key: cord-0948738-mfie3gdy
authors: Wilson, Lauren A.; Zhong, Haoyan; Poeran, Jashvant; Liu, Jiabin; Memtsoudis, Stavros G.
title: Recommendations for resuming elective spine surgery in the COVID-19 era
date: 2020-06-26
journal: Br J Anaesth
DOI: 10.1016/j.bja.2020.06.022
sha: 87dbf477308fa0729529e55962748fdac83caff7
doc_id: 948738
cord_uid: mfie3gdy

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We therefore sought to determine which spine procedures and surgical approaches are the least resource-intensive and which patient populations are the least likely to require these resources. This information could guide selection of procedures that might be considered earlier in a "return-to-normal" plan. We evaluated ICU admission, use of mechanical ventilation, and blood transfusion in the context of elective spinal fusions, stratified by location, surgical approach, and number of levels fused.

After Institutional Review Board approval (IRB#2016-436) we conducted a retrospective analysis of patients who underwent elective inpatient spinal fusion surgery captured in the Premier Healthcare database (2006-2016; add URL, location, source). Surgeries were classified by level of the spine (cervical, thoracolumbar, or lumbar), surgical approach (anterior, posterior, or combined), and number of vertebrae fused (2-3 or 4+) . For each distinct category we identified frequency of ICU admission, length of ICU and hospital stay, use and length of ventilation (≥96 h or <96 h), and blood transfusion on or after the day of surgery. Separate multivariable logistic regression models were run for the three outcomes of ICU admission, any form of ventilation, and blood transfusion. Models were adjusted for patient age and comorbidity burden as measured by Charlson-Deyo index 4 . Odds ratios (OR) and 95% confidence intervals (CI) were reported. Analyses were performed with SAS version 9.4 (SAS Institute, Cary, NC, USA).

Thoracolumbar fusions had the greatest resource utilization with over half of patients requiring a postoperative ICU stay, which on average lasted > 2 days. Thoracolumbar fusions with a combined anterior and posterior approach were particularly resource intensive, with 19.8% of patients requiring ventilation and 56.8% requiring blood transfusion. Anterior cervical discectomy and fusions were the least resource intensive with only 6.8% of patients admitted to the ICU postoperatively, 1% requiring ventilation, and < 1% requiring blood transfusion. This was followed closely by anterior or posterior lumbar fusions, which had relatively low resource utilization compared to other procedures. Regardless of surgical approach, higher level fusions were more resource intensive with more patients requiring ICU admission, ventilation, or blood transfusion relative to lower level fusions (Table 1) . Across almost all surgical cohorts, older age and greater comorbidity burden were associated with significantly increased odds of ICU admission, any form of ventilation, and blood transfusion (Supplementary Figure 1) .

While representing the smallest cohort, thoracolumbar fusion procedures had the highest ICU, ventilation, and blood transfusion utilization of all elective spine surgeries. Anterior cervical discectomy and fusions as well as anterior or posterior lumbar fusions were the least resource intensive procedures, with relatively low rates of ICU admission, ventilation, or blood transfusions. Across all sections of the spine and surgical approaches, a higher number of levels fused was associated with high resource utilization.

Based on these findings, elective thoracolumbar and/or high level fusions should be greatly limited if not avoided entirely while concerns regarding recurrent COVID-19 outbreaks persist requiring a renewed need for critical care and other resources. The frequency with which these procedures are performed should also be considered. While highly resource intensive, thoracolumbar fusions are less common compared to cervical or lumbar fusions. Therefore additional factors should be taken into account when scheduling more common yet less resource intensive procedures such as anterior cervical discectomy and fusions or anterior or posterior lumbar fusions. In almost all surgical cohorts, older patients with a high comorbidity burden were more likely to require ICU admission, ventilation, and/or blood transfusion. Therefore, for all spinal fusion procedures, surgeries should be limited or at least prioritized to younger, healthier patients.

There are obvious ethical considerations in delaying elective spine surgery given that these procedures are commonly performed in order to relieve pain. While thoracolumbar multilevel fusions may utilize the most resources, decision-making should not be based solely on cost but also on what benefits are derived with that cost. Potential benefits for the patient must be weighed against potential shortages of resources or resource needs. Patient suffering from worsening pain and discomfort due to postponing surgery must be taken into account in each assessment; here, resource-intensive procedures should be scheduled further apart to maximise hospital capacity and resource availability.

Limitations of this study include its retrospective nature, but given that we evaluated 11 years of data, it is likely that these patterns persist today. Additionally this study does not include urgent and emergent cases, which many spine surgeries are categorized as given concern for neurologic involvement.

In conclusion, when resuming elective spine surgeries thoracolumbar and higher level fusions should be limited if possible in favor of lower level fusions of the cervical or lumbar spine. In addition, restricting these procedures to younger patients with fewer comorbidities could aid in further reducing resource utilization.

Authors' contributions LAW: study design/planning, data analysis, interpretation of results, manuscript preparation and review. HZ, JL: study design/planning, interpretation of results, and manuscript review. JL: study design/planning, interpretation of results, and manuscript review. JP, SGM: study design/planning, interpretation of results, manuscript preparation and review.

SGM is a director on the boards of the American Society of Regional Anesthesia and Pain Medicine (ASRA) and the Society of Anesthesia and Sleep Medicine (SASM). He is a one-time consultant for Sandoz Inc. and Teikoku and is currently on the medical advisory board of HATH. He has a pending US Patent application for a Multicatheter Infusion System. US-2017-0361063. He is the owner of SGM Consulting, LLC and co-owner of FC Monmouth, LLC. None of the above relations influenced the conduct of the present study. All other authors declare no conflicts of interest. ventilators to treat all non-elective patients given the possibility of a second wave of COVID-19

patients. 1 Spine fusion surgeries are among the more resource intensive elective procedures, 2 however but delaying spine surgery can result in prolonged or worsening pain and discomfort.

Thus it is important for policymakers to consider average resource utilization rates following common elective spine surgeries when strategizing their "return-to-normal" operations.

Increasing patient access to care while maintaining the availability of ICU beds and ventilators is not the only concern institutions face. As a consequence of social distancing and stay-at-home orders, there has been a major reduction in blood donations. 3 Given that certain spine surgeries are associated with high blood loss and need for transfusion, maintaining institutional blood supply is an additional concern.

We therefore sought to determine which spine procedures and surgical approaches are the least resource resource-intensive and which patient populations are the least likely to require these resources. This information may could guide the selection of procedures that might be considered earlier in a "return-to-normal" plan. To do so wWe evaluated ICU admission, and 1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59 For each distinct category we identified frequency of ICU admission, length of ICU and hospital stay, use and length of ventilation (≥96 hours or <96 hours), and blood transfusion on or after the day of surgery. Separate multivariable logistic regression models were run for the three outcomes of ICU admission, any form of ventilation, and blood transfusion. Models were adjusted for patient age and comorbidity burden as measured by Charlson-Deyo index 4 . Odds ratios (OR) and 95% confidence intervals (CI) were reported. Analyses were performed with SAS version 9.4 (SAS Institute, Cary, NC, USA).

Thoracolumbar fusions had the greatest resource utilization with over half of patients requiring a postoperative ICU stay, which on average lasted at least> 2 days. Thoracolumbar fusions with a combined anterior and posterior approach were particularly resource intensive, with 19.8% of patients requiring ventilation and 56.8% requiring a blood transfusion.

Anterior cervical discectomy and fusions were the least resource intensive with only 6.8% of patients admitted to the ICU postoperatively, 1% requiring ventilation, and less than< 1% requiring a blood transfusion. This was followed closely by anterior or posterior lumbar fusions, which had relatively low resource utilization compared to other procedures.

Regardless of surgical approach, higher level fusions were more resource intensive with more patients requiring ICU admission, ventilation, and or blood transfusion relative to lower level fusions (Table 1) .

Across almost all surgical cohorts, older age and greater comorbidity burden were associated with significantly increased odds of ICU admission, any form of ventilation, and blood transfusion (Supplementary Figure 1) .

British Journal of Anaesthesia Therefore additional factors should be taken into account when scheduling more common yet less resource intensive procedures such as anterior cervical discectomy and fusions or anterior or posterior lumbar fusions. In almost all surgical cohorts, older patients with a high comorbidity burden were more likely to require ICU admission, ventilation, and/or blood transfusion.

Therefore, for all spinal fusion procedures, surgeries should be limited or at least prioritized among to younger, healthier patients.

There are obvious ethical considerations in delaying elective spine surgery given that these procedures are commonly performed in order to relieve pain and/or discomfort. While thoracolumbar multilevel fusions may utilize the most resources, this is only half of the equation.

Ddecision-making should not be based solely on the 'cost' but also on what is boughtbenefits are derived with that cost. Potential benefits from for the patient perspective must be weighed against potential shortages of (critical care) resources or resource needs. Patients' suffering from 1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  P  e  e  r  R  e  v  i  e  w   5 worsening pain and discomfort due to postponing surgery must be taken into account in each assessment; here, resource-intensive procedures should be scheduled further apart to maximize maximise hospital capacity and resource availability.

Limitations of this study include its retrospective nature, but given that we evaluated 11 years of data, it is likely that these patterns persist today. Additionally this study does not include urgent and emergent cases, which many spine surgeries can be are categorized as, given concern for neurologic involvement. R  e  v  i  e  w  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59 1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  P  e  e  r  R  e  v  i  e  w  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60 F o r P e e r R e v i e w 

Association of periOperative Registered Nurses, American Hospital Association. Joint Statement: Roadmap for Resuming Elective Surgery after COVID-19 Pandemic. 2020

Return to normal-prioritizing elective surgeries with low resource utilization

Blood transfusion during the COVID-19 outbreak

Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases

Association of periOperative Registered Nurses, American Hospital Association. Joint Statement: Roadmap for Resuming Elective Surgery after COVID-19 Pandemic. 2020

Return to normal-prioritizing elective surgeries with low resource utilization

Blood transfusion during the COVID-19 outbreak

Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases

None.

Stavros G. Memtsoudis is a director on the boards of the American Society of Regional Anesthesia and Pain Medicine (ASRA) and the Society of Anesthesia and Sleep Medicine (SASM). He is a one-time consultant for Sandoz Inc. and Teikoku and is currently on the medical advisory board of HATH. He has a pending US Patent application for a Multicatheter Infusion System. US-2017-0361063. He is the owner of SGM Consulting, LLC and co-owner of FC Monmouth, LLC. None of the above relations influenced the conduct of the present study. All other authors declare no conflicts of interest.

This study was funded internally by the Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY

Authors' contributions LAW: study design/planning, data analysis, interpretation of results, manuscript preparation and review. HZ, JL: study design/planning, interpretation of results, and manuscript review. JL: study design/planning, interpretation of results, and manuscript review. JP, SGM: study design/planning, interpretation of results, manuscript preparation and review.

SGM is a director on the boards of the American Society of Regional Anesthesia and Pain Medicine (ASRA) and the Society of Anesthesia and Sleep Medicine (SASM). He is a one-time consultant for Sandoz Inc. and Teikoku and is currently on the medical advisory board of HATH. He has a pending US Patent application for a Multicatheter Infusion System. US-2017-0361063. He is the owner of SGM Consulting, LLC and co-owner of FC Monmouth, LLC. None of the above relations influenced the conduct of the present study. All other authors declare no conflicts of interest.