key: cord-0713098-q31ul671
authors: Dowlati, Ehsan; Zhou, Tianzan; Sarpong, Kwadwo; Pivazyan, Gnel; Briscoe, Jessica; Fayed, Islam; Mualem, William; Black, Jordan; Kalhorn, Christopher G.; Nair, Mani N.; Felbaum, Daniel R.
title: Case Volumes and Perioperative Coronavirus Disease 2019 Incidence in Neurosurgical Patients During a Pandemic: Experiences at Two Tertiary Care Centers in Washington, DC
date: 2020-08-07
journal: World Neurosurg
DOI: 10.1016/j.wneu.2020.08.015
sha: 16063477d89f6360c778076fce626c582a6e37a6
doc_id: 713098
cord_uid: q31ul671

OBJECTIVE: The true incidence of perioperative coronavirus disease 2019 (COVID-19) has not been well elucidated in neurosurgical studies. We reviewed the effects of the pandemic on the neurosurgical case volume to study the incidence of COVID-19 in patients undergoing these procedures during the perioperative period and compared the characteristics and outcomes of this group to those of patients without COVID-19. METHODS: The neurosurgical and neurointerventional procedures at 2 tertiary care centers during the pandemic were reviewed. The case volume, type, and acuity were compared to those during the same period in 2019. The perioperative COVID-19 tests and results were evaluated to obtain the incidence. The baseline characteristics, including a modified Medically Necessary Time Sensitive (mMeNTS) score, and outcome measures were compared between those with and without COVID-19. RESULTS: A total of 405 cases were reviewed, and a significant decrease was found in total spine, cervical spine, lumbar spine, and functional/pain cases. No significant differences were found in the number of cranial or neurointerventional cases. Of the 334 patients tested, 18 (5.4%) had tested positive for COVID-19. Five of these patients were diagnosed postoperatively. The mMeNTS score, complications, and case acuity were significantly different between the patients with and without COVID-19. CONCLUSION: A small, but real, risk exists of perioperative COVID-19 in neurosurgical patients, and those patients have tended to have a greater complication rate. Use of the mMeNTS score might play a role in decision making for scheduling elective cases. Further studies are warranted to develop risk stratification and validate the incidence.

T he coronavirus disease 2019 , caused by severe acute respiratory syndrome coronavirus 2, has significantly affected healthcare systems and hospitals worldwide, with >11 million cases and >520,000 deaths confirmed as of July 5, 2020. 1 In line with the preservation of resources and redeployment of the healthcare workforce in the wake of an anticipated surge, the Surgeon General and the American College of Surgeons called for cancellation of elective procedures in mid-March. 2 Specifically, neurosurgical volumes experienced a drastic reduction. [3] [4] [5] [6] In an international survey of 494 neurosurgeons, 46.1% reported a >50% decrease in case volumes at the peak of the global pandemic. 4 Even with a global pandemic, the field of neurosurgery performs some of the most time-sensitive procedures to preserve life and/or function. Even in patients for whom symptoms might not be as overt, operating in a timely fashion can result in better outcomes. 7 Neurosurgical care also requires significant healthcare expenditure and frequent use of intensive care resources. Additionally, the risk of mortality is increased for surgical patients with a COVID-19 diagnosis. 8, 9 The increased resource usage and risks of transmission and mortality must be balanced against the benefits of surgery. Several specialty societies have attempted to provide guidance for triaging patients during a resource-restricted timeline. [10] [11] [12] Additionally, a slew of editorials regarding individual institutional experiences on management, measures to stop the spread of COVID-19, resource allocation, and service line reorganization have been reported. 13 However, the neurosurgical community has been left to determine the most appropriate course of action from anecdotal experience and paucity of objective data. Specifically, reported data are lacking regarding the perioperative incidence of COVID-19 and the risk of nosocomial spread specific to the neurosurgical population. 14 To the best of our knowledge, only 1 such study has been reported. 15 That study included 55 neurosurgical patients, of whom 4 had tested positive for COVID-19 preoperatively and none postoperatively. 15 We have described the experience at 2 tertiary care centers in Washington, DC, during the first 3 months of the pandemic and the perioperative incidence of COVID-19 in these patients. We hypothesized that a true risk of transmission would be found and that patients with COVID-19 would have higher risk profiles and worse outcomes.

A retrospective review of all consecutive adult patients who had undergone neurosurgical and neurointerventional procedures under general anesthesia was performed at 2 tertiary care medical centers in Washington, DC (MedStar Georgetown University Hospital and MedStar Washington Hospital Center). The inclusion dates spanned the first 3 months of the pandemic from March 8 to June 8, 2020. March 8 was the first day a positive test was recorded in Washington, DC ( Figure 1 ). Effective March 19 until May 31, 2020, all elective surgeries and procedures were cancelled across both study centers. Data from procedures during the same period in 2019 were also collected for comparison. The respective institutional review boards at the 2 study centers approved the present study.

Surgical and neurointerventional cases were categorized by type and acuity. Cases were designated as elective, urgent, or emergent according to the presenting symptoms and neurologic The patient variables collected included age, sex, race, ethnicity, diagnosis, presenting symptoms, neurologic examination findings, comorbidities, American Society of Anesthesiologists physical status class, postoperative complications, length of stay (LOS), WORLD NEUROSURGERY 143: e550-e560, NOVEMBER 2020 www.journals.elsevier.com/world-neurosurgery e553 ORIGINAL ARTICLE discharge disposition, 30-day readmission, preoperative COVID-19 status, postoperative COVID-19 status at 1 month, and date of testing. The patient variables between those with and without COVID-19 were compared. Additionally, a simplified and modified Medically Necessary, Time-Sensitive (mMeNTS) score was assigned to all patients by a study member blinded to COVID-19 diagnosis ( Table 1 ). The mMeNTS scoring system was established as a preoperative guide to minimize poor perioperative outcomes and transmission risk for patients requiring operative intervention. 16 

Continuous variables were summarized as the mean AE standard deviation. The t test or Wilcoxon rank sum test were used to compare the differences between continuous variables depending on the distribution. Categorical variables were aggregated as frequencies and percentages. The c 2 and Fisher exact tests were used to compare the proportional differences in the categorical variables. Logistic regression was used to assess the differences in variables between COVID-19epositive andenegative patients. Multivariable ordinal and logistic regression analysis were used to analyze all independent variables against COVID-19 status. All analyses were performed using Stata, version 16.0 (StataCorp, College Station, Texas, USA). Statistical significance was defined as P < 0.05.

A total of 405 operative neurosurgical cases for 386 patients and 121 neurointerventional cases for 112 patients were performed during the study period ( Table 2 ). In comparison, in 2019, the total was 812 operative neurosurgical cases and 159 neurointerventional cases at the 2 centers. Thus, a 50.1% decrease in the volume of operative cases (P < 0.0001) and a 23.9% decrease in neurointerventional cases (P ¼ 0.0975) had occurred in the 2020 study period. The largest decrease in case volumes corresponded to the stoppage of elective cases on March 19, 2020 ( Figure 2 ).

Cases classified as lumbar spine, cervical spine, and functional/ pain procedures had the most significant decrease in volume ( Figure 3) . A significant decrease had also occurred in total spine cases (P ¼ 0.0002) compared with cranial cases during the pandemic period versus the same period in 2019 (P ¼ 0.2808; Figure 3B ).

For the neurointerventional cases, no significant decrease occurred in any case category between 2020 and 2019. The largest decline was seen in diagnostic procedures (51 vs. 39). An increase was found in the number of thrombectomy cases (25 vs. 29) and middle meningeal artery embolization cases (4 vs. 10). However, the differences were not statistically significant ( Figure 3C) .

When categorized by acuity, a significant decrease had occurred in elective cases (P < 0.0001), with no significant change in the number of urgent or emergent cases in the surgical category. In the neurointerventional category, no significant changes were found in the number of elective, urgent, or emergent cases, although the elective procedures had decreased by 52.3% ( Figure 4 ).

A total of 319 patients (64.1%) had undergone preoperative testing for COVID-19 (231 surgical; 88 neurointerventional). Of these patients, 6 (2.6%) in the surgical group and 7 (8.0%) in the neurointerventional group had tested positive for COVID-19 preoperatively. Of these 13 patients, 10 had tested positive within 1 day of surgery. The other 3 had tested positive an average of 11 days before surgery. It was determined that their surgery could be postponed, and they were retested immediately before surgery with negative results. Postoperatively, 179 tests were administered (115 surgical; 64 neurointerventional). Of these, 4 patients (3.5%) tested positive in the surgical group (3.5%) and 1 tested positive in the neurointerventional group (1.6%) within 30 days after their procedure ( Table 2 ). All patients who tested positive postoperatively had tested negative preoperatively. The criteria for postoperative testing included clinical suspicion, an upcoming procedure, and placement to another facility. positive test rate) had tested positive postoperatively ( Table 4 ). All 18 patients had undergone urgent or emergent procedures. The overall case acuity was significantly greater for the COVID-19e positive patients (P < 0.0001). 

A significant difference was found in the race and/or ethnicity of the patients testing positive, with significantly more patients identifying as Hispanic and African American in the positive group (odds ratio [OR], 3.68; 95% confidence interval [CI],1.25e10.43; P ¼ 0.0266; Figure 5 ). The mean mMeNTS score was significantly greater for the COVID-19epositive patients than for those with negative test results (9.8 vs. 8.4; P ¼ 0.0013; Figure 5D ). Compared with the COVID-19enegative patients, those with positive test results also had had an increased LOS by almost 6 days (16.2 vs. 10.5; P ¼ 0.0316; Figure 5B ) and were more likely to develop an in-hospital complication other than the COVID-19 diagnosis (OR, 7.42; 95% CI, 2.66e19.22; P < 0.0001). Additionally, a significant difference was found in the overall disposition for the COVID-19epositive patients (P ¼ 0.0009), with fewer going home compared with those with negative test results (16.7% vs. 58.9%; P ¼ 0.0027; Figure 5C ). Two patients (11.1%) who had tested positive died in-hospital. Both had had large vessel occlusions ( Table 3) . All other COVID-19epositive patients who survived hospitalization were alive at the 30-day follow-up from the index case.

Case acuity, the occurrence of inpatient complications, and the mMeNTS score remained significantly different between the 2 groups on multivariate analysis controlling for confounding variables ( Table 5) . Of the 5 patients with a postoperative diagnosis of COVID-19, all had been diagnosed !8 days after surgery (mean, 13.3 days), had had a mMeNTS score of !9 (mean, 10.0), had developed inpatient complications, and had been discharged to locations other than home ( Table 3 ). status, procedure type, length of stay, disposition, and readmission were also adjusted for on multivariate analysis, but the differences were not statistically significant (P < 0.05). yStatistically significant.

WORLD NEUROSURGERY 143: e550-e560, NOVEMBER 2020 www.journals.elsevier.com/world-neurosurgery e557 ORIGINAL ARTICLE

In the present 2-center study, a decrease was found in the total case volumes, elective cases, and spine and functional/pain procedures, with no appreciable decrease in neurointerventional cases. The incidence of perioperative COVID-19 in the neurosurgical population was 5.4%, with, specifically, a 2.8% positive test rate after a confirmed negative preoperative test (i.e., hospitalacquired COVID-19). The incidence of a perioperative diagnosis of COVID-19 in the neurosurgical population is an important consideration given the increased complications, increased LOS, and greater risk profiles observed for these patients.

The reduction in case volume was not surprising given the halt of elective cases and has been reported by others. 3, 17 The larger decrease in spine cases also resulted because of their mostly elective nature. 3 Cranial procedures also showed a decrease, although the difference was not significant. In Ancona, Italy, neuro-oncologic cases and the proportion of acute neurooncologic cases also increased, with 57.1% of tumor cases defined as emergent compared with 31.1% in the same months in 2019. This was attributed to patient concerns regarding exposure from hospitalization and difficulty in accessing radiologic examinations, resulting in more acute presentations. 18 Their findings are consistent with those from our study, demonstrating an increase from 53.5% to 89.8% in nonelective cranial neurooncology cases from 2019 to 2020.

However, the overall number of neurointerventional cases did not decrease significantly. This could have resulted from the selection of cases specifically for general anesthesia and the relatively acute nature of these procedures. Fiehler et al. 19 reported the results from an international survey, demonstrating a significant decrease in emergent neurointerventional volume reported by 69% of the responders. We did not find such a decrease in our study. Although a decrease had occurred in nonelective neurointerventional cases, the difference was not significant. This could have resulted from the acquisition of new referring community hospitals since 2019, increasing the overall volume. Similarly, Sweid et al. 20 reported an increase in thrombectomies at their institution in Philadelphia despite an overall decrease in acute stroke admissions.

The total census of COVID-19epositive patients at both institutions peaked at 268 on April 30, 2020 and averaged >220 for !2 weeks before and after the peak (Figure 1) . The average LOS for COVID-19epositive patients at the 2 centers was 10.79 days, with a 15.3% mortality rate for inpatients. However, for our COVID-19 cohort, the average LOS was 16.2 days, with an 11.1% mortality rate. The increased LOS could have been because of the overall increased care that neurosurgical patients require. The lower mortality rate could have been from a selection bias, because only operative patients were studied, excluding patients who were too critically ill.

It is well established that people of ethnic and minority populations have a disproportionately increased risk of acquiring COVID-19 and experience poorer outcomes, irrespective of age. [21] [22] [23] Similarly, our study showed more positive cases in ethnic and minority patients compared with non-Hispanic white patients. We found an almost 30% increase in the proportion of black and Hispanic patients in the COVID-19epositive group compared with the negative group ( Figure 5A and Table 4 ). These findings are comparable to other data from Washington, DC, with 37% of positive patients identifying as black and 28% as Hispanic or Latino, despite constituting only 11.3% of the total city population. 24 Nosocomial Infection Rate Although the nosocomial transmission of COVID-19 presents an obvious risk for patients admitted during the peak pandemic period, this risk has not been well defined in the current data. Several studies have investigated the transmission of COVID-19 to healthcare workers, with rates ranging from 1.1% to 11.6% reported. [25] [26] [27] We found a 2.8% positive COVID-19 rate among our patients who had had a negative test before their procedure. As expected, this rate was lower than most of the nosocomial transmission rates to healthcare workers that have been reported in previous studies. [25] [26] [27] In contrast, the risk of any nosocomial infection among patients admitted to a neurosurgical intensive care unit before the COVID-19 pandemic was estimated at 3. 7%e5%. 28 Therefore, the risk of COVID-19 transmission during this period represents a 40%e50% increase in the risk of all nosocomial infections to this patient population.

The average LOS for the patients with nosocomial transmission of COVID-19 was also markedly longer at 21.6 days compared with 10.5 days for the patients without COVID-19 during their hospital stay (P ¼ 0.0219). Additionally, the group with nosocomial transmission had been diagnosed further out from surgery although the difference was not significant (13.3 vs. 11.5 days postoperatively). Moreover, all 5 patients who had tested positive postoperatively had experienced major in-hospital complications, in addition to the COVID-19 diagnosis. These data highlight the added risk to patients who had undergone neurosurgical or neurointerventional procedures in the setting of the COVID-19 pandemic.

No COVID-19 transmissions were observed among the neurosurgical residents, advanced care practitioners, or attendings at the 2 centers. However, the risk to providers remains a concern, with 3387 confirmed cases among medical professionals in 476 healthcare organization worldwide recorded in March. 29 

Since June 1, 2020, elective neurosurgical cases have resumed at the study centers. Using the mMeNTS tool, each case is scored by the surgeon at the time of posting ( Table 1) . Cases for patients with a score >10 are advised to be postponed. All patients are tested for COVID-19 within 5 days before surgery. If a patient tests positive, the surgery is delayed for 1 month and the patient is retested. If the surgeon needs to proceed with the case before then, the case proceeds under the COVID-19 precautions. If the procedure is considered at high risk for generating aerosols (e.g., endonasal cases), COVID-19 precautions are required regardless of the COVID status of the patient. The need for an intensive care unit bed postoperatively, blood transfusions, and rehabilitation e558 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2020.08.015 ORIGINAL ARTICLE placement after hospitalization are also considered. These factors are a part of an overall algorithm specific to neurosurgical patients and similar to that discussed by Burke et al. 30 Although established as a preoperative scoring system, 16 the mMeNTS score was applied post hoc to our study population. The score for patients requiring intervention during the pandemic was 8.4 AE 1.7, well below the cutoff of 10 used for posting elective cases. Nonetheless, a significant difference was found in the mMeNTS scores between the COVID-19epositive andenegative patients on multivariate analysis (9.8 vs. 8.4; OR, 2.03; 95% CI, 1.13e3.86; P ¼ 0.0226). Thus, the mMeNTS score allows for quick risk stratification for scheduling cases and could be beneficial if incorporated into practice during this pandemic.

We performed a retrospective analysis of COVID-19 incidence during the pandemic period. Our findings might not be generalizable to other institutions or regions that could have had a different experience with the pandemic and different methods for managing the outbreak. Although blinded independent reviewers the assigned acuity and mMeNTS scores in our cohort, the post hoc assignments could have been biased, and the full circumstances surrounding a case might not have been available. Further prospective and multiregional studies with increased sample sizes are warranted to provide a more representative view of perioperative COVID-19 incidence and risk in the neurosurgical population.

The rate of COVID-19 infection in patients requiring neurosurgical intervention during the pandemic has been low but should be considered when scheduling cases. As testing becomes more prevalent, further multi-institutional studies are needed to truly determine the incidence of COVID-19 and its impact on how and when surgeries are performed. To maximize the safety of providers and patients, precautions will be required for the foreseeable future as elective cases increase in quantity.

Coronavirus Disease (COVID-19) Situation Report 167

COVID-19: Recommendations for Management of Elective Surgical Procedures

COVID-19 non-essential surgery restrictions and spine surgery: a German experience

The impact of COVID-19 on neurosurgeons and the strategy for triaging non-emergent operations: a global neurosurgery study

Elective surgery cancellations due to the COVID-19 pandemic: global predictive modelling to inform surgical recovery plans

Neurosurgical practice during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic: a worldwide survey

Immediate versus delayed surgical treatment of lumbar disc herniation for acute motor deficits: the impact of surgical timing on functional outcome

Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Factors associated with surgical mortality and complications among patients with and without coronavirus disease 2019 (COVID-19) in Italy

Neurosurgical practice during coronavirus disease 2019 (COVID-19) pandemic. World Neurosurg

Coronavirus disease 2019 (COVID-19) and neurosurgery: literature and neurosurgical societies recommendations update. World Neurosurg

Minimizing SARS-CoV-2 exposure when performing surgical interventions during the COVID-19 pandemic

Early responses of neurosurgical practice to the COVID-19 pandemic: a rapid review

Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection

Letter to the editor: risk of hospital-acquired coronavirus disease 2019 (COVID-19) infection during admission for semiurgent neurosurgical procedures

Medically necessary, time-sensitive procedures: scoring system to ethically and efficiently manage resource scarcity and provider risk during the COVID-19 pandemic

Impact of COVID-19 on an academic neurosurgery department: The Johns Hopkins experience

Letter to the editor regarding "coronavirus disease 2019 (COVID-19) and neurosurgery: literature and neurosurgical societies recommendations update

COVID-19 and neurointerventional service worldwide: a survey of the European Society of Minimally Invasive Neurological Therapy (ESMINT

Letter to the editor: incidence of acute ischemic stroke and rate of mechanical thrombectomy during the COVID-19 pandemic in a large tertiary care telemedicine network

Disparities in outcomes among COVID-19 patients in a large health care system in California. Health Aff (Millwood)

The disproportionate impact of COVID-19 on racial and ethnic minorities in the United States

Available at

Office of the Mayor. Coronavirus Data. Government of the District of Columbia

SARS-CoV-2 infection in health care

Screening of healthcare workers for SARS-CoV-2 highlights the role of asymptomatic carriage in COVID-19 transmission

Coronavirus disease 2019 (COVID-2019) infection among health care workers and implications for prevention measures in a tertiary hospital in Wuhan, China

Healthcare-associated infections in the neurological intensive care unit: results of a 6-year surveillance study at a major tertiary care center

Response to COVID-19 in Chinese neurosurgery and beyond

Letter: the coronavirus disease 2019 global pandemic: a neurosurgical treatment algorithm

Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.