Introduction

The coronavirus disease 2019 (COVID-19) pandemic caused due to 2019 novel coronavirus (severe acute respiratory syndrome coronavirus 2) has threatened the human civilization1. Coronavirus infection was first identified in India on January 30, 2020, linked to China.2 The number of cases and transmission increased during subsequent months mostly linked with a travel history to affected countries and close contacts of infected individuals. On March 12, 2020, it was declared as a global pandemic by WHO (World Health Organization). On March 24, 2020, the Prime Minister of India declared a nationwide lockdown for 21 days, affecting 1.3 billion people of India.2 3 In India, till now lockdown has been implicated in four phases, viz., lockdown 1 (March 25, 2020 to April 14, 2020), lockdown 2 (April 15, 2020 to May 3, 2020), lockdown 3 (May 4, 2020 to May 17, 2020), and lockdown 4 (May 18, 2020 to May 31, 2020). During these lockdown periods, all the outpatient departments (OPDs) and elective surgeries were temporarily suspended in government hospitals. This lockdown and COVID-19 pandemic has imposed a striking repercussion on the neurosurgery specialty. Management protocol for patient care coming to neurosurgical emergency is very critical for the safety of both the health care workers (HCWs) (including neurosurgeons, nurses, and hospital sanitary staff) and the patient party. This study aims at determining the magnitude of repercussion of COVID-19 pandemic on neurosurgical specialty and formulate a management approach for better management and safety of neurosurgeons and other health care staff keeping in mind the constraints and limitations in a government hospital of a developing country.

Material and Methods

This combined retrospective and prospective study was done in neurosurgical specialty of IMS–BHU, Varanasi, India, a tertiary care center, between January 1, 2020 and May 31, 2020. Retrospective data were collected from medical and surgical records before lockdown (i.e., from January 1, 2020 to March 24, 2020). Thereafter, data were collected prospectively from March 25, 2020 till May 31, 2020 during lockdown 1 to 4.

Four timelines were considered for evaluating the repercussion of COVID-19 pandemic on neurosurgical specialty. These were: (1) before pandemic (January 1, 2020 to February 29, 2020), (2) during pandemic before lockdown (March 1, 2020 to March 24, 2020), (3) Lockdown 1 and 2 (March 25, 2020 to May 3, 2020) with total lockdown, and (4) Lockdown 3 and 4 (May 4, 2020 to May 31, 2020) with relaxations. Analysis of impact on neurosurgical emergency was done considering admissions, mode of injury, total number of surgeries, number of cranial surgeries, number of spinal surgeries, number of conservatively managed cases, and mortality over these four timelines.

For impact on elective neurosurgical cases, OPD attendance/Telemedicine OPD attendance, OPD admissions/Telemedicine OPD admissions, total number of elective surgeries, number of elective cranial surgeries, and number of elective spinal surgeries, mortality and discharges were analyzed before COVID-19 pandemic, before lockdown and during lockdown timeline.

Psychological and physical impacts on 50 HCWs (including neurosurgeons, nursing, and ground staff) based on common interview format were also analyzed. We also tried to determine the repercussion of COVID-19 pandemic on neurosurgical patients and their relatives by interviewing 88 patients and relatives attending our trauma center casualty. Consent was taken from all and their identities were not revealed.

Effect of COVID-19 pandemic on residency training was also evaluated. Virtual classes and webinars as an alternative to actual neurosurgical resident training were assessed. For this seven senior residents and six consultants of our department were given questionnaires regarding participation in neurosurgical virtual learning activities, paying fees to participate in webinars, increase/decrease in participation in neurosurgical virtual learning activities, participation in international/national organized virtual learning activity, change in practice based on what they learned from these activities, improvement of skills based on virtual learning, increased communication with professional colleagues, opportunities provided, future participation in virtual learning, and alteration in neurosurgical training and education strategies.

All patients coming to the casualty were triaged for suspected COVID-19 infection as per our institutional protocol (Fig. 1). As report of COVID-19 testing is available in 24 to 48 hours at our center so to safeguard the patient and the HCWs including neurosurgeons, we used an algorithmic approach to handle such cases (Fig. 1). Detailed account of management approach is dealt with in discussion.

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Fig. 1 Management algorithm of neurosurgical emergency patient in COVID-19 pandemic. (COVID designated wards are wards where COVID-19 suspected patients are quarantined and treated). COVID-19, coronavirus disease 2019.

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Fig. 1 Management algorithm of neurosurgical emergency patient in COVID-19 pandemic. (COVID designated wards are wards where COVID-19 suspected patients are quarantined and treated). COVID-19, coronavirus disease 2019.

Statistical tests were done using GraphPad Prism version 8.3.0 software. The data were summarized using medians/mean and counts and percentages for continuous and categorical variables, respectively. Ordinary one-way ANOVA (analysis of variance) and unpaired t-test were used according to data analyzed. p < 0.05 was considered statistically significant.

Results

Total number of patients admitted in neurotrauma within 2 months before the pandemic in January and February were 493. On an average, 8.22 patients were admitted during this time period. However, during pandemic before the lockdown was enacted in India, i.e., between March 1, 2010 and March 25, 2020, a total of 202 patients with admission rate of 8.42 patients per day was evident. After lockdown these figures reduced to 128 admissions (3.2/d) during lockdown 1 and 2 and to 150 admissions (5.36/d) during lockdown 3 and 4 (Table 1). There was significant reduction in neurotrauma admission rate during lockdown (p < 0.0001) at our center (Table 1).

There appears to be an increase in physical assault as mode of injury when compared with earlier values. However, no significant difference between modes of injury was found (p = 0.8318) on comparing the four timelines (Table 1). There was significant decrease in cranial injury (p < 0.0001) and spinal injury (p < 0.0001) admissions in neurotrauma at our center. Number of surgeries performed in emergency also suffered significant reduction (p < 0.0001) during lockdown (Table 1). Number of conservatively managed patients (p < 0.0001) and mortality (p < 0.0001) also were significantly reduced, respectively (Table 1).

During COVID-19 pandemic, 0.8 cases per day and before pandemic 1.56 cases per day were the average rates of surgery. There was 76% reduction in emergency neurosurgical cases during pandemic.

Neurosurgery OPD attendance per day was on an average of 166 patients during January and February (before pandemic), 133 patients during pandemic but before lockdown and 15 patients in Telemedicine OPD, respectively. During lockdown OPD, elective admissions and surgeries were suspended and Telemedicine OPD was started and semiemergent/emergency cases were admitted via telemedicine OPD and operated (Table 2). There was a significant reduction in OPD attendance per day (p < 0.0001), OPD admissions per day (p < 0.0001), total elective surgeries (p < 0.0001), cranial and spinal surgeries (each p < 0.0001) and elective mortality (p < 0.0001), and discharges (p < 0.0001) during these three timelines (Table 2).

Of all cases operated on emergency basis, EDH (33.7%), contusions (23.9%), and acute SDH (14.1%) constituted the majority of cases before pandemic. Similarly, EDH (27%), contusions (23%), and acute SDH (17.6%) were the most common emergency cases operated during pandemic (Table 3). No significant difference was found between the patterns of diagnosis of operated patients (p = 0.8943).

Of 50 neurosurgical team members (neurosurgeons, nursing and ground staff) interviewed, 90% of them had fear of contacting the COVID-19 disease, fear of well-being of family and children, and difficulty in transport. Other common psychological impacts of COVID-19 on them were lack of satisfaction with protective gears provided (78%), suffocating feeling in PPE kit (40%), breathing difficulty while using N95 mask (30%), anxiety (24%), and depression (10%) (Table 4). Of 88 patients and attendants interviewed, all of them (100%) were having fear and anxiety of contacting the COVID-19 disease and were having difficulty in getting food and necessary transportation for patient. Most of them were having difficulty in getting shelters near hospital (81.8%) and were having difficulty in follow-up after discharge (71.6%) (Table 4).

Impact of virtual learning and webinars on neurosurgical training was assessed on 13 neurosurgeons (residents + consultants) and most of them (84.6%) were willing to participate in such activities and had perhaps increased their participation in such activities in this pandemic era. They agreed on future participation in such activities (84.6%) and admitted that virtual learning and webinars increase communication with professional colleagues (Table 5). Only three neurosurgeons (23.1%) agreed on change in practice based on what they learned from these activities and only two of them (15.4%) accepted improvement of skills based on virtual learning (Table 5).

Discussion

The clinical presentation of COVID-19 disease ranges from mild, moderate to severe disease. Severity of disease is heralded by severe pneumonia, acute respiratory distress syndrome, and septicemia progressing to septic shock. Coronavirus infection may also present as asymptomatic carrier state. Elderly and immunocompromised patients may show atypical symptoms. Usual presentations are fever, breathlessness, sore throat, dry cough, and generalized malaise and weakness.9 The progression of disease is attributed to cytokine storm (IL2 or interleukin-2, IL10, TNFα etc.).10 Studies have reported that intensive care unit (ICU) requirements in these symptomatic patients vary from 25 to 30%. Recovery starts from 2nd to 3rd week. Mortality associated with this disease varies from 2 to 3%.11

Any person presenting with the above mentioned symptoms with history of international/containment/hotspot zone travelling or having contacts with positive COVID-19 cases or persons having similar travelling history are suspected cases of COVID-19. However, asymptomatic and afebrile cases have been also reported.12 RT-PCR (reverse transcription polymerase chain reaction) for COVID-19 virus on secretions of nasopharyngeal and pharyngeal region, tracheal/endotracheal aspirates, and bronchoalveolar lavage sample is the investigation of choice for confirming COVID-19 infection.12 The leucocyte count is normal or low (leukopenia) in severe disease. The C-reactive protein and erythrocyte sedimentation rate are usually raised but procalcitonin levels are generally normal which may be raised if a bacterial co-infection is present. Higher levels of aminotransferase, prothrombin time, serum creatinine, D-dimer, ferritin, and lactate dehydrogenase are attributed to the severity of disease.12

The chest X-ray usually depicts findings of pulmonary infiltrates present bilaterally in late course of disease. The sensitivity and specificity of computed tomography scan (CT scan) of lungs are more with findings of bilateral pulmonary infiltrates and ground glass opacification. Subsegmental pulmonary consolidation may be present. Abnormal CT scans are utilized to diagnose coronavirus disease in suspected patients that have initially negative RT-PCR reports.13 Treatment is mainly symptomatic and supportive.14 As there is no proven or recommended treatment for coronavirus infection, main aim is to emphasize and practice prevention guidelines. There is substantial risk of transmission of COVID-19 infection to HCWs.15

In this study, there was significant reduction in neurotrauma admission rate, number of cranial and spinal injury cases, total number of emergency surgeries performed, number of conservatively managed cases, and mortality during lockdown phases when compared with prelockdown time. This can be attributed to restrictions on people for use of vehicle or other transport means and road/rail/air travel leading to a marked reduction in the incidence of accidents and neurotrauma. Moreover, limiting people to their homes by enacting law has also reduced neurotrauma cases. There was no significant difference between patterns of diagnosis of operated patients.

In this study, neurosurgical electives were the most affected due to pandemic as OPDs and elective surgery was completely shut down during the lockdown period as per government guidelines and later Telemedicine OPDs were started to help neurosurgical patients. This has worsened the prognosis of elective neurosurgical patients due to delay in elective surgery. This also had bad impact on neurosurgery resident training modules and practice. Though the use of online teaching modules as well as webinars had tried to fill neurosurgical teaching gap but most neurosurgical trainees were of the opinion that still practical aspects and operative part were neglected. Moreover, these were poor substitutes for conventional well-established training. In our study, only 23.1% of neurosurgeons agreed on change in practice based on what they learned from these activities and only 15.4% accepted improvement of skills based on virtual learning.

Health care workers are trained to work under stress. But COVID-19 pandemic is posing a significant effect on their mental health. Tan et al16 studied the impact of the COVID-19 pandemic on psychology of health care and found that prevalence of anxiety was 8.9%, depression was 6.6%, and clinical concern of PTSD was 7.7% in their study. In our study, most (90%) of the neurosurgical health care providers had fear of contacting the COVID-19 disease and had fear of well-being of family and children and difficulty in transport. Anxiety was present in 24% and depression was present in 10% of the interviewed neurosurgery health care providers at our center. Therefore, psychological counseling to health care staff is as important as providing adequate personal protective gears for effective functioning.

At most of the centers, teams of neurosurgeons have been utilized as an intensive care specialist, patients are shifted in non-COVID wards, protocols for testing all patients ahead of neurosurgical procedures have been implemented, and hospitals have been rearranged to “hub-and-spoke” pattern to limit neurosurgery to selected centers.17 18 Recent studies have reported a decrease of more than 50% in their neurosurgical operative numbers worldwide during this pandemic.19 We found a drop of 76% in neurosurgical emergency operated cases during pandemic.

Since personal protective equipment are in limited quantity, the safety of HCWs is a valid reason to operate only emergency procedures.20 The “Stanford protocol” whistled an alert during endonasal surgeries during the pandemic, quoting a transsphenoidal operation done in Wuhan, China where more than a dozen members of the operating team got infected due to coronavirus spread from nasopharyngeal and oropharyngeal regions.21 This has raised concerns regarding the use of endonasal procedures in neurosurgical procedures.

Impacts on patients and their attendants are also considerable. In our study, all of them were having fear of contacting the COVID-19 disease and were having difficulty in getting food and necessary transportation for patient. Proper rehabilitation and care of them is a challenge during this phase of COVID-19 pandemic.

Neurosurgeons should screen their remedial action in the light of any new requests put upon by their administrations. They should keep on auditing their own practices and results, recognizing and featuring any deficiencies emerging out of the current emergency.22

Conclusion

The COVID-19 pandemic is having a significant repercussion on health care facilities all over the world. For conserving resources elective surgical procedures should be limited. Only emergency and semi-emergency neurosurgical cases should be operated. All of the emergency surgical load is reduced in this lockdown period. This pandemic has also a negative impact on neurosurgical resident training program and psychology of both neurosurgical unit and patients. A strategic scheme for management approach should be created for sensible triaging of emergent neurosurgical cases keeping in mind the constraints, so neurosurgeons can keep on serving their patients without hurting them either neurologically through deferring medical or surgical procedure, or by superfluously presenting them to the coronavirus infection at the zenith of the COVID-19 disease surge.