Is Elective Neurosurgery Justified During COVID-19 Pandemic?
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.310113
Source of Support: None, Conflict of Interest: None
Keywords: Cancellation, COVID-19, elective neurosurgery, guidelines, perioperative risk
As the world grapples with the COVID-19 pandemic, which has spread across all the continents, faster than most countries could realize and act, health care priorities and policies were redefined immensely and on a real time basis. Every tiny detail about the modes of transmission, contagiousness, clinical features, complications and options to treat had to be learnt fast, howsoever incomplete information as it came. Early experience from China in the management of these patients was the basis for formulation of most health care systems in the world. The most important reaction from the health care was to organize and equip the hospitals, in terms of manpower, infrastructure, and resources. The need for ICUs and the inpatient beds increased exponentially in reality or in projections of the pandemic. N95 masks, PPEs, specialized operating theatres, which were once required in very rare situations, suddenly became a daily necessity. As the governments and administration struggled to re-organize the resources, it was logical to significantly curtail the regular hospital services, so that more resources can be diverted to address the pandemic.
De-congestion of hospitals was meant to work in many ways. The reduction in crowd would result in better social distancing; people who are uninfected can avoid exposure by attending hospitals. Many governments and societies issued guidelines to avoid visiting hospitals for nonessential or nonurgent services. In March 2020, as the disease spread rapidly in Europe, Americas and many Asian countries, authorities issued guidelines to either postpone/cancel/delay elective surgeries. The American College of Surgeons, in an unprecedent move, recommended cancellation or postponement of all elective surgeries. Ghandour et al. in a world-wide survey from 96 countries noted that complete cancellation of elective surgeries/clinics occurred in 51.9% hospitals in government practice and 57.5% in private practice.
In the heat of the flaring pandemic, nothing else matters over limiting the spread of COVID-19 and preservation of human life. Public health measures take precedence over individual illnesses. Other diseases are often less of a priority for governments and health care systems. Hospital beds and resources that have geared up for a public health emergency maybe misdirected and prematurely exhausted by mis-prioritized elective surgery. However, today's planned elective procedure if left undone, could be a life threatening emergency within a few days. In places with overwhelming community spread of the pandemic, preventing in-hospital spread is top priority. Hospitals may serve as centers of cure or become amplifiers of disease., Nevertheless, elective surgery though less of a priority, cannot be ignored altogether. Lessons from elective surgery during the COVID-19 pandemic have been learnt from China, US, UK, Italy, Spain, India and other nations. Surgical triaging for pandemic times as outlined by the American College of Surgeons (ACS), the National Health System (NHS), UK, etc., help in making surgical scheduling decisions. Thus, each surgical service is advised to devise their own surgical triaging system taking into account the surgical urgency, pandemic community burden and available resources.,,,
What are the risks due to COVID-19 during elective surgery?
The reasons for concern due to COVID-19 in a hospital setting have to be understood from two perspectives. From the hospital perspective, all measures for identification of COVID-19 in a patient or staff working in a hospital are aimed at providing safe work atmosphere, protecting the manpower from falling sick or going out of service, to eliminate or minimise cross infection risks among patients and staff, develop infrastructure and policies to isolate and manage suspect or confirmed cases, and to ensure all necessary safety protocols are followed etc., These are essentially public health protocols, with enhanced rigor to be followed in hospitals, so that they do not become breeding grounds.
From a patient perspective, especially in neurosurgical setting, one has to carefully assess the perioperative risks involved in the background of COVID-19 infection. In the pre-COVID era, patients are counselled about the risks involved in any elective neurosurgery procedure ranging from 3-5%, including bleeding or infection. The neurological risks may be slightly higher in more complex surgeries and may depend on the region of involvement in brain. Whether the presence of active COVID-19 infection increases perioperative risk needs to be known, which would influence the decision making for surgery. The earliest information was provided by Lei et al., who retrospectively reported the outcomes of elective surgery in 34 patients during the incubation period of COVID-19 infection. The authors noted that all patients developed COVID-19 pneumonia after surgery, 44.1% patients required admission in intensive care unit, with an overall mortality rate of 20.5%. The surgeries were spread across multiple specialities. These were early days of pandemic, with not much awareness about testing and preoperative preparations. As the data was very worrisome to the surgeons worldwide, some of the authors questioned the strength of the inference, citing the lack of comparable multi-parameter matched control group during the same period, as well as the need to evaluate and compare the outcome in all elective surgeries performed in the same period., In May 2020, Nahshon et al. reviewed four reports on 64 COVID-19 patients who underwent surgery and noted a which reported the perioperative mortality of 27.5% and strongly advised universal sampling of all asymptomatic patients before surgery. The strongest evidence till date was provided by Covidsurg Collaborative group. In an international, multi-center observational study, morbidity in 1128 patients with perioperative COVID-19 infection was analyzed. The diagnosis was made by RT-PCR test in most cases. SARS-CoV-2 infection was diagnosed preoperatively in 294 (26·1%) of 1128 patients and postoperatively in 806 (71·5%), with timing of diagnosis missing for 28 patients. 835 (74·0%) patients underwent emergency surgery, and elective surgery was performed in 280 (24·8%), while the category was not available for 13 patients. Neurosurgical procedures comprised of 3.5% of all the cases (n = 39). 51.2% of patients had at least one pulmonary complication, 40.4% had pneumonia, 21.3% had unexpected ventilation. The 7 day mortality was 5.2%, while the 30 day mortality was 23.8%. Among the patients who underwent elective surgery (n = 268), 53.1% developed pulmonary complications and 30 day mortality rate was 19.1%. While the rate of pulmonary complications was similar in patients with emergency surgery (52.5%, P = 0.873), mortality was significantly higher following emergency surgery (26.0%, P = 0.020). Among the patients who underwent neurosurgical procedures, pulmonary complications occurred in 50% cases and overall mortality rate was 18.4%. These rates of morbidity and mortality have to be evaluated against the average risks involved in elective surgeries in pre-COVID era. It is now clearly evident that active COVID-19 infection significantly increases the perioperative morbidity and mortality and has to be a serious concern for all surgical specialties. Many centers in India have now performed emergency neurosurgical procedures in a number of COVID-19 positive patients; it would be interesting to evaluate the morbidity and outcome in these patients. Elective neurosurgery has been deferred in patients with confirmed COVID-19 infection to mitigate additional perioperative risks involved.
What is the impact of postponed surgeries?
As the pandemic swept across the world, hospitals in most countries suspended or postponed elective surgeries, which was essential to channelize the available resources. What appears rational and necessary at one point may not be sustainable long term as the situation evolves. An extremely large number of elective surgeries were cancelled or postponed world-wide. Johns Hopkins University cancelled 7600 surgeries in the month between March 18, 2020 and April 17, 2020. The neurosurgical department recorded a year on year reduction of 68.89% in the number of surgeries performed. A global expert-response study was conducted by Covidsurg collaborative group which predicted that, on the best estimates, around 28,404,603 surgeries will be cancelled or postponed during a 12 week period of peak pandemic. They also calculated that if post pandemic surgical capacity was enhanced by 20%, it would take 45 weeks to clear the backlog. Soreide et al. discussed a model wherein only emergency surgeries are considered during the peak of epidemic, with planning and restarting of elective procedures as the curve flattens. The line of divide between emergent procedures and nonemergent procedures gets blurred as the duration of deferral gets prolonged. While some intracranial tumors, recurrences, sellar lesions, degenerative spine disease etc., can be delayed for a short time, denial of early treatment can result in development of newer deficits and can adversely impact the outcome. Ahluvalia et al. elucidated the consequences of delay in elective pediatric neurosurgery and advocated risk-stratified approach. They highlighted the negative effects on neurocognitive development, neurologic functioning, and potential long-term health states due to delay in treatment.
Therefore, it is amply clear that neurosurgery as a discipline, faces a complex and daunting challenge. Due to the significant strain on resources, the need to protect manpower and ensure emergency services amidst highly contagious viral pandemic, and a high perioperative risks due to COVID-19, postponement of elective procedures appears completely justified. However, such a situation cannot be sustained for a longer period, as more patients will suffer due to lack of care and timely intervention. Therefore, it is prudent to evaluate the ground reality and work out a reasonable, scientifically sound solution to provide optimal care, with a caveat of flexibility and reversal/roll back of services, if the situation demands.
Many health care centers have redefined their work flow so that separate processes are followed for COVID suspect cases, like separate wards, staff, operating theaters, etc., with abundant precautions. Elective neurosurgery admissions and surgical procedures can be considered only when the infrastructure namely treatment areas, theaters and manpower including doctors and nurses are available adequately over and above the emergency needs and standby for any eventuality. As the hospitals endeavor to provide safe health care to patients, they are equally committed to ensure safety of the health care professionals while discharging their duties. A number of guidelines and protocols have been published about hospital organization and safety during COVID times.
Risk mitigation for elective neurosurgery
The word “elective neurosurgery” becomes less defined for most cases which constitute the middle part of the spectrum, as most neurosurgical conditions progress and cause fresh neurological deficits over a period of time. Those surgeries that can be safely postponed by more than six months need not be considered at this point of time. The rest nonemergency conditions with potential risks of deterioration will constitute the cohort for further discussion in this article. These patients need to be properly counselled regarding their illness, need for surgery and the risks involved with surgery or postponement of the procedure. Pre-admission testing of the patients and preferably the attender too, allowing no or only one attender inside the hospital premises, dedicated wards and ICUs, are very essential to perform safe elective surgical procedures. Certain additional concerns to be addressed in the COVID times in the surgical informed consent should be included. All patients can undergo testing for COVID-19 infection by RT-PCR within 48–72 h before the procedure., While the testing guidelines by the authorities are relevant and useful from public health perspective, pre-operative COVID testing is very essential at individual level for risk optimization. The available evidence reveals that the all-cause mortality rates with perioperative COVID infection are 18·9% in elective patients, 25·6% in emergency patients, 16·3% in patients who had minor surgery, and 26·9% in patients who had major surgery. A recent study from India found that, among patients planned for elective cancer surgery, 8.0% tested positive for COVID-19 by RTPCR, though they were asymptomatic. As this infection runs a benign course in a majority of patients, with recovery in 2–3 weeks, it is best to avoid surgery during the infection. Testing for COVID may be akin to evaluating with ECG, echocardiography or a blood sugar level to identify risk factors and optimize them before undertaking a surgical procedure.
Surgical scheduling recommendation for COVID times: Can a one-size-fits-all be suitable for all neurosurgical services?
As the community burden of COVID-19 varies over time in different states in India, there cannot be a one-size-fits-all surgical scheduling recommendation. The community burden of COVID-19, resource limitations and basic principles of surgical triaging help guide this decision making process. The situation and demands for surgical scheduling are often dynamic in pandemic times requiring continuous reassessment. As access to surgical care for patients is also restricted due to lockdowns (shelter-in-place), postponing surgical procedures poses further grave concerns. Staff rationing, use of telemedicine for review and planned re-schedulements in keeping with best practices are recommended.,,, In Indian scenario, multiple factors influence decision making, in addition to the COVID-19 prevalence. Major and tertiary neurosurgical services are mostly available in major cities, which are unfortunately the same zones with higher prevalence of COVID-19 infection. Therefore, postponement of elective surgery services till all these major cities become green zones may be a difficult proposition.
Guidelines and practices worldwide: The unlocking with caution.
Many neurosurgical societies, like EANS, NSI, Italian Skull base surgery society, German Society of Neurosurgery (DGNC), and various other authors from across the world have published their guidelines for neurosurgical services during the pandemic.,,, All of them stressed on the following tenets in practice:
Re-organization of services: The healthcare services need to be re-organized so that specific component can be taken care by each hospital. The spoke-and-hub model of Lombardy, Italy, had four hub neurosurgical centers managing neurosurgical patients, while others as spokes were dedicated for COVID-19 care., Such arrangements are more useful in organization of government hospitals. Treating teams in a hospital should be divided into multiple nonoverlapping groups, with a standby group, to facilitate continuum of care and prevent cross infection.,, It is very essential to restructure the hospital areas into green, orange and red zones for COVID negative, COVID suspect/unknown and COVID positive patients respectively. The dedicated manpower for each zone with adequate protection will ensure continuum of care as well as safety of health care professionals and patients.
Triaging of patient care linked to COVID-19 prevalence: Many authors have described strategies to plan both elective and emergency procedures based on the COVID burden in the hospital and community. This is very relevant for both government and private sector, for continuing services. They describe services based on low, intermediate and high COVID burden in community. Elective procedures can be continued with low community burden, while they should be avoided in high burden areas. D'Amico et al. from NYC, USA describe a staged approach of re-starting neurosurgery again based on the community burden. EANS has proposed their guidelines for elective neurosurgery, and proposed triaging neurosurgery into three tiers. In India, the pandemic is evolving and we see different states and cities experiencing vastly different COVID load. It has been six months since the pandemic started in India and still the COVID-19 cases are on the rise. Neurosurgical procedures cannot be postponed for longer periods, which will result in higher disease related morbidity. While healthcare in some cities are overwhelmed, some states are faring better as of now. Therefore, it is clear that the guidelines need to be designed based on local situation.
Preoperative testing for COVID: Preoperative COVID-19 testing by RT-PCR has been mandatorily recommended by many authors.,, The Johns Hopkins Hospital protocol for patients undergoing surgery involves a COVID nucleic acid amplification test (NAT) screening within the 48 h prior to scheduled surgery, but not more than 72 h before the surgery. Italian skull base surgery society recommends mandatory test for COVID-19 in all patients who are candidates for surgery (except for emergency procedures), with at least 2 tests, repeated at a distance of 2–4 days, in order to minimize the possibility of false negatives. The last test must be performed within 48 h prior to surgery. This will significantly reduce the perioperative risks to the patient as well as avoid inadvertent cross infection to patients and hospital staff. With widespread availability of RT-PCR testing now in India, it is advisable that all patients are tested for COVID-19 just before an elective neurosurgical procedure.
Notwithstanding the initial decision to postpone/cancel all nonemergency surgeries worldwide, it has now become clear that this pandemic will be around for a longer duration. Therefore, a prolonged suspension of elective services, like economic lockdown, is not sustainable. It is important to take a middle path, where there is concern for safety of both the patients with COVID-19, as well as for the patients with neurosurgical diseases who warrant semi-urgent care, rather than a blanket refusal to do all elective surgeries.
In a rapidly developing situation, it is important to remember that most guidelines can only be rough suggestions, which would need revisions based on new emerging evidence. There are few principles involved for all the guidelines which are published, and will probably be published in the future:
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.