COVlD-19 pandemic:An update on the reaction attitude of the spine societies and their members worldwide

lNTRODUCTlON

With the start of the global pandemic of severe acute respiratory syndrome coronavirus 2(SARS-CoV-2)in December of 2019,governments and healthcare providers were put on alert,fearing this novel virus that would ultimately lead to the declaration of a global pandemic on March 11.

This naturally resulted in healthcare systems around the world bracing for impact.The biggest hurdle that these systems expected was the need to accommodate a huge surge of patients requiring intensive care(early data suggested that 15%-35% of patients affected with the virus would need admission to the intensive care units).This load would effectively break a healthcare system.

The scientific community has continued to study SARS-CoV-2 to understand its pathogenicity while also trying to avoid the collapse of the healthcare structure and decrease the number of collateral deaths.

Several studies on the recommendations have been published by the major spine scientific societies worldwide[1-5].The concluding observations of this review highlighted how these surgical scientific communities had promptly reacted to the emergency by issuing documents and guidelines.Here we review the literature concerning the release of documents,guidelines,or recommendations by spine societies,providing a comprehensive overview on these topics,thus providing a useful resource for spine surgeons worldwide.

MATERlALS AND METHODS

According to the PRISMA guidelines,a review of the MEDLINE database(PubMed-National Library of Medicine),Google,and Google scholar were performed on Monday,March 2,2020,to date,for articles published in the English language.Search terms included:COVID-19 coronavirus AND pandemic AND spine AND surgery AND spine societies AND guidelines AND recommendations(Figure 1).We reviewed search results to assess the relevance of documents on these topics,including editorials,letters,and webpages.References were reviewed to locate other articles of interest.

RESULTS

Twenty-eight associations and societies deal with the scientific aspects and interventional treatment of spine disorders.Spine associations and societies worldwide were divided into three groups:Continental(C)(= 8),specialty(Sb)(= 7),and country-based(Cb)(= 12)societies.There were eight Ccompanies(Table 1),but only three[North America Spine Society(NASS),World Spine Column Society(WSCS),Asia Pacific Spine Society]published guidelines in international scientific journals.The Sb societies(Table 2)seem not to have addressed the topic.Only the Spine Intervention Society(SIS)published an online paper on their website with its guidelines.Furthermore,the AO spine website shows different strategies for maintaining internal research and training.

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All 12 Cb(Table 3)produced a publication:seven in scientific journals(French Spine Surgery Society),Saudi Spine Society(Saudi SS),Singapore Spine Society,Chinese Spine Society,The Japanese Society for Spine Surgery and Related Research,Egyptian Spine Association,Brazilian Spine Society)and the remaining five in websites or editorial documents(British Association of Spine Surgeons,Italian Spine Society,Association of Spine Surgeons of India,German Spine Society,Canadian Spine Society).

Ramieri A and Miscusi M designed the research;Alshafeei O and Trungu S performed the research;Ramieri A and Alshafeei O analyzed the data;Alshafeei O and Ramieri A wrote the paper;Costanzo G and Raco A supervised the paper;all authors read and approved the final manuscript.

DlSCUSSlON

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Similarly,we wanted to verify the reaction of the worldwide spine societies to this emergency.This topic,to our knowledge,has not previously been addressed in the literature.Twenty-six associations,present on the web as companies or networks that deal with the interventional treatment of spinal pathologies,were identified.Three out of eight(37.5%)major continental companies(Saudi SS,NASS,WSCS)had issued guidelines in the form of scientific work in a journal or document.In particular,the NASS guidance,released on April 22,probably remains the most cited and applied document in subsequent scientific paper[21,26-28]:“”(see the entire document by the link in Table 2).The Asia Pacific society published a survey about the impact of a pandemic on surgical activity[11]:a total of 222 respondents from 19 countries completed the questionnaire.The mean reduction of clinic volume for all countries was 48.1%.Surgical theatres were closed,reduced,or limited to semi-emergency and emergency surgeries,and spine surgeons were moderately concerned about contracting COVID-19 during their clinical practice extremely concerned to transmit the disease to their family members.

Most Sb societies seem not to have addressed the topic.Only the SIS published a website document with its guidance.The AO spine website shows some corporate strategies for maintaining internal research and training.The greatest interest was from 12 Cb,with publications in journals,websites,or editorial documents.However,other regional societies are lacking.Four themes were seen recurring in our review of 28 articles relating to the new proposed guidelines and line of action.The highest recurring theme,which was seen in 100% of the articles,was the use of protective personal equipment and protocols to follow with COVID positive and COVID suspected patients to curb the spread and limit the transmission(Table 4).

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The second was the use of a multidisciplinary panel to evaluate each patient admitted and the urgency[8,9,13]:doctors would have to decide based on the COVID burden imposed on the healthcare system and hospitals[15,17,19,24].

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The third theme aimed to decrease the general activity of the healthcare system,increasing the number of hospital intensive care and departments able to treat infected people and the expected wave of patients.This topic was further discussed in detail the distinction of patients concerning their clinical picture and severity[20,22,23,25,27],given priority and urgency in treatment.

The fourth and last theme,which was seen only in seven articles,was the use of a team-based approach:each team could act independent,developing its own schedule and location,reducing work delay and decreasing the mixing of the different teams.A minimal effect on their department’s function was recorded.When viewing the Cb spine societies,we found different approaches to achieve similar objectives,ensuring a treatment activity on the most urgent patients or patients who cannot be postponed without increasing the risks of exposure or contact with the virus.

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Most of the approaches were directed towards a “second phase”,which defines a period when the healthcare system is not overburdened by the pandemic.One point shared was the distinction and separation of patients based on clinical urgency and COVID status,resulting in the avoidance of unneeded risk.Checklists and forms,along with history taking and evaluation of the physician to both the patient’s condition and the system’s utilization,were extremely useful.The evaluation of the system was carried out by taking into consideration risks and resources.These were respectively weighted on the patient’s history and system capabilities,for example,by checking the ability of a healthcare facility to deal with an emergency situation.Surgery was chosen only when possible and needed,while a deferral was preferred to elective and low urgency cases.To guarantee patients during the hospital stay,hygiene,self-isolation rules,and restrictions on companionship rules were adopted.Fast-track recovery and online follow-up restricted the number of unneeded people in the hospital.

CONCLUSlON

Only one-third of continental spine societies have issued recommendations.The international specialist companies have little addressed the topic,except for the SIS and partly the AO spine.Paradoxically,the national companies were more stimulated to issue their guidelines.The local epidemiological severity has likely influenced the reactive corporate attitude.Spine specialists at different levels realized the liability of not addressing spinal cases and the possible liabilities that could arise if taken up during a pandemic.Articles and online video conferences presented real-life scenarios that proved the gravity of the situation.The discussed guidelines and seminars showed their efficacy to control the spread of COVID-19 and the efficiency of the healthcare system.The points raised by the spine worldwide societies may not solve all issues related to spinal case management in the COVID era,but at least they have set forward a relevant ground to raise possible questions for the future’s sake,as well as the possibilities of reflecting upon these ideas on other similar areas of medicine.As a doctor of the Singaporean Spine Society commented,“We are all in the same storm,just different boats,and we should all work together to save each other”.

ARTlCLE HlGHLlGHTS

Research background

During the second phase of the coronavirus disease 2019(COVID-19)pandemic,some authors have felt the need to summarize and order data on the recommendations issued by the major surgical scientific societies in the world.The concluding observations of this review highlighted how these surgical scientific communities had promptly reacted to the emergency by issuing documents and guidelines.In particular,the neurosurgical scientific community has promptly developed recommendations for managing patients with cranial or spinal pathologies.

Research motivation

We designed a review of the literature concerning the release of documents,guidelines,or recommendations by the spine societies in the world,intending to offer an overview on these topics to which spine surgeons worldwide can easily refer.

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Research objectives

This study aimed to discuss the recommendations by many spine societies for the management of spinal diseases during the COVID-19 pandemic.

Research methods

A review of the MEDLINE database according to the PRISMA guidelines.

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Research results

Only one-third of continental spine societies have issued recommendations.The international specialist companies have dealt little or nothing with the topic,except the SIS and partly AO spine.Paradoxically,the national companies were more stimulated to issue their guidelines.The local epidemiological severity has likely influenced the reactive corporate attitude.

COVID-19,also known as acute respiratory disease,is an infectious respiratory disease caused by SARSCoV-2.The first cases were identified in China,and after that,diffused around the world through respiratory droplets,with a high lethality rate.In this scenario,the COVID-19 pandemic has changedmedical and surgical practices worldwide.Major scientific societies have issued guidelines and recommendations to optimize resources and ensure treatment without putting patients’ lives at risk.Urgent or non-deferrable emergency interventions were favoured,postponing those in the election but seeking their reactivation as soon as possible[6,10,12,14,18].These changes have had a significant socioeconomic impact.Specialty-based societies have also taken action,and in particular,the neurosurgical scientific community has promptly developed recommendations for managing patients with cranial or spinal pathologies[29].A group of Italian neurosurgeons summarized these guidelines in a recent publication[30].They discussed the “grey zone” left by the generalized guidelines regarding neurosurgery and how they should be acting to resume control.

Research conclusions

We identified 28 associations present on the Internet as companies or networks that deal with the interventional treatment of spinal pathologies.We distinguished societies,associations,or networks worldwide into three groups.The literature search yielded a sum of 28 articles that were relevant to spine surgery and COVID-19.

Research perspectives

Articles and online video conferences presented real-life scenarios that proved the gravity of the situation.The discussed guidelines and seminars showed their efficacy to control the spread of COVID-19 and the efficiency of the healthcare system.The discussing points by the spine worldwide societies may not solve all issues related to spinal case management in the COVID era,but at least they have set forward a relevant ground to raise possible questions for the future’s sake,as well as the possibilities of reflecting upon these ideas on other similar areas of medicine.

FOOTNOTES

The literature search yielded a sum of 28 articles that were relevant to spine surgery and coronavirus disease 2019(COVID-19)(Table 4).We were able to identify four main topics developed in these papers.

Alessandro Ramieri,Omar Alshafeei,Massimo Miscusi,Trungu Sokol,Antonino Raco,and Giuseppe Costanzo have nothing to disclose.

The authors have read the PRISMA 2009 Checklist,and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers.It is distributed in accordance with the Creative Commons Attribution Non-Commercial(CC BYNC 4.0)license,which permits others to distribute,remix,adapt,build upon this work non-commercially,and license their derivative works on different terms,provided the original work is properly cited,and the use is noncommercial.See:https://creativecommons.org/Licenses/by-nc/4.0/

Italy

Alessandro Ramieri 0000-0002-3504-7381;Omar Alshafeei 0000-0003-2012-3350;Sokol Trungu 0000-0002-5087-6006;Antonino Raco 0000-0001-8401-9339;Giuseppe Costanzo 0000-0003-3304-7078;Massimo Miscusi 0000-0002-5101-9073.

Wang JL

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Wang JL