key: cord-268939-ws74xprt
authors: Ozoner, Baris; Gungor, Abuzer; Hasanov, Teyyup; Toktas, Zafer Orcun; Kilic, Turker
title: Neurosurgery Practice During Coronavirus Disease 2019 (COVID-19) Pandemic
date: 2020-05-28
journal: World Neurosurg
DOI: 10.1016/j.wneu.2020.05.195
sha: 
doc_id: 268939
cord_uid: ws74xprt

Abstract Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a highly contagious, life-threatening condition with unprecedented impacts for worldwide societies and healthcare systems. Since the first detection in China, it has spread rapidly worldwide. The increased burden has substantially impacted the neurosurgery practice and intensive modifications were required in surgical scheduling, inpatient and outpatient clinics, management of emergency cases, and even academic activities. In some systems, non-overlapping teams were created to minimize transmission among healthcare workers. In case of a massive burden, neurosurgeons may be needed to reassign to the COVID-19 wards, or teams from other regions may be needed to send to severely affected areas. In outpatient practice, if possible, appointments should be turned into telemedicine. All staff assigned in the non-COVID treatment unit should be clothed in level 1 personal protective equipment. If possible, postponement is recommended for operations that do not require urgent or emergent intervention. All patients indicated for surgery must receive a COVID-19 screening, including nasopharyngeal swab, and thorax computed tomography. Level 2 protection measures would be appropriate during COVID-19 negative patients' operations. Operations of COVID-19 positive patients, and emergency cases, where screening can not be obtained, should be performed following level 3 protective measures. During surgery, the use of high-speed drills and electrocautery should be reduced to minimize aerosol production. Screening is crucial in all patients since the surgical outcome is highly mortal in COVID-19 patients. All educational and academic conferences can be turned into virtual webinars.

Coronavirus disease 2019 (COVID- 19) is an exceedingly infectious, life-threatening condition and its outbreak is now constituting unprecedented extraordinary threats and difficulties for worldwide societies and healthcare systems. [1] [2] [3] Since the first detection in China in late December 2019, it has spread rapidly to 213 countries around the globe and reached approximately 3.000.000 confirmed cases with more than 200.000 deaths on April 28, 2020. 4 The increased burden of this pandemic disease has substantially impacted the entire health system, including the neurosurgery practice in most countries. [5] [6] [7] In neurosurgery practice, intensive modifications were required in surgical scheduling, administration of inpatient and outpatient clinics, management of emergency cases, and even academic & educational activities. The major goal of this review is to compose a comprehensive guide using existing guides and recommendations for reorganizing daily practice and the academic routine of neurosurgery during the COVID-19 pandemic. This study also aimed to refine the substantial information for neurosurgery practice about this pandemic disease.

An outbreak of pneumonia of unknown origin showed up in Wuhan city, the capital of Hubei province in People's Republic of China, in late December 2019. 8, 9 On 7 January 2020, China isolated a new coronavirus formerly called 2019 novel coronavirus (2019-nCoV) and

presented virus genome data to the international society. 10 Later, coincidentally, on 11

February 2020, the Coronavirus Study Group of the International Committee on Taxonomy of Viruses gave a new name to the virus "severe acute respiratory syndrome coronavirus 2" (SARS-CoV-2) 11 and the World Health Organization designed a name for epidemic disease "coronavirus disease 2019" . 12 Virology SARS-CoV-2, a positive-sense single-stranded RNA virus, a member of the subgenus betacoronaviruses, is the seventh determined coronavirus that infects humans. 8, 13, 14 The genetic sequence of the SARS-CoV-2 presents approximately 80% analogy to SARS-CoV. 13 SARS-CoV-2 comprises four structural proteins: N (nucleocapsid), E (envelope), M (membrane), and S (spike) proteins ( Figure 1 ). 15 The N protein supports the RNA genome, and E, M, and S proteins compose the viral envelope. The S protein also is responsible for binding to the angiotensin-converting enzyme 2 receptor on the human cell membrane. 15 

The median incubation period is approximately 5 days and practically all cases experience symptoms in 14 days after exposure to SARS-CoV-2. 16 Transmission occurs mainly through direct contact with the infected material or via droplets spread by sneezing or coughing. 17 SARS-CoV-2 primarily targets the respiratory system. 18 The main clinical symptoms of COVID-19 are fever, cough, myalgia or fatigue, expectoration, and dyspnea. 18, 19 Minor symptoms include headache or dizziness, diarrhea, and nausea & vomiting. 18, 19 Dyspnea may be observed in critical patients and may proceed to severe acute respiratory syndrome, sepsis, and multiple organ dysfunction syndrome. 18 Reduced total leukocyte and lymphocyte counts, increased C-reactive protein and lactate dehydrogenase are common results in the laboratory tests. 18, 19 The typical appearance is bilateral, subpleural, ground-glass opacities with air bronchograms on thorax computed tomography (CT). 20 The viral load is elevated throughout the upper respiratory tract mucosa, including the nasal cavity, and naso-oropharynx. 9 The viral ribonucleic acid (RNA) can be identified in the sputum, saliva, as well as in the serum. 9

The blood-brain barrier works as a natural barrier against pathogenic microorganisms and reduces the risk of intracranial infection. 21 Some human coronaviruses can invade the central nervous system (CNS) through hematogenous or neuronal retrograde dissemination, leading to encephalitis and exacerbation of existing neurologic diseases. 22 The brainstem involvement of SARS CoV has been described in both clinic and experimental studies. [23] [24] [25] Given the high analogy between SARS CoV and SARS CoV-2, it clarifies that the CNS spread of SARS CoV-2 may be partly responsible for acute respiratory failure in COVID 19 disease. 26 A recent study from Wuhan City, China reported that some severe COVID-19 patients developed neurologic manifestations, such as acute cerebrovascular diseases (5.7%), and impaired consciousness (14.8%). 27 Cerebrovascular accidents may occur due to a systemic highly prothrombotic state of COVID-19. 28 Furthermore, SARS-CoV-2 was isolated in cerebrospinal fluid (CSF) by gene sequencing from a COVID-19 patient in Beijing Ditan Hospital, China on 4 March 2020. 29 Since results of encephalitis are highly mortal, early diagnosis is essential. 26 Severely affected and comatose patients with neurologic symptoms should undergo brain imaging and CSF examination. Magnetic resonance imaging (MRI) would yield the definitive marks about the presence of infectious intracranial processes. The regional hyperintense abnormalities on T1weighted(W), T2-W, FLAIR, and diffusion-weighted images are considered suspicious for viral encephalitis. 30 In case of suspected CNS infections, lumbar puncture is indicated. 31 The obtained CSF can be investigated to detect viral genetic material through a polymerase chain reaction (PCR) examination or using antibody testing. 32 Viral encephalitis may also be presented with neurologic deterioration related to massive cerebral edema. 33, 34 In case of conservative management (corticosteroids, hyperventilation, hypertonics, hypothermia, and barbiturate coma) fails, decompressive craniectomy can be considered an option for the last chance therapy in selected cases. 35, 36 Faculty planning

The regional disease burden surges during the pandemic and the disease also shows a significant transmission to healthcare professionals. In the algorithm proposed by the University of California San Francisco (UCSF), surgical scheduling is organized according to the ''surge level'' that correlates with the rising viral transmission between local community. 37

Using this system, the green, yellow, red, and black levels represent the lowest, moderate, high and highest levels of the surge, respectively. In the green level (< 6 COVID-19 + inpatients, and no staffing shortages), all elective operations proceed as scheduled. In the yellow level (7-16 COVID-19 + inpatients, or < 20% staffing shortages), the schedule is rearranged as yielding a 25% reduction in the capacity of all elective procedures and all outpatient procedures is designated to an off-site (COVID-19 free) hospital. In the red level (> 17 COVID-19 + inpatients, or > 21% staffing shortages), a 50% reduction is done in elective scheduling. Finally, at the black level, in which significant assistance required from outside institutions to resist the outbreak, only emergent surgical cases will be performed. UCSF recommends a system, based on the "paired coverage model", designed to minimize patient and provider viral exposure while providing continuous inpatient coverage for neurosurgical emergencies. 37 In this model, each department is covered by 2 nonoverlapping teams (rotating in 3d cycles: 3 d on, 3 d off), in which members will have contact only within the same team. This model is activated by a red level of surge and includes an assigned alternate pool of providers to replace who show COVID-19 prodrome.

In case of a massive increase in COVID-19 cases, non-specialized physicians in respiratory or infectious diseases, including neurosurgeons, may need to be reassigned to the COVID-19

wards to initiate supplementary emergency responses. Remodeling the hospital system by identifying concentration centers for neurosurgical activities would be necessary for managing emergent and urgent cases. An instance of this circumstance is present in Lombardy, Northern Italy. Lombardy Health System was rearranged as a ''spoke-and-hub system''. [38] [39] [40] [41] The local neurosurgical network was assembled in 4 hub hospitals (3 for cranial or spinal emergencies, and one for oncological emergencies 41 ). All the other neurosurgery departments have converted the spokes. In this way, hub hospitals are available to manage neurosurgical emergencies, whereas spoke hospitals concentrate on COVID-19 patients. [38] [39] [40] [41] In this system, a huge increase may be expected in the number of patients treated in hub hospitals. According to an early report from the University of Insubria, Italy, there was an increase of 265% and 144%, respectively, of hospitalized and surgically treated neurosurgical emergencies. 42 Healthcare professionals from other areas may need to be sent to regions that are heavily affected by pandemics. During the outbreak, more than 30,000 medical staff including 74 teams from other regions of China have been dispatched to Hubei Province, of which 9 teams are comprised of neurosurgeons. 43 Owing to the newly appointed teams, emergency operations could be performed even during worst times of the epidemic peak. 43 Robertson et al. suggested a ''task shifting and task sharing'' method that involves training, practice, and maintenance phases for increasing workforce capacity during the pandemic. 44 According to this method, the most experienced neurosurgeons who are also from the most vulnerable age groups may practice on telemedicine encounters, guiding ethical decisions on appropriate neurosurgical interventions, or neurosurgery-specific cases. 44 And, residents skilled in neurocritical care may receive intensive skills training in endotracheal intubation and mechanical ventilator management. 44, 45 Residents may serve remotely when possible to perform virtual visits, record notes, give orders, and call consults. 44

According to the physicians' preference, patient follow-up and appointments should be turned into telemedicine, if possible. 46, 47 Besides, remote examinations are reported that they are often applicable. According to the Harvard Medical School experience, more than 80% of the outpatient visits have been able to be switched to telemedicine. 47 Also, in a validation study by Neumarkt Clinic, Germany, remote neurological examination consisting of 22 items performed via audio-visual telemedicine presented comparable results to bedside examination. 48 On occasions, the assist of a person may be required for the patient to perform some parts of the examination, such as the Laségue test for the spinal examination. 49 The transmission of patients' radiological images to the outpatient team via a data transfer method before telemedicine appointment would be beneficial. 50 Actual visits should be preserved for selected patients, such as patients requiring wound control and stitch removal. 47 Also, the use of absorbable sutures in neurosurgical surgeries could be considered to decrease the contacts among clinicians and patients after discharge. 51 Besides, patients aged > 65 years should be encouraged to shun visiting the out-patient clinic.

The out-patient facilities and personnel should be separated in non-COVID and COVID treatment units during the pandemic. 46 The work schedule should be organized with as minimal staff as possible using the proper protective equipment. 46 Physicians and staff assigned in out-patient facilities should be clothed in level 1 personal protective equipment (PPE) during their practice. PPE according to Handbook of Covid-19 Prevention and Treatment is presented in Table 1 . 52 Accompanies for pediatric or non-ambulatory patients should be reduced to one person. 46 And, ambulatory individuals should visit the outpatient clinics alone.

The ''lockdown'' and the ''stay at home'' strategies during pandemic dramatically reduced the spinal and cranial traumas allowing the medical professionals to focus on COVID-19 patients. 53, 54 Also a reduction in surgical treatments for degenerative pathologies is present.

The drop of traumatic events can be explained by the reduced traffic and work activities. 53 Two potential reasons have been argued by Dobran et al. for the demand decrease in surgical treatment for spinal degenerative pathologies: (1) the prevalent fear in the community that regarding hospitals as a risky place for a possible infection; and (2) the patients' overrating their impairments and pains that resulting in surgical overtreatment. 53 A global study, which conducted on the impact of COVID-19 on neurosurgeons and generated an acuity index for the triaging strategy for non-emergent operations, surveyed 494 respondents from 60 countries. 55 53% of respondents reported that all elective cases canceled and their clinics closed down. 46% of respondents reported that their operative density reduced more than 50%, and this rate was 55% in the most affected countries. 55 If possible, medical care methods requiring less invasive interventions such as endovascular treatment in neurovascular conditions, and radiosurgery in certain neuro-oncological diseases may be considered. 57 Endotracheal intubation or high-speed drill use is not required during stereotactic radiosurgery, which reduces the risk of exposure to aerosols compared to open surgeries. 58

The summary of measures during the COVID-19 pandemic is presented in Table 3 .

Healthcare personnel including operation room staff are at high-level risk of exposure to the Sars-Cov-2. Up to 29% of the confirmed cases were healthcare staff in the initial cohort reports. 59 Later, according to the report of the Chinese Center for Disease Control and Prevention, which included more than 72,000 cases, 3.9% of the confirmed cases were medical staff, and 14.8% of them were in critical or severe condition. 60 Minimal or no symptoms are observed during the incubation period (first 3 -6 days) in the majority of the cases. 61 Still, these asymptomatic patients are able to spread the virus. 62 So, all patients indicated for surgery must receive a COVID-19 screening, including measuring body temperature, symptoms investigation, SARS-CoV-2 PCR and antibody test, nasopharyngeal swab, and thorax CT scan. 63 Different recommendations are present for COVID 19 negative patients for the protection of medical staff in the operating theatre. 63 According to a surgical neuro-oncology team perspective, patients from low-risk areas who are verified COVID-19 negative can be operated following level 1 precautions. 63 Other perspectives from Tongji Medical College, Wuhan, China 64 and Heinrich-Heine University, Düsseldorf, Germany 57 recommended that medical staff should take level 2 protection measures due to the long incubation period. 57, 64 For patients who are suspected or confirmed COVID-19 positive, or patients from a high-risk area, the operations should be performed under level 3 precautions. 63, 64 In emergency cases, the results of SARS-CoV-2 tests may not be obtained before the surgery, therefore the surgery should be performed following strict measures (level 3 protective measures) to reduce potential exposure. 65

The route from the ward to the operation room, including the elevators, should be cleared during the transfer of a COVID (+) patient. The transfer should be performed by the COVID-19 ward nurses in full personal protective equipment (PPE 3). 66 The operation room of COVID-19 (+) patients should be separated. 67 An operation room with negative atmospheric pressure setting, and with independent access should be designated for all confirmed or suspected COVID-19 (+) cases. 66, 67 During the pandemic, the same operating room, and the same continuous flow anesthetic machine should be used for only COVID-19 (+) patients. 66 Since the endotracheal intubation can generate aerosols, 68 the intubation should be performed via the method with the maximum possibility of first-time success using a video-laryngoscope to avoid multiple attempts. 69 During the operation of confirmed or suspected COVID-19 patients, all operating room staff must wear Level 3 PPE 52 under a surgical gown to prevent contamination. 70 PPE is obligatory for all interventions involving close contacts, such as surgery, endotracheal intubation, intravenous cannulation, cardiac catheterization, and regional anesthesia. Using powered air-purifying respirators (PAPR) by the surgical team is recommended. 57 All personnel should be trained about wearing and removing PPE to prevent contamination. 67 After extubation, it is recommended that the patient is worn a surgical mask as soon as possible. 67 The viral exposure load of the operating room staff can be considered to be proportional to the duration of the surgery. During the pandemic period, the staff number in the operating theatre must be reduced to the absolute minimum. 67 Also, all neurosurgical procedures ought to be designed to reduce the operating theater time. 57 If possible, only a single experienced neurosurgeon beyond her/his learning curve ought to carry out the procedure to reduce operation time and to prevent exposure of other physicians. 57

Powered instruments such as the high-speed drills, which are commonly used tools for cranial and spinal procedures, had been demonstrated to produce blood-containing aerosols with the identification of hemoglobin in the ambient air. 71 And viruses, such as human immunodeficiency virus-1, was showed to be survival in the aerosols produced by surgical power instruments. 72 Since the coronaviral RNA can be determined in plasma or lymphocytes of confirmed or asymptomatic patients, 73 so these aerosols produced during neurosurgical operations can be contagious. Also, a recent study used the Bayesian regression model (a statistical model uses probability to represent all uncertainty within the model) indicated that aerosol transmission of SARS-CoV-2 is plausible. 74 So, attention should be paid to minimize aerosol generation in operations performed during the pandemic period. Upholding the increase of using traditional hand drills and rongeurs would be beneficial. 75 More meticulous irrigation and reduction of drill speed are some precautions that should be taken if cranial or spinal drilling is necessary. 76 Special caution should be taken during anterior skull base surgeries, to avoid breach frontal or ethmoidal sinuses. 76 The use of electrocautery creates a gaseous by-product containing aerosol commonly referred to as ''surgical smoke''. 77 Viral transmission of human papillomavirus from patients to treating physicians through surgical smoke has been demonstrated. 78, 79 Due to potential transmission risk, using time of monopolar and bipolar electrocautery should be reduced and their power settings ought to be minimized to decrease aerosol dispersal during the pandemic period. 57 Endonasal procedures, using debriders and drills inside the nasal cavity, generate highly hazardous aerosols. 76 Otolaryngologists are among the worst affected medical professionals in Wuhan City, China, and even N95 / (filtering face piece) FFP3 masks did not prevent transmission. 76, 80 Also, a patient with a mass lesion in the sellar region that underwent endonasal endoscopic surgery in Neurosurgery Department, Tongji Medical College, Wuhan City, China was diagnosed with COVID-19 after surgery, and disease was confirmed in 14 healthcare professionals in the same clinic afterwards. 81 According to an initial perspective from the Society of British Neurological Surgeons, endonasal transsphenoidal endoscopic surgical approaches should be avoided during the pandemic period. Alternatives routes to endoscopic surgery should be considered for patients whose surgery can not be postponed: (1) craniotomy; and (2) microscopic endonasal transsphenoidal surgery, with the submucosal approach and non-drill techniques used during the endonasal and sellar phase. 76 Another recent perspective from Singapore suggests that endonasal procedures should be managed according to the COVID-19 test results. 82 They suggested wearing N95 / FFP3 mask, eye protection (goggles and full-face shield), and standard personal level 2 equipment (gown and gloves) in patients whose test results are negative. 82 And in patients with positive test results, they recommended doning an additional PAPR by the entire surgical and anesthesia team, including the circulating nurse and operating room attendant. 82 They also recommended using rongeurs and chisels instead of power instruments during surgical exposure, and avoiding the use of nasal pledgets, whose removal may stimulate gagging or coughing in the postoperative phase. 82 Also, gowns, N95 / FFP3 masks, and face shelters are recommended to use during all outpatient nasal endoscopies. 83

Since the disease is asymptomatic in some patients, COVID-19 screening is crucial in all patients before the operation. Because, in addition to protecting healthcare professionals, high mortality risk is present in COVID-19 patients who have undergone surgical intervention.

University of Brescia, Italy was reported that the mortality rate of chronic subdural hematoma was 80% in COVID-19 (+) patients. 84 This rate was reported as 3.7% in the control group treated before the pandemic. 84 A meta-analysis including nearly 1800 COVID-19 patients revealed that lower platelet count was associated with severe COVID-19. 85 The thrombocytopenia can lead to re-bleeding that resulting in a poor outcome. Also, in subclinical COVID-19 patients, surgical intervention could impair the immune system, leading to the emergence of the COVID-19 disease. 86, 87 Interstitial pneumonia progression after the surgical intervention may worsen the outcome. The conservative strategy should be preferred whenever operation could be postponed. 84 This situation may be different for the baby and children population. The general observation is that newborns, infants, and children are relatively resistant to COVID-19. 88 A case report from Milan, Italy presented that an 8-month-old infant with complex hydrocephalus underwent two consequent shunt revision interventions while his nasopharyngeal swab was positive for SARS-CoV-2. 89 The baby, who underwent two operations under general anesthesia without respiratory complications, showed a favorable neurological course. 89

Web-based conferencing systems have emerged and reached primacy. 5, 90 All in-person conferences such as resident education lectures, multidisciplinary board meetings, and weekly morbidity & mortality conferences should be converted to video teleconferences with an individual person participating in the conference from one site. 47, 91, 92 Many elements of medical students' lectures may be converted into virtual webinars. 93 Involving of neurosurgery-willing students in department educational video teleconferences would intensify student learning and provide accessibility of the department to students. 93

Our country, Turkey, is among the 10 most-affected countries by the pandemic. In our country, the pandemic burden is being managed by in collaboration of state and private health institutions. A substantial or all part of the many hospitals were modified to COVID-19 wards. When necessary, some of the operation rooms were used as intensive care units.

During the pandemic period, most of the neurosurgeons attended in the front lines. The urgent and emergent surgeries were performed and the schedule for elective procedures was postponed. In India, one of the most affected countries in Asia, a consensus was suggested for neuro-interventional teams to switch coverage model including 14 days on work and 14 days of self-isolation cycles. 94 In this consensus statement, the categorization of the patients based on priority and postponing non-essential elective surgeries and outpatient visits are advocated. 94 In an experience report from Iran, one of the 10 most-affected countries, it was reported that out-patient clinics were shut down, elective surgeries were canceled, and postponed, neurosurgery residents were reassigned in COVID-19 wards. 95 According to the Iran University of Medical Sciences and Health Services experience, a significant decrease (56%) was noticed in elective and emergency neurological surgeries. 95 An experience report from Germany declared that spine cases fell 64.4% below baseline (2019) levels. 96

With the increasing burden of COVID-19 pandemic worldwide, the need for various modifications in neurosurgery practice will proceed. During the pandemic period, strict measures are essential for both medical staff safety and patient care. In this paper, we outline substantial information and recommendations for the daily outpatient and inpatient practice, 

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The authors would like to thank to Mrs. Senay Guner Ozoner for her illustrative figure work.

All authors certify that they have no affiliations with or involvement in any organization or entity withany financial or non-financial interest in the subject matter or materials discussed in this manuscript