key: cord-0891094-cebxiy88
authors: Bajunaid, Khalid; Alatar, Abdullah; Alqurashi, Ashwag; Alkutbi, Mohammad; Alzahrani, Anas H.; Sabbagh, Abdulrahman J.; Alobaid, Abdullah; Barnawi, Abdulwahed; Alferayan, Ahmed A.; Alkhani, Ahmed M.; Salamah, Ali Bin; Sheikh, Bassem Y.; Alotaibi, Fahad E.; Alabbas, Faisal; Farrash, Faisal; Al-Jehani, Hosam M.; Alhabib, Husam; Alnaami, Ibrahim; Altweijri, Ikhlass; Khoja, Isam; Taha, Mahmoud; Alzahrani, Moajeb; S Bafaquh, Mohammed; Binmahfoodh, Mohammed; Algahtany, Mubarak A.; Al-Rashed, Sabah; Raza, Syed M.; Elwatidy, Sherif; Alomar, Soha A.; Al-Issawi, Wisam; Khormi, Yahya H.; Ammar, Ahmad; Al-Habib, Amro; Baeesa, Saleh S.; Ajlan, Abdulrazag
title: The longitudinal impact of COVID-19 pandemic on neurosurgical practice
date: 2020-09-17
journal: Clin Neurol Neurosurg
DOI: 10.1016/j.clineuro.2020.106237
sha: b1c0d65aee4c2a42683d19388631112f4aedf373
doc_id: 891094
cord_uid: cebxiy88

OBJECTIVE: This observational cross-sectional multicenter study aimed to evaluate the longitudinal impact of the coronavirus disease 2019 (COVID-19) pandemic on neurosurgical practice. METHODS: We included 29 participating neurosurgeons in centers from all geographical regions in the Kingdom of Saudi Arabia. The study period, which was between March 5, 2020 and May 20, 2020, was divided into three equal periods to determine the longitudinal effect of COVID-19 measures on neurosurgical practice over time. RESULTS: During the 11-week study period, 474 neurosurgical interventions were performed. The median number of neurosurgical procedures per day was 5.5 (interquartile range [IQR]: 3.5–8). The number of cases declined from 72 in the first week and plateaued at the 30′s range in subsequent weeks. The most and least number of performed procedures were oncology (129 [27.2 %]) and functional procedures (6 [1.3 %]), respectively. Emergency (Priority 1) cases were more frequent than non-urgent (Priority 4) cases (178 [37.6 %] vs. 74 [15.6 %], respectively). In our series, there were three positive COVID-19 cases. There was a significant among-period difference in the length of hospital stay, which dropped from a median stay of 7 days (IQR: 4–18) to 6 (IQR: 3–13) to 5 days (IQR: 2–8). There was no significant among-period difference with respect to institution type, complications, or mortality. CONCLUSION: Our study demonstrated that the COVID-19 pandemic decreased the number of procedures performed in neurosurgery practice. The load of emergency neurosurgery procedures did not change throughout the three periods, which reflects the need to designate ample resources to cover emergencies. Notably, with strict screening for COVID -19 infections, neurosurgical procedures could be safely performed during the early pandemic phase. We recommend to restart performing neurosurgical procedures once the pandemic gets stabilized to avoid possible post pandemic health-care system intolerable overload.

This observational cross-sectional multicenter study aimed to evaluate the longitudinal impact of the coronavirus disease 2019 (COVID-19) pandemic on neurosurgical practice.

We included 29 participating neurosurgeons in centers from all geographical regions in the Kingdom of Saudi Arabia. The study period, which was between March 5, 2020 and May 20, 2020, was divided into three equal periods to determine the longitudinal effect of COVID-19 measures on neurosurgical practice over time.

During the 11-week study period, 474 neurosurgical interventions were performed. The median number of neurosurgical procedures per day was 5.5 (interquartile range [IQR]: 3. [5] [6] [7] [8] . The number of cases declined from 72 in the first week and plateaued at the 30's range in subsequent weeks. The most and least number of performed procedures were oncology (129 [27.2%]) and functional procedures (6 [1.3%]), respectively. Emergency (Priority 1) cases were more frequent than non-urgent (Priority 4) cases (178 [37.6%] vs. 74 [15.6%] , respectively). In our series, there were three positive COVID-19 cases. There was a significant among-period difference in the length of hospital stay, which dropped from a median stay of 7 days (IQR: 4 -18) to 6 (IQR: 3 -13) to 5 days (IQR: 2 -8). There was no significant among-period difference with respect to institution type, complications, or mortality.

Our study demonstrated that the COVID-19 pandemic decreased the number of procedures performed in neurosurgery practice. The load of emergency neurosurgery procedures did not change throughout the three periods, which reflects the need to designate ample resources to cover emergencies. Notably, with strict screening for COVID -19 infections, neurosurgical procedures could be safely performed during the early pandemic phase. We recommend to restart

In December 2019, the novel coronavirus was first reported in the Wuhan region of China. The number of people infected with the novel respiratory viral illness has rapidly increased in all continents as it continues to globally spread. On March 11, 2020 , the World Health Organization declared COVID-19 a pandemic. 1 Recently, we published a quantitative study evaluating the early pandemic phase and its effect on the distribution of neurosurgical cases compared to the pre-pandemic periods. 9 This previous study reported no change in the absolute number of acute neurosurgery emergencies. Notably, J o u r n a l P r e -p r o o f

We performed an observational cross-sectional multicenter study to assess the longitudinal impact of COVID-19 on neurosurgical practice in Saudi Arabia. Data were collected from March 5, 2020 through May 20, 2020. The centers were included from all major cities and geographical regions in the Kingdom. We included both private and public hospitals providing full neurosurgical services. Public hospitals were from all healthcare sectors, including the academic sector, military, and ministry of health.

The study was approved by the Institutional Review Board (IRB) at King Saud University Medical City, Riyadh, Saudi Arabia (IRB no. 20/0341/IRB).

We collected data from 29 neurosurgeons. The participants were fully privileged consultants at their institution with a practice of ≥2 years. To study the longitudinal effect of COVID-19 measures on neurosurgical practice over time, the study timeline was divided into three equal periods as follows: Period 1 (March 5-March 30), Period 2 (March 31-April 25), and Period 3 (April 26-May 20). We included neurosurgical procedures performed on both adult and pediatric patients and collected the following data: demographic information; e.g., age, gender, and institution type (public or private). Additionally, we collected information regarding surgical interventions, including diagnosis, surgical intervention category, case priority, general and craniospinal complications, length of hospital stay, and 30-day mortality. Surgical interventions were categorized into the following nine major subcategories: trauma, oncology, spine, vascular, congenital, hydrocephalus, peripheral nerves, functional, and infection. Intervention priorities J o u r n a l P r e -p r o o f were set according to the previously published Saudi Association of Neurological Surgery priority list consensus statement. 8 We define the four major priority levels as follows. Priority 1 (immediate) indicates cases requiring immediate intervention. Priority 1 (1-24 h) is for urgent cases that can be performed within 24 h of presentation. Priority 2 is for cases requiring intervention within one week. Priority 3 is for cases requiring intervention between one and four weeks. Priority 4 is for cases that can be delayed for >4 weeks. We collected information regarding COVID-19 testing, timing of testing, and COVID-19 related complications. At the end of the study period, the participating surgeons received a simple survey questionnaire for evaluating the reasons underlying the decreasing number of surgical procedures in their practice during the study period.

The study duration was divided into three distinct periods. Normally distributed demographic and surgical intervention characteristics during the three study periods were compared using a two-way T-test. Non-normally distributed and cross-tabulation data were compared using the Mann-Whitney and Pearson's chi-squared test, respectively. Statistical significance was set at Pvalue < 0.05. Statistical analyses were performed using Stata 14 statistical software (StataCorp, College Station, Texas).

We included 474 neurosurgical interventions performed during the 11-week study period (Table.1 During the study period, 117 (24.7%) patients underwent COVID-19 testing using nasopharyngeal swabs. Only three patients who underwent surgical intervention tested positive for COVID-19 swab while the remaining patients were either negative or did not exhibit clinical signs associated with COVID-19 in the perioperative period.

The number of procedures in the three consecutive periods was 209, 133, and 132, respectively.

The median number of cases per day were significantly lesser in the latter two periods than in the first period (7; IQR: 4-13), (5; IQR: 3-6), and (5; IQR: 4-7), respectively (Table 2) .

With regard to the category of cases, there were significant among-period differences in only the vascular and peripheral nerve cases (P-values 0.03 and 0.02, respectively) ( Figure 2 ). With regard to the intervention priority, there was a significant among-period difference in Priority 4 interventions, which declined from 49 (23.4%) to 13 (9.8%) and 12 (9.1%) over the three periods (P-value < 0.001) (Figure 3 ). There was a significant among-period difference in the length of J o u r n a l P r e -p r o o f hospital stay, which dropped from a median of 7 days (IQR: 4-18) to 6 (IQR: 3-13) and 5 days (IQR: 2-8). There was no significant among-period difference with respect to the institution type, complications, and mortality.

The impact of the COVID-19 pandemic on neurosurgical practice in our region was similar to that reported in other regions. [10] [11] [12] [13] [14] [15] [16] [17] We recently compared 50 days during the early phase of the COVID-19 pandemic with a similar period in 2019. 9 We found a 44% reduction in the number of neurosurgical procedures performed during the COVID-19 pandemic compared to the previous year. Moreover, there was a significantly lower median number of procedures performed per day during the pandemic than during the same period in the previous year. In the previous study, we observed that the proportions of Priority 1 (immediate) and Priority 1 (1-24 h) cases were 82% and 63%, respectively, and these cases were more likely to occur during the pandemic period. On the other hand, Priority 4 cases were 72% less likely to occur during the pandemic period than during the pre-pandemic period. In the present study, we assessed the longitudinal impact of COVID-19 on neurosurgical practice in Saudi Arabia during the early pandemic months. Our findings revealed a decrease in the number of operations performed throughout the study period, which was concomitant with the increased number of COVID-19 cases in Saudi Arabia, as shown in Figure 1 to delay elective non-urgent operations to limit the risk of COVID-19 transmission between patients and health care workers. Some patients preferred delaying non-urgent procedures to avoid exposure and contracting the virus from the hospitals. Limited resources in some hospitals, including a decreased capacity of the surgical intensive care unit, which affected other aspects of health care delivery, could have contributed to our findings. However, during the study period, the health care system in Saudi Arabia was not severely affected by the pandemic.

As shown in Figure 1 , the number of cases during the early weeks was higher than that during the subsequent weeks. Initially, there were 72 and 64 cases during the first two weeks, which subsequently dropped and plateaued to 30-40 during the following weeks. This occurred concomitantly with an increase in the number of COVID-19 confirmed cases in the country.

During the study period, predominantly during and after period 2, we saw an increase in the Several measures have been proposed to limit the spread of COVID-19 infections during surgery. [18] [19] [20] All patients undergoing emergency procedures should be considered positive until proven otherwise, with development of a dedicated route from the emergency department to the operating room (OR) and the use of separate designated ORs. Use of negative pressure ORs is highly encouraged, particularly for aerosol-generating procedures such as intubation, extubation, and transnasal procedures. Limiting unnecessary staff and unnecessary movements in and out of ORs, along with ensuring that all staff wear proper PPE, including N95 masks, and appropriately dispose all PPE and OR attire, is mandatory. In addition, good communication between hospital teams is crucial for better safety control and risk minimization during any outbreak.

We found that oncology procedures were the most commonly performed throughout the three periods ( Figure 2 ). The majority of oncological procedures were performed for Priority 2 (61 [47.3%]) cases, followed by Priority 3 (34 [26.4%]), Priority 1 (24 [18.6%]), and Priority 4 (10 [7.7%]) cases. We observed that with progression of time, between periods, there was a decrease in priority 4 procedures and a shift towards more critical and urgent cases, priority 1 and 2, which reflects the high patients' selection among surgeons as we advanced through the pandemic. The oncological procedures varied, although the majority were performed for tumors compressing the brain and causing acute focal neurological deficits, tumors causing J o u r n a l P r e -p r o o f hydrocephalus, or tumors causing high intracranial pressure. Vascular procedures were the third most common, which could be attributed to their urgency, including ruptured aneurysms, hemorrhagic strokes, or malignant vascular strokes, which cause a mass effect. There was a decreased number of vascular procedures during the second study period, which was mainly attributed to more hospital restrictions in accepting referred cases among leading vascular centers due to increased COVID-19 cases. Khalafallah et al. 16 Cancellation of operative cases varied by subspecialty with spine procedures being the most affected, followed by tumor, vascular, functional, and pediatric surgeries. Contrastingly, there was a non-significant trend of a decrease in trauma cases.

With regard to the trauma cases, there was a decreased number of cases performed throughout the three periods. This is consistent with previous reports, which could be explained by reduced road traffic accidents from the strict curfew imposed by the governments. 16 With regard to complication rates, 13.1% of our patients presented with either general or craniospinal complications. This rate is close to the 14.3% complication rate reported by an analysis of a large database from the American College of Surgeons, which included >38,000 procedures from hundreds of US hospitals. 22 However, the complication rate could be higher for COVID-19 positive patients undergoing surgical procedures. A retrospective analysis of 34 COVID-19 positive cases who underwent elective surgical procedures during the disease incubation period reported that all patients developed COVID-19 pneumonia soon after surgery, Another important issue is the burden of patients on waiting lists for elective procedures, as well as difficulty in accessing emergency departments and outpatient visits. A previous study 24 reported that 3 patients admitted to an emergency department in 1 week presented with complications associated with delayed seeking of healthcare advice or misinterpretation of the complaint as being COVID-19 related. Delaying early interventions could negatively affect patients and exert long-term consequences, especially in patients with cancer. Several measures have been suggested to guide cancer treatment, including designating cancer surgeries as essential and of high priority surgeries, transferring patients with cancer to less overwhelmed institutions, high-level guidance for prioritizing cancer surgeries if delaying is essential, and concrete planning for performing delayed surgeries in a reasonable time period. 25 Our study demonstrated no change in the safety profile for both patients and healthcare workers throughout the study period. Therefore, we suggest that optimal resource utilization and continuation of essential neurosurgical procedures could benefit patients requiring time-sensitive intervention for certain pathologies before the healthcare system is overwhelmed and "life-or-limb" procedures dominate the practice. In a study published in the United States, an algorithmic approach based on institutional and local community volume surges of COVID-19 cases was set, aiming for better resource distribution to meet the outbreak need as well as provision of care for neurosurgical patients. 26 The surge levels were categorized into four types according to the cases in the community, positive inpatients, and staff shortage; "green" reflected a light load of COVID-19 infections in the community and institutes, while "black" represented the highest level warranting postponement of all elective cases and outpatients visits until settlement of the surge. This, along with individualized patient selection procedures, could be an acceptable and dynamic approach for institutes providing neurosurgical services during the pandemic.

This study has several limitations. First, we did not evaluate the impact of the COVID-19 pandemic on other neurosurgical services, including outpatient clinic care, inpatient care, or the effects on the workforce. Second, we did not assess the COVID-19 pandemic impact on neurosurgical patients on waiting lists for elective or semi-elective procedures, which could improve further strategic planning for optimal patient care. Lastly, our cohort is not representative of patients with COVID-19. Further studies are needed to address these issues.

This study evaluated the longitudinal effect of COVID-19 pandemic on neurosurgery practice.

The number of neurosurgical procedures per week decreased in the early pandemic period and then plateaued. Although our health care system was not significantly affected, the pandemic impact on the neurosurgical practice is apparent. The load of emergency neurosurgery procedures remained unchanged throughout the three periods while that of unurgent elective cases significantly declined. This reflects the need to designate ample resources to cater for emergencies. Our findings could contribute toward developing a long-term strategy for surgical services during pandemics. We recommend to restart performing neurosurgical procedures once the pandemic gets stabilized to avoid a possible post-pandemic intolerable overload on the healthcare system. The asterisks indicate a significant reduction in the number of cases between the three periods.

J o u r n a l P r e -p r o o f 

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SD: standard deviation

The authors extend their appreciation to the Deanship of Scientific Research at King Saud University, Riyadh, Saudi Arabia for funding this work through Researchers Supporting Project

 Figure 3 : Case distribution according to priority during the three periodsThe asterisks indicate a significant reduction in the number of cases between the three periods.