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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 2020–15th May 2020) compared to pre-COVID-19 (18th of January 2020–17th 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.
Neurosurgery and coronavirus: impact and challengeslessons
learnt from the first wave of a global pandemic
Keyoumars Ashkan
&Josephine Jung
&Alexandra Maria Velicu
&Ahmed Raslan
&Mohammed Faruque
Pandurang Kulkarni
&Cristina Bleil
&Harutomo Hasegawa
&Ahilan Kailaya-Vasan
&Eleni Maratos
Gordan Grahovac
&Francesco Vergani
&Bassel Zebian
&Sinan Barazi
&Irfan Malik
&David Bell
&Daniel Walsh
Ranjeev Bhangoo
&Christos Tolias
&Sanjeev Bassi
&Richard Selway
&Nick Thomas
&Christopher Chandler
Richard Gullan
Received: 22 September 2020 /Accepted: 12 November 2020
#The Author(s) 2020
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
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
Department of Neurosurgery, Kings College Hospital, Denmark
Hill, London SE5 9RS, UK
Neurosciences Clinical Trials Unit, Kings College Hospital,
London, UK
/ Published online: 21 November 2020
Acta Neurochirurgica (2021) 163:317–329
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
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.
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/
Rota change, guidelines, and operating theatre
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
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
318 Acta Neurochir (2021) 163:317–329
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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
Day 0 was the 04th of
March 2020
319Acta Neurochir (2021) 163:317–329
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Whitney Utest were used to assess the statistical significance
of observed differences between cohorts before and during the
COVID-19 pandemic.
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).
320 Acta Neurochir (2021) 163:317–329
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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
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)
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
Glasgow coma scale
321Acta Neurochir (2021) 163:317–329
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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
for Parkinsons disease/tremor 8 (2.0) 0 (0.0)
Intractable epilepsy/VNS
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)
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)
Deep brain stimulation
Vagal nerve stimulator
Metastatic spinal cord compression
Cerebrospinal fluid
322 Acta Neurochir (2021) 163:317–329
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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
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)
323Acta Neurochir (2021) 163:317–329
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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)
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
or AVF
2/4 0/4
Elective, clip/coil 8/9 0/0
Intracranial aneurysms 5/8 0/0
or AVF
3/1 0/0
Spinal MDT
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
Arteriovenous malformation
Arteriovenous fistula
Multidisciplinary team
324 Acta Neurochir (2021) 163:317–329
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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
), % 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)
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)
39 (11.9) 6 (5.9)
Treatment recommendation
Meningioma, total 93 34 p<0.05
Intervention (surgery/SRS
), % 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
), % 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.
Stereotactic radiosurgery
Chondrosarcoma, chordoma, craniopharyngioma, etc.
325Acta Neurochir (2021) 163:317–329
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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.
Impact of COVID-19 on neurosurgical referrals and
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
326 Acta Neurochir (2021) 163:317–329
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Table 6 Characteristics of neurosurgical patients with COVID-19 infection
Nr. Age, sex Ethnic group Admission Co-morbidities Diagnosis Procedure Complications ITU Outcome LoS
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)
327Acta Neurochir (2021) 163:317–329
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
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
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.
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
328 Acta Neurochir (2021) 163:317–329
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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
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
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
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... 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 In a study in India, it was reported that cranial surgery operations increased from 71.2% in the period before the COVID-19 to 88.7% during the pandemic, and the ratio of spinal cases decreased from 27.9% to 11.3%, which is statistically significant. 9 In Isfahan (Iran), the number of neurosurgery operations showed a decrease of 50%. ...
... 22,23 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 On the other hand, diagnostic procedures such as imaging and laboratory, in addition to the long queues, made patients act as disease carriers for surgeons and staff. 20,23 In the meantime, false negative results of screening tests also led to surgery, which greatly increased the risk of infection. ...
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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. Objectives: 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. Results: This 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. Conclusion: The outbreak of epidemics has different risks for specialties, among them neurosurgery. Accordingly, to observe patien
... A total of 659 patients who underwent neuro-operation were included in the study of Ashkan [32], 453 in the pre-COVID-19 period and 206 in the COVID-19 period. In the proportion of emergency operations, a signi cant increase was performed during COVID-19 (75.2%, n = 155) compared to pre-COVID-19 (n = 198, p < 0.001). ...
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Background The coronavirus disease-2019 (COVID-19) pandemic has created a global crisis unique to the health care system around the world. It also had a profound impact on the management of neurosurgical patients. In our research, we intended to investigate the effect of COVID-19 pandemic on neurosurgery, particular including vascular and oncological neurosurgery. Method Two investigators independently and systematically searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL) to identify relevant studies respecting the criteria for inclusion and exclusion published up to June 30th, 2022. The outcomes of our research including mortality rate, length of stay, modified Rankin Score, delay in care, Glasgow outcome scale and major complications. Results Two investigators independently and systematically searched 1270 results from PubMed, Embase, Cochrane database, and extracted the detailed data from 13 articles assessed for eligibility, including 2 intracerebral hemorrhage, five subarachnoid hemorrhage, two neuro-oncology and 2 unspecified neurosurgery. A total of 25,864 patients were included in our research. Conclusion Some of our included studies suggested that pandemic caused negative effect on the outcomes of neurosurgery while others suggested that the pandemic didn't cause significant effect on the neurosurgery. Meanwhile, the effect of pandemic on neurosurgery may differ from different region.
... Given that certain cancer patients during the non-pandemic period have shown that delayed surgical treatment is associated with worse overall survival, a balance is needed between the risk of postoperative complications and the risk of overall worse outcomes due to the primary disease (24). The patients who had concomitant comorbidities had postoperative complications or were more susceptible to postoperative infections (25). A large population study conducted in the United States that included 5,479 patients showed that patients who underwent surgery near the time of infection had an associated risk of postoperative pneumonia, respiratory failure, pulmonary embolism, and sepsis. ...
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Objective Over the past two years during the pandemic, the German health system has taken drastic measures, like the continuous use of face masks for all staff, restrictions of hospital visits as well as cancellation of elective surgical procedures. As a potential side effect of these measures, a significant reduction of surgical site infections was reported for neurosurgical patients. The purpose of our study was to analyze the impact of these measures on spinal surgery. Methods We performed a retrospective analysis to compare patient samples, procedures and infection rates before (January 2019 – March 2020) and during (April 2020 – June 2021) the pandemic to evaluate the impact of the measures mentioned above. Demographic and clinical data were collected and correlated with the occurrence of postoperative complications, especially infection. Results Our analysis showed no relevant decrease of spine surgeries (838 surgeries in non-pandemic group vs. 831 surgeries pandemic group). The most common postoperative complication was wound infection in both groups, followed by urinary tract infection and pneumonia. In both patient groups, infections were more prevalent in surgeries of multilevel posterior instrumentation. Comparing the two groups of patients, a slight, non-significant (0.5%) reduction of overall postoperative complications in the pandemic group was observed. However, the number of spinal surgeries classified as emergencies in our institution increased by 10.2% during the last 15 months of the COVID-19 pandemic. In line with this finding the urgent transfer of patients from smaller hospitals increased by 14.2%, compared to previous years. Conclusion The volume of spinal surgeries remained high and complication rates stable during the pandemic. A reason why complication rates did not drop as reported previously might be a significant change in patient sample due to the increase of emergency surgeries. A decrease of complication rates, especially infections by the measures of infection prevention for the pandemic was not observed.
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Abstract Background The coronavirus disease-2019 (COVID-19) pandemic has created a global crisis unique to the healthcare system around the world. It also had a profound impact on the management of neurosurgical patients. In our research, we investigated the effect of the COVID-19 pandemic on clinical outcomes in people undergoing neurosurgery, particularly vascular and oncological neurosurgery. Method Two investigators independently and systematically searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrail.Gov, and Web of Science to identify relevant studies respecting the criteria for inclusion and exclusion published up to June 30, 2022. The outcomes of our research included mortality rate, length of stay, modified Rankin Score, delay in care, Glasgow outcome scale, and major complications. The risk of bias was assessed using the Methodological Index for Non-randomized Studies (MINORS) checklist. Results Two investigators independently and systematically searched 1378 results from MEDLINE, EMBASE, Cochrane database, ClinicalTrail.Gov, and Web of Science and extracted the detailed data from 13 studies that met the review’s eligibility criteria. Two articles reported on patients with intracerebral hemorrhages, five on patients with subarachnoid hemorrhages, four on patients undergoing surgery for neuro-oncology, and in two studies the patients’ conditions were unspecified. A total of 26,831 patients were included in our research. The number who died was significantly increased in the COVID-19 pandemic group (OR 1.52, 95% CI 1.36–1.69, P
Background: The coronavirus disease 19 (COVID-19) pandemic affected all countries' health systems and people's lifestyles. In this study, we aimed to investigate its effects in a university hospital neurosurgery clinic. Methods: The 2019 year's six months' data as a pre-pandemic period compared to the 2020 year's same period as a pandemic date. Demographic data were collected. Operations were divided into seven groups: tumor, spinal, vascular, cerebrospinal fluid disorders, hematoma, local, and minor surgery respectively. We classified the hematoma cluster into subgroups to evaluate the etiology: epidural, acute subdural, subarachnoid hemorrhage, intracerebral hemorrhage, depressed skull fractures, and others. Patients' COVID-19 test results were collected. Results: Total operations decreased from 972 to 795 (Δ18.2%) during the pandemic. All groups, except minor surgery cases, decreased compared to the pre-pandemic period. Also, vascular procedures for females increased during the pandemic period. While focusing on the hematoma subgroups, there was decreasing in epidural and subdural hematomas, depressed skull fractures, and total case numbers; an increase in subarachnoid hemorrhage and intracerebral hemorrhage. Overall mortality significantly increased to 9.6% from 6.8% during the pandemic (p=0.033). Eight (1.0%) of 795 patients were COVID-19-positive; three of them died. Neurosurgery residents and academicians were unsatisfied with decreased number of operations, training, and research productivity. Conclusions: The pandemic and restrictions affected negatively the health system and people's access to healthcare. Our retrospective observational study aimed to evaluate these effects and take lessons for the next similar situations. People's access to health care should be considered when lockdown restrictions.
Introduction: The COVID19 pandemic had a strong impact on the healthcare system, particularly in oncology. Brain tumor are usually revealed by acute and life threatening symptoms. We wanted to evaluate the possible consequences of the COVID19 pandemic in 2020 on the activity of neuro-oncology multidisciplinary tumor board in a Normandy region (France). Methods: A descriptive, retrospective, multicenter study was conducted in the four referent centers (two universitary hospitals and two cancer centers). The main objective was to compare the average number of neuro-oncology patients presented per multidisciplinary tumor board per week between a pre-COVID19 reference period (period 1 from December 2018 to December 2019) and the pre-vaccination period (period 2 from December 2019 to November 2020). Results: Across Normandy, 1540 cases were presented in neuro-oncology multidisciplinary tumor board in 2019 and 2020. No difference was observed between period 1 and 2: respectively 9.8 per week versus 10.7, p=0.36. The number of cases per week also did not significantly differ during the lockdown periods: 9.1/week versus 10.4 during the non-lockdown periods, p=0.26. The only difference observed was a higher proportion of tumor resection during the lockdown periods: 81.4% (n=79/174) versus 64.5% (n=408/1366), p=0.001. Conclusion: The pre-vaccination era of the COVID19 pandemic did not impact the activity of neuro-oncology multidisciplinary tumor board in the Normandy region. The possible consequences in terms of public health (excess mortality) due to this tumor location should now be investigated.
The COVID-19 pandemic has had a significant impact on medical services. Many countries postponed nonemergent procedures to preserve hospital resources for the unprecedented situation. Surgical backlogs caused by the COVID-19 pandemic have been evaluated by different groups. However, the impact of this pandemic on pathology and specifically neuropathology (NP) services has received limited attention. In this study, we reviewed all NP reports of the London Health Sciences Centre from January 2018 (2 years before the pandemic declaration) until the end of the year 2021. Demographic information and pathology details were collected. For tumors, site, histopathology types, and WHO grading were analyzed. In nontumoral specimens, pathological diagnoses were compared in pre- and postpandemic time. The total number of NP samples reached its lowest in April 2020, corresponding to the first Ontario provincial lockdown, and fluctuated throughout the studied period. Among the different types of NP surgical specimens, muscle and epilepsy-related specimens showed a more significant reduction, compared to neoplastic specimens. In 2020, the proportion of tumor specimens from patients older than 40 years of age increased. Similarly, the proportion of high-grade glioma and brain metastasis diagnoses also increased. Lastly, we observed a marked increase in biopsies for temporal arteritis and other inflammatory lesions.
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BACKGROUND : The COVID-19 pandemic has left an indelible effect on healthcare delivery and education system, including residency training. Particularly, neurosurgical departments worldwide had to adapt their operating model to the constantly changing pandemic landscape. This review aimed to quantify the reduction in neurosurgical operative volume and describe the impact of these trends on neurosurgical residency training. METHODS : We performed a comprehensive search of PubMed and EMBASE between December 2019 and October 2022 to identify studies comparing pre-pandemic and pandemic neurosurgical caseloads as well as articles detailing the impact of COVID-19 on neurosurgery residency training. Statistical analysis of quantitative data was presented as pooled odds ratio (OR) and 95% confidence intervals (CI). RESULTS : A total of 49 studies met the inclusion criteria, of which 12 (24.5%) were survey-based. The case volume of elective surgeries and non-elective procedures decreased by 70.4% (OR=0.296, 95%CI 0.210–0.418) and 68.2% (OR=0.318, 95%CI 0.193–0.525), respectively. A significant decrease was also observed in functional (OR=0.542, 95%CI 0.394–0.746), spine (OR=0.545, 95%CI 0.409–0.725), and skull base surgery (OR=0.545, 95%CI 0.409–0.725), whereas the caseloads for tumor (OR=1.029, 95%CI 0.838–1.263), trauma (OR=1.021, 95%CI 0.846–1.232), vascular (OR=1.001, 95%CI 0.870–1.152), and pediatric neurosurgery (OR=0.589, 95%CI 0.344–1.010) remained relatively the same between pre-pandemic and pandemic periods. The reduction in caseloads had caused concerns among residents and program directors in regard to the diminished clinical exposure, financial constraints, and mental well-being. Some positives highlighted were rapid adaptation to virtual educational platforms and increasing time for self-learning and research activities. CONCLUSION : While COVID-19 has brought about significant disruptions in neurosurgical practice and training, this unprecedented challenge has opened the door for technological advances and collaboration that broaden the accessibility of resources and reduce the worldwide gap in neurosurgical education.
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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.
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Background Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 or Covid-19), which began as an epidemic in China and spread globally as a pandemic, has necessitated resource management to meet emergency needs of Covid-19 patients and other emergent cases. We have conducted a survey to analyze caseload and measures to adapt indications for a perception of crisis.Methods We constructed a questionnaire to survey a snapshot of neurosurgical activity, resources, and indications during 1 week with usual activity in December 2019 and 1 week during SARS-CoV-2 pandemic in March 2020. The questionnaire was sent to 34 neurosurgical departments in Europe; 25 departments returned responses within 5 days.ResultsWe found unexpectedly large differences in resources and indications already before the pandemic. Differences were also large in how much practice and resources changed during the pandemic. Neurosurgical beds and neuro-intensive care beds were significantly decreased from December 2019 to March 2020. The utilization of resources decreased via less demand for care of brain injuries and subarachnoid hemorrhage, postponing surgery and changed surgical indications as a method of rationing resources. Twenty departments (80%) reduced activity extensively, and the same proportion stated that they were no longer able to provide care according to legitimate medical needs.Conclusion Neurosurgical centers responded swiftly and effectively to a sudden decrease of neurosurgical capacity due to relocation of resources to pandemic care. The pandemic led to rationing of neurosurgical care in 80% of responding centers. We saw a relation between resources before the pandemic and ability to uphold neurosurgical services. The observation of extensive differences of available beds provided an opportunity to show how resources that had been restricted already under normal conditions translated to rationing of care that may not be acceptable to the public of seemingly affluent European countries.
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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.
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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
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Background The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 82·6% (219 of 265) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p<0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p<0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p<0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Interpretation Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research.
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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.
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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.
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.
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.
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.