Essential Spine Surgery During the COVID-19 Pandemic: A Comprehensive Framework for Clinical Practice from a Specialty Orthopedic Hospital in New York City.

Abstract

During the March 18, 2020, White House Coronavirus Task Force Press Briefing, representatives from the Centers for Medicare and Medicaid Services (CMS) and the US Surgeon General’s office announced a plan for all “elective” and “non-essential” surgeries and procedures to be delayed in order to enhance response to coronavirus disease 2019 (COVID-19) [21]. In the three-tiered CMS hierarchy, spine surgery was included in tier 2a, along with a recommendation to “consider postponing surgery” for “non-urgent spine” and “elective spine” procedures [8]. Deferring these services conserves beds, ventilators, personal protective equipment (PPE), and essential workforce and was therefore a priority for hospitals preparing for or experiencing a surge of patients with COVID-19. Postponing elective surgeries may have minimized additional risk of exposure through social distancing, further protecting patients and healthcare workers. The CMS recommendations outlined several factors that surgeons may consider, including patient risk, availability of beds, staff and equipment, and the urgency of the procedure, but they lacked a clear framework to assist operative decision-making. Translating the CMS recommendations into practical management and triaging of patients for surgical vs. non-surgical treatment have carried significant clinical and ethical challenges for spine surgeons. Which cases were “essential”? Which could wait? How could we temporize the condition of patients waiting for surgery during the surge of critically ill patients in the pandemic? Conversely, the decision to operate required comprehensive anesthetic and peri-operative protocols for patients with known or suspected COVID-19. Such protocols had to achieve dual goals of protecting patients and practitioners, while conserving PPE and hospital resources. Although evidence had accumulated from countries afflicted earlier in the pandemic, these protocols needed to be evaluated and adapted to suit the local hospital environment and they often raised more questions than they answered [7, 13, 22, 31]. How could we protect the vital medical workforce and ensure the safety of COVID-19-negative patients admitted for urgent-emergent surgery? How could we screen for disease when testing capability lagged testing demand, and how could we safely reintegrate essential staff after a period of quarantine or illness? Every surgery was accompanied by specific anesthetic risks which needed to be mitigated for optimal outcomes. However, unique additional challenges had to be addressed when caring for spine surgery patients during the surge phase of the pandemic. How could pre-operative evaluation and optimization be achieved while respecting social distancing orders? Could we safely use steroids and non-steroidal anti-inflammatories (NSAIDs) in COVID-19 patients? How could we safely intubate and extubate, particularly when spine surgery patients frequently require complex airway management? Finally, several issues surrounded the practical and ethical distribution of resources during the surge crisis. How could we consistently allocate peri-operative resources when planning for post-operative care and/or complications? This included not only intensive care unit (ICU) services and ventilators but also blood management in a time of progressive shortages, and allied physical therapy, nursing, and pain management services. As spine surgeons and anesthesiologists at a specialty orthopedic surgery hospital in New York City, we were confronted with these questions early in the pandemic. Here, we share our experiences in developing the Hospital for Special Surgery (HSS) Spine Care Institute’s response to the challenge of providing care at the leading edge of the COVID-19 pandemic. Key institutional, surgical, and anesthetic aspects of the response are presented and which when implemented together addressed the important questions raised here.