Medical care for spinal diseases during the COVID-19 pandemic

Coronavirus disease (COVID-19), caused by the novel coronavirus (SARS-CoV-2), reached pandemic levels in March 2020, and has the potential to overburden health systems, compromise medical staff, and deplete essential hospital supplies. To minimize these adverse consequences and guarantee adequate treatment for patients with other conditions, it is necessary to develop balanced strategies (11. Coccolini F, Perrone G, Chiarugi M, Di Marzo F, Ansaloni L, Scandroglio I, et al. Surgery in COVID-19 patients: operational directives. World J Emerg Surg. 2020;15(1):25. https://doi.org/10.1186/s13017-020-00307-2.
https://doi.org/10.1186/s13017-020-00307...
). Healthcare professionals must be prepared for abrupt changes in the availability of hospital beds and human and material resources during this period, and must be aware that hospitals can become locations of elevated transmission of the disease (22. Brindle M, Gawande A. Managing COVID-19 in Surgical Systems. Ann Surg. 2020. https://doi.org/10.1097/SLA.0000000000003923.
https://doi.org/10.1097/SLA.000000000000...
).

Outpatient care should be restricted and performed only in cases of great need. The Brazilian Ministry of Health has temporarily authorized and regulated telemedicine activity in the country during the pandemic period. This decision may reduce the circulation of people and must be considered by doctors and health care services to preserve the health of patients and avoid overcrowding in health units (33. Ministério da Saúde (BR). Portaria n° 467, March 20, 2020. Dispõe, em caráter excepcional e temporário, sobre as ações de Telemedicina, com o objetivo de regulamentar e operacionalizar as medidas de enfrentamento da emergência de saúde pública de importância internacional previstas no art. 3° da Lei n° 13.979, February 6th, 2020, decorrente da epidemia de COVID-19. Diário Oficial União 23/03/2020 | Edição: 56-B | Seção: 1.).

Elective surgeries should be considered on a case-by-case basis, and postponed if possible. This action reduces unnecessary foot traffic in hospitals, reduces the spread of the disease, conserves hospital supplies, and preserves the health of surgical teams (22. Brindle M, Gawande A. Managing COVID-19 in Surgical Systems. Ann Surg. 2020. https://doi.org/10.1097/SLA.0000000000003923.
https://doi.org/10.1097/SLA.000000000000...
). Nevertheless, it is essential that health services develop strategies for performing urgent and emergency surgeries during the crisis period.

To guide specialists involved in the treatment of spinal disorders, this editorial summarizes the recommendations of the North American Spine Society (44. North American Spine Society. NASS Guidance Document on Elective, Emergent and Urgent Procedures. Available from: https://www.spine.org/Portals/0/assets/downloads/Publications/NASSInsider/NASSGuidanceDocument040320.pdf. Published April 3, 2020. Accessed April 10, 2020.
https://www.spine.org/Portals/0/assets/d...
), the American College of Surgeons (55. American College of Surgeons. ACS recommendations for management of elective surgical procedures. Available from: https://www.facs.org/covid-19/clinical-guidance/elective-surgery. Published March 13th, 2020. Accessed April 8th, 2020.
https://www.facs.org/covid-19/clinical-g...
), and the document signed by the Brazilian Spine Society, the Brazilian Society of Neurosurgery, and the Brazilian Society of Orthopedics and Traumatology (66. Sociedade Brasileira de Coluna, Sociedade Brasileira de Neurocirurgia, Sociedade Brasileira de Ortopedia e Traumatologia. Documento conjunto SBC, SBN, SBOT referente a prioridades terapêuticas em cirurgia de coluna durante o período de crise relacionado a COVID-19. Available from: http://portalsbc.org/documento-conjunto-sbc-sbn-sbot-referente-a-prioridades-terapeuticas-em-cirurgia-de-coluna-durante-o-periodo-de-crise-relacionado-ao-covid-19/. Published March 29th, 2020. Accessed April 10th, 2020.
http://portalsbc.org/documento-conjunto-...
) (Table 1).

Table 1
Spine surgery recommendations during the COVID-19 pandemic.

The characteristics of the COVID-19 pandemic are dynamic and distinct between regions and even between hospitals, therefore, therapeutic decisions must be individualized, and discussed with patients. The clinical condition of the patient and the availability of medical staff, personal protective equipment (PPE), and intensive care unit beds should be considered. Surgeons must also assess the risk of transmission of the virus in each region and in specific intrahospital sectors (44. North American Spine Society. NASS Guidance Document on Elective, Emergent and Urgent Procedures. Available from: https://www.spine.org/Portals/0/assets/downloads/Publications/NASSInsider/NASSGuidanceDocument040320.pdf. Published April 3, 2020. Accessed April 10, 2020.
https://www.spine.org/Portals/0/assets/d...
).

General considerations for surgical assistance during the COVID-19 pandemic

It is essential that professionals who provide medical assistance during the pandemic receive adequate training to avoid the infection of patients, companions, and the medical team itself. Strategies for reducing the length of hospital stays and limiting the number of visitors should be encouraged, as well as the isolation of patients with COVID-19 in inpatient units and in operating rooms (ORs) (22. Brindle M, Gawande A. Managing COVID-19 in Surgical Systems. Ann Surg. 2020. https://doi.org/10.1097/SLA.0000000000003923.
https://doi.org/10.1097/SLA.000000000000...
). Handwashing and hand hygiene with alcohol-based solutions should be encouraged whenever necessary, and the use of disposable resources should be prioritized (11. Coccolini F, Perrone G, Chiarugi M, Di Marzo F, Ansaloni L, Scandroglio I, et al. Surgery in COVID-19 patients: operational directives. World J Emerg Surg. 2020;15(1):25. https://doi.org/10.1186/s13017-020-00307-2.
https://doi.org/10.1186/s13017-020-00307...
).

Health care professionals should constantly assess for respiratory symptoms, and patients with suspected or confirmed COVID-19 should be identified. Such patients must receive appropriate clinical evaluation to analyze the risks and benefits of the procedure and the most appropriate time to perform it (22. Brindle M, Gawande A. Managing COVID-19 in Surgical Systems. Ann Surg. 2020. https://doi.org/10.1097/SLA.0000000000003923.
https://doi.org/10.1097/SLA.000000000000...
). Lei et al. suggest that surgical procedures in patients infected with SARS-CoV-2, even if they are asymptomatic, are implicated in the development of more severe forms of the disease and a higher mortality rate (77. Lei S, Jiang F, Su W, Chen C, Chen J, Mei W, et al. Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection. EClinicalMedicine. 2020. https://doi.org/10.1016/j.eclinm.2020.100331.
https://doi.org/10.1016/j.eclinm.2020.10...
).

The following are recommended for surgical procedures with patients who are suspected or confirmed cases of COVID-19: minimally invasive procedures with shorter operation times, careful and proper anesthetic planning to accelerate intubation and reduce manual ventilation, preference for the prone position to prevent droplet spread, minimization of the use and power of electrocautery, and avoidance of contamination of people and external materials with body fluids (11. Coccolini F, Perrone G, Chiarugi M, Di Marzo F, Ansaloni L, Scandroglio I, et al. Surgery in COVID-19 patients: operational directives. World J Emerg Surg. 2020;15(1):25. https://doi.org/10.1186/s13017-020-00307-2.
https://doi.org/10.1186/s13017-020-00307...
,88. Zou J, Yu H, Song D, Niu J, Yang H. Advice on Standardized Diagnosis and Treatment for Spinal Diseases during the Coronavirus Disease 2019 Pandemic. Asian Spine J. 2020;14(2):258-63. https://doi.org/10.31616/asj.2020.0122.
https://doi.org/10.31616/asj.2020.0122...
).

Regarding the OR, the number of professionals involved in the surgical procedure and the circulation of people should be limited as much as possible. Ideally, everyone in the OR should use the following types of PPE: masks (n95/PFF2), long sleeve disposable coats, protective goggles or face shields, disposable caps, shoe covers, and disposable double pairs of gloves. Special attention must be given to donning and doffing procedures, as proper procedures are often neglected (11. Coccolini F, Perrone G, Chiarugi M, Di Marzo F, Ansaloni L, Scandroglio I, et al. Surgery in COVID-19 patients: operational directives. World J Emerg Surg. 2020;15(1):25. https://doi.org/10.1186/s13017-020-00307-2.
https://doi.org/10.1186/s13017-020-00307...
,88. Zou J, Yu H, Song D, Niu J, Yang H. Advice on Standardized Diagnosis and Treatment for Spinal Diseases during the Coronavirus Disease 2019 Pandemic. Asian Spine J. 2020;14(2):258-63. https://doi.org/10.31616/asj.2020.0122.
https://doi.org/10.31616/asj.2020.0122...
).

Efforts must be made to reduce contact and proximity between patients and health professionals. Strategies to accomplish this include anesthetic recovery in the OR, short and planned intrahospital routes, restrictions on the number of professionals responsible for the internal transport of patients, and the avoidance of transfers between different hospital sectors. The use of disposable masks by patients is recommended during each of these steps (11. Coccolini F, Perrone G, Chiarugi M, Di Marzo F, Ansaloni L, Scandroglio I, et al. Surgery in COVID-19 patients: operational directives. World J Emerg Surg. 2020;15(1):25. https://doi.org/10.1186/s13017-020-00307-2.
https://doi.org/10.1186/s13017-020-00307...
,99. Forrester JD, Nassar AK, Maggio PM, Hawn MT. Precautions for Operating Room Team Members During the COVID-19 Pandemic. J Am Coll Surg. 2020. pii: S1072-7515(20)30303-3. https://doi.org/10.1016/j.jamcollsurg.2020.03.030.
https://doi.org/10.1016/j.jamcollsurg.20...
).

Strict techniques for the proper disposal of contaminated materials, the sanitization of ORs and surgical materials, and the maintenance of adequate ventilation systems must also be developed in cooperation with the internal hospital infection commission and clinical engineers (11. Coccolini F, Perrone G, Chiarugi M, Di Marzo F, Ansaloni L, Scandroglio I, et al. Surgery in COVID-19 patients: operational directives. World J Emerg Surg. 2020;15(1):25. https://doi.org/10.1186/s13017-020-00307-2.
https://doi.org/10.1186/s13017-020-00307...
,22. Brindle M, Gawande A. Managing COVID-19 in Surgical Systems. Ann Surg. 2020. https://doi.org/10.1097/SLA.0000000000003923.
https://doi.org/10.1097/SLA.000000000000...
).

In summary, the COVID-19 pandemic is especially challenging due to the dual efforts to control the pandemic and simultaneously guarantee essential healthcare. The recommendations presented in this editorial may help spine surgeons to make decisions and should be analyzed carefully according to the evolution of the pandemic and the concerns of each region and hospital.

REFERENCES

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    » https://doi.org/10.1186/s13017-020-00307-2
  • 2
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    » https://doi.org/10.1097/SLA.0000000000003923
  • 3
    Ministério da Saúde (BR). Portaria n° 467, March 20, 2020. Dispõe, em caráter excepcional e temporário, sobre as ações de Telemedicina, com o objetivo de regulamentar e operacionalizar as medidas de enfrentamento da emergência de saúde pública de importância internacional previstas no art. 3° da Lei n° 13.979, February 6th, 2020, decorrente da epidemia de COVID-19. Diário Oficial União 23/03/2020 | Edição: 56-B | Seção: 1.
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    North American Spine Society. NASS Guidance Document on Elective, Emergent and Urgent Procedures. Available from: https://www.spine.org/Portals/0/assets/downloads/Publications/NASSInsider/NASSGuidanceDocument040320.pdf Published April 3, 2020. Accessed April 10, 2020.
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    American College of Surgeons. ACS recommendations for management of elective surgical procedures. Available from: https://www.facs.org/covid-19/clinical-guidance/elective-surgery Published March 13th, 2020. Accessed April 8th, 2020.
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    Sociedade Brasileira de Coluna, Sociedade Brasileira de Neurocirurgia, Sociedade Brasileira de Ortopedia e Traumatologia. Documento conjunto SBC, SBN, SBOT referente a prioridades terapêuticas em cirurgia de coluna durante o período de crise relacionado a COVID-19. Available from: http://portalsbc.org/documento-conjunto-sbc-sbn-sbot-referente-a-prioridades-terapeuticas-em-cirurgia-de-coluna-durante-o-periodo-de-crise-relacionado-ao-covid-19/ Published March 29th, 2020. Accessed April 10th, 2020.
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    Lei S, Jiang F, Su W, Chen C, Chen J, Mei W, et al. Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection. EClinicalMedicine. 2020. https://doi.org/10.1016/j.eclinm.2020.100331
    » https://doi.org/10.1016/j.eclinm.2020.100331
  • 8
    Zou J, Yu H, Song D, Niu J, Yang H. Advice on Standardized Diagnosis and Treatment for Spinal Diseases during the Coronavirus Disease 2019 Pandemic. Asian Spine J. 2020;14(2):258-63. https://doi.org/10.31616/asj.2020.0122
    » https://doi.org/10.31616/asj.2020.0122
  • 9
    Forrester JD, Nassar AK, Maggio PM, Hawn MT. Precautions for Operating Room Team Members During the COVID-19 Pandemic. J Am Coll Surg. 2020. pii: S1072-7515(20)30303-3. https://doi.org/10.1016/j.jamcollsurg.2020.03.030
    » https://doi.org/10.1016/j.jamcollsurg.2020.03.030

Publication Dates

  • Publication in this collection
    08 May 2020
  • Date of issue
    2020

History

  • Received
    23 Apr 2020
  • Accepted
    24 Apr 2020
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