the neurosurgical ward, and 80 surgical procedures were performed. Furthermore, 130 outpatient clinics were scheduled. A total of 258 nasopharyngeal swabs and 249 specific interviews were performed. In our series, no cases of positivity for severe acute respiratory syndrome coronavirus-2 infection were found, and no surgical cases were postponed.

DISCUSSION

We present the management of the neurosurgical activity after the emergency phase at the Neurosurgical Department of Giannina Gaslini Children's Hospital in Genoa, Italy.

CONCLUSIONS

The Italian health care system is undertaking a process of reorganization of resources, in an attempt to restore all nonurgent activities while ensuring safety. After the emergency phase, we are learning to live together with COVID-19 and, although epidemiologic data are encouraging, we must be prepared for an eventual second peak.

Home Program for Acquisition and Maintenance of Microsurgical Skills During the Coronavirus Disease 2019 Outbreak

BACKGROUND

During the current global crisis unleashed by the severe acute respiratory syndrome coronavirus 2 outbreak, surgical departments have considerably reduced the amount of elective surgeries. This decrease leads to less time in the surgical room to develop and improve the surgical skills of residents. In this study, we developed a training program to obtain and maintain microsurgical skills at home, using a smartphone camera and low-cost materials, affordable for everyone.

METHODS

Using a smartphone camera as a magnification device, 6 participants performed 5 exercises (coloring grids, grouping colors, unraveling of a gauze, knots with suture threads, and tower of Hanoi), both with the dominant and with the nondominant hand, for 4 weeks. We compared performance at the beginning and at the end of the training process. Each participant filled out an anonymous survey.

RESULTS

When we compared the performance at the beginning and at the end of the training process, we found significant improvements (P = 0.05) with the dominant as well as the nondominant hand in all the exercises. All participants were satisfied or very satisfied with the definition of the objectives of the training process, material availability, the exercises performed, the choice of the time to train, and general satisfaction with the training program.

CONCLUSIONS

We developed a microsurgical skills training program to be performed at home, which can be easily reproduced. It allows residents to improve manual coordination skills and is regarded as a feasible adjunct for ongoing training for surgical residents.