The Impact of COVID-19 Pandemic on Spine Surgeons Worldwide: A One Year Prospective Comparative Study

STUDY DESIGN

Survey.

OBJECTIVE

In March of 2020, an original study by Louie et al investigated the impact of COVID-19 on 902 spine surgeons internationally. Since then, due to varying government responses and public health initiatives to the pandemic, individual countries and regions of the world have been affected differently. Therefore, this follow-up study aimed to assess how the COVID-19 impact on spine surgeons has changed 1 year later.

METHODS

A repeat, multi-dimensional, 90-item survey written in English was distributed to spine surgeons worldwide via email to the AO Spine membership who agreed to receive surveys. Questions were categorized into the following domains: demographics, COVID-19 observations, preparedness, personal impact, patient care, and future perceptions.

RESULTS

Basic respondent demographics, such as gender, age, home demographics, medical comorbidities, practice type, and years since training completion, were similar to those of the original 2020 survey. Significant differences between groups included reasons for COVID testing, opinions of media coverage, hospital unemployment, likelihood to be performing elective surgery, percentage of cases cancelled, percentage of personal income, sick leave, personal time allocation, stress coping mechanisms, and the belief that future guidelines were needed (P<.05).

CONCLUSION

Compared to baseline results collected at the beginning of the COVID-19 pandemic in 2020, significant differences in various domains related to COVID-19 perceptions, hospital preparedness, practice impact, personal impact, and future perceptions have developed. Follow-up assessment of spine surgeons has further indicated that telemedicine and virtual education are mainstays. Such findings may help to inform and manage expectations and responses to any future outbreaks.

Twenty-Year Radiographic Outcomes Following Single-Level Cervical Disc Arthroplasty: Results From a Prospective Randomized Controlled Trial

STUDY DESIGN

Prospective randomized controlled trial.

OBJECTIVE

Compare range of motion (ROM) and adjacent segment degeneration (ASD) following cervical disc arthroplasty (CDA) versus anterior cervical discectomy and fusion (ACDF) at 20-year follow-up.

SUMMARY OF BACKGROUND DATA

Anterior cervical discectomy and fusion is the standard of treatment for single-level cervical disc degeneration causing radiculopathy. CDA is claimed to reduce shear strain, and adjacent-level ROM changes are hypothesized to hasten ASD with ACDF.

MATERIALS AND METHODS

This study collected data on 47 patients randomized to ACDF or CDA. Lateral cervical spine radiographs were evaluated preoperatively, postoperatively, and at 20 years for alignment, ROM, ASD, and heterotopic ossification.

RESULTS

Eighty-two percent (18/22) of CDA patients and 84% (21/25) of ACDF patients followed up at 20 years. At 20 years, total cervical (C2-C7) ROM was statistically different between the CDA and fusion groups (47.8° vs . 33.4°, P =0.005). Total cervical ROM was not significantly different between preoperative and 20-year periods following CDA (45.6° vs . 47.4°, P =0.772) or ACDF (40.6° vs . 33.0°, P =0.192). Differences in postoperative and 20-year index-level ROM following CDA were not significant (10.1° vs . 10.2°, P =0.952). Final ASD grading was statistically lower following CDA versus ACDF at both adjacent levels ( P <0.005). Twenty-year adjacent-level ossification development was increased following ACDF versus CDA ( P <0.001). Polyethylene mean thickness decreased from 9.4 mm immediately postoperatively to 9.1 mm at 20-year follow up ( P =0.013). Differences in adjacent-level ROM from preoperative to 20-year follow-up in both the ACDF and CDA groups did not meet statistical significance ( P >0.05).

CONCLUSIONS

Cervical disc arthroplasty maintains index-level and total cervical ROM with very long-term follow-up. Total cervical ROM was higher at 20 years in CDA relative to ACDF. CDA results in lower rates of ASD and adjacent-level ossification development than ACDF.

Bone Density Distribution in the Cervical Spine

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Given changes in bone density induced by degenerative disease, general measures of bone health (ie DEXA) are inadequate to evaluate bone density in surgical areas of interest. Regional differences in HU in the cervical spine may influence surgical strategies. The purposes of our study were to determine whether cervical Hounsfield units (HU) vary by level, examine their relationship with age, comorbidities, and alignment, and propose a technique to measure HU in the lateral masses.

METHODS

Two hundred twenty-four patients with degenerative spine pathology with a cervical computed tomography were included (2015-2019). Measurements were performed in each vertebral body (C2-T1; mid-axial, anterior-axial, posterior-axial, mid-coronal, and mid-sagittal) and 2 regions of the lateral masses (C3-C6; mid-cor, mid-sag). To evaluate reliability, 6 observers each measured 355 HU values, inter-relater reliability assessed with intraclass correlation coefficients Correlations of HU with age, BMI, comorbidities, and cervical alignment were evaluated.

RESULTS

Bone density differed by level, with the lowest HU scores in the lower cervical spine (C6-T1) (P < .001). No correlations were found between LM HU and age, BMI, CCI, or alignment (P > .05). Increased kyphosis was weakly correlated with VB HU, while age and CCI showed moderate correlations with VB HU at all levels (P<.001). ICC for HU measurements were good to excellent for the VBs, but poor to moderate for the LMs.

CONCLUSION

Bone is least dense in the lower cervical spine. HU scoring is not reliable in the lateral masses. We recommend that a level-specific approach to bone density is considered in surgical planning.

How Much Lumbar Lordosis does a Patient Need to Reach their Age-Adjusted Alignment Target? A Formulated Approach Predicting Successful Surgical Outcomes

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

Identify optimal lumbar lordosis in adult deformity correction to achieve age-adjusted targets and sustained alignment.

METHODS

Surgical adult spinal deformity patients reaching an age-adjusted ideal alignment at one year were identified. Multilinear regression analysis was used to identify the relationship between regional curvatures (LL and TK) that enabled achievement of a given global alignment (T1 pelvic angle, TPA) based on pelvic incidence (PI).

RESULTS

347 patients out of 1048 available reached their age-adjusted TPA within 5° (60-year-old, 72% women, body mass index 29 ± 6.2). They had a significant improvement in all sagittal parameters (except PI) from pre-operative baseline to 1 year following surgery (P < .001). Multilinear regression predicting L1-S1 based on TK, TPA, and PI demonstrated excellent results (R2 = .85). Simplification of the coefficients of prediction combined with a conversion to an age-based formula led to the following: LL = PI - 0.3TK - 0.5Age + 10. Internal validation of the formula led to a mean error of -.4°, and an absolute error of 5.0°. Internal validation on patients with an age-adjusted alignment revealed similar accuracy across the entire age-adjusted TPA spectrum (ranges of LL errors: ME = .2° to 1.7°, AE = 4.0° to 5.3°).

CONCLUSION

This study provides a simple guideline to identify the amount of LL needed to reach a given alignment (i.e., age-adjusted target) based on PI and associated TK. Implementation of this predictive formula during pre-operative surgical planning may help to reduce unexpected sub-optimal post-operative alignment outcomes.

Telemedicine in Spine Surgery: Global Perspectives and Practices

STUDY DESIGN

Cross-sectional, anonymous, international survey.

OBJECTIVES

The COVID-19 pandemic has resulted in the rapid adoption of telemedicine in spine surgery. This study sought to determine the extent of adoption and global perspectives on telemedicine in spine surgery.

METHODS

All members of AO Spine International were emailed an anonymous survey covering the participant's experiences with and perceptions of telemedicine. Descriptive statistics were used to depict responses. Responses were compared among regions.

RESULTS

485 spine surgeons participated in the survey. Telemedicine usage rose from <10.0% to >39.0% of all visits. A majority of providers (60.5%) performed at least one telemedicine visit. The format of "telemedicine" varied widely by region: European (50.0%) and African (45.2%) surgeons were more likely to use phone calls, whereas North (66.7%) and South American (77.0%) surgeons more commonly used video (P < 0.001). North American providers used telemedicine the most during COVID-19 (>60.0% of all visits). 81.9% of all providers "agreed/strongly agreed" telemedicine was easy to use. Respondents tended to "agree" that imaging review, the initial appointment, and postoperative care could be performed using telemedicine. Almost all (95.4%) surgeons preferred at least one in-person visit prior to the day of surgery.

CONCLUSION

Our study noted significant geographical differences in the rate of telemedicine adoption and the platform of telemedicine utilized. The results suggest a significant increase in telemedicine utilization, particularly in North America. Spine surgeons found telemedicine feasible for imaging review, initial visits, and follow-up visits although the vast majority still preferred at least one in-person preoperative visit.

Classification system for cervical spine deformity morphology: a validation study

OBJECTIVE

The objective of this study was to initially validate a recent morphological classification of cervical spine deformity pathology.

METHODS

The records of 10 patients for each of the 3 classification subgroups (flat neck, focal deformity, and cervicothoracic), as well as for 8 patients with coronal deformity only, were extracted from a prospective multicenter database of patients with cervical deformity (CD). A panel of 15 physicians of various training and professional levels (i.e., residents, fellows, and surgeons) categorized each patient into one of the 4 groups. The Fleiss kappa coefficient was utilized to evaluate intra- and interrater reliability. Accuracy, defined as properly selecting the main driver of deformity, was reported overall, by morphotype, and by reviewer experience.

RESULTS

The overall classification demonstrated a moderate to substantial agreement (round 1: interrater Fleiss kappa = 0.563, 95% CI 0.559-0.568; round 2: interrater Fleiss kappa = 0.612, 95% CI 0.606-0.619). Stratification by level of training demonstrated similar mean interrater coefficients (residents 0.547, fellows 0.600, surgeons 0.524). The mean intrarater score was 0.686 (range 0.531-0.823). A substantial agreement between rounds 1 and 2 was demonstrated in 81.8% of the raters, with a kappa score > 0.61. Stratification by level of training demonstrated similar mean intrarater coefficients (residents 0.715, fellows 0.640, surgeons 0.682). Of 570 possible questions, reviewers provided 419 correct answers (73.5%). When considering the true answer as being selected by at least one of the two main drivers of deformity, the overall accuracy increased to 86.0%.

CONCLUSIONS

This initial validation of a CD morphological classification system reiterates the importance of dynamic plain radiographs for the evaluation of patients with CD. The overall reliability of this CD morphological classification has been demonstrated. The overall accuracy of the classification system was not impacted by rater experience, demonstrating its simplicity.

Spine Surgery and COVID-19: The Influence of Practice Type on Preparedness, Response, and Economic Impact

STUDY DESIGN

Cross-sectional observational cohort study.

OBJECTIVE

To investigate preparation, response, and economic impact of COVID-19 on private, public, academic, and privademic spine surgeons.

METHODS

AO Spine COVID-19 and Spine Surgeon Global Impact Survey includes domains on surgeon demographics, location of practice, type of practice, COVID-19 perceptions, institutional preparedness and response, personal and practice impact, and future perceptions. The survey was distributed by AO Spine via email to members (n = 3805). Univariate and multivariate analyses were performed to identify differences between practice settings.

RESULTS

A total of 902 surgeons completed the survey. In all, 45.4% of respondents worked in an academic setting, 22.9% in privademics, 16.1% in private practice, and 15.6% in public hospitals. Academic practice setting was independently associated with performing elective and emergent spine surgeries at the time of survey distribution. A majority of surgeons reported a >75% decrease in case volume. Private practice and privademic surgeons reported losing income at a higher rate compared with academic or public surgeons. Practice setting was associated with personal protective equipment availability and economic issues as a source of stress.

CONCLUSIONS

The current study indicates that practice setting affected both preparedness and response to COVID-19. Surgeons in private and privademic practices reported increased worry about the economic implications of the current crisis compared with surgeons in academic and public hospitals. COVID-19 decreased overall clinical productivity, revenue, and income. Government response to the current pandemic and preparation for future pandemics needs to be adaptable to surgeons in all practice settings.

Assessing the Early Impact of the COVID-19 Pandemic on Spine Surgery Fellowship Education

STUDY DESIGN

This was a cross-sectional study.

OBJECTIVE

The objective of this study is to report the impact of COVID-19 on spine surgery fellow education and readiness for practice.

SUMMARY OF BACKGROUND DATA

COVID-19 has emerged as one of the most devastating global health crises of our time. To minimize transmission risk and to ensure availability of health resources, many hospitals have cancelled elective surgeries. There may be unintended consequences of this decision on the education and preparedness of current surgical trainees.

MATERIALS AND METHODS

A multidimensional survey was created and distributed to all current AO Spine fellows and fellowship directors across the United States and Canada.

RESULTS

Forty-five spine surgery fellows and 25 fellowship directors completed the survey. 62.2% of fellows reported >50% decrease in overall case volume since cancellation of elective surgeries. Mean hours worked per week decreased by 56.2%. Fellows reported completing a mean of 188.4±64.8 cases before the COVID-19 crisis and 84.1% expect at least an 11%-25% reduction in case volume compared with previous spine fellows. In all, 95.5% of fellows did not expect COVID-19 to impact their ability to complete fellowship. Only 2 directors were concerned about their fellows successfully completing fellowship; however, 32% of directors reported hearing concerns regarding preparedness from their fellows and 25% of fellows were concerned about job opportunities.

CONCLUSIONS

COVID-19 has universally impacted work hours and case volume for spine surgery fellows set to complete fellowship in the middle of 2020. Nevertheless, spine surgery fellows generally feel ready to enter practice and are supported by the confidence of their fellowship directors. The survey highlights a number of opportunities for improvement and innovation in the future training of spine surgeons.

LEVEL OF EVIDENCE

Level III.

COVID-19 and the rise of virtual medicine in spine surgery: a worldwide study

PURPOSE

The COVID-19 pandemic forced many surgeons to adopt "virtual medicine" practices, defined as telehealth services for patient care and online platforms for continuing medical education. The purpose of this study was to assess spine surgeon reliance on virtual medicine during the pandemic and to discuss the future of virtual medicine in spine surgery.

METHODS

A comprehensive survey addressing demographic data and virtual medicine practices was distributed to spine surgeons worldwide between March 27, 2020, and April 4, 2020.

RESULTS

902 spine surgeons representing seven global regions responded. 35.6% of surgeons were identified as "high telehealth users," conducting more than half of clinic visits virtually. Predictors of high telehealth utilization included working in an academic practice (OR = 1.68, p = 0.0015) and practicing in Europe/North America (OR 3.42, p < 0.0001). 80.1% of all surgeons were interested in online education. Dedicating more than 25% of one's practice to teaching (OR = 1.89, p = 0.037) predicted increased interest in online education. 26.2% of respondents were identified as "virtual medicine surgeons," defined as surgeons with both high telehealth usage and increased interest in online education. Living in Europe/North America and practicing in an academic practice increased odds of being a virtual medicine surgeon by 2.28 (p = 0.002) and 1.15 (p = 0.0082), respectively. 93.8% of surgeons reported interest in a centralized platform facilitating surgeon-to-surgeon communication.

CONCLUSION

COVID-19 has changed spine surgery by triggering rapid adoption of virtual medicine practices. The demonstrated global interest in virtual medicine suggests that it may become part of the "new normal" for surgeons in the post-pandemic era.

Narrative review of intraoperative image guidance for transforaminal lumbar interbody fusion

Recent advancements in imaging technology have changed the landscape of transforaminal lumbar interbody fusion (TLIF) with the objective of improving safety and efficacy for the patient and surgical team. Spine surgery, and specifically TLIFs, involve challenging anatomy and command precise surgical accuracy, creating an essential role for intraoperative imaging, navigation, and robotics. Traditionally, surgeons have relied upon fluoroscopy for pedicle screw and interbody placement. More recently, intraoperative 3-dimensional navigation (ION) has risen in popularity in TLIF surgery. This technology utilizes intra-operative advanced imaging, such as computed tomography (CT) and 3D-fluroscopy, to accurately track instruments and implants in relation to the patient’s anatomy. ION has demonstrated improved accuracy of pedicle screw placement, decreased operating room times, and lower radiation exposure to the surgeon and staff. However, conventional fluoroscopy, 3D fluoroscopy, intraoperative CT, image-guided navigation, and robot-assisted surgery all have a role in TLIF surgery. Numerous studies have been published regarding the benefits and pitfalls of these intraoperative tools in spine surgery, but there is a relative lack of research regarding some of the newer technologies surrounding TLIF. As future studies are published, and technology continues to evolve, surgeons must stay abreast of novel techniques to maximize patient safety and outcomes. Over the coming decade, we can expect intraoperative navigation and robotics to play a more significant role in spine surgery.

Intraoperative image guidance for lateral position surgery

Recent advances in minimally invasive spine surgery techniques have precipitated the popularity of lateral position spine surgery, such as lateral lumbar interbody fusion (LLIF) and oblique lumbar interbody fusion (OLIF). Lateral position surgery offers a unique, minimally invasive approach to the lumbar spine that allows for preservation of anterior and posterior spinal elements. Traditionally, surgeons have relied upon fluoroscopy for triangulation and implant placement. Over the last decade, intraoperative 3-dimensional navigation (ION) has risen to the forefront of innovation in LLIF and OLIF. This technology utilizes intra-operative advanced imaging, such as comminuted tomography (CT), to map the patient’s 3D anatomy and allows the surgeon to accurately visualize instruments and implants in spatial relationship to the patient’s anatomy in real time. ION has the potential to improve accuracy during instrumentation, decrease operating room times, lower radiation exposure to the surgeon and staff, and increase feasibility of single-position surgery during which the spine is instrumented both laterally and posteriorly while the patient remains in the lateral decubitus position. Despite the advantages of ION, the intra-operative radiation exposure risk to patients is controversial. Future directions include continued innovation in ultra low radiation imaging (ULRI) techniques and image enhancement technology and in uses of robot-assisted navigation in single-position spine surgery.

COVID-19: Current and future challenges in spine care and education - a worldwide study

BACKGROUND

The COVID-19 pandemic has impacted spine care around the globe. Much uncertainty remains regarding the immediate and long-term future of spine care and education in this COVID-19 era.

STUDY DESIGN

Cross-sectional, international study of spine surgeons.

METHODS

A multi-dimensional survey was distributed to spine surgeons around the world. A total of 73 questions were asked regarding demographics, COVID-19 observations, personal impact, effect on education, adoption of telemedicine, and anticipated challenges moving forward. Multivariate analysis was performed to assess factors related to likelihood of future conference attendance, future online education, and changes in surgical indications.

RESULTS

A total of 902 spine surgeons from seven global regions completed the survey. Respondents reported a mean level of overall concern of 3.7 on a scale of one to five. 84.0% reported a decrease in clinical duties, and 67.0% reported a loss in personal income. The 82.5% reported being interested in continuing a high level of online education moving forward. Respondents who personally knew someone who tested positive for COVID-19 were more likely to be unwilling to attend a medical conference 1 year from now (OR: 0.61, 95% CI: [0.39, 0.95], P = .029). The 20.0% reported they plan to pursue an increased degree of nonoperative measures prior to surgery 1 year from now, and respondents with a spouse at home (OR: 3.55, 95% CI: [1.14, 11.08], P = .029) or who spend a large percentage of their time teaching (OR: 1.45, 95% CI: [1.02, 2.07], P = .040) were more likely to adopt this practice.

CONCLUSIONS

The COVID-19 pandemic has had an adverse effect on surgeon teaching, clinical volume, and personal income. In the future, surgeons with family and those personally affected by COVID-19 may be more willing to alter surgical indications and change education and conference plans. Anticipating these changes may help the spine community appropriately plan for future challenges.

Provider confidence in the telemedicine spine evaluation: results from a global study

Purpose

To utilize data from a global spine surgeon survey to elucidate (1) overall confidence in the telemedicine evaluation and (2) determinants of provider confidence.

Methods

Members of AO Spine International were sent a survey encompassing participant’s experience with, perception of, and comparison of telemedicine to in-person visits. The survey was designed through a Delphi approach, with four rounds of question review by the multi-disciplinary authors. Data were stratified by provider age, experience, telemedicine platform, trust in telemedicine, and specialty.

Results

Four hundred and eighty-five surgeons participated in the survey. The global effort included respondents from Africa (19.9%), Asia Pacific (19.7%), Europe (24.3%), North America (9.4%), and South America (26.6%). Providers felt that physical exam-based tasks (e.g., provocative testing, assessing neurologic deficits/myelopathy, etc.) were inferior to in-person exams, while communication-based aspects (e.g., history taking, imaging review, etc.) were equivalent. Participants who performed greater than 50 visits were more likely to believe telemedicine was at least equivalent to in-person visits in the ability to make an accurate diagnosis (OR 2.37, 95% C.I. 1.03–5.43). Compared to in-person encounters, video (versus phone only) visits were associated with increased confidence in the ability of telemedicine to formulate and communicate a treatment plan (OR 3.88, 95% C.I. 1.71–8.84).

Conclusion

Spine surgeons are confident in the ability of telemedicine to communicate with patients, but are concerned about its capacity to accurately make physical exam-based diagnoses. Future research should concentrate on standardizing the remote examination and the development of appropriate use criteria in order to increase provider confidence in telemedicine technology.

The Impact of COVID-19 Pandemic on Spine Surgeons Worldwide

STUDY DESIGN

Cross-sectional, international survey.

OBJECTIVES

The current study addressed the multi-dimensional impact of COVID-19 upon healthcare professionals, particularly spine surgeons, worldwide. Secondly, it aimed to identify geographical variations and similarities.

METHODS

A multi-dimensional survey was distributed to surgeons worldwide. Questions were categorized into domains: demographics, COVID-19 observations, preparedness, personal impact, patient care, and future perceptions.

RESULTS

902 spine surgeons representing 7 global regions completed the survey. 36.8% reported co-morbidities. Of those that underwent viral testing, 15.8% tested positive for COVID-19, and testing likelihood was region-dependent; however, 7.2% would not disclose their infection to their patients. Family health concerns were greatest stressor globally (76.0%), with anxiety levels moderately high. Loss of income, clinical practice and current surgical management were region-dependent, whereby 50.4% indicated personal-protective-equipment were not adequate. 82.3% envisioned a change in their clinical practice as a result of COVID-19. More than 33% of clinical practice was via telemedicine. Research output and teaching/training impact was similar globally. 96.9% were interested in online medical education. 94.7% expressed a need for formal, international guidelines to manage COVID-19 patients.

CONCLUSIONS

In this first, international study to assess the impact of COVID-19 on surgeons worldwide, we identified overall/regional variations and infection rate. The study raises awareness of the needs and challenges of surgeons that will serve as the foundation to establish interventions and guidelines to face future public health crises.

Strategies to Achieve Spinal Fusion in Multilevel Anterior Cervical Spine Surgery: An Overview

BACKGROUND

Anterior cervical fusion offers surgeons a safe and reliable surgical option for single-level and multilevel pathology; however, multilevel fusions pose a higher risk of complications than single-level fusions, including possible pseudoarthrosis, adjacent segment disease, sagittal imbalance, and construct subsidence. Various techniques can be used to mitigate risk in multilevel anterior cervical fusion.

QUESTIONS/PURPOSES

We reviewed the literature to determine the best surgical strategies in multilevel anterior cervical fusion.

METHODS

We searched the PubMed database for articles published from January 1980 through July 2019. Two authors identified relevant articles and then manually screened them for others to include in this review.

RESULTS

We initially identified 1936 articles and included 48 in our review. We found that clinical outcomes of multilevel anterior cervical fusion can be optimized through the use of biologics and graft selection, the evaluation of pre-existing deformity, the assessment of comorbidities, and the selection of fusion levels. Meticulous surgical technique in conjunction with modern surgical tools, such as instrumentation and biologics, allow surgeons to address complex cervical problems while limiting morbidity and enhancing clinical outcomes.

CONCLUSIONS

Multilevel anterior cervical fusions offer a relatively safe and reliable treatment option for both single-level and multilevel pathology.

Learning from the past: did experience with previous epidemics help mitigate the impact of COVID-19 among spine surgeons worldwide?

Purpose

Spine surgeons around the world have been universally impacted by COVID-19. The current study addressed whether prior experience with disease epidemics among the spine surgeon community had an impact on preparedness and response toward COVID-19.

Methods

A 73-item survey was distributed to spine surgeons worldwide via AO Spine. Questions focused on: demographics, COVID-19 preparedness, response, and impact. Respondents with and without prior epidemic experience (e.g., SARS, H1NI, MERS) were assessed on preparedness and response via univariate and multivariate modeling. Results of the survey were compared against the Global Health Security Index.

Results

Totally, 902 surgeons from 7 global regions completed the survey. 24.2% of respondents had prior experience with global health crises. Only 49.6% reported adequate access to personal protective equipment. There were no differences in preparedness reported by respondents with prior epidemic exposure. Government and hospital responses were fairly consistent around the world. Prior epidemic experience did not impact the presence of preparedness guidelines. There were subtle differences in sources of stress, coping strategies, performance of elective surgeries, and impact on income driven by prior epidemic exposure. 94.7% expressed a need for formal, international guidelines to help mitigate the impact of the current and future pandemics.

Conclusions

This is the first study to note that prior experience with infectious disease crises did not appear to help spine surgeons prepare for the current COVID-19 pandemic. Based on survey results, the GHSI was not an effective measure of COVID-19 preparedness. Formal international guidelines for crisis preparedness are needed to mitigate future pandemics.

Personal Health of Spine Surgeons Can Impact Perceptions, Decision-Making and Healthcare Delivery During the COVID-19 Pandemic - A Worldwide Study

OBJECTIVE

To determine if personal health of spine surgeons worldwide influences perceptions, healthcare delivery, and decision-making during the coronavirus disease 2019 (COVID-19) pandemic.

METHODS

A cross-sectional study was performed by distributing a multidimensional survey to spine surgeons worldwide. Questions addressed demographics, impacts and perceptions of COVID-19, and the presence of surgeon comorbidities, which included cancer, cardiac disease, diabetes, obesity, hypertension, respiratory illness, renal disease, and current tobacco use. Multivariate analysis was performed to identify specific comorbidities that influenced various impact measures.

RESULTS

Across 7 global regions, 36.8% out of 902 respondents reported a comorbidity, of which hypertension (21.9%) and obesity (15.6%) were the most common. Multivariate analysis noted tobacco users were more likely to continue performing elective surgery during the pandemic (odds ratio [OR], 2.62; 95% confidence interval [CI], 1.46-4.72; p = 0.001) and were less likely to utilize telecommunication (OR, 0.51; 95% CI, 0.31-0.86; p = 0.011), whereas those with hypertension were less likely to warn their patients should the surgeon become infected with COVID-19 (OR, 0.57; 95% CI, 0.37-0.91; p = 0.017). Clinicians with multiple comorbidities were more likely to cite personal health as a current stressor (OR, 1.32; 95% CI, 1.07-1.63; p = 0.009) and perceived their hospital's management unfavorably (OR, 0.74; 95% CI, 0.60-0.91; p = 0.005).

CONCLUSION

This is the first study to have mapped global variations of personal health of spine surgeons, key in the development for future wellness and patient management initiatives. This study underscored that spine surgeons worldwide are not immune to comorbidities, and their personal health influences various perceptions, healthcare delivery, and decision-making during the COVID-19 pandemic.

The Effectiveness of Bioskills Training for Simulated Lumbar Pedicle Screw Placement

STUDY DESIGN

Prospective randomized study.

OBJECTIVES

To define the impact of an inexpensive, user-friendly, and reproducible lumbar pedicle screw instrumentation bioskills training module and evaluation protocol.

METHODS

Participants were randomized to control (n = 9) or intervention (n = 10) groups controlling for level of experience (medical students, junior resident, or senior resident). The intervention group underwent a 20-minute bioskills training module while the control group spent the same time with self-directed study. Pre- and posttest performance was self-reported (Physician Performance Diagnostic Inventory Scale [PPDIS]). Objective outcome scores were obtained from a blinded fellowship-trained attending orthopedic spine surgeon using Objective Structured Assessment of Technical Skills (OSATS) and Objective Pedicle Instrumentation Score metrics. In addition, identification of pedicle breach and breach anatomic location was measured pre- and posttest in lumbar spine models.

RESULTS

The intervention group showed a 30.8% improvement in PPDIS scores, compared with 13.4% for the control group (P = .01). The intervention group demonstrated statistically significant 66% decrease in breaches (P = .001) compared with 28% decrease in the control group (P = .06). Breach identification demonstrated no change in accuracy of the control group (incorrect identification from 32.2% pre- to posttest 35%; P = .71), whereas the intervention group's improvement was statistically significant (42% pre- to posttest 36.5%; P = .0047).

CONCLUSIONS

We conclude that a concise lumbar pedicle screw instrumentation bioskills training session can be a useful educational tool to augment clinical education.

Nerve root enhancement on spinal MRI in pediatric Guillain-Barré syndrome

Guillain-Barré syndrome diagnosis is based on clinical presentation and supportive diagnostic testing. In its early stage, no single, reliable diagnostic test is available. However, a finding of nerve root enhancement on spinal magnetic resonance imaging may be useful. We evaluated the frequency of nerve root enhancement on spinal magnetic resonance imaging in children with Guillain-Barré syndrome. At a single tertiary pediatric center, we conducted a retrospective chart review of children with Guillain-Barré syndrome who had complete spinal or lumbosacral spinal magnetic resonance imaging with gadolinium administration from January 2002-January 2009. Twenty-four consecutive patients were identified. Spinal nerve root enhancement with gadolinium was present in 92% (22/24) of children with Guillain-Barré syndrome on initial spinal magnetic resonance imaging (95% confidence interval, 0.745-0.978). This finding increased to 100% of patients, after two patients underwent repeat spinal magnetic resonance imaging that did reveal nerve root enhancement. Patterns of enhancement were variable, but involved the thoracolumbar nerve roots in all patients. Enhancement of nerve roots with gadolinium on initial spinal magnetic resonance imaging was frequently present in these children with Guillain-Barré syndrome. Spinal magnetic resonance imaging is a sensitive diagnostic test and should be considered an additional diagnostic tool in select cases.