Key-words:
COVID-19 - impact - neurosurgery - triage
Introduction
In late December 2019, China detected pneumonia of unknown origin in its Wuhan city,
Hubei province. They declared it to the WHO regional office in China on December 31,
2019.[[1]] The causative organism was found out to be a novel member of the coronavirus family
on January 8, 2020.[[1]] The disease became widespread across the globe over the next 2 months. The WHO
declared it a pandemic on March 11, 2020, and named the disease COVID-19.[[2]],[[3]] The center of the pandemic is now in the USA; South America; and few Asian nations
such as India, Iran, and Russia. Many of the European nations have already started
flattening of the pandemic curve. The number of cases diagnosed has increased to 12.2
million cases worldwide and 793,802 cases in India as on July 10, 2020.[[4]]
As the number of positive cases climbs exponentially, the hospitals and the overall
health-care system have become overwhelmed. The bulk of the hospital beds are dedicated
to managing COVID-19-positive and suspected patients. Not only do the clinical works,
including outpatient departments (OPDs) and elective surgeries, but also the academic
activities have been affected. In this article, we undertook a systematic review of
the articles detailing the impact of the current pandemic on neurosurgical practice
and tried to find a safe way of practicing neurosurgery among highly infectious patients
with COVID-19 disease.
Materials and Methods
We used Preferred Reporting of Items for Systematic Reviews and Meta-Analyses Protocols
for literature search.[[5]] Medical databases, including PubMed Central (from January 1, 2019, to May 20, 2020)
and EMBASE (from January 1, 2019, to May 20, 2020) were searched. Search terms, “COVID-19”
and “Neurosurgery,” were used for the literature search. We assessed the search result
for its relevance on the impact of the current pandemic on neurosurgical practice,
academic and clinical training, neurosurgical resource allocation, and methods of
triaging neurosurgical cases.
Results
The literature search yielded 425 articles, including original articles, letters to
the editor, and editorials. We excluded articles that were concerned with epidemiological
and clinical characteristics of COVID-19, impact on other specialties, neurological
signs of COVID-19, severe respiratory syndrome, COVID-19 critical care, epidemic control
measures, risk factors for COVID-19 infection, and psychological care of dedicated
medical staff. Similarly, articles written in languages other than English (two of
them) and case reports were excluded. After exclusion, 128 articles were found out
to be eligible [[Figure 1]]. These articles were concerned with the impact of the COVID-19 pandemic on neurosurgical
practice; human resources distribution; resource allocation for continuing ethical
neurosurgical practice, protocols, and algorithms for neurosurgical case triaging
with limited resources; the role of telemedicine in neurosurgical practice; and neurosurgical
research and academic activities during this pandemic. Most of these articles were
in the form of expert opinions or explaining difficulties faced by the individual
institution and their ways of overcoming such difficulties due to this pandemic. The
abstract from these studies has been discussed in the following text.{Figure 1}
Figure 1: Flow diagram (Preferred Reporting of Items for Systematic Reviews and Meta-Analyses)
showing study selection
Impact on elective surgeries and triage systems
As the hospitals are flooded with waves of patients with COVID-19 after the pandemic,
they started experiencing an acute shortage in hospital beds, ventilators, personal
protective equipment (PPE), and, more importantly, health-care providers. The countries
which are facing an exponential growth in the number of COVID-19-positive cases have
already reduced or halted the elective surgeries throughout the globe.[[6]],[[7]],[[8]],[[9]] In a global survey by Jean et al.,[[10]] it was found that a high prevalence of COVID-19-positive cases and government policy
on lockdown of shops and public transport services were responsible for the closure
of elective surgeries, and clinics. As the COVID-19 disease started to spread alarmingly
in the USA, the American College of Surgeons recommended suspension of all elective
surgeries on March 13, 2020, to cope up with the increasing number of patients.[[6]] Similarly, many countries in the European Union made recommendations for postponing
the elective surgeries.[[7]]
Throughout the globe, many institutions have formulated strategies based on the local,
regional, and national policies to preserve and optimally utilize the available resources
such as hospital beds, ventilators, operation theaters, and PPE.[[11]],[[12]] As the number of patients with COVID-19 has been increasing exponentially, hospital
resources such as intensive care unit (ICU) beds and ventilators have become sparsely
available. Neurosurgical residents and faculties are redeployed to manage the loads
of COVID-19 patients. To make use of the limited beds and operation room (OR), developing
a triage system and protocols to prioritize neurosurgical cases based on the urgency
with which patients need surgical intervention has become mandatory.[[13]],[[14]],[[15]],[[16]],[[17]]
[[Table 1]] compares the various triaging systems for emergency and elective neurosurgical
procedures followed at many centers. The Centers for Medicare and Medicaid Services
(CMS) has provided guidelines for nonemergent, elective medical services. The CMS
has recommended a three-tiered framework to prioritize health-care services to those
who require emergent or urgent attention.[[11]]{Table 1}
Table 1: Various systems to triage emergent and nonemergent neurosurgical cases during the
COVID-19 pandemic
Burke et al.[[14]] formulated a method to utilize the OR service according to the community COVID-19
disease burden. They created a color-coded system (green, yellow, red, and black)
to quantify the “surge level” of the disease based on the severity of the viral transmission
in the community. OR services are caped as per the color coding of the region. At
the green level, all the elective cases are permitted. Similarly, at yellow and red
levels, OR service is allowed to work at 75% and 50% of their capacity, respectively.
As the number of cases increases, the color-code of the particular region is updated
to contend with COVID-19 patient load. They also developed a system based on a “paired
coverage model” to manage emergency and semi-emergency neurosurgical cases. In this
model, each hospital is covered by two nonoverlapping teams and an alternative pool
for substituting those who show symptoms of COVID-19 disease. All the information
transfer between the teams is entirely virtual via videoconferencing. This system
ensures adequate coverage and minimizes inter-team disease transmission.
Arnaout et al.[[15]] divided the neurosurgical cases into five categories. Category 1 includes emergency
cases which have to be operated or intervened within an hour or two. These cases include
traumatic intracranial hematomas such as extradural hematomas, subdural hematomas,
intracranial hemorrhage (traumatic or spontaneous) with mass effects, and acute stroke
requiring thrombectomy. Category 2 or urgent cases where the intervention is required
in hours to days include pituitary apoplexy and tumors with mass effect. This stratification
is simple and easy to triage the neurosurgical cases. Similarly, Elective Surgery
Acuity Scale, a five-tier classification system, was developed by the American College
of Surgeons.[[12]]
Zacharia et al.[[16]] created three neurosurgical case scenarios, namely emergent, urgent, and semi-urgent
cases. Emergent cases such as any space-occupying lesions with impending herniation
need to be operated as early as possible, and all the patients should be considered
as COVID-19 positive. Urgent cases should be operated within a week and include high-grade
glioma and tumors with rapidly progressive deficits. Semi-urgent cases, including
benign tumors with no or minimal mass effect, can be scheduled in 1–4 weeks' period.
Disease-specific approach
Malignant tumors such as high-grade glioma, solitary brain and spinal metastasis,
and any lesion with impending herniation could result in permanent neurological deficits
if not operated promptly. Low-grade glioma and other benign tumors such as cerebellopontine
angle tumors can be delayed probably for 1–3 months unless the seizures are uncontrolled,
or they produce a mass effect, hydrocephalus.[[18]],[[19]] Cauda equina syndrome due to any cause should be considered an emergency, and early
surgery within hours would be appropriate instead of waiting for the COVID-19 status.[[18]] Traumatic spine injuries such as traumatic spinal instabilities, incomplete spinal
cord injury with persistent cord compression, or progressive spinal cord injuries
require emergency surgery within 24–48 h.[[20]] Patients who require emergency surgeries before the virology results are considered
positive patients, and all standard precautions for COVID-19 are strictly followed.[[21]]
High-risk procedures
Procedures such as transnasal endoscopic procedures, transoral odontoidectomy, and
any procedure that violates mucosa of the paranasal sinuses have been considered high-risk
procedures. These procedures generate high load of aerosol-containing viral particles
and have higher chances of infection spread to the surgical team.[[22]] Similarly, skull-based approaches that require mastoid drilling carry the risk
of aerosolization of virus particles. Across the world, many neurosurgical societies
recommend against the routine use of transsphenoidal approaches for pituitary tumors
during the pandemic.[[23]],[[24]],[[25]],[[26]],[[27]] Many advised that the transcranial procedures may be preferred to transnasal transsphenoidal
approach. However, sellar–suprasellar tumors without significant visual deficits or
hydrocephalus can be scheduled to a later date. In situations such as pituitary apoplexy
or acute visual deterioration, early surgery is required for better neurological outcomes.
Many institutions across India and world over have suspended OPDs due to the pandemic
except the emergency department.[[3]],[[8]],[[9]],[[17]] They have adopted telemedicine strategy, including phone visits and video calls,
to fill the gap between the patients and health-care workers.[[9]],[[28]] The impact of the current pandemic on neurosurgical education, training, and research
is immense and widely reported across the world.[[29]],[[30]],[[31]] Reduced number of elective surgeries, closure of OPDs, redeployment of neurosurgical
and research fellows for COVID-19 management, and physical distancing norms have been
reported to be the cause for this negative impact.[[30]],[[31]] These factors have brought deficits in physical examination, training in the intensive
care of pre- and postoperative neurosurgical patients, and hands-on surgical training.
Also, across the world, conferences and annual meetings and workshops have been deferred
or postponed.[[30]],[[31]]
Discussion
Need for reorganization of the health-care system
We are currently experiencing very rapid spread of COVID-19 among our population in
India. To combat the current situation, we and other institutes across India are forced
to rearrange our hospital system.[[17]] We follow a zonal system to triage the patients according to their COVID-19 status.
A contaminated zone has been created in a separate section of the hospital building
to completely isolate the COVID-19-positive patients from the rest of the areas. This
zone handles all the COVID-19-positive cases with dedicated intensive care facilities
for severe cases. A semi-contaminated zone is an area where the suspected patients
are isolated. Individual accommodation is followed in contaminated and semi-contaminated
zones, and the COVID-19-negative patients are kept in the clean zone. We have created
two entry points for receiving the patients. One of them is for trauma- and nontrauma-related
emergency cases, and the second one is for nonemergency and follow-up patients. At
both entry points, the patients are screened for signs and symptoms of COVID-19 disease,
body temperature, and possible exposure to the virus transmission. Nasal and oropharyngeal
swabs are collected from all patients for diagnosing COVID-19 disease using reverse
transcriptase-polymerase chain reaction. A dedicated OR with negative pressure has
been established for COVID-19-positive patients or suspected patients. Having a perioperative
checklist helps us to avoid any breach in the protocol [[Table 2]].{Table 2}
Table 2: Perioperative checklist for neurosurgical procedures
[[Table 3]] describes the triage system for elective and emergency cases followed in our institute.
In neurosurgical specialty, all the cases are prioritized as elective, semi-elective,
semi-urgent, urgent, and emergency [[Figure 2]]. With this policy, we could effectively triage all patients based on the urgency
with which they require intervention. It helps us to use the limited beds and PPE
kits effectively. Whenever possible, urgent cases are closely monitored in the ICU
until the COVID-19 status of the patient is available to avoid the stress of performing
long procedures in PPE. Postoperatively, those patients who are positive for COVID-19
are monitored at the contamination zone along with the infectious disease team. COVID-19-negative
patients are shifted back to the neurosurgical wards or ICU in the clean zone.{Figure
2}{Table 3}
Figure 2: Flow diagram showing the steps of triaging emergent and nonemergent neurosurgical
cases
Table 3: Triage of emergent and nonemergent neurosurgical cases in our institute
Residents, faculties, and nursing officers need to be given rapid training on airway
management, ventilator management, arterial blood gas analysis, electrocardiogram
interpretation, proper methods of donning and doffing of the PPE, and sterilization
methods. Others, including housekeeping and other technical staff, should also be
educated about the standard practices that should be followed to avoid virus transmission
among the hospital workers. Nonoverlapping teams of residents and faculties should
manage all the zones on rotation for a given period. A separate reserve team should
be identified to replace the persons who may require quarantine during patient care.
Interaction between the teams should be strictly maintained via phone calls and videoconferencing.
Perioperative strategies
At the point of initial contact in the hospital, all patients should be screened for
symptoms such as unexplained fever, headache, chills, cough, breathing difficulties,
myalgia, sore throat, anosmia, and ageusia within the last 2 weeks. They should also
be assessed for the possible exposure to someone diagnosed with COVID-19 in the past
14 days.[[32]] One should remember that only 44% of patients with COVID-19 disease had a fever
in a previous study.[[33]] A significant number of patients with COVID-19 disease can be asymptomatic, and
the reported incidence varies from 1.6% to 56.5%.[[34]] It is mandatory to test all patients who require hospitalization for COVID-19.
The sensitivity and specificity of any test to detect SARS-CoV-2 depend on the type
of sample, the sampling technique, the tests performed, and the phase of the disease
course during the testing. The reported sensitivity of SARS-CoV-2 testing may vary
from 70% to 90%.[[35]] Nucleic acid amplification testing for the detection of viral ribonucleic acid
is the investigation of choice for preoperative diagnosis.[[32]] The American Society of Anesthesiologists and Anesthesia Patient Safety Foundation
have given perioperative COVID-19 testing guidelines for elective surgery.[[36]],[[37]] For all elective surgeries, two negative nasopharyngeal swabs alone or with oropharyngeal
swabs 24–48 h apart should be mandatory to avoid false-negative reports.[[32]],[[36]],[[37]] Computed tomography chest is not useful in the preoperative evaluation of COVID-19
status in asymptomatic patients. Hence, it is not recommended for screening before
elective surgery. If a patient tests positive for SARS-CoV-2, elective surgical procedures
should be delayed. As per the Centers for Disease Control and Prevention recommendation,
a patient can be infectious until resolution of fever and respiratory symptoms and
two negative SARS-CoV-2 tests more than 24 h apart or the resolution of fever and
respiratory symptoms for at least 72 h and at least 10 days since initial symptom
presentation.[[32]]
Aerosolized droplets with viable SARS-CoV-2 can remain suspended for 3 h. The estimated
median half-life of SARS-CoV-2 can be approximately 5.6 and 6.8 h on stainless steel
and plastic surfaces, respectively.[[22]] Nasopharyngeal and oropharyngeal mucosa carry the bulk of the virus load. Any procedure
violating these mucosae can produce droplets and aerosols, which can permeate through
the entire OR.[[23]] Such procedures carry a high risk for disease spread to the entire surgical team.
The surgical team should exercise the following precautions to minimize aerosol generation
and to avoid infection spread while operating on COVID-19-definite or suspected patients.
OR personnel should be kept minimum, and a single surgeon is preferred as far as
possible All the personnel in the OR are required to use enhanced PPE (N95 mask/powered
air-purifying respirator mask, full body and head cover, face shields/eye protection
glasses, surgical suits, and double gloves) Use of electrocautery and powered drills
and ultrasonic cavitating devices intraoperatively should be avoided as they generate
excessive aerosols and help to disperse the viral particles.[[23]] If the use of powered tools is unavoidable, they should be used at lower power
with gentle saline irrigation. Drilling areas can be isolated with transparent adhesives
or tents. Wide-bore suction can be used to reduce the free particulate matter and
aerosol[[38]] Nasal mucosal violation should be kept minimum. Routine stripping of the sphenoid
mucosa should be avoided in transsphenoidal approaches The operative team should have
a “quick-in” and “quick-out” strategy to reduce the exposure to viral load.
Resuming outpatient departments and academic activities
Telemedicine plays an immense role in continuing the patient care amidst the disadvantages
brought by the lockdown and social-distancing measures. Health-care professionals
can use any telemedicine tool suitable for carrying out technology-based patient consultation
(e.g., telephone; video; devices connected over local area network, wide area network,
Internet; mobile or landline phones; chat platforms such as WhatsApp and Facebook
Messenger; and mobile apps, or internet-based digital platforms for telemedicine,
or data transmission systems such as Skype/email/fax).[[39]]
The current pandemic has brought several critical changes in the pre-COVID-19 telemedicine
regulatory guidelines. Insurance coverage for telehealth visits, allowing the use
of non-Health Insurance Portability and Accountability Act-compliant applications,
and the ability to prescribe Schedules II to V controlled substances to patients seen
using telemedicine communication are some of them.[[28]],[[39]] When telemedicine is properly utilized, we would be able to briefly evaluate the
patients' neurological status and review the images. Thus, a provisional diagnosis
and management plan can be arrived at without the need for multiple visits. Patients
who require urgent surgical care can be triaged even without personal contact. However,
telemedicine is still in the early stage of development in India despite the success
of various projects such as the Indian Council of Medical Research-AROGYASREE, National
e-Health Authority, and village resource centers.[[40]]
Academic institutions have adopted many technologies which have made video teleconferencing
a new normal for the continuation of academic activities such as journal clubs, seminars,
and operative video teaching sessions, which also allows for the interaction between
the patient care teams.[[41]],[[42]],[[43]] Simulation technologies and virtual reality technologies such as Microsoft HoloLens
(Microsoft Corporation, Redmond, WA, USA) and Oculus Rift (Facebook Technologies,
West Menlo Park, CA, USA) can overcome the decline in the operative experience. Online
education programs and operative video atlas developed by national and international
neurosurgical societies could become an integral part of neurosurgical training during
this pandemic.[[44]],[[45]]
The Congress of Neurological Surgeons has developed web-based education programs such
as “grand round webinars” and live interactive “virtual visiting professor sessions.”[[44]] Neuroanatomy online resources such as “the Rhoton Collection” and “virtual operating
room” under the Neurosurgical Atlas have been made available by the American Association
of Neurological Surgeons (AANS).[[45]] Online conferences and webinars have gained widespread recognition and are helpful
in knowledge sharing without geographical boundaries. Under the Neurological Society
of India, neurosurgical anatomy webinar series are conducted via Zoom meeting where
the neurosurgical experts across the world are invited to take part in the educational
program.
Way forward
Although it is straightforward in many cases to decide the priority level of the intervention,
there are gray areas where the decision to postpone the surgery is difficult to make,
especially if the natural course of the disease is unpredictable. Before deciding
to postpone surgery for a patient, one should answer the following questions:
-
How long is this pandemic going to last?
-
Can the patient have a disease course without affecting his/her functional status
until the resources will be available?
-
What are the chances of incurring permanent neurological deficits if the proposed
treatment is postponed?
-
How severe would the neurological deficits be?
-
Is there a possibility of death if the intervention is postponed?
The decision to operate or to delay the surgery is confounded by the limited availability
of hospital beds, ICU admission, and ventilators. It cannot be based on a “first to
come and first to be served” policy or lottery system.[[46]] Factors such as the age of the patient, comorbid diseases, the risk for severe
postoperative neurological deficits, the need for prolonged ventilatory care after
surgery, and the life expectancy of the patient after the surgery come into play when
the resources are limited. An ethical way for a health-care provider is to triage
individually, and the treating physician has the ultimate responsibility to treat
each patient tailored according to the natural course of the disease.
There are no established guidelines for resuming elective surgeries and OPDs. Elective
surgeries can be started if the incidence of new COVID-19 cases shows a consistent
decline for at least 2 weeks.[[47]],[[48]] The hospital resources should be adequate to restart the elective work without
resorting to the crisis phase. One should be cautious that premature relaxation of
restriction could lead to a second wave of infection. Guidelines and regulations for
COVID-19 control should be maintained to prevent new infection recurrence during the
transition period.
Conclusion
Standard protocols have to be formulated to utilize limited resources and preserve
human resources efficiently. Strict adherence to the departmental and hospital policies,
efficient and timely interaction, and coordination between the various specialties
are essential for better patient care during this pandemic. In an unprecedented time
like this, no single algorithm will clear the ethical dilemma faced by us. Individual
patient triage based on the natural course of each disease is a better way for maintaining
our ethical practice and, at the same time, for efficiently utilizing the limited
resources. We must make use of various technologies and web-based educational materials
to continue the clinical, academic, and research activities to overcome the disadvantages
brought by the social-distancing norms. As the pandemic progresses, new guidelines
and protocols will continue to evolve for better neurosurgical practice.
