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ORIGINAL ARTICLE - INFECTION
Neurosurgery and coronavirus: impact and challengeslessons
learnt from the first wave of a global pandemic
Keyoumars Ashkan
1,2
&Josephine Jung
1,2
&Alexandra Maria Velicu
1,2
&Ahmed Raslan
1
&Mohammed Faruque
1
&
Pandurang Kulkarni
1
&Cristina Bleil
1
&Harutomo Hasegawa
1
&Ahilan Kailaya-Vasan
1
&Eleni Maratos
1
&
Gordan Grahovac
1
&Francesco Vergani
1
&Bassel Zebian
1
&Sinan Barazi
1
&Irfan Malik
1
&David Bell
1
&Daniel Walsh
1
&
Ranjeev Bhangoo
1
&Christos Tolias
1
&Sanjeev Bassi
1
&Richard Selway
1
&Nick Thomas
1
&Christopher Chandler
1
&
Richard Gullan
1
Received: 22 September 2020 /Accepted: 12 November 2020
#The Author(s) 2020
Abstract
Introduction and objectives The novel severe acute respiratory syndrome coronavirus 2 (COVID-19) pandemic has had drastic
effects on global healthcare with the UK amongst the countries most severely impacted. The aim of this study was to examine how
COVID-19 challenged the neurosurgical delivery of care in a busy tertiary unit serving a socio-economically diverse population.
Methods A prospective single-centre cohort study including all patients referred to the acute neurosurgical service or the
subspecialty multidisciplinary teams (MDT) as well as all emergency and elective admissions during COVID-19 (18th
March 202015th May 2020) compared to pre-COVID-19 (18th of January 202017th March 2020). Data on demographics,
diagnosis, operation, and treatment recommendation/outcome were collected and analysed.
Results Overall, there was a reduction in neurosurgical emergency referrals by 33.6% and operations by 55.6% during the course
of COVID-19. There was a significant increase in the proportion of emergency operations performed during COVID-19 (75.2%
of total, n=155) when compared to pre-COVID-19 (n= 198, 43.7% of total, p< 0.00001). In contrast to other published series,
the 30-day perioperative mortality remained low (2.0%) with the majority of post-operative COVID-19-infected patients (n=13)
having underlying medical co-morbidities and/or suffering from post-operative complications.
Conclusion The capacity to safely treat patients requiring urgent or emergency neurosurgical care was maintained at all times. Strategies
adopted to enable this included proactively approaching the referrers to maintain lines of communications, incorporating modern
technology to run clinics and MDTs, restructuring patient pathways/facilities, and initiating the delivery of NHS care within private
sector hospitals. Through this multi-modal approach we were able to minimize service disruptions, the complications, and mortality.
Keywords Coronavirus .Emergency referrals .Neurosurgery .Pandemic
Introduction
Kings College Hospital NHS Foundation Trust (KCH), built
in 1840, is one of the largest teaching hospitals in the UK,
serving a local inner-city population of 700,000 in the London
districts of Southwark and Lambeth. The tertiary neurosurgi-
cal service is amongst the busiest in the country covering a
regional catchment population of approximately 4 million
across South East London and the county of Kent [13].
The local London boroughs have a multi-ethnic population
with a comparatively high proportion of Black people
(25.9%), compared to the whole London (10.9%). Amongst
the largest ethnic minority groups are Black African (16.1%)
and Black Caribbean (8.0%). Approximately half of the local
population identifies as White British (52.2%), much lower
than the national average. The socio-economic profile of the
local population shows the lowest level of employment
amongst all London districts [16,21].
This article is part of the Topical Collection on Infection
*Josephine Jung
Josephine.Jung@nhs.net
1
Department of Neurosurgery, Kings College Hospital, Denmark
Hill, London SE5 9RS, UK
2
Neurosciences Clinical Trials Unit, Kings College Hospital,
London, UK
Acta Neurochirurgica
https://doi.org/10.1007/s00701-020-04652-8
The novel severe acute respiratory syndrome coronavirus 2
(COVID-19) pandemic had a drastic effect on global
healthcare and Europe was at the epicentre of the pandemic
from March to May 2020. The UK had one of the highest
death tolls across Europe and London was the worst affected.
KCH had at its peak 517 inpatients with COVID-19 of which
96 were being cared for in the intensive treatment unit (ITU).
The GlobalSurg group recently published that surgical ser-
vices, both elective and emergency, were severely impacted
by COVID-19 and that there was an increased 30-day mortal-
ity of up to 23.8% in patients infected with COVID-19 [2].
The aim of the paper here was to examine specifically the
impact of the COVID-19 pandemic on the neurosurgical de-
livery of care in a busy unit serving a socio-economically
challenging population. We also examined the patient out-
comes as well as described the strategies adopted to allow safe
delivery of neurosurgical services.
Methods
Study design
On 18th March 2020, our unit entered the acute COVID-19
phase, demarcated by the day of the first pre-operatively
suspected COVID-19 infection in a neurosurgical patient,
and when neurosurgical rota and service changes were
adopted. The phase officially ended on 15th May (59 days
later) when our hospital, in line with the NHS directive, en-
tered the recovery phase. During the COVID-19 period, data
were collected prospectively on all patients referred to the
acute neurosurgical service, patients who were admitted elec-
tively, and patients referred to subspecialty multidisciplinary
teams (MDT). These data were then compared to those ob-
tained in the immediately preceding 59-day period (18th
January to 17th March), the pre-COVID-19,toassessthe
impact of the pandemic. The manuscript was written follow-
ing the Strengthening the Reporting of Observational Studies
in Epidemiology (STROBE) checklist [24].
Data collection and outcome measures
Data on the acute neurosurgical referrals were obtained
through an online Patient Care System (PCS) and data on
referrals to the MDTs were obtained from the relevant coor-
dinators. Emergency and elective operating lists were sourced
through the software Galaxy Operating Theatres.Electronic
patient records were accessed to capture the following: age,
gender, diagnosis, type of procedure (emergency vs. elective,
adult vs. paediatric, cranial vs. spinal), subspecialty (function-
al, neuro-oncology, trauma, neurovascular, skull base, spinal,
paediatric neurosurgery), COVID-19 infection (pre-operative-
ly vs. post-operatively), and post-operative complications. For
COVID-19-infected patients, data on ethnicity, co-morbid-
ities, perioperative complications, ITU/hospital stay, dis-
charge destination, and mortality were also included.
Additionally, referral data included type of referral (new vs.
follow-up), pathology, MDT outcome, and treatment delay/
recommendation.
Rota change, guidelines, and operating theatre
adjustments
Rota and service provision changes were put in place during
the pandemic on 18th of March 2020. Given the rapidly
evolving Public Health England [20], NHS England [15],
and the Society of British Neurological Surgeons guidelines
[22], a local KCH Neurosurgery working group was
established to actively review the evidence and synthesize a
Guidance [12] for adjustments to elective and emergency op-
erations, theatre ventilation, and use of personal protective
equipment (PPE).
KCH had its first two COVID-19-positive patients on 04th
of March 2020 (Fig. 1day 0) and reached its peak on the 8th
of April 2020 with 517 COVID-19-positive inpatients of
which 96 were in ITU. The first change to our neurosurgical
practice was put in place on 18th March 2020 where the rota
was revised from a subspecialty team-based system
(consisting of 12 neurosurgical trainees working for a specif-
ic consultant) to a twilight rota with 1 greenteam (no
COVID-19 patient contact), 1 redteam (COVID-19-posi-
tive/suspected patient contact), and 1 stand-by team in case
other team members fell ill and had to consequently self-iso-
late. Consultant and trainee rotas both switched to a 24-h shift
with one on-site consultant at all times and another on-call in
reserve.
The three daily elective operating lists were condensed into
one list per day from the 23rd of March 2020. Throughout the
pandemic, one emergency neurosurgical theatre remained ac-
tive. The allocation of theatre resources was undertaken by the
Executive board of the hospital. The neurosurgical lists were
arranged/triaged by the on-call neurosurgery consultant on the
day. Trust guidelines recommended that ventilation in both
laminar flow and conventionally ventilated theatres should
remain fully switched on during surgical procedures where
patients may have COVID-19 infection. All operations were
performed with full PPE, including either FFP3 mask (for
aerosol-generating procedures) or fluid-resistant mask (non-
aerosol-generating procedures), hat, visor, gloves and fluid-
resistant disposable gown. Staff training for proper donning
and doffing was mandatory.
Our inpatient neurosurgical service usually consists of one
purely elective 31-bedded ward, three wards for emergency
and additional elective neurosurgical patients (~ 5060 beds),
and one dedicated 12-bedded neurosurgery high dependency
unit (HDU). During COVID-19, out of these, one emergency
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admission ward and its adjacent HDU were closed to neuro-
surgery admissions to provide capacity for the hospitalsgen-
eral COVID-19 patients. The HDU was relocated to replace
one of the other neurosurgical wards with level 2 bed numbers
expanded to 32. The remaining two neurosurgical wards were
divided into dirty(COVID-19 positive) and clean(non-
COVID-19) wards (Fig. 2).
Nearly all face-to-face outpatient appointments were can-
celled and essential appointments were conducted via phone
consultations. The MDT referral process remained un-
changed; however, meetings took place virtually via
Microsoft® Teams (Redmond, USA) from 01st April 2020.
Statistical analysis
Descriptive statistics were used to characterize the patient
population. Statistical analysis was performed using
GraphPad Prism V7. Chi-squared test and the Mann-
Fig. 2 Flowchart describing admission pathway for patients requiring urgent
treatment during COVID-19. All neurosurgical patients were swabbed for
COVID-19 upon arrival at KCH. If urgent surgery was required, they were
taken to theatre and treated as COVID-19 positive until the test result was
available. If urgent surgery was not required, they were isolated in a side room
in a dedicated holding ward until the COVID-19 test result was available and
then either cared for in a COVID-19-positive ward or allocated to a COVID-
19-negative ward based on the results
Fig. 1 This graph describes the
number of patients admitted to
our hospital with COVID-19
infection. Overall number of
inpatients is depicted in black,
and the number of patients in
intensivecareisprovidedingrey.
Day 0 was the 04th of
March 2020
Acta Neurochir
Whitney Utest were used to assess the statistical significance
of observed differences between cohorts before and during the
COVID-19 pandemic.
Results
Emergency referrals during COVID-19
Pre-COVID-19, the median number of new acute referrals
was 31 (range 1745) per 24 h. During COVID-19, this de-
creased to 21 (range 1034) per day. There was a statistically
significant reduction in the overall number of referrals from
1847 to 1227 (Table 1;p<0.05).
Subspecialty emergency referrals changed to proportion-
ately fewer skull base and spinal referrals, but proportionately
increased trauma, vascular, oncology, and paediatric referrals
(Table 1;p< 0.01). Approximately 10% of patients referred as
an emergency pre-COVID-19 (n= 190) and during COVID-
19 (n= 119) were accepted for emergency transfer. There was
no change to the definition of what constituted an emergency
during or pre-COVID-19, namely being a condition that was
life or limb threatening within a matter of days if left untreat-
ed. There was no significant change in the proportion of pa-
tients with neurological deficit, GCS 8, or age > 65 years
being transferred to our neurosurgical centre (p>0.05).
In fact, there was no statistically significant difference in
age amongst patients that were admitted pre-COVID-19 (me-
dian age 53 (range 092) years) and during COVID-19 (me-
dian age 51 (range 089) years. There was however a change
in gender of patients admitted pre-COVID-19 and during
COVID-19 with proportionately more males being admitted
during COVID-19 (59.67% compared to 52.31% pre-
COVID-19, p< 0.05). This may potentially reflect the gener-
ally more health averse and risk-prone occupational and non-
occupational behaviour amongst men resulting in acute ad-
missions. The distribution of ethnic minority patients admitted
pre-COVID-19 (8.15% Black, 3.94% Asian, 0.41% Hispanic)
and during COVID-19 (9.54% Black, 3.54% Asian, 0.54%
Hispanic) remained stable, albeit in a higher proportion of
patients the ethnicity was not recorded during COVID-19
(24.73% pre-COVID-19, 36.24% during COVID-19), possi-
bly reflecting the limited availability of hospital administrative
support staff to record these during COVID-19.
Emergency and elective neurosurgical operations
performed before and during COVID-19
The total number of operations decreased from n= 453 (pre-
COVID-19) to n= 206 (Table 1;p< 0.0001) with the daily
median number of operations decreasing from 8 to 3. A higher
percentage of emergency operations was performed during
COVID-19 (75.2% of total, n= 155) compared to pre-
COVID-19 (n= 198, 43.7% of total, p< 0.00001). There
was no significant change in the proportion of cranial versus
spinal operations (Table 1). Overall, significantly fewer pa-
tients aged > 65 years underwent an operation during
COVID-19 (p< 0.01). The operations for adults and paediat-
rics per neurosurgical subspecialty changed significantly (p<
0.01) with subspecialties with a high proportion of elective
work, such as functional, skull base, and spinal neurosurgery,
being affected the most.
Tables 2and 3summarize the data on patients undergoing
neurosurgery in adult and paediatric cases, respectively. The
total number of adult operations performed dropped from n=
408 to n= 173 during COVID-19, with a significant amount
of functional and degenerative spinal neurosurgical work be-
ing deferred or cancelled (p<0.01;Table2). The number of
operations amongst the emergency subspecialties, such as
trauma and vascular neurosurgery, also decreased during
COVID-19 by approximately 50%; however, the case mix
remained similar. The most common traumatic pathologies
requiring emergency operation were chronic subdural hema-
toma (pre-COVID-19 n= 26, COVID-19 n=19),vertebral
fracture (pre-COVID-19 n= 11, COVID-19 n=5),andacute
subdural hematoma (pre-COVID-19 n= 9, COVID-19 n=3).
Although all the numbers decreased, the smallest drop in cases
was amongst surgeries for chronic subdural haematomas, pos-
sibly related to their relatively more chronic presentation.
Similarly, vascular operations decreased with fewer aneu-
rysms being clipped during COVID-19 (n=1)comparedto
pre-COVID-19 (n=9).
Within the neuro-oncology service, the overall number of
operations decreased from n=60(14.7%oftotal)ton=31
(17.9% of total) during COVID-19. Similarly, the number of
craniotomies for high-grade gliomas decreased from n=31
(7.6% of total) to n= 12 (6.9% of total) during the pandemic.
Our skull base service was severely affected during
COVID-19 with only 3 operations for pituitary adenoma/
apoplexy being performed during COVID-19 (1.7% of total)
from a previous number of 16 operations pre-COVID-19
(3.9% of total). No operations for trigeminal neuralgia, vestib-
ular schwannoma, or chiari malformation were performed
during COVID-19.
In functional neurosurgery, no new implantations for deep
brain stimulation (DBS), spinal cord stimulation, or occipital
nerve stimulation were performed. The battery change service
for patients with movement disorders, however, continued
albeit in the day case setting (DBS battery change n=5in
both periods). All spinal surgeries decreased during COVID-
19; however, notably, operations for cauda equina syndrome
(pre-COVID-19 n=26,COVID-19n= 14) and myelopathies
(pre-COVID-19 n=28,COVID-19n=8)werereducedby
50% during COVID-19, whereas operations within spinal on-
cology category remained stable (pre-COVID-19 n=14,
COVID-19 n=15).
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Neurovascular referral service
The total number of referrals to the vascular MDT decreased
from n=245ton= 161 during COVID-19 (p<0.05).The
total number of patients referred with an intracranial aneurysm
decreased from n= 185 (75.5% of total pre-COVID-19) to n=
132 (82.0% of total during COVID-19; Table 4). Within that
group, referred unruptured symptomatic aneurysms remained
approximately stable (~ 2.5 of total). The number of AVMs
referred decreased from n= 34 (13.9% of total pre-COVID-
19) to n= 8 (5.0% of total during COVID-19).
Sixteen patients underwent emergency treatment pre-
COVID-19, 6 of those underwent open surgery and 10
underwent endovascular treatment. During COVID-19, only
Table 1 Characteristics of
emergency referrals and
operations
Period Pre-COVID-19 COVID-19 pvalue
Emergency referrals, total (%) 1847 (100.0) 1227 (100.0) p<0.01
Trauma/vascular 956 (51.8) 656 (53.5)
Oncology 210 (11.4) 171 (13.9)
Skull base 36 (1.9) 12 (1.0)
Spinal 428 (23.2) 229 (18.7)
Paediatrics 75 (4.1) 59 (4.8)
Other* 141 (7.6) 100 (8.1)
Emergency transfer, total (%) 190 (100.0) 119 (100.0) p>0.05
Neurological deficit 92 (48.4) 55 (46.2)
GCS
a
8 12 (6.3) 10 (8.4)
Age > 65 years 42 (22.1) 21 (17.6)
Surgery, total (%) 453 (100.0) 206 (100.0)
Emergency 198 (43.7) 155 (75.2) p< 0.00001
Elective 255 (56.3) 51 (24.8)
Cranial 263 (58.1) 134 (65.0) ns
Spinal 190 (41.9) 72 (35.0)
Adult 408 (90.1) 173 (84.0) p<0.05
Paediatric 45 (9.9) 33 (16.0)
Age at operation (years) p>0.05
Mean ± SD 50 ± 21 47 ± 22
Range 092 086
Operative age groups (years) p<0.01
017 44 33
1865 292 178
>65 117 41
COVID-19 infection
Pre-operatively 0 4
Post-operatively (during inpatient stay) 7 6
Mortality, total (% of operations) 5 (1.1) 4 (2.0)
30-day perioperative (emergencies) 5 (2.5) 3 (1.9)
30-day perioperative (electives) 0 (0.0) 1 (2.2)
Operations per subspecialty (adult and paediatric) p<0.01
Trauma/vascular 75 (16.6) 44 (21.4)
Oncology 67 (14.8) 40 (19.4)
Skull base 37 (8.2) 8 (3.9)
Spinal 149 (32.9) 55 (26.7)
Functional 43 (9.5) 8 (3.9)
Other* 82 (18.1) 51 (24.8)
*Emergency referrals and operations for other reasons such as hydrocephalus and infection were excluded from
statistic calculation
a
Glasgow coma scale
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Table 2 Number and
composition of adult operations
performed by subspecialty
Adult Pre-COVID-19 COVID-19 pvalue
Number of operations in N(% of total) 408 (100.0) 173 (100.0)
Functional 37 (9.1) 8 (4.6) p<0.01
DBS
a
for Parkinsons disease/tremor 8 (2.0) 0 (0.0)
Intractable epilepsy/VNS
b
18 (4.4) 1 (0.6)
Peripheral nerve 3 (0.7) 1 (0.6)
Baclofen pump/other 2 (0.4) 1 (0.6)
DBS battery change 5 (2.7) 5 (2.9)
Spinal 145 (35.5) 51 (29.5) p<0.01
Myelopathy 28 ( 6.9) 8 (4.6)
Radiculopathy 73 (17.9) 13 (7.5)
Cauda equina syndrome 26 (6.4) 14 (8.1)
MSCC
d
and spinal tumour 14 (3.4) 15 (8.7)
Spinal haematoma and other 4 (1.0) 1 (0.6)
Trauma 50 (12.3) 31 (17.9) p>0.05
Acute subdural hematoma 9 (2.2) 3 (1.7)
Chronic subdural hematoma 26 (6.4) 19 (11.0)
Extradural hematoma 4 (1.0) 2 (1.2)
Traumatic brain injury/other 0 (0.0) 1 (0.6)
Traumatic vertebral fracture 11 (2.7) 5 (2.9)
Vascular 22 (5.4) 9 (5.2) p>0.05
Aneurysm 9 (2.2) 1 (0.6)
Intracranial haemorrhage 5 (1.2) 5 (2.9)
Ischemic stroke 1 (0.2) 1 (0.6)
Arteriovenous malformation 7 (1.7) 0 (0.0)
Arteriovenous fistula 1 (0.2) 2 (1.2)
Oncology 60 (14.7) 31 (17.9) p>0.05
Low-grade glioma 4 (1.0) 1 (0.6)
High-grade glioma 31 (7.6) 12 (6.9)
Cerebral metastasis 6 (1.5) 6 (3.5)
Meningioma 13 (3.2) 7 (4.0)
Other 6 (1.5) 5 (2.9)
Skull base 36 (8.8) 7 (4.0) p>0.05
Pituitary adenoma/apoplexy 16 (3.9) 3 (1.7)
Sphenoid wing meningioma 5 (1.2) 2 (1.2)
Vestibular schwannoma 6 (1.2) 0 (0.0)
Chiari malformation 5 (1.2) 0 (0.0)
Chondrosarcoma 2 (0.5) 0 (0.0)
Trigeminal neuralgia 1 (0.2) 0 (0.0)
Craniopharyngioma 1 (0.2) 2 (1.2)
Other 58 (14.2) 37 (21.4) p>0.05
Hydrocephalus 30 (7.4) 18 (10.4)
Primary infections 7 (1.7) 4 (2.3)
Secondary infections 15 (3.7) 11 (6.4)
Post-operative hematoma 2 (0.5) 0 (0.0)
CSF leak/pseudomeningocele 4 (1.0) 4 (2.3)
a
Deep brain stimulation
b
Vagal nerve stimulator
c
Metastatic spinal cord compression
d
Cerebrospinal fluid
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1 patient underwent emergency open surgery and 17 patients
underwent emergency endovascular treatment. All elective
surgery was halted during COVID-19 (Table 4).
Neuro-oncology and skull base referral service
The total number of referrals to the neuro-oncology MDT
decreased from n=443ton= 275 during COVID-19 (p<
0.05) with the median number of referrals per MDT dropping
from 53 ± 11.63 to 37 ± 9.58. There was no significant change
in the ratio of new to follow-up referrals during these periods.
Equally, there was no significant change in the treatment rec-
ommendation provided for patients with high-grade gliomas
(HGG), low-grade gliomas (LGG), and cerebral metastases
(CM) (p>0.05;Table5). However, there was a significant
treatment delay (surgery or adjuvant therapy), n= 4 patients
(0.9% of total) pre-COVID-19 versus n=32patients(11.6%
of total, p< 0.00001) during COVID-19, with patients with a
meningioma affected more severely (n=16overall)compared
to patients with gliomas or malignant tumours (n= 7 HGG, n
= 2 LGG, n= 3 CM). The most common reasons for treatment
delay were surgery delay due to COVID-19 because of re-
source limitations (n= 26), secondly unrelated reasons (n=
7), patient preference due to fear of infection (n= 2) and
chemotherapy delay due to COVID-19 (n=2).
Within the skull base service, the number of referrals was
significantly reduced from n=329ton= 101 during COVID-
19 (p< 0.001). Notably, the overall number of patients referred
for a pituitary adenoma reduced from n=80ton=31(p<
0.001). Out of those, n= 11 were referred with pituitary apo-
plexy pre-COVID-19 and n= 3 during COVID-19. There was
no statistically significant difference in treatment recommenda-
tion between patients referred pre-COVID-19 and during
COVID-19 for patients with vestibular schwannoma and pitu-
itary adenoma/apoplexy. However, in a higher proportion of
patients referred with a meningioma during COVID-19, active
treatments such as surgery or SRS, instead of monitoring were
recommended, possibly indicating that larger or more clinically
symptomatic lesions were being referred during the COVID-19
period (p< 0.05; Table 5). All meningioma cases, where spe-
cialist intervention was recommended, were located in the me-
dial sphenoid wing. Surgery was recommended to 3 patients
with pituitary adenomas during COVID-19: 1 had pituitary
apoplexy, 1 had progressively deteriorating vision, and in 1
patient, the pituitary mass had progressed over a short period
of time and turned out to be a metastasis. Surgical intervention
was deferred in n= 5 for sphenoid wing meningiomas, and n=
15 for pituitary adenoma.
Referrals to the spinal MDT
The total number of referrals to the spinal MDT decreased
significantly during COVID-19 from n=526ton=248(p
< 0.001; Table 4). The proportion of patients referred with
Table 3 Number and
composition of paediatric
operations performed by
subspecialty
Paediatric Pre-COVID-19 COVID-19 pvalue
Number of operations in N(% of total) 45 (100.0) 33 (100.0)
Functional (intractable epilepsy) 6 (13.3) 0 (0.0)
Spinal 4 (8.9) 4 (12.1) p>0.05
Myelomeningocele 3 (6.7) 4 (12.1)
Tethered cord 1 (2.2) 0 (0.0)
Trauma 2 (4.4) 5 (15.2) p>0.05
Acute subdural hematoma 0 (0.0) 1 (3.0)
Extradural hematoma 1 (2.2) 0 (0.0)
Traumatic brain injury/intracranial haemorrhage 0 (0.0) 3 (9.1)
Traumatic vertebral fracture 1 (1.1) 1 (3.0)
Vascular (cavernoma) 1 (2.2) 0 (0.0)
Oncology 7 (15.6) 9 (27.3) p>0.05
LGG 1 (2.2) 4 (12.1)
HGG 5 (11.1) 2 (6.1)
Medulloblastoma 1 (2.2) 2 (6.1)
Ependymoma 0 (0.0) 1 (3.0)
Skull base (chiari malformation) 1 (2.2) 1 (3.0)
Other 24 (53.3) 14 (42.4) p>0.05
Hydrocephalus 20 (44.4) 14 (42.4)
Primary infections 2 (4.4) 0 (0.0)
Secondary infections 2 (4.4) 0 (0.0)
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cauda equina syndrome increased significantly from 4.0% (n
= 21) to 10.5% (n=26,p< 0.001). There was no statistically
significant difference between spinal MDT treatment recom-
mendations before and during COVID-19 (Table 4).
Functional and paediatric neurosurgery
The number of functional neurosurgery MDTs was reduced
from twice-weekly pre-COVID-19 to 3 during COVID-19.
No elective functional neurosurgery took place during
COVID-19 although battery replacement for movement dis-
order patients continued (Table 2).
In the paediatric service, the total number of operations
performed was not as severely affected as the adult service
(pre-COVID-19 n= 45, during COVID-19 n=33)butthe
case load amongst the subspecialties changed (Table 3). In
particular, trauma cases increased from n= 2 (4.4% of total
pre-COVID-19) to n= 5 (15.2% of total during COVID-19).
Oncology operations also increased from n= 7 (15.6% of
total) to n= 9 (27.3% of total) during COVID-19. No func-
tional or neurovascular operations were performed during
COVID-19 within our paediatric cohort.
Surgical outcomes and COVID-19 infections in neuro-
surgical patients
Overall, 30-day perioperative mortality remained low during
COVID-19 (n= 4, 2.0%) compared to pre-COVID-19 (n=5,
Table 4 Referrals to
neurovascular and spinal
multidisciplinary teams
Period Pre-COVID-19 COVID-19 pvalue
Vascular referral age groups (years) p<0.01
017 7 5
1865 183 97
>65 55 59
Vascular diagnosis, total (%) 245 (100.0) 161 (100.0) p<0.01
Aneurysm(s) 185 (75.5) 132 (82.0)
Previously ruptured 79 (32.2) 22 (13.7)
Unruptured symptomatic 6 (2.4) 4 (2.5)
Unruptured incidental 100 (40.8) 106 (65.8)
AVM
a
34 (13.9) 8 (5.0)
Previously ruptured cranial 12 (4.9) 1 (0.6)
Unruptured cranial 20 (44.4) 7 (4.3)
Spinal 2 (0.8) 0 (0.0)
Cavernoma 1 (0.4) 5 (3.1)
Other* 25 (10.2) 17 (10.6)
Vascular treatment
Emergency, clip/coil 6/10 1/17 p>0.05
Ruptured or dissecting intracranial aneurysm 4/6 1/13
Ruptured or symptomatic AVM
a
or AVF
b
2/4 0/4
Elective, clip/coil 8/9 0/0
Intracranial aneurysms 5/8 0/0
AVM
a
or AVF
b
3/1 0/0
Spinal MDT
c
referrals, total (%) 526 (100.0) 248 (100.0) p<0.001
Cauda equina syndrome 21 (4.0) 26 (10.5)
Degenerative spine 505 (96.0) 222 (89.5)
Spinal treatment recommendation (% of total) p>0.05
Routine outpatient 334 (63.5) 151 (60.9)
Urgent outpatient 24 (4.6) 7 (2.8)
Conservative or other 168 (31.9) 90 (36.3)
*Intracranial haemorrhagenoabnormality, non-aneurysmal subarachnoid haemorrhage, stenosis, family history
a
Arteriovenous malformation
b
Arteriovenous fistula
c
Multidisciplinary team
Acta Neurochir
Table 5 Referrals to neuro-
oncology and skull base
multidisciplinary teams
Period Pre-COVID-19 COVID-19 pvalue
Neuro-oncology diagnosis, total (%) 443 (100.0) 276 (100.0) p>0.05
New referrals 298 (67.3) 185 (67.0)
High-grade glioma 65 (14.7) 33 (12.0)
Low-grade glioma 22 (5.0) 9 (3.3)
Cerebral metastasis 80 (18.1) 60 (21.7)
Meningioma 59 (13.3) 37 (13.4)
Other* 72 (16.3) 46 (16.7)
Follow-up (including post-operative) 145 (32.7) 91 (33.0)
High-grade glioma 34 (7.7) 26 (9.4)
Low-grade glioma 11 (2.5) 8 (2.9)
Cerebral metastasis 41 (9.3) 32 (11.6)
Meningioma 35 (7.9) 17 (6.2)
Other* 24 (5.4) 8 (2.9)
Treatment recommendation
High-grade glioma, total 99 59 p>0.05
Surgery, % 32 (32.3) 12 (20.3)
Monitoring, conservative or other, % 67 (67.7) 47 (79.7)
Low-grade glioma, total 33 17 p>0.05
Surgery, % 6 (18.2) 4 (23.5)
Monitoring, conservative or other, % 27 (81.8) 13 (76.5)
Cerebral metastasis, total 121 92 p>0.05
Intervention (surgery/SRS
a
), % 30 (7/23) (24.8) 32 (6/26) (34.8)
Monitoring, conservative or other, % 91 (75.2) 60 (65.2)
Skull base diagnosis, total (%) 329 (100.0) 101 (100.0) p<0.05
New referrals 112 (34.0) 48 (47.5)
Meningioma 25 (7.6) 14 (13.9)
Vestibular schwannoma 17 (5.2) 7 (6.9)
Pituitary adenoma and/or apoplexy 29 (8.8) 14 (13.9)
Chiari malformation 11 (3.3) 2 (2.0)
Other
&
30 (9.1) 11 (10.9)
Follow-up (incl. post-operative) 217 (66.0) 53 (52.5)
Meningioma 68 (20.7) 20 (19.8)
Vestibular schwannoma 56 (17.0) 10 (9.9)
Pituitary adenoma and/or apoplexy 51 (15.5) 17 (16.8)
Chiari malformation 3 (0.9) 0 (0.0)
Other
&
39 (11.9) 6 (5.9)
Treatment recommendation
Meningioma, total 93 34 p<0.05
Intervention (surgery/SRS
a
), % 9 (5/4) (9.7) 9 (7/2) (26.5)
Interval imaging, % 84 (90.3) 25 (73.5)
Vestibular schwannoma, total 73 17 p>0.05
Intervention (surgery/SRS
a
), % 9 (6/3) (12.3) 2 (1/1) (11.8)
Interval imaging, % 64 (87.7) 15 (88.2)
Pituitary adenoma/apoplexy, total 80 31 p>0.05
Surgery, % 16 (20.0) 3 (9.7)
Interval imaging, % 64 (80.0) 28 (90.3)
*Ependymoma, nerve sheath tumour, haemangioblastoma, arachnoid/colloid cyst, etc.
a
Stereotactic radiosurgery
&
Chondrosarcoma, chordoma, craniopharyngioma, etc.
Acta Neurochir
1.1%; Table 1). Within emergency operations, 30-day periop-
erative mortality was lower during COVID-19 (1.9%, n=3)
compared to pre-COVID-19 (2.5%, n= 5), partly reflecting
the process of patient selection with higher threshold for trans-
fer and surgery in critically ill patients during the COVID-19
period. The single elective mortality in the COVID-19 period
related to a 28-year-old patient with a solitary CM who sub-
sequently passed away due to leptomeningeal disease
(Table 1; 30-day perioperative elective mortality during
COVID-19 n=1,2.2%).
There were 17 neurosurgical patients who were diagnosed
with COVID-19 either pre-operatively (n=4)orpost-
operatively (operation pre-COVID-19 n= 7, operation during
COVID-19 n= 6; all patients tested negative before surgery;
Table 1), representing 2.6% of total neurosurgical operations.
Out of these 17 patients, 6 (35.3%) were from a black and
minority ethnic (BAME) background (Table 6) and one of
these BAME patients died of post-operative COVID-19 infec-
tion (accounting for 20.0% of all deaths after emergency op-
eration). This was an 86-year-old Asian man with hyperten-
sion who underwent burr hole drainage of a chronic subdural
hematoma but developed COVID-19 infection 15 days post-
operatively and died 6 days later of COVID-19-related pneu-
monia. This was the only single mortality of a neurosurgical
patient with COVID-19 infection within our cohort. There
was no difference in the ethnic mix of our patients between
the pre-COVID and COVID periods. The median age
amongst these 17 patients was 63 ± 15.44 years and
male:female ratio was 10:7. Overall, n= 4 patients (23.5%)
were admitted to ITU because of COVID-19-related compli-
cations. The majority of patients who were infected with
COVID-19 had underlying co-morbidities such as hyperten-
sion and diabetes mellitus, and all patients admitted to ITU
had underlying health problems. Out of the 13 patients who
developed post-operative COVID-19 infection, 53.8% (n=7)
had suffered from a post-operative complication (n= 6 wound
infection, n= 1 hematoma, n= 1 CSF leak) with a median
time to post-operative infection of 18 ± 9.5 days. The median
length of stay for the 17 patients diagnosed with COVID-19
was 36 ± 23.97 days; 4 (23.5%) were discharged to a rehabil-
itation unit, and 11 (64.7%) were discharged home.
Discussion
Impact of COVID-19 on neurosurgical referrals and
service
Overall, we saw a reduction in acute referrals during COVID-
19 by approximately 33.6% and in the number of operations
performed by approximately 55.6%. This is comparable to the
published literature where a reduction of more than 50% has
been described by 226 respondents from more than 60
countries [9]. Mathiesen et al. demonstrated in a European
snapshot that in 80% of respondents (20 neurosurgical depart-
ments), neurosurgical beds and neuro-intensive care beds
were rationalized by postponing elective surgery, fewer acute
traumatic brain injuries and subarachnoid haemorrhages ad-
missions, and changing surgical indications in order to ration
resources [14]. Although we did not see a statistically signif-
icant difference in patients with neurological deficit, GCS 8,
or age > 65 years being transferred to our neurosurgical unit
during COVID-19, there was a trend towards admitting fewer
elderly patients with depressed GCS. This may represent the
tendency to protect the ventilated ITU bed capacity by limit-
ing the admission of patients with extremely poor prognosis.
Additionally, referrals to our neurosurgical subspecialist
MDTs were decreased although subspecialties with a more
elective case mix (skull base, spine, functional) were worse
affected than those with a more urgent case mix (neuro-oncol-
ogy, neurovascular, paediatrics).
Hecht et al. described a similar percentage reduction for
neurosurgical emergency admissions although across all sub-
specialties (p= 0.0007) during COVID-19 [6]. In keeping
with their findings, we observed a reduction in the total num-
bers of patients presenting with sub-/epidural hematomas,
traumatic vertebral fractures, and hydrocephalus (as described
in Table 2). Interestingly, operations for cauda equina syn-
drome and spinal myelopathy decreased during COVID-19,
which could be either due to a delay in presentation to the
emergency department (patient-related factors) or due to a
delay in referral through the general practitioner as many
had their practice disrupted during COVID-19 (physician-re-
lated factors). In contrast though, we observed a similar num-
ber of patients with neurovascular emergencies (i.e. ruptured
intracranial aneurysm) presenting during and pre-COVID-19
with a higher proportion undergoing endovascular treatment
during COVID-19; the treatment decision was not based on
resource allocation but was merely a result of the type of
aneurysms presenting during the COVID-19 period.
However, this also helped to reduce theatre usage and length
of hospital stay.
Although there was a reduction in the referrals to our sub-
specialist MDTs, we developed strategies to avoid critical
delays. For example, in neuro-oncology, we actively reached
out to our referring centres to encourage continued referral of
patients. Importantly, there was no significant change in treat-
ment recommendation with regard to gliomas and CMs in our
cohort (p> 0.05; Table 5). In terms of delivery of surgery, we
mitigated the effects of reduced theatre space during COVID-
19 in our unit by securing additional theatre capacity in the
private healthcare sector, contracted through the NHS. This
also meant that the operations performed during COVID-19 in
the private sector (n= 26) were provided by a cleanneuro-
surgical team to a clean(COVID-19 negative) cohort of
neuro-oncology patients, further reducing the risks. Similar
Acta Neurochir
Table 6 Characteristics of neurosurgical patients with COVID-19 infection
Nr. Age, sex Ethnic group Admission Co-morbidities Diagnosis Procedure Complications ITU Outcome LoS
Type COVID
1 54, M White Em d0 HTN Pineal lesion Endoscopic third
ventriculostomy + biopsy
None Yes Home 46 days
2 38, M Black Em d0 Illicit drugs Subarachnoid haemorrhage External ventricular drain None Yes Home 15 days
3 54, M White Em d0 Pancytopaenia Colloid cyst Endoscopic resection None No Home 27 days
4 41, M White Em d0 HTN, NIDDM, asthma Intracranial haemorrhage Craniotomy None Yes Home 55 days
5 59, M White Elec d16 Metastatic cancer Cerebral metastasis Craniotomy None No Home 24 days
6 67, M White Em d34 HTN, NIDDM, CholesterolMeningitis External ventricular drain None Yes Rehab 90 days
7 51, M White Em d20 None Degenerative spine Lumbar fixation Cerebrospinal fluid leak,
wound infection
No Home 36 days
8 72, M White Elec d31 None Parkinsons Deep brain stimulation Wound infection No Inpatient 94 days
9 72, F Asian Elec d42 HTN, NIDDM Meningioma Craniotomy Wound infection No Home 65 days
10 86, M Asian Em d15 HTN, dementia Subdural hematoma Burr hole evacuation None No RIP 21 days
11 64, F White Em d14 None Meningioma Craniotomy/cranioplasty Wound infection No Rehab 29 days
12 86, F White Em d18 HTN, AF, cholesterolSpinal hematoma Decompression Wound infection Yes Rehab 31 days
13 48, F Black Elec d21 Asthma, cholesterolMeningioma Craniotomy Haematoma Yes Rehab 67 days
14 66, M White Em d14 Metastatic cancer Metastatic cord compression Decompression + fixation None No Home 22 days
15 33, F Hispanic Elec d11 None High-grade glioma Craniotomy Wound infection No Home 23 days
16 81, F Black Em d11 HTN, NIDDM, AF Cauda equina syndrome Laminectomy + discectomy None No Home 37 days
17 63, F White Em d24 None Meningitis Endoscopic third
ventriculostomy + Rickham
None No Home 47 days
Admission: TypeEm(ergency) vs. Elec(tive); COVIDtime to COVID-19 infection from day of admission (days)
ITU, admission to intensive treatment unit; LoS, length of inpatient hospital stay (days)
Co-morbidities: hypertension (HTN), non-insulin-dependent diabetes mellitus (NIDDM), atrial fibrillation (AF)
Acta Neurochir
arrangements were used to maintain the delivery of the degen-
erative spine disease for medically refractory neural compres-
sion, with no significant difference in waiting times between
pre-COVID-19 and COVID-19 periods, matching the capac-
ity to referrals (p> 0.05, median waiting times 28 and 27
weeks respectively).
Impact of COVID-19 on subspecialties and neurosur-
gical training
There has been little focus on the impact of COVID-19 on
neurosurgical training [1]. During the COVID-19, and as part
of restructuring the services to release capacity to deal with
COVID-19, most of our neurosurgical trainees were rede-
ployed to ITU or COVID-19 wards. This combined with the
fact that fewer operations were performed, meant a reduction
in training opportunities. There was a move to teach through
Zoom (Communications Technology Company, San Jose,
CA) conference calls within our unit as elsewhere [19]tokeep
theoretical knowledge up-to-date; however, this cannot re-
place actual operative experience. This is further confounded
as certain subspecialties have had to modify their operative
techniques based on recommendations from various neurosur-
gical societies, particularly to avoid approaches through the
respiratory tract (e.g. trans-sphenoidal surgery) or to limit the
use of aerosol-generating instruments (including drills, ultra-
sonic aspirator) [3,7].
As part of an effort to reduce physical contacts, in our unit,
face-to-face outpatient clinic appointments were almost exclu-
sively changed to telephone. The majority of telephone clinics
were for patients being under regular follow-up with stable
imaging findings and clinical course. All postponed or can-
celled elective patients were equally kept under close tele-
phone follow-up and prioritized for re-scheduling according
to disease/symptom severity. Follow-up outcomes included
further telephone consultations, repeat imaging, face-to-face
assessment, or rescheduled surgery. None of these patients
required emergency admission. Only patients who required
neurosurgical intervention were seen in face-to-face clinic in
order to be pre-assessed for surgery. Overall, this system
worked well and may have potential implications on outpa-
tient management for the future [4,10]. In our experience,
remote access platforms such as Attend Anywhere®
(Melbourne, Australia) or secure patient online chat-rooms
such as The Brain Tumour Charitys BRIAN [23] provide
invaluable tools in keeping contact with patients.
COVID-19-positive patients and perioperative
mortality
The GlobalSurg reported a 30-day perioperative mortality of
23.8% amongst COVID-19 patients undergoing emergency or
elective surgery [2]. In contrast, within our cohort, 30-day
perioperative mortality remained low during COVID-19
(2.0%). In fact, none of our four neurosurgical patients that
underwent surgery whilst infected with COVID-19 died. We
noted that 13 patients (2.0%) who underwent neurosurgery
before and during COVID-19 were infected with COVID-19
whilst being an inpatient; however, no single factor could be
identified to trace the cause of these post-operative inpatient
infections. Importantly, the majority of these patients had un-
derlying co-morbidities or suffered a post-operative complica-
tion, hence making them more susceptible to COVID-19 in-
fection [5]. There is new evidence suggesting that people from
a BAME background are more severely affected by COVID-
19 [8,11,17,18]. 35.3% of our patients with COVID-19 were
from a BAME background, of which one died. More data and
larger cohorts are needed to further study this aspect.
Limitations of this study
Patient numbers were limited due to the relatively short time
period observed. This was however inevitable and a reflection
of the dynamic nature of the pandemic since the last day of
recruitment was dictated by a national change in strategy to-
wards the next phase to restore services. Our retrospective
data collection for the pre-COVID-19 phase may also be an-
other limitation here. We further did not analyse the impact of
COVID-19 on excess/indirect neurosurgical mortality due to
lack of presentation to hospitals such as the case maybe, for
example, for ruptured aneurysms.
Conclusions
There was a reduction in neurosurgical referrals by 33.6% and
operations by 55.6% during the course of COVID-19. The 30-
day perioperative mortality, however, remained low at 2.0%,
considerably lower than that in other published series [2], with
the majority of patients who contracted post-operative
COVID-19 infection having underlying co-morbidities and/
or suffering from post-operative complications. Despite the
challenges, capacity to treat patients requiring urgent or emer-
gency neurosurgical care was maintained at all times. The
strategies we adopted allowed creation of new capacity and
safe delivery of neurosurgical care, with restructuring the pa-
tient pathways and facilities into COVID-19 positive and non-
COVID-19, arguably as the most important step. We strongly
believe our multi-modal approach was the key to minimize the
disruptions, complications, and mortality and that lessons
learned will have direct relevance for neurosurgical care dur-
ing the current and future pandemics.
Contributors All authors made substantive intellectual contributions to
the development of this research. KA, JJ, AMV, and AR contributed to
study conception and development, data collection and data
Acta Neurochir
interpretation, and critical revision of the manuscript. All other authors
contributed to study conception and development, and critical revision of
the manuscript, and approved the final version of this manuscript. The
corresponding author attests that all listed authors meet authorshipcriteria
and that no others meeting the criteria have been omitted. JJ is the
guarantor.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
Ethical approval All procedures performed in studies involving human
participants were in accordance with the ethical standards of the institu-
tional and/or national research committee (Kings College Hospital clin-
ical governance approval has been obtained for this audit) and with the
1964 Helsinki declaration and its later amendments or comparable ethical
standards. For this type of study, formal consent is not required.
Open Access This article is licensed under a Creative Commons
Attribution 4.0 International License, which permits use, sharing, adap-
tation, distribution and reproduction in any medium or format, as long as
you give appropriate credit to the original author(s) and the source, pro-
vide a link to the Creative Commons licence, and indicate if changes were
made. The images or other third party material in this article are included
in the article's Creative Commons licence, unless indicated otherwise in a
credit line to the material. If material is not included in the article's
Creative Commons licence and your intended use is not permitted by
statutory regulation or exceeds the permitted use, you will need to obtain
permission directly from the copyright holder. To view a copy of this
licence, visit http://creativecommons.org/licenses/by/4.0/.
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... Due to the rising case numbers of coronavirus disease 2019 (COVID-19) patients, the American College of Surgeons recommended postponing or canceling nonemergent surgeries in mid-March 2020, with similar recommendations made worldwide. [1][2][3][4][5] The consequences of these recommendations led to significant decreases in the volume of neurosurgical cases, as many neurosurgical and neurointensive care beds were rationed to support COVID-19 patients. 3,[5][6][7] Nigeria, too, was affected by a rising number of COVID-19 cases 4,8 and to cope with the difficulties posed by the pandemic, the health care system appropriately shifted attention and resources to treating patients with COVID-19. ...
... [1][2][3][4][5] The consequences of these recommendations led to significant decreases in the volume of neurosurgical cases, as many neurosurgical and neurointensive care beds were rationed to support COVID-19 patients. 3,[5][6][7] Nigeria, too, was affected by a rising number of COVID-19 cases 4,8 and to cope with the difficulties posed by the pandemic, the health care system appropriately shifted attention and resources to treating patients with COVID-19. As a result of restructuring, modifications were made to streamline operations, and a 60-bed block was dedicated to patients with COVID-19. ...
... Overall, this reduction is consistent with available literature with a reported 50 þ % reduction of neurosurgical cases during this time. 1,3 Similarly, in a cross-sectional survey given to African neurosurgeons, 54.7% of responders reported that elective surgeries were not being performed, with an overall median reduction of 80% of elective cases per clinician. 4 The overall significant reduction in elective procedures likely reflected the widespread recommendation to reduce and postpone the number of elective procedures and the reallocation of health care workers to manage COVID-19 patients. ...
Article
Full-text available
Background The outbreak of COVID-19 caused a significant impact on neurosurgical case volume in Nigeria due to the widespread recommendation to minimize elective procedures and redistribute healthcare resources to support COVID-19 patients. This study aims to analyze the effect of COVID-19 in one tertiary care Nigerian hospital on the demographic characteristics, diagnostic classes, and elective/non-elective procedure statuses. Methods A retrospective single-center chart review study was conducted to review all patients undergoing a neurosurgical procedure between March to June in 2019 and 2020. Descriptive data on patient age, gender, sex, diagnosis, surgical procedure, elective/non-elective surgery status, and month and year of admission were recorded. Diagnoses were categorized into one of seven types by author review. Pearson's Chi-Square and Fisher's Exact Tests were utilized to test for independence of the categorical variables to the year of patient admission, and a Welch two-sample t-test was used to test for a significant difference in mean age between the two cohorts. Results A total of 143 cases were reviewed. There was a 59.8% reduction in overall neurosurgical case volume with an 82% reduction in elective procedures (39 vs. 7, p = 0.017, 95% CI: 1.15 – 8.77) between 2019 and 2020. No significant differences were noted in patient cohorts when comparing demographic characteristics, diagnosis type, or month of admission between the two years. Conclusion There was a significant reduction in elective neurosurgical procedures during the early months of COVID-19 in Nigeria. Further studies should consider examining the effects of COVID-19 into 2021.
... The COVID-19 pandemic has led to major changes in patient and staff resources management worldwide [1][2][3]. Elective surgeries, routine diagnostics and time of in-hospital stays were reduced in the interest of patient safety and as a measure to prevent the collapse of medical institutions [4,5]. The expected onslaught of COVID-19 positive patients resulted in a reduction of elective surgical activities to free up beds in the ward and Intensive Care Unit (ICU) [3]. ...
... However, the insufficiency of facility and staff resources during the pandemic with consequent cancelling of elective operations hazards the high standards of elective care to patients with an extensive impact on patients and the healthcare system overall [1,4]. The delay of urgent surgeries results in worsening of health conditions and quality of life, increased social costs and probably unnecessary deaths [6][7][8][9]. ...
... The delay of urgent surgeries results in worsening of health conditions and quality of life, increased social costs and probably unnecessary deaths [6][7][8][9]. Surgical disciplines had to define and implement triage strategies within a very short time during the pandemic in order to cope with the ongoing surge of urgent operations of non-COVID-19 patients [1,10]. This study aimed to quantify OR capacity resources, the changes as well as fluctuations of neurosurgical treated patients and outpatient clinics visits during the global COVID-19 pandemic in 2020 and 2021 compared to previous years. ...
Article
Full-text available
Background The COVID-19 pandemic raised major challenges to the management of patient flows and medical staff resource allocation. To prevent the collapse of medical facilities, elective diagnostic and surgical procedures were drastically reduced, canceled or rescheduled. Methods We recorded all in-hospital treated patients and outpatient clinics visits of our neurosurgical department from March 2017 to February 2021. Changes of OR capacity, in-hospital neurosurgical treatments and outpatient clinics visits during the pandemic episode was compared on a monthly bases to the previous years. Results A total of 3’214 data points from in-house treated patients and 11’400 outpatient clinics visits were collected. The ratio of elective (73.5% ± 1.5) to emergency surgeries (26.5% ± 1.5) remained unchanged from 2017 to 2021. Significantly less neurosurgical interventions were performed in April 2020 (-42%), significantly more in July 2020 (+36%). Number of outpatient clinics visits remained in the expected monthly range (mean n=211 ± 67). Total OR capacity was reduced to 30% in April 2020 and 55% in January 2021. No significant delay of urgent surgical treatments was detected during restricted (<85%) OR capacity. On average, the delay of rescheduled consultations was 58 days (range 3 – 183 days), three (6.5%) were referred as emergencies. Conclusions Dynamic monitoring and adjustment of resources is essential to maintain surgical care. The sharp restrictions of surgical activities resulted in significant fluctuations and 5% decrease of treated neurosurgical patients during the COVID-19 pandemic. However, urgent neurosurgical care was assured without significant time delay during periods of reduced OR capacity.
... In the United Kingdom (2021), the results of a study showed that emergency neurosurgery operations were associated with a 33.6% reduction during the Covid-19 pandemic. Mortality rate was 30% thirty days after the surgery where most patients were infected with the Covid-19 and had underlying diseases or postoperative complications (8). ...
... More emphasis on writing systematic review articles and meta-analyzes (23) 3.27±1. 42 15 The effect of e-learning for assistants and staff (8,32,33) 3.18±1. 16 16 Training and application of personal protective equipment instructions (11,16,34,35) 3.00±1. ...
... Presence in Corona wards increased the risk of contamination with the Covid-19 in the personnel with underlying diseases, so there were transferred to other wards and the problem of staff shortage became more apparent than before (8,10,11,16,17,18,28). ...
Preprint
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Background Covid-19 quickly spread around the world as an epidemic with potentially unknown hazards. Like its impacts on various occupations, neurosurgery has undergone changes due to the virus, including changes in surgical planning, inpatient and outpatient clinics, emergency management, and even academic activities. The present study was performed to determine neurosurgery challenges during the Covid-19 pandemic in Iran.Methods The present study was conducted as a mixed qualitative and quantitative study in 2021. In the qualitative section using the targeted sampling method, 11 members of the target community were selected using the available sampling method and completed a questionnaire. The qualitative part was conducted in two stages of reviewing texts and interviewing experts and in the quantitative part we evaluated the validity of the structure and the reliability of the questionnaire.ResultsThis study examined in detail all aspects of the effects of Covid-19 on neurosurgery. 9 dimensions and 61 items were identified as the challenges of neurosurgery during the Covid-19 pandemic. In order of importance, the aspects were: treatment outcome, manpower, management psychological and physical diseases, education and research, tools and physical space, ethics, financial implications and information technology.ConclusionThe outbreak of epidemics has different risks for specialties, among them neurosurgery. Accordingly, to observe patients' right to treatment, all necessary measures were first taken to provide instructions, regulations, policies and ethical guidelines.
... 122 articles remained, which have been referenced in this manuscript ( Fig. 1) All centres maintained neurosurgical treatment for CNS tumours to some degree, however, it is clear that the pandemic obstructed the regular delivery of care (Table 1). Many centres described a reduction in new referrals and Neuro-oncological procedures [21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38], although emergency operations largely remained unaffected. One centre described how a national COVID-19 vaccination campaign allowed them to recommence operations for brain tumours [37]. ...
... Experiences were mixed in paediatric centres (Table 3). Some centres had sustained or increased treatment numbers [21,26], whilst others experienced reductions [34,39]. One centre had a reduction in number of new brain cancer diagnoses [44]. ...
Article
The COVID-19 pandemic has challenged the continued delivery of healthcare globally. Due to disease risk, clinicians were forced to re-evaluate the safety and priorities of pre-pandemic care. Neuro-oncology presents unique challenges, as patients can deteriorate rapidly without intervention. These challenges were also observed in countries with reduced COVID-19 burden with centres required to rapidly develop strategies to maintain efficient and equitable care. This review aims to summarise the impact of the pandemic on clinical care and research within the practice of Neuro-oncology. A narrative review of the literature was performed using MEDLINE and EMBASS and results screened using PRISMA guidelines with relevant inclusion and exclusion criteria. Search strategies included variations of ‘Neuro-oncology’ combined with COVID-19 and other clinical-related terms. Most adult and paediatric neurosurgical centres experienced reductions in new referrals and operations for brain malignancies, and those who did present for treatment frequently had operations cancelled or delayed. Many radiation therapy and medical oncology centres altered treatment plans to mitigate COVID-19 risk for patients and staff. New protocols were developed that aimed to reduce in-person visits and reduce the risk of developing severe complications from COVID-19. The COVID-19 pandemic has presented many challenges to the provision of safe and accessible healthcare. Despite these challenges, some benefits to healthcare provision such as the use of telemedicine are likely to remain in future practice. Neuro-oncology staff must remain vigilant to ensure patient and staff safety.
... We identified a 58.5% decrease in neurosurgical caseload across 7 academic departments after the ACS issued elective surgery recommendations, similar to other reports on neurosurgical volume during COVID-19. 21,22 However, neurosurgery was not the only specialty dramatically affected in the early pandemic surge; inpatient otolaryngology procedures reportedly decreased by 60% in some regions, and orthopedic surgical cases decreased by 88%. 23,24 We focused on neurosurgery subspecialty volumes to elucidate their distinct roles during limited surgical access. ...
... The proportion of open vascular and neuro-oncology procedures increased while that of spine and functional neurosurgery decreased. These differences are in line with the findings of single-center analysis by Ashkan et al. 22 and the assessments by 166 international neurosurgeons who ranked cases of cerebellar metastasis, glioblastoma, and giant aneurysms with the highest acuity among 9 hypothetical cases in the context of COVID-19 restrictions. 25 Although those cases do not represent the overall subspecialty practice and its necessity during a pandemic, they highlight the average acuity differences of each subspecialty's practice. ...
Article
Objective: Changes to neurosurgical practices during the COVID-19 pandemic have not been thoroughly analyzed. We report the effects of operative restrictions imposed under variable local COVID-19 infection rates and healthcare policies using a retrospective multi-center cohort study and highlight shifts in operative volumes and subspecialty practice. Methods: Seven academic neurosurgery departments' neurosurgical case logs were collected; procedures in April 2020 (COVID-19 surge) and April 2019 (historical control) were analyzed overall and by 6 subspecialties. Patient acuity, surgical scheduling policies, and local surge levels were assessed. Results: Operative volume during COVID-19 decreased 58.5% from the previous year (602 vs 1449, p=0.001). COVID-19 infection rates within departments' counties correlated with decreased operative volume (r=0.695, p=0.04) and increased patient categorical acuity (p=0.001). Spine procedure volume decreased by 63.9% (220 vs 609, p=0.002), for a significantly smaller proportion of overall practice during the COVID-19 surge (36.5%) versus the control period (42.0%) (p=0.02). Vascular volume decreased by 39.5% (72 vs 119, p=0.01) but increased as a percentage of caseload (8.2% in 2019 vs 12.0% in 2020, p=0.04). Neuro-oncology procedure volume decreased by 45.5% (174 vs 318, p=0.04) but maintained a consistent proportion of all neurosurgeries (28.9% in 2020 vs 21.9% in 2019, p=0.09). Functional neurosurgery volume, which declined by 81.4% (41 vs 220, p=0.008), represented only 6.8% of cases during the pandemic versus 15.2% in 2019 (p=0.02). Conclusions: Operative restrictions during COVID-19 led to distinct shifts in neurosurgical practice, and local infective burden played a significant role in operative volume and patient acuity.
... In the COVID-19 era, there was a reduction in neurosurgical emergency by 33.6% and operations by 55.6%. 21 The patients in the study were mainly from 2020, and followed up in 2021. Spine surgery is usually not life-threatening. ...
Article
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Abstract Objective Lumbar radiculopathy is a major health problem, which often treated by neurosurgery or guided lumbar epidural steroids for pain relief. We used autologous Platelet Rich Plasma (PRP) as a novel pharmaceutical agent that has strongly emerged in recent years to treat patients of lumbar disc herniation. From that, we evaluated the efficacy of PRP via transforaminal route in treatment of radicular pain in patients with lumbar disc herniation. Methods Twenty-five patients were enrolled and injected with 4 ml of autologous platelet rich plasma under fluoroscopic guidance via transforaminal epidural injection into area of affected nerve root. They were followed using Visual Analogue Scale (VAS), Modified Oswestry Disability Index (ODI) and Straight Leg Raising Test (SLRT) for clinical assessment. Results Patients who received transforaminal injections with autologous PRP showed statistically significant improvements on all three evaluation tools (VAS, ODI, SLRT). The improvements were sustained over twelve-month follow-up and there were no associated complications. Conclusion Transforaminal injection with autologous PRP helps patients relieve chronic pains and be able return to work. Besides, autologous PRP can be considered as a good alternative to epidural steroids in management of lumbar disc herniation. Keywords Autologous platelet-rich plasmaLumbar disc herniationTransforaminal injection
... 38 patients (60 %) were classified as Hunt and Hess grade 1 on initial presentation while 9, 11 and 5 patients were A study from tertiary neurosurgical center in UK reported reduction in neurosurgical emergency referrals by 33.6% and operations by 55.6% during the pandemic. 3 In a retrospective cross-sectional study conducted across 6 continents and 140 centers, a relative decrease in volume of SAH hospitalizations, aneurysmal SAH hospitalizations and ruptured aneurysm embolization was reported during the first wave of the pandemic and was consistent with decrease in other emergencies such as stroke and myocardial infarction. 4 Located in the confines of the capital city of Nepal, Annapurna Neurological Institute and Allied Sciences (ANIAS) is a full-fledged tertiary referral neurological and neurosurgical center. ...
Article
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Introduction: Aneurysmal Subarachnoid Hemorrhage(SAH) is a neurosurgical emergency for which testing for COVID PCR was not an option and was unlikely to change the management of the case. Hence, all surgeries were performed without COVID PCR and Rapid Diagnostic Test (RDT) at our center for the welfare of the patient despite risks involved for the surgeons and supporting staff.
... All physicians learn during their early years of medical schools that their safety is a priority even during lifesaving emergencies [2]. Ensuring their safety is, for example, the first step in cardiopulmonary resuscitation As duty to care has no less weight than the physician safety, it is worth mentioning that patients needing neurosurgical interventions are special group of patients whose diseases are time sensitive. ...
... In contrast, TBI admission numbers to ICU have remained steady [11,18]. Mortality rates of 1.1 and 2.0% were reported in all referrals and admissions to a tertiary neurosurgical unit in London in a non-COVID and COVID period [19]. Similarly, in patients admitted to a neurosurgical ICU in Finland with TBI or aneurysmal subarachnoid haemorrhage (SAH), no difference in mortality was seen (in either diagnosis) [18]. ...
Article
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Background To investigate the impact of COVID-19 on trauma admissions to a National Neurosurgical Centre in Ireland.Methods Retrospective analysis of a prospectively maintained database of all trauma admissions to the National Neurosurgical Centre at Beaumont Hospital, Dublin, during the period March 1 to May 31, 2019 and 2020. Primary outcome was 30-day mortality rate. Secondary outcomes included time transfer time, time from admission to time of surgery, and intensive care unit (ICU) admissions. Patients under the age of 16 were excluded.ResultsA total of 32 and 39 patients were admitted to the National Neurosurgical Centre following trauma over the 3-month period in 2020 and 2019 respectively, giving a 17.9% reduction in admissions. The 30-day mortality rate increased from 7.7% in 2019 to 15.6% on 2020 (p = 0.45). Mean transfer time was 4 h 58 min in 2019 and 3 h 55 min in 2020 (0.22). Mean time from admission to time of surgery was 9 h 10 min in 2019 and 5 h 37 min in 2020 respectively (p = 0.35). In 2019, 20 patients (51.3%) were admitted to ICU. This increased to 23 patients (69.7%) in 2020 (p = 0.08).Conclusions Traumatic brain injury 30-day mortality rates increased during the first COVID-19 lockdown period. Trauma admission rates to ICU remained unchanged despite an overall reduction in trauma admissions. Transfer time, time to surgery, and length of stay were impacted by COVID-19. Despite the challenges COVID-19 has posed, it is important to maintain a fully functioning neurosurgical and neurocritical care service during the pandemic.
Article
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The COVID-19 pandemic has challenged the delivery of care worldwide, with many outpatient clinics changing from face-to-face to telephone consultations [1]. This is particularly challenging in neuro-oncology, where often complex interventions need to be discussed and where communication can be compromised due to tumour-related language/cognitive deficits. We therefore sought to evaluate the patient-reported experience on telephone clinics that were conducted and formulated a voluntary, confidential nine-question patient-reported experiencemeasureeKing's Patient Experience Measure in Neuro-oncology Questionnaire (K-PEN Q; see Supplementary Material) to prospectively evaluate the experience of 50consecutive neuro-oncology patients at our quaternary neurosurgical centre with four domains: clinic environment/time (three questions), patients' questions/queries(three questions), follow-up (two questions) and feedback(one question); the answers were divided into a Likert scale of strongly agree, agree, neutral, disagree and strongly disagree. Although more than 90% of patients had had previous face-to-face clinic consultations in the pre-COVIDera; more than a third agreed on preferring telephone over the face-to-face clinic and almost half still preferred the face-to-face consultations.
Article
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Background To investigate whether patients with critical emergency conditions are seeking or receiving the medical care that they require, we characterized the reality of care for patients presenting with neuro-emergencies during the first phase of the COVID-19 pandemic.Methods In this observational, longitudinal cohort study, all neurosurgical admissions that presented to our department between February 1 and April 15 during the COVID-19 pandemic and during the same time period in 2019 were identified and categorized according to the presence of a neuro-emergency, the route of admission, management, and the category of disease. Further, the clinical course of patients with aneurysmal subarachnoid hemorrhage (aSAH) and chronic subdural hematoma (cSDH) was investigated representatively for severe vascular and semi-urgent traumatic conditions that present with a wide variety of symptoms.ResultsDuring the pandemic, the percentage of neuro-emergencies among all neurosurgical admissions remained similar but a larger proportion presented through the emergency department than through the outpatient clinic or by referral (*p = 0.009). The total number of neuro-emergencies was significantly reduced (*p = 0.0007) across all types of disease, particularly in vascular (*p = 0.036) but also in spinal (*p = 0.007) and hydrocephalus (*p = 0.048) emergencies. Patients with spinal emergencies presented 48 h later (*p = 0.001) despite comparable symptom severity. For aSAH, the number of cases, aSAH grade, aneurysm localization, and treatment modality did not change but strikingly, elderly patients with cSDH presented less frequently, with more severe symptoms (*p = 0.046), and were less likely to reach favorable outcome (*p = 0.003) at discharge compared with previous years.Conclusions Despite pandemic-related restrictive measures and reallocation of resources, patients with neuro-emergencies should be encouraged to present regardless of the severity of symptoms because deferred presentation may result in adverse outcome. Thus, conservation of critical healthcare resources remains essential in spite of fighting COVID-19.
Article
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Background The relationship between ethnicity and COVID-19 is uncertain. We performed a systematic review to assess whether ethnicity has been reported in patients with COVID-19 and its relation to clinical outcomes. Methods We searched EMBASE, MEDLINE, Cochrane Library and PROSPERO for English-language citations on ethnicity and COVID-19 (1st December 2019-15th May 2020). We also reviewed: COVID-19 articles in NEJM, Lancet, BMJ, JAMA, clinical trial protocols, grey literature, surveillance data and preprint articles on COVID-19 in MedRxiv to evaluate if the association between ethnicity and clinical outcomes were reported and what they showed. PROSPERO:180654. Findings Of 207 articles in the database search, five reported ethnicity; two reported no association between ethnicity and mortality. Of 690 articles identified from medical journals, 12 reported ethnicity; three reported no association between ethnicity and mortality. Of 209 preprints, 34 reported ethnicity – 13 found Black, Asian and Minority Ethnic (BAME) individuals had an increased risk of infection with SARS-CoV-2 and 12 reported worse clinical outcomes, including ITU admission and mortality, in BAME patients compared to White patients. Of 12 grey literature reports, seven with original data reported poorer clinical outcomes in BAME groups compared to White groups. Interpretation Data on ethnicity in patients with COVID-19 in the published medical literature remains limited. However, emerging data from the grey literature and preprint articles suggest BAME individuals are at an increased risk of acquiring SARS-CoV-2 infection compared to White individuals and also worse clinical outcomes from COVID-19. Further work on the role of ethnicity in the current pandemic is of urgent public health importance. Funding NIHR
Article
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Since the first reports that the novel coronavirus was showing human-to-human transmission characteristics and asymptomatic cases, the number of patients with associated pneumonia has continued to rise and the epidemic has grown. It now threatens the health and lives of people across the world. The governments of many countries have attached great importance to the prevention of SARS-CoV-2, via research into the etiology and epidemiology of this newly emerged disease. Clinical signs, treatment, and prevention characteristics of the novel coronavirus pneumonia have been receiving attention worldwide, especially from medical personnel. However, owing to the different experimental methods, sample sizes, sample sources, and research perspectives of various studies, results have been inconsistent, or relate to an isolated aspect of the virus or the disease it causes. Currently, systematic summary data on the novel coronavirus are limited. This review combines experimental and clinical evidence into a systematic analysis and summary of the current progress of research into SARS-CoV-2, from multiple perspectives, with the aim of gaining a better overall understanding of the disease. Our report provides important information for current clinicians, for the prevention and treatment of COVID-19 pneumonia.
Article
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Background The novel Coronavirus disease (COVID-19) is a life-threatening illness, which represents a challenge to all the health-care workers. Neurosurgeons around the world are being affected in different ways. Objectives This is the first study regarding the readiness of neurosurgery residents towards the COVID-19 pandemic and its impact. The aim is to identify the level of knowledge, readiness, and the impact of this virus among neurosurgery residents in different programs. Methods A cross-sectional analysis in which 52 neurosurgery residents from different centers were selected to complete a questionnaire-based survey. The questionnaire comprised of three sections and 27 questions that ranged from knowledge to impact of the current pandemic on various features. Results The median knowledge score was 4 out of 5. The proportion of participants with satisfactory knowledge level was 60%. There was a statistically significant difference between the knowledge score and location of the program. Around 48% of the neurosurgery residents dealt directly with COVID-19 patients. Receiving a session about personal protective equipment (PPE) was reported by 57.7%. The neurosurgery training at the hospital was affected. About 90% believed that this pandemic influenced their mental health. Conclusion Neurosurgery residents have a relatively good knowledge about COVID-19. The location of the program was associated with knowledge level. Most of the participants did not receive a sufficient training about PPE. Almost all responders agree that their training at the hospital was affected. Further studies are needed to study the impact of this pandemic on neurosurgery residents.
Article
Objective: Coronavirus disease 2019 (COVID-19) is a disruptive pandemic that has continued to test the limits of health care system capacities. It is important to highlight the specific challenges facing US neurosurgery during these difficult circumstances. In the present study, we have described our neurosurgery department's unique experience during the COVID-19 pandemic. Methods: We analyzed the following data points both before and during the first months of the COVID-19 pandemic: the number of patients infected with COVID-19 at our institution, changes in neurosurgical operative workflow, changes in neurosurgical outpatient and inpatient clinic workflows, resident redeployment statistics and changes in call schedules, and changes in neurosurgical education. Results: At our institution, the adult surgery numbers decreased from 120 during the week of March 4-11, 2020 (before the World Health Organization had classified the COVID-19 outbreak as a pandemic) to 17 during the week of April 13-17, 2020. The number of pediatric surgeries decreased from 15 to 3 during the same period. Significantly more surgeries were cancelled than were delayed (P < 0.0001). A drastic decline occurred in the number of in-person neurosurgery clinic visits (97.12%) between March and April 2020 (P = 0.0020). The inpatient census declined from mid-March to mid-April 2020 by 44.68% compared with a 4.26% decline during the same period in 2019 (P < 0.0001). Finally, neurosurgery education has largely shifted toward video-conferencing sessions rather than in-person sessions. Conclusion: By detailing our experience during the COVID-19 pandemic, we hope to have provided a detailed picture of the challenges facing neurosurgery within an academic medical center.
Article
Background The COVID-19 pandemic has led to the postponement of a large proportion of neurosurgical cases with an accordant radical change in resident experiences. As residents rely upon operative exposure and in-person didactic lectures for education, the disruptions caused by the pandemic have forced programs to revise how they educate residents. Here we surveyed program directors (PDs) to ascertain how they have altered the education and clinical care responsibilities of residents in response to the COVID-19 pandemic. Methods Surveys were sent to the PDs of all ACGME-accredited neurosurgery programs. Survey questions targeted changes in resident staffing and coverage, changes in didactic material delivery, and changes in resident wellness initiatives. PD concerns were also elicited. Results Of the 116 program PDs invited, 57 responded (49.1%). We found that most programs have reduced resident work weeks (65%) and in-hospital resident shift census (95%). Few have redeployed residents and most are increasingly relying on teleconferencing solutions for meetings and resident education. Most commonly programs are using faculty- (91%) or resident-led (65%) lectures, though nearly 75% are supplementing resident education with materials from the Congress of Neurological Surgeons (CNS). Continuing education in spite of decreased case volume and maintaining resident morale are cited as the most common concerns of PDs. Conclusion Here we find that there is great homogeneity in the responses of neurosurgical residency programs to the COVID-19 pandemic. Programs are increasingly incorporating teleconferencing platforms and third-party education materials, most commonly materials from the CNS. Additionally, most respondents indicated that their program has not redeployed residents in the care of COVID-19 positive patients. The results of the present study may assist program directors in developing a uniform resident curriculum and consider wellness initiatives during this time of crisis.
Article
Background Since January 2020, 3 months ago, when the pathogen causing the Coronavirus-disease was identified in humans, the literature on COVID-19 has grown exponentially to over 4000 publications. There is the need to provide an update for each single medical discipline, including neurosurgery, to be used by single professionals or to be distributed through the neurosurgical community and to be used by governments in designing new scenario of care. Methods A review of the MEDLINE database was performed on April 13th, 2020. Search terms included “COVID-19”, “neurosurgery,” and “surgery”. A review of documents published on the web-page of the WFNS and of the 5 continental associations of neurosurgical societies AANS, AASNS, CAANS, EANS, and FLANC representing the 119 national Neurosurgical Societies around the world was performed. Results The literature search yielded 38 results that were manually reviewed. Fourteen manuscripts were considered eligible. They described suggestions and considerations to optimize care of neurosurgical patients, editorials on operational models, perspectives from neurosurgical departments, letters to the editor describing experiences on how to help medical staff to be prepared in advance for pandemic situations, description of regional or departmental models and/or organizational schemes. The webpages of the searched societies reported a total of 57 documents. Conclusions The neurosurgical scientific community has promptly reacted to the COVID-19 outbreak by producing a growing number of documents that could serve as guidance for neurosurgeons all over the world. Neurosurgical Societies will represent the key-institutions for guiding the neurosurgical community to overcome the COVID-19 crisis.