In the Extraordinary Times of Coronavirus Disease 2019: Clinical Strategies for Performing Spinal Surgery

Abstract

<p>The coronavirus disease 2019 (COVID-19) pandemic has caused pronounced strain on global healthcare systems, forcing the streamlining of clinical activities and conservation of health resources. There is a pressing need for institutions to present discipline-specific strategies for the management of COVID-19 patients. We present the comprehensive considerations at the National University Hospital, Singapore from the surgeon’s and anesthetist’s perspectives in the performance of spinal surgery in COVID-19 patients. These are based on national guidelines and overarching principles of protection for the healthcare workers (HCWs) and efficiency in surgical planning. The workflow begins with the emergency department screening that has been adapted to the local epidemiology of COVID-19 in order to identify suspected/confirmed cases. If patient history cannot be obtained, demographic, clinical, and imaging data are used. Designated orthopedic “contaminated teams” are available 24/7 with an activation time of <30 minutes for review. In cases where sub-specialty spine surgeons were required, these professionals were inducted into the “contaminated team” and quarantined until cleared to return to work. Indications for emergency spine surgery were determined pre-emptively. Preoperative surgical considerations included the minimization of manpower, limited dissection, reduced operative time, and judicious use of equipment, leading to reduced aerosolization. Anesthesia considerations include preoperative screening for COVID-19–related concerns that influence surgery, operating room process planning and induction, intraoperative, reversal, recovery, and resuscitation considerations. Focused multi-disciplinary preoperative briefing facilitates familiarization. Surgical, anesthetic, and postoperative workflows were designed to reduce the risk of transmission and protect HCWs while effectively performing spinal surgery. The COVID-19 pandemic has necessitated paradigm shifts in healthcare planning, hospital workflows, and operative protocols. The viral burden does not discriminate between surgeons and physicians, and it is crucial that we, as medical professionals, adapt practices to be malleable and fluid to address the ever-changing developments.</p>

Orthopaedic operating room considerations in covid-19 pandemic: A systematic review

“…Recommended air changes per hour in OR ventilation is variable in different articles. Barry TWL et al 7 recommend 6-12 air change per hour for aerosol generating procedures; Geevarughese NM and Ul-Haq R 11 recommend minimum 12 air changes per hour, whereas Sadigale O et al 16 recommend minimum 20 air changes per hour in arthroplasty surgeries.…”

“…Seven articles 5 , 6 , 7 , 8 , 13 , 19 , 20 mention and recommend about having separate designated OR for COVID positive or suspected patients. Hospitals should also designate separate specific corridors/ walkways for transfer of COVID positive or suspected patients to OR 10 .…”

“…Twelve out of 16 articles recommend that minimum number of staff members should be kept inside the OR for any surgical procedure 5 , 6 , 7 , 10 , 11 , 13 , 14 , 15 , 16 , 18 , 19 , 20 , 25 . Less number of staff will facilitate the implementation of social distancing and also reduce the PPE demand 18 .…”

“…Less number of staff will facilitate the implementation of social distancing and also reduce the PPE demand 18 . It is advised that experienced surgeon with highest skill should perform the procedure to avoid prolonged surgical duration and hence exposure time 5 , 7 , 13 , 14 , 16 , 18 . Sadigale O et al 16 recommend maximum of 8 persons in surgical team with carefully selected personnel based on their experience and familiarity to the procedure.…”

“…Verma V et al 18 utilized a surgical team including chief surgeon, senior resident, junior resident, and scrub nurse. Barry TWL et al 7 utilized minimal personnel in spine surgeries which consisted of the spine surgeon, a resident, one scrub nurse, and one circulating nurse. It is advised to do daily screening and close monitoring of peri-operative teams with temperature assessment to identify early disease 17 .…”