Resource Utilization and Ethics of Urgent Orthopedic Spine Surgery During the COVID-19 Pandemic: A Case Report
Vol 6 | Issue 2 | July-December 2020 | page: 7-10 | Matthew J. Partan, Peter B. White, Randy M. Cohn, Gus Katsigiorgis, Kanwarpaul Grewal
Authors: Matthew J. Partan [1, 2], Peter B. White [1, 2], Randy M. Cohn [1, 3, 4], Gus Katsigiorgis [1, 4], Kanwarpaul Grewal [1, 2, 4]
 Department of Orthopaedic Surgery, Northwell Health Plainview Hospital, Plainview, NY, USA.
 Department of Orthopaedic Surgery, Huntington, Northwell Health Huntington Hospital, NY, USA.
 Donald and Barbara Zucker School of Medicine at Hofstra, Hempstead, NY, USA.  Department of Orthopaedic Surgery, Long Island Jewish Valley Stream Hospital, Valley Stream, NY, USA.
Address of Correspondence
Dr. Matthew J. Partan,
Department of Orthopaedic Surgery, Plainview Hospital, 888 Old Country Road, Plainview, NY, USA.
Introduction: Severe acute respiratory syndrome coronavirus-2 (SARs-CoV-2), also known as a coronavirus disease-19 (COVID-19), is a novel respiratory disease that has quickly surmounted to pandemic proportions. The purpose of this case report is to discuss the decision-making process, and resource utilization for spine cases that necessitate urgent surgical intervention in light of the COVID-19 pandemic.
Case Presentation: A twenty-five-year-old Hispanic male presented to an emergency department in Long Island, New York on March 30th, 2020 with incomplete cauda equina with altered bladder function. An MRI revealed a moderately large central disc extrusion of L4/5 with deformation at the ventral thecal sac which resulted in severe spinal stenosis. Given displacement of immediately available resources, the patient required a transfer to an affiliate hospital with readily available operating room staff.
Conclusion: From the time of initial presentation to the emergency room the patient was successfully transferred and brought to the operating room suite within eight hours. The patient underwent an L4/5 decompression and microdiscectomy for a large extruded disk herniation at L4/5 level without complications. With our healthcare system in the epicenter of the COVID-19 pandemic, we are in a unique environment exposed to the harsh characteristics of the surge. In parallel with similarly challenged organizations, our system quickly adapted and adopted various guidelines and committees to organize resource allocation. As demonstrated in this case, the displacement of immediately available resources, such as anesthesia staff, placed strain on the routine workings of surgical coordination. In normal times the decision-making in this case may seem straightforward; however, this case demonstrates the strains that the COVID-19 pandemic placed on our healthcare system especially with regards to surgical acuity, COVID-19 exposure risk and resource allocation.
Keywords: Cauda equine; Spine; Medical ethics; COVID-19.
1. Richardson S, Hirsch JS, Narasimhan M, et al. Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. JAMA. Published online April 22, 2020. doi:10.1001/jama.2020.6775.
2. Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19): cases in US. Accessed April 22nd, 2020. https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html.
3. Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. JAMA. Published online February 24, 2020.
4. Emmanuel EJ, Persad G, Upshur R, et al. Fair Allocation of Scare Medical Resources in the time of COVID-19. Published March 23,2020; DOI: 10.1056/NEJMsb2005114.
5. Cuomo, A., 2020. Executive Order: Continuing Temporary Suspension And Modification Of Laws Relating To The Disaster Emergency. [online] <https://www.governor.ny.gov/sites/governor.ny.gov/files/atoms/files/EO_202.10.pdf> [Accessed 18 April 2020].
6. Murphy, P., 2020. Executive Order 109. [online] <https://nj.gov/infobank/eo/056murphy/pdf/EO-109.pdf> [Accessed 18 April 2020]. (2020), Global guidance for surgical care during the COVID‐19 pandemic. Br J Surg. doi:10.1002/bjs.11646
7. ACS Statement on the Importance of Maintaining the Emergency Care System udring the COVID-19 Pandemic, http://facs.org/covid-19/clinical-guidance/statement-maintain; 2020 [accessed 20 April 2020].
8. Center for Medicare and Medicaid Services: Opening up America again. Accessed April 23rd, 2020. https://www.cms.gov/files/document/covid-flexibility-reopen-essential-non-covid-services.pdf
9. Center for Medicare and Medicaid Services, 2020. Non-Emergent, Elective Medical Services, And Treatment Recommendations. [online] Available at: <https://www.cms.gov/files/document/cms-non-emergent-elective-medical-recommendations.pdf> [Accessed 18 April 2020].
10. Pandemic influenza plan: 2017 update. Washington, DC: Department of Health and Human Services, 2017 (https://www.cdc.gov/flu/pandemic-resources/pdf/pan-flu-report-2017v2.pdf opens in new tab). Accessed April 20th, 2020.
11. Emanuel, Ezekiel J., et al. Fair Allocation of Scarce Medical Resources in the Time of COVID-19. NEJM: 2020; www.nejm.org/doi/full/10.1056/NEJMsb005114.
12. Dinning, T A. R., and H. R. Schaeffer. Discogenic Compression Of The Cauda Equina: A Surgical Emergency. ANZ Journal of Surgery; 1993(63): 927-924., doi: 10.111/j.1445-2197.1993.tb01721.x.
13. Chau AMT, Xu LL, Pelzer NR, Gragnaniello C. Timing of surgical intervention in cauda equina syndrome: a systematic critical review. World Neurosurg 2014;81:640–50.
14. N. V. Todd & R. A. Dickson (2016) Standards of care in cauda equina syndrome, British Journal of Neurosurgery, 30:5, 518-522.5
15. Srikandarajah N, Boissaud-Cooke MA, Clark S, Wilby MJ. Does early surgical decompression in cauda equina syndrome improve bladder outcome? Spine (Phila Pa 1976) 2015;40:580–3. doi:10.1097/BRS.000000 0000000813
16.Shapiro S. Medical realities of cauda equina syndrome secondary to lumbar disc herniation. Spine 2000;25:348–52.
17.Todd NV. Cauda equina syndrome: the timing of surgery probably does influence outcome. Br J Neurosurgery 2005;301–6.
18. Jerwood D, Todd NV. Re-analysis of the timing of cauda equina surgery. Br J Neurosurg 2006;20:178–9.
19. Todd NV. Causes and outcomes of cauda equina syndrome in medicolegal practice: a single neurosurgical experience of 40 consecutive cases. Br J Neurosurg 2011;25:503–8.
20. Gleave JRW, Macfarlane R. Cauda equina syndrome: what is the relationship between timing of surgery and outcome? Br J Neurosurg 2002; 16:325–8.
21. Gleave JRW, Macfarlane R. Prognosis for recovery of bladder function following lumbar central disc prolapse. Br J Neurosurg 1990;4:205–10
22. McLain RF, Agrawal BM, Silverstein MP. Acute cauda equina syndrome caused by a disk herniation-is emergent surgery the correct option? Surgical decompression remains the standard of care. Spine (Phila Pa 1976) 2015;40:639–41. doi:10.1097/BRS.0000000000000848.
23. Zhu, J., Ji, P., Pang, J., Zhong, Z., Li, H., He, C., Zhang, J. and Zhao, C., 2020. Clinical characteristics of 3,062 COVID-19 patients: a meta-analysis. Journal of Medical Virology,.
24. Bai Y, Yao L, Wei T. Presumed asymptomatic carrier transmission of COVID 19. JAMA. Epub ahead of press
25. Lie SA, Wong SW, Wong LT, Wong TGL, Chong SY. Practical considerations for performing regional anesthesia: lessons learned from the COVID-19 pandemic. Can J Anaesth. 202 Mar 24.
26. Lei S, Jang F, Su W, et al. Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection. EClinical Medicine. [Epub ahead of press]
27. The origin, transmission and clinical therapies on coronavirus disease 2019 (COVID-19) outbreak – an update on the status. Mil Med Res. 2020 Mar;7(1):11..
|How to Cite this article: Partan MJ, White PB, Cohn RM, Katsigiorgis G, Grewal K | Resource Utilization and Ethics of Urgent Orthopedic Spine Surgery During the COVID-19 Pandemic: A Case Report | Trauma International | July-December 2020; 6(2): —.|