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Table of Contents    
Year : 2021  |  Volume : 69  |  Issue : 1  |  Page : 2-3

Starting Elective Neurosurgeries: Recovering From COVID Pandemic

Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India

Date of Submission02-Feb-2021
Date of Decision02-Feb-2021
Date of Acceptance02-Feb-2021
Date of Web Publication24-Feb-2021

Correspondence Address:
Prof. P Sarat Chandra
Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.310077

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How to cite this article:
Chandra P S. Starting Elective Neurosurgeries: Recovering From COVID Pandemic. Neurol India 2021;69:2-3

How to cite this URL:
Chandra P S. Starting Elective Neurosurgeries: Recovering From COVID Pandemic. Neurol India [serial online] 2021 [cited 2021 Jul 28];69:2-3. Available from:

The Editorial Team of Neurology India wishes all its readers a very Happy New Year!

I would like to pen this Editorial with a sense of optimism as we are hopefully looking towards the end of COVID pandemic.

COVID-19 pandemic has placed immense challenges for everyone. For the neurosurgeon, one of the biggest challenges has been the need for streamlining and starting of elective neurosurgeries. This is true especially for large tertiary hospitals which is handling a large burden of Covid patients and a substantial number of staff, residents and faculty are performing regular rotation at the COVID dedicated hospital/centres.[1],[2]

A survey done from 60 countries done in April, 2020 involving 494 respondents revealed that over 52% of all elective cases and clinics were shut down by the main hospital. Over 46% reported that their operative volume was down by more than 50%. This study had the majority of the respondents from United States (200) while India contributed to 21 respondents.[2]

Other major centres reported similar significant reduction in elective neurosurgeries (Emory & Grady, USA, 80%[3], Bergamo, Italy[4], 75%, Hubei[5], China, >90%).

However, in contrast to this, some countries like Germany were able to continue their elective procedures by creating strict protocols. In a single centre study by Voellger et al.[6], they demonstrated no significant decrease of their elective procedures during the first wave of the pandemic. The main indications for elective admissions was because of increasing motor and/or visual deficits. The study attributed this due to strict Governmental policies including public awareness and social distancing.

Triaging was very important for selecting the patients who should be operated first. Most centres used the 4 Tier triaging which include Tier 1 cases included emergencies needed to be performed within 1 hour from presentation (mostly trauma and bleeds). Tier 2 cases included urgent cases that should be done within 24 hours of presentation (mostly tumours with sub-acute deterioration). Tier 3 cases included time-sensitive cases that need to be done within four weeks of diagnosis. Examples of these are patients with high-grade glioma or patients with idiopathic intracranial hypertension and threatened vision. Tier 4 cases included essential surgeries that can be postponed for >1 month.

A large study[7] consisting of over 176 respondents from various major centres in India reported that elective procedures consisted of only 30% of the total, with exception of smaller private hospitals who were operating a higher proportion of elective neurosurgeries. More than 60% of all surgeons followed the universal precautions of wearing surgical gloves, N95 masks and double scrubs. Most of the health care personnel had significant apprehension of acquiring infection or passing it on to their family members. The pandemic also necessitated creation of separate rooms in OR and special protocols for donning and doffing.[8],[9],[10]

The Mayo clinic evolved a bipartite protocol to minimize the risk of exposure to SARS-CoV-2 infection for patients undergoing non-elective surgical procedures. These included measures taken by staff which included travel restrictions, virtual platform interaction, twice daily temperature checks, dedicated hotline for staff and creating mandatory protocols for masks for all staff. Measures for patients included no-visit of attendants of patients, temperature checks of all patients before entering hospital, postpone elective surgeries, testing of all patients 48 hours before undergoing surgery. Strict regimentation of this protocols allowed them to operate over 100 patients in relative short time without cancelling or delaying any surgery because of SARS-CoV-2 infections. Of the 103 surgeries, 61 (59%) were spine cases, 37 (61%) of which involved a fusion; 29 (28%) were cranial cases; 8 (8%) functional surgeries; and 5 (5%) vascular surgeries.[11] They felt that such strategies could provide an optimal path for reopening of elective surgery in the COVID-19 pandemic.

Arimappamagan et al.[12] in the current paper discuss the strategies to perform elective surgery during COVID-19 pandemic. It is recommended that at least one RT-PCR testing must be performed within 48 hours of any elective surgery. Some studies have recommended 2 tests within an interval of 2-4 days. This is especially recommended for major skull base surgeries and endonasal procedures. Agarwal et al.[13] have elegantly discussed about the guidelines for preoperative testing. It is recommended to perform CBNAAT or TrueNAT for all emergencies as the result may be obtained within 30-45 minutes. (specificity of 96-100% vs RT-PCR- 98-100% but a higher sensitivity of 96-100% vs RT-PCR- 71-98%). It is also recommended that any centre starting elective surgeries should keep these patients separate from emergency cases. Regular testing of all health care workers is also mandatory.

The decreasing number of SARS-Cov-19 infections for India currently look encouraging while US and Europe continues to battle the third wave. But we cannot drop our guard.

For centres looking at re-starting Elective cases, the need to follow caution cannot be understated. All precautions as emphasized by us earlier must be followed.[1] There should be adequate segregation of elective and non-elective cases, all health care personnel must continue to take rounds wearing adequate protective gear (masks, face shields etc). Rounding must be done in small teams with a common round being done virtually. All academics must still be continued online. Telemedicine outpatient services must be encouraged to the extent possible.

Hopefully, we are seeing the light at the end of the tunnel with the start of the vaccinations. Hopefully what we see now is not the 'new normal' and we would return to what it was before the pandemic.

  References Top

Gupta P, Muthukumar N, Rajshekhar V, Tripathi M, Thomas S, Gupta SK, et al. Neurosurgery and Neurology Practices during the Novel COVID-19 Pandemic: A Consensus Statement from India. Neurol India 2020;68:246-54.  Back to cited text no. 1
[PUBMED]  [Full text]  
Chandra PS. The Need for Uniform Residency Training Programs and the challenges during COVID Pandemic for India. Neurol India 2020;68:1279-80.  Back to cited text no. 2
[PUBMED]  [Full text]  
Jean WC, Ironside NT, Sack KD, Felbaum DR, Syed HR. The impact of COVID-19 on neurosurgeons and the strategy for triaging non-emergent operations: a global neurosurgery study. Acta Neurochir (Wien) 2020;162:1229-40.  Back to cited text no. 3
Saad H, Alawieh A, Oyesiku N, Barrow DL, Olson J. Sheltered Neurosurgery During COVID-19: The Emory Experience. World Neurosurg 2020;144:e204-e209.  Back to cited text no. 4
Bernucci C, Brembilla C, Veiceschi P. Effects of the COVID-19 Outbreak in Northern Italy: Perspectives from the Bergamo Neurosurgery Department. World Neurosurg 2020;137:465-468.e1.  Back to cited text no. 5
Sheng L, Chen Y, Li H, Wang Z, Bie B, You H, Ye J, Feng J, Zhang C, Li J. Experience in Neurosurgery During the Prevalence of COVID-19. J Craniofac Surg 2020;31:e622-e624.  Back to cited text no. 6
Rupa R, Sass B, Morales Lema MA, Nimsky C, Voellger B. The Demand for Elective Neurosurgery at a German University Hospital during the First Wave of COVID-19. Healthcare (Basel) 2020;8:483.  Back to cited text no. 7
Deora H, Mishra S, Tripathi M, Garg K, Tandon V, Borkar S, et al. Adapting Neurosurgery Practice During the COVID-19 Pandemic in the Indian Subcontinent. World Neurosurg 2020;142:e396-e406.  Back to cited text no. 8
Verma SK, Dharanipathy S, Suri A, Chandra PS, Kale SS. Video Section-Operative Nuances: Step by Step-Donning and Doffing in Neurosurgical Operating Room. Neurol India 2020;68:796-9.  Back to cited text no. 9
[PUBMED]  [Full text]  
Guleria R. The Need to Change and the Necessity to Evolve During the COVID-19 Pandemic. Neurol India 2020;68:726-7.  Back to cited text no. 10
[PUBMED]  [Full text]  
De Biase G, Freeman W, Elder B, Nottmeier E, Smith N, Jerreld D, et al. Path to Reopening Surgery in the COVID-19 Pandemic: Neurosurgery Experience. Mayo Clin Proc Innov Qual Outcomes 2020;4:557-64.  Back to cited text no. 11
Arimappamagan A, Vilanilam G, Pandey P. Is Elective Neurosurgery Justified During COVID-19 Pandemic? Neurology India [in this issue]  Back to cited text no. 12
Agarwal N, Raheja A, Suri A. Guidelines for Preoperative Testing for Neurosurgery in Coronavirus Disease 2019 (COVID-19) Era: Indian Viewpoint Amidst Global Practice. World Neurosurg 2020;146:103-12.  Back to cited text no. 13


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