COVID-19 and Spine Surgery

As we’ve all learned these past years, COVID-19, caused by the SARS-COV-2 virus, can lead to a highly variable spectrum of disease, ranging from mild respiratory illness to severe pneumonia, respiratory failure, and death. The symptoms in most patients are mild and include fever, cough, and fatigue. Other less common symptoms include sputum production, headache, and diarrhea.

About 80% of patients develop mild to moderate disease, 14% have severe disease with shortness of breath, and 6% may develop a hyperinflammatory response, septic shock, or acute respiratory distress syndrome (ARDS), which may require mechanical intervention or extracorporeal membrane oxygenation.

Risk Factors

The median age of COVID-19 patients who develop symptoms is 47 years, and most cases occur in patients aged between 30 and 79 years. About 58% of cases occur in males, and less than half of the patients have underlying chronic medical conditions.

Patients who are 80 years and older have a higher mortality rate of approximately 15%, and the overall mortality rate is 2.3%. The mortality rate is also higher in patients with comorbidities such as cardiovascular disease, diabetes, pulmonary disorders, and cancer. Epidemiological data on COVID-19 is continually being analyzed and published.

Diagnosis

To diagnose COVID-19, healthcare providers obtain the patient’s epidemiological history, clinical symptoms, lab results, and diagnostic imaging, as necessary. Reverse transcription-polymerase chain reaction (RT-PCR) and real-time RT-PCR are currently used to detect the SARS-COV-2 virus in respiratory samples.

But false negatives can occur due to various factors such as sample quality, sampling technique, and viral load. Serology antibody testing is also being developed for diagnosis and to assess prior exposure and immunity, but is not yet widely available.

Treatment

Currently, there are no approved treatments for COVID-19, and management focuses on early detection, isolation, and treatment of viral symptoms. However, there are 282 studies registered at clinicaltrials.gov investigating the efficacy and safety of various medications and vaccines for COVID-19. Off-label and compassionate use therapies have been reported using medications such as remdesivir, ribavirin, favipiravir, lopinavir-ritonavir, chloroquine, hydroxychloroquine, azithromycin, steroids, and convalescent plasma.

Several drugs, such as hydroxychloroquine, chloroquine, remdesivir, ribavirin, favipiravir, lopinavir-ritonavir, azithromycin, steroids, and convalescent plasma, have been used in compassionate use therapies or off-label for COVID-19 treatment. However, there is no approved treatment to date, and clinical trials are investigating the efficacy and safety of these medications.

Studies on hydroxychloroquine and chloroquine have shown mixed results with some indicating a potential benefit, while others demonstrated no clinical benefit. The main limitations of most studies are small sample sizes, lack of randomization, and the absence of a control group, which prevents these medications from being widely recommended.

Amidst the current pandemic, doctors at Complete Orthopedics are responsible for treating patients with spinal issues in a safe and efficient manner while conserving healthcare resources. This is especially important as many of these patients may be at a higher risk of developing severe COVID-19 due to age and underlying medical conditions.

Spine Surgery During the Pandemic

Various medical organizations have released guidelines to help healthcare professionals prioritize patients with spinal conditions that require immediate or urgent surgery over those who can wait for several months. The aim is to reduce the consumption of healthcare resources.

However, there is still a lack of agreement on how to identify and triage patients in this area. Triage for spine surgery presents distinctive difficulties, and the severity of cases may surpass that of numerous other surgical fields.

It is important not to postpone cases involving progressive or severe neurologic deficits resulting from neurologic compression due to any cause, spinal instability that may lead to neurologic injury, epidural abscesses accompanied by neurologic deficits, and postoperative wound infections.

If local healthcare guidelines permit and there are sufficient healthcare resources to safely perform the procedure, cases involving myelopathy that has progressed recently, spinal infections that are unresponsive to medical treatment, persistent neurologic deficits that are not severe, and spinal conditions that result in intractable pain or functional limitations that restrict activities of daily living and self-care should be addressed.

It is advisable to delay addressing spinal conditions that can be adequately managed without surgery, and where pain and dysfunction can be reasonably controlled through non-operative means.

It is highly recommended to test all patients for COVID-19 before urgent or emergent spine surgery. This is because patients can be asymptomatic. In cases where testing is not possible or delaying surgery is not an option, it should be assumed that the patient has COVID-19, and appropriate precautions should be taken during the surgical procedure.

Operating Room Setup

When operating on patients with COVID-19, specialized operating rooms will be available. ORs will be converted to negative pressure rooms to minimize the outflow of contaminated air. In situations where this is not possible, measures such as covering all instruments, stocking sufficient equipment and supplies, and using disposable equipment will be implemented to minimize operating room traffic.

In order to reduce the risk of viral transmission during surgery, our doctors will consider using minimally invasive techniques, positioning the patient in a prone position, and avoiding bodily fluid splatter. Additionally, the use of a smoke evacuator will be considered to minimize electrocautery smoke in the operating room.

Intubation and Extubation

Transmission of SARS-CoV-2 can occur through direct contact with respiratory droplets or indirectly through exposure to aerosolized viral particles or contaminated surfaces. Intubation and extubation are considered the most risky aspects of spine surgery for these reasons. Performing intubation in a negative pressure room will be considered whenever it is feasible.

During the intubation procedure, all nonessential staff will leave the room. The use of video laryngoscopy may be considered as an alternative to direct laryngoscopy to maintain a safe distance between our doctors and the patient. Our staff will wait for 15 to 30 minutes after intubation and extubation before reentering the OR.

Postoperative Recovery

Adequate sedation and muscle relaxation will be provided to the patient after the surgery to prevent coughing or movement during transfer, and they should be transported through dedicated routes and elevators.

Call/Inpatient Management

During a pandemic, spinal injuries are expected to occur less frequently due to quarantine and government orders for people to stay at home. However, regular spinal conditions such as trauma will still occur.

That’s why our doctors at Complete Orthopedic will still be on call, promptly assessing patients in the emergency department, and providing care for hospitalized individuals. Our team has specific roles including managing inpatients, performing surgeries, providing on-call evaluations, or overseeing outpatient settings.

Telemedicine offers a way to reduce the risk of exposure for healthcare providers and enable patients to adhere to public health guidelines by staying at home during the pandemic.

Patients who need to be examined in person should undergo screening procedures to detect any symptoms related to COVID-19, or the likelihood of having such symptoms, that would require additional testing.

COVID-19 pandemic is unparalleled in contemporary times. As healthcare providers, and advocates for public health, our surgeons at Complete Orthopedics have a vital responsibility to fulfill. Properly categorizing patients who require urgent or emergent surgery versus those whose surgical needs can be safely postponed will aid in conserving healthcare resources that can be redirected towards treating COVID-19 patients.

Reducing the risk of healthcare worker infections can be achieved by enhancing safety measures for healthcare providers in both the inpatient setting and operating room. Finally, utilizing telemedicine to the fullest extent possible in the outpatient setting can aid in public health efforts aimed at reducing the spread of the virus through community transmission.

If you are interested in knowing more about Covid-19 and Spine Surgery you have come to the right place!