What’s Important: Managing the Impact of Coronavirus on Pediatric Spine Surgery

Coronavirus disease 2019 (COVID-19) impacts all involved in the delivery of health care, including patients, surgeons and care team members, hospitals, insurance companies, and many others. At the time of this writing, some parts of the U.S. have been without elective pediatric spine surgery for >9 weeks. The waiting list for surgeons continues to grow in anticipation of the safe return to elective surgical procedures. In the present article, we offer our thoughts on the rescheduling of pediatric spine procedures in the wake of COVID-19. Outside of the U.S., both the U.K. and Canada have publicly funded health-care systems that use a waiting list for surgical treatment of pediatric spinal deformity; however, studies suggest that a waiting time of >6 months puts patients with idiopathic scoliosis at risk of deformity progression, especially those who are skeletally immature, with a Risser stage of 0 or open triradiate cartilage1. Delayed intervention is associated with needing additional surgical procedures, prolonged operative times, greater blood loss, and increased likelihood of an adverse event2–4. In addition, there is the negative impact that surgical delay has on the patient and the family. Patients with longer waiting times have demonstrated lower Scoliosis Research Society scores, specifically in the pain, satisfaction with management, and self-image domains5. As the number of cancelled cases increases as a result of the need for social distancing to “flatten the curve” and prioritize personal protective equipment for frontline workers, surgeons must begin to think how we will prioritize surgical procedures once the go-ahead is given for elective procedures. Recently published literature suggests that dedicated teams for pediatric spinal fusion operations can reduce cost and operative time6,7. Will health-care systems be willing to partner with surgeons to provide these teams during off-hours and weekends? Such partnerships could potentially help decrease waiting times, minimize an increase in surgical case complexity by limiting postponement, optimize family-member social distancing while in the hospital, and improve overall access to care for patients. The prioritization of pediatric spinal deformity procedures is a complex undertaking. Although many families historically pick surgical dates that are based on school, sport seasons, or vacation schedules, we support the creation of a new urgency list to help guide rescheduling while also minimizing potential risk to patients. Cases would be categorized as follows: Class 1, Emergency; Class 2, Urgent (<2 months); Class 3, Semi-Urgent (2 to 4 months); and Class 4, Elective (4 to 6 months) (Table I). TABLE I - Pediatric Spine Surgery Urgency List During the COVID-19 Pandemic* Class 1 Class 2 Class 3 Class 4 Indication Cauda equina and/or nerve-root deterioration Epidural abscess Unstable spine fractures Myelopathic pathology (e.g., tumor and instability) Tumor resection timed with chemotherapy and/or radiation Early-onset scoliosis growing instrumentation insertion Adolescent idiopathic spine fusions (R0, open triradiate cartilage, Sander 3) Fusion in traction Mehta casting Chest-wall expansion Early onset scoliosis growing instrumentation lengthening Adolescent idiopathic scoliosis posterior spine fusion (R1-R4) Stiff neuromuscular scoliosis posterior spine fusion Early onset scoliosis growing instrumentation final fusion Adolescent idiopathic scoliosis posterior spine fusion, R5 Flexible neuromuscular scoliosis posterior spine fusion *Class 1 = emergency cases, Class 2 = urgent cases requiring surgical intervention within 2 months, Class 3 = semi-urgent cases requiring surgical intervention in between 2 and 4 months, and Class 4 = elective cases requiring surgical intervention in 4 to 6 months. We recognize that the phrase “safe return to elective surgery” cannot be applied uniformly across all patients. For example, a healthy patient with adolescent idiopathic scoliosis and a curve of 50° is an inherently different surgical patient than a patient with neuromuscular scoliosis, a 75° curve, and 30° of pelvic obliquity, and who is assessed as Gross Motor Function Classification System (GMFCS) level 5 with medical comorbidities and is in need of the intensive care unit postoperatively. In the setting of the COVID-19 pandemic, a prolonged hospitalization for a child with early-onset scoliosis and poor pulmonary reserve or a child with neuromuscular scoliosis who has serious medical comorbidities could result in a poor respiratory outcome were they to contract COVID-19 perioperatively. A fine balance must be struck when weighing the risk of delaying deformity procedures against the frailty of the patient because the potential complications of a perioperative COVID-19 infection may be worse than a more complex operation months to years later, albeit with an increased complication profile. Being mindful of virus activity, we believe it is prudent to balance the relative risk to the patient outcome against the local activity of the virus (Fig. 1). Class-1, emergency cases should continue with appropriate caution, utilizing preoperative COVID-19 testing and personal protective equipment as indicated. Class-2, urgent cases should be performed when (1) indications appear that the local COVID-19 curve is flattening and (2) the risk has decreased that children’s hospitals would need to be utilized to offload patients with COVID-19. Class-3, semi-urgent cases, in which a delay of several months will result in a less-optimal clinical outcome, should occur further on the downslope, closer to the nadir of the local epidemiologic curve. Class-4, elective cases that might require a prolonged stay in the intensive care unit, that will be more intensive in the usage of health-care resources, or that involve children with competing risks of medical conditions, or cases for which the outcome will be no different if delayed up to 6 months should wait until the nadir of the current pandemic.Fig. 1: Prevalence of COVID-19 and the prioritization of pediatric spine surgery.Spine surgeons who treat adult patients have attempted to create a similar algorithm for surgeon and/or hospital guidance; however, that algorithm revolves around saving neurologic function and diminishing pain, whereas the algorithm in the present study focuses on minimizing risk and complexity, preserving pulmonary function, managing infection, preventing neurologic injury, and limiting additional fusion levels8. A system such as this could be described in any practice or set of circumstances, with additional guidance provided by the American Academy of Orthopaedic Surgeons9. Difficult conversations lie ahead when we must explain to patients that their July 2020 operation date, scheduled in October 2019, may no longer be possible. The fear of the unknown regarding surgical timing is understandably anxiety-provoking for patients and families, as evidenced by the increasing number of emails, calls, and electronic medical record messages about surgical rescheduling. Seattle Children’s Hospital dealt with an operating-room closure because of an Aspergillus outbreak at the end of 2019. Thus, the situation we find ourselves in during 2020 may have been managed previously, albeit on a much smaller scale, giving us an opportunity to learn from past experience and limit repeat mistakes. Flexibility with scheduling, based on the prevalence of COVID-19, will be paramount moving forward. Whenever we turn the corner, having a plan of action to ramp up in a safe and organized fashion will benefit everyone: the health system, surgeons, care teams, and, most importantly, patients.

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