The editorial below was published in the Vertebral Columns (Spring 2020), published quarterly by the International Society for the Advancement of Spine Surgery (ISASS).
Written by Dr. Kern Singh, Editor in Chief, Vertebral Columns
The first case of the novel coronavirus, COVID-19, in the United States was confirmed on January 14, 2020.¹ In 3 months, the spread exploded to the point that the United States now has nearly 4 times more cases of COVID-19 than any other country. By mid-April, more than 500,000 cases were reported in the United States, with more than 20,000 succumbing to the virus.¹ Based on data from March 17, case-fatality rates indicated anywhere between a 2.3% fatality rate in China to a 7.2% fatality rate in Italy.²
The pandemic has also resulted in a substantial economic crisis and potentially an unprecedented unemployment rate of 30%.3 Approximately 3.3 million people in the United States filed unemployment claims the week of March 21, and more than 65 million people are working jobs that are likely in jeopardy.3 About a month ago, the Dow Jones Industrial Average dropped approximately 25%, which is the second worst decline after the Great Depression.4 It is likely that more than 47 million jobs will be lost, ultimately leading to unemployment rates higher than that of the Great Depression.³
Information is limited regarding how contagious the disease is from asymptomatic infected individuals, but local and national government officials, hospital workers, and patients in the United States are doing whatever possible to slow the spread of the virus. However, much of the battle against COVID-19 has been hindered by the struggle to find adequate personal protective equipment (PPE). Healthcare workers have not been spared from the PPE shortage, with workers facing significant supply chain concerns with a shortage of N95 masks.5 In fact, some healthcare workers are being given a single mask to wear for indefinite periods, putting themselves, their families, and patients at risk.6
Elective surgeries are being cancelled or drastically reduced as a result of the pandemic.7 England’s National Health Service hospital system has suspended all nonurgent elective surgeries for a minimum of 3 months starting April 15.8 Stateside, we are observing similar trends to halt elective surgeries among health groups in an effort to slow the spread of COVID-19. In a recent report, National Coronavirus Response: A Roadmap to Reopening, Gottlieb et al recommend a 4-phase response, initially slowing the spread, moving to state-by-state reopening, reducing physical distancing once immune protection has been established, and finally rebuilding our readiness for the next pandemic.9
Currently we are in Phase I: slowing the transmission of COVID-19 to ensure the healthcare system can handle the patient burden. Protecting the functioning of our healthcare system requires that hospitals be able to rapidly respond to surges in demand. The reassignment of discretionary resources such as elective procedures is one of those requirements. Secondary to infection control, limited resources also require a revaluation of what is essential in the hospital. Unexpected postoperative patient stays, ventilation requirements, or intensive care unit visits all might come at the cost of removing capabilities to offer care for COVID-19 patients. The phrase “life over limb” has become ever more applicable. Chronic low back pain with radicular symptoms will now need to undergo more extensive empirical treatment with conservative therapy than before. Those complaining of saddle anesthesia, bladder and bowel incontinence, or trauma will consequently require emergent evaluation and surgery.
Once the initial spread of this disease is brought to a halt for roughly 2 weeks, we will move to Phase II, which will be characterized as the precautionary reopening of schools, businesses, and universities.9 Even during this time, significant discretion will be exercised with vulnerable populations, such as those older than 60 years and patients with compromised heart and lung function. Apart from the detrimental economic effects that we will have endured by this point, a major part of our precautionary management will likely entail a significant reduction in the number of elective procedures performed.
One possible silver lining of this delay in elective surgery could be the opportunity to optimize patients. Given the stressors of increasing unemployment, a global pandemic, and the corresponding uncertainty, a patient’s mental health will become critical to quality outcomes. Treatments such as cognitive behavioral therapy can be modified for telehealth and have been shown to reduce preoperative symptoms of anxiety and depression. Unfortunately, people will continue to require orthopedic surgery during this pandemic, and they may experience extended suffering given the current moratorium on elective surgery. How, then, do we best alleviate our patients’ pain and ensure quality outcomes while our operating room time is restricted?
We now have to reach into our bag of tricks to find social-distancing-appropriate methods of treating patients. Telehealth may have been on the back burner for years, but now it is thrusted into the forefront as an essential modality to evaluate, diagnose, and treat patients. Now more than ever we need to empower our patients with the knowledge and skills to manage their symptoms. Over the coming months, as we progress through summer and fall, we can expect a waxing and waning of this pandemic. We will slowly start to awaken from this protective hibernation, although the world we will return to will be different. With high unemployment rates and signs of economic recession, people may not have the financial means to undergo elective surgeries. The contraction of the market will entail a compensatory reduction in practices until economies start to recover. Until that recovery occurs, we will need to adapt our practices to adjust to the COVID-19 world.