Peer Review: Prioritizing Patients Post-COVID

We asked the SpineUniverse Editorial Board how they plan to prioritize their case backlog as COVID-19 pandemic restrictions begin to ease. Here’s what they said.

Ever wanted to get a question answered by some of the most preeminent spine specialists? Us too. That’s why we’re polling SpineUniverse Editorial Board members on questions of import every month. This month’s question:

As parts of North America are reopening amidst the coronavirus pandemic, how will you prioritize (or how have you prioritized) rescheduling cancelled appointments and surgeries? What sorts of patients or conditions will get priority? What sorts of challenges are you anticipating (or have already encountered)?

Prioritizing spine surgery post covid

As the country begins to open up, "elective" patients are gradually seen by the spine surgeons and physicians for various spinal conditions.  During the COVID-19 "lock-down," only the patients with emergency conditions such as unstable fractures, neurologic loss (eg, cauda equina syndrome), and infections were seen and taken care of. 

The first priority of seeing "elective" patients is the safety of the patients and caretakers.  The hospitals, clinics, and institutions must have safety measures in place to take care of the patients without jeopardizing COVID-19 infection, which includes careful planning the number and type of patients seen in the office, the clinics and peri-operative care with social distance, adequate COVID-19 testing, PPE, etc.

Increasingly, telemedicine is utilized to decrease the number of patients seen in the office and also for safety and convenience.  Secondly, the spinal conditions should be categorized as emergency, urgent, essential, elective, etc.  Some examples of urgent conditions are spinal tumors with impending neurologic loss, cervical and thoracic myelopathy with worse prognosis without prompt surgical intervention, etc.  

Howard An, MDAn example of essential surgery or procedure is microdiscectomy or epidural steroid injection for severe unrelenting radiculopathy despite non-invasive conservative treatment.  Elective procedures such as scoliosis correction, decompression, or fusion surgery can be delayed as long as the patient's neurologic condition is stable and the prognosis is not altered by performing the surgery at a later date. 

The challenge is that it is difficult to predict the short-term and long-term future regarding the prevalence of COVID-19 infection, resurgence with the country opening-up, the timing of availability of therapeutic drugs, and vaccine for the COVID-19 infection. 

Another challenge for academic medical centers is to perform clinical research and educate fellows, residents, and medical and allied health students as regular meetings, lectures, rounds, clinical clerkship, etc. have been decreased or modified due to the social distance issues. 

Despite these challenges, I am optimistic that the medical community will utilize many resources, technology, and sheer dedication to put the optimal patient care at the top of priority while continuing important medical research and education, which will ultimately serve to help improve the lives of patients.

Howard An, MD
Orthopedic surgeon
The Morton International Endowed Chair Professor of Orthopedic Surgery, Director Spine Fellowship Program, Rush University Medical Center, Chicago, Il.

 

We in San Diego have been fortunate as our COVID burden has been relatively low compared to other hot spots in California.  We are now starting to perform elective surgeries.  However, we are not allowing family members into the hospital.  Patients are dropped off in the lobby and the patients come up to surgery by themselves.  And, family are not allowed to visit while they are in the hospital as inpatients. 

Choll Kim, MD, PhD

This has led to a natural tendency to focus on surgeries that are ambulatory or short stay, as patients are reluctant to undergo elective surgeries where they may be in the hospital for several days without family and friends to help them get through the post-operative recovery.

 A poignant example is my effort treat patients with symptomatic degenerative scoliosis through “focal treatment”, focusing surgery on the most symptomatic portion of the curve, rather than the treating the entire curve.  The treatment of patients with complex deformities are challenging already.  Adding in the need to limit hospital stay in this group of patients remains the greatest challenge for me.   

Choll W. Kim, MD PhD
Spine Institute of San Diego

 

We have a large backlog of patients needing surgery for progressive scoliosis in particular in the skeletally immature pediatric population. These patients have been given priority for surgery over our adult patients with chronic pain and slowly progressive curves.

Barron Lonner MDI have been performing telemedicine video consults from the first week of the COVID-19 shutdown and have been able to remotely review X-rays and evaluate my patients in their home settings several days each week. We began operating on our priority patients during the last week in May and anticipate a very busy summer. Telemedicine will remain an important part of my practice going forward.

Baron Lonner, MD
Chief of Minimally Invasive Scoliosis Surgery Mount Sinai Hospital
Professor of Orthopaedic Surgery Icahn School of Medicine, New York City

 

Most of my practice, and I imagine similarly other spine surgeons, is essentially an “urgent elective” practice.  People don’t choose spine surgery flippantly-or they shouldn’t.  They usually are in severe pain and not enjoying life.  So one could make a reasonable argument that most spine surgery patients are already a top priority.  The hard thing is choosing which patients are higher priority than others. 

My criteria is : neurological deficit that is not likely to improve if surgery is delayed. The next criteria would be intractable pain causing inability to perform acts of daily living.  And then the next priority would be patients with myelopathy. 

Mark McLaughlin, MD

Ed Benzel once asked me at his infamous spine workshop out in Albuquerque “If someone is standing on your spinal cord, when would you like them to get off?” Obviously the answer is as soon as possible, but that can’t always be accomplished.  Patients need clearances and, unless they are rapidly deteriorating, they need to be COVID19 negative. Ed answered his own question with what I think is the most reasonable answer.  And that is: “When the window for surgical and medical safety is the widest open.”

As the pandemic number subside we will likely be back to doing the majority of our spine patient needs.

Mark R. McLaughlin, MD
Neurosurgeon
Princeton Brain, Spine & Sports Medicine, Princeton, NJ

 

I continued clinic throughout the pandemic but for 6 weeks it was telehealth. My case load dropped by about a third. I still offered surgery to patients with myelopathy or severe deficit. No one over 65 had surgery. In Reno, we’ve not had the East Coast experience. As we’ve opened, every patient gets tested- all negative. We’ve returned to normal surgery.

Lali Sekhon, MDThankfully I don’t have a full 2-3 months of backlog and within a month will be back on track. Summer for us typically slows down so that will soak up excess demand. Patients are keen to get things done and recovered before next winter. We are offering telehealth but 95% of patients want in-person visits. As a small- to medium-sized city, Reno and Northern Nevada got lucky. 

Lali Sekhon, MD, PhD, FACS, FAANS
Neurosurgeon
President, ThinkFirst of Northern Nevada
Clinical  Associate Professor, University of Nevada, Reno

Have a question you’d like to put to our Board? Email customer.service@spineuniverse.com with the subject line “EB Question,” or tweet us @spineuniverse and you may see your question featured in future installments!

Updated on: 06/19/20
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