The Impact of the COVID-19 Pandemic on Spine Surgery in Central Europe: A Questionnaire-Based Study

Objective The severe acute respiratory coronavirus 2 (SARS-CoV2) crisis led to many restrictions in daily life and protective health care actions in all hospitals to ensure basic medical supply. This questionnaire-based study among spinal surgeons in central Europe was generated to investigate the impact of coronavirus disease 2019 (COVID-19) and consecutively the differences in restrictions in spinal surgery units. Methods An online survey consisting of 32 questions on the impact of the COVID-19 pandemic and the related restrictions on spinal surgery units was created. Surgical fellows and consultants from neurosurgical, orthopedic, and trauma departments were included in our questionnaire-based study with the help of Austrian, German, and Swiss scientific societies. Results In a total of 406 completed questionnaires, most participants reported increased preventive measurements at daily clinical work (split-team work schedule [44%], cancellation of elective and/or semielective surgeries [91%]), reduced occurrence of emergencies (91%), decreased outpatient work (45%) with increased telemedical care (73%) and a reduced availability of medical equipment (75%) as well as medical staff (30%). Although most physicians considered the political restrictive decisions to be not suitable, most considered the medical measures to be appropriate. Conclusions The COVID-19 pandemic resulted in comparable restrictive measures for spinal surgical departments in central Europe. Elective surgical interventions were reduced, providing additional resources reserved for severe acute respiratory coronavirus 2–positive patients. Although similar restrictions were introduced in most participants' departments, the supply of personal protective equipment and the outpatient care remained insufficient and should be re-evaluated intensively for future global health care crises.

The Impact of the COVID-19 Pandemic on Spine Surgery in Central Europe: A Questionnaire-Based Study Anto Abramovic 1 , Sara Lener 1 , Lukas Grassner 1 , Martin Thaler 2 , Daniel Pinggera 1 , Christian F. Freyschlag 1 , Claudius Thomé 1 , Sebastian Hartmann 1 -OBJECTIVE: The severe acute respiratory coronavirus 2 (SARS-CoV2) crisis led to many restrictions in daily life and protective health care actions in all hospitals to ensure basic medical supply. This questionnaire-based study among spinal surgeons in central Europe was generated to investigate the impact of coronavirus disease 2019  and consecutively the differences in restrictions in spinal surgery units.
-METHODS: An online survey consisting of 32 questions on the impact of the COVID-19 pandemic and the related restrictions on spinal surgery units was created. Surgical fellows and consultants from neurosurgical, orthopedic, and trauma departments were included in our questionnairebased study with the help of Austrian, German, and Swiss scientific societies.
-RESULTS: In a total of 406 completed questionnaires, most participants reported increased preventive measurements at daily clinical work (split-team work schedule [44%], cancellation of elective and/or semielective surgeries [91%]), reduced occurrence of emergencies (91%), decreased outpatient work (45%) with increased telemedical care (73%) and a reduced availability of medical equipment (75%) as well as medical staff (30%). Although most physicians considered the political restrictive decisions to be not suitable, most considered the medical measures to be appropriate.
-CONCLUSIONS: The COVID-19 pandemic resulted in comparable restrictive measures for spinal surgical departments in central Europe. Elective surgical interventions were reduced, providing additional resources reserved for severe acute respiratory coronavirus 2epositive patients. Although similar restrictions were introduced in most participants' departments, the supply of personal protective equipment and the outpatient care remained insufficient and should be re-evaluated intensively for future global health care crises. INTRODUCTION 2 020 was marked mainly by the sudden appearance and rapid spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV2). 1 In approximately 20% of the infected patients, especially those at high risk (>50 years old, previous cardiovascular diseases, and diabetes mellitus), symptoms may deteriorate quickly, leading to respiratory failure, with the requirement of mechanical ventilation. 1 Rarely, healthy patients without relevant preexisting comorbidities may show severe courses of coronavirus disease 2019 (COVID- 19) infections, sometimes resulting even in death. 2,3 On March 3, 2020 the World Health Organization defined a case fatality rate of approximately 3.4%, which has been adjusted to 2%e3% according to recent literature. 4,5 On February 25, the first 2 cases of COVID-19 were identified in Austria. Since then, a chain of prevention measures has been activated, which in some cases led to a near-total lockdown of the system, in which public life was restricted and work bans issued ( Figure 1).
As a result of this development, many hospitals in central Europe, particularly in Italy, decided to reduce elective patient care to empty normal wards, especially intensive care units (ICUs) of all disciplines, which were kept free to be prepared for COVID-19e positive patients. In addition, personal protective equipment (PPE) was upgraded, and specialized training to handle SARS-CoV2e positive patients was implemented in some institutions. Because of these constraints, the COVID-19 pandemic was linked to enormous changes in many departments, so that surgical procedures were gradually reduced and elective surgeries were cancelled or postponed.
There has not been a clear consensus regarding the workflow of surgical departments during the initial COVID-19 peak, and hence, many hospitals or even single departments within a hospital association set up their own and individual COVID-19 guidelines, which changed daily during the most critical episode of the pandemic. Based on the absence of any guidelines, we developed a questionnaire-based study to assess the differences of spinal surgery units in central Europe regarding the impact of the spread of this pandemic as well as the preventive measures taken by the departments. The results of this questionnaire study may be used as a basis for a consensus of spine centers for future pandemics.

METHODS
An online survey consisting of 32 questions on the impact of the COVID-19 pandemic and the related restrictions of spinal surgical departments using a software-based survey creation tool (Survey-Monkey, San Mateo, California, USA) was developed. The survey was based on a previously established questionnaire for orthopedic surgery, 6 with additional adaptations where needed. All surgeon contacts were provided by the German Spine Society (Deutsche Wirbelsäulengesellschaft), German Society for Neurosurgery (Deutsche Gesellschaft für Neurochirurgie), Austrian Spine Society (Österreichische Gesellschaft für Wirbelsäulenchirurgie), Austrian Society for Neurosurgery (Österreichische Gesellschaft für Neurochirurgie), Swiss Society for Neurosurgery (Schweizerischen Gesellschaft für Neurochirurgie), and Swiss Society of Spinal Surgery (Schweizerische Gesellschaft für spinale Chirurgie) or by an online invitation using social media (e.g., Twitter). Surgical fellows as well as surgical consultants from neurosurgical, orthopedic, and trauma departments were included in our study. Apart from basic questions (age group, gender, number of inhabitants of the work place, and specialty), the survey contained questions regarding the influence of COVID-19 on private as well as on daily working life (restrictions in the operating theater, communication, and daily visits) and the effect on the outpatient clinic (e.g., appointment allocation, emergency calls, and follow-up visits) as well as medical staff preventions (systematic SARS-CoV2 tests, PPE, and specialized COVID-19 training). The online questionnaire was carried out from April 2 to 16. During this period, all participating countries were in lockdown. The responses were represented in relative and absolute numbers as a function of total replies.

RESULTS
A total of 406 completed individual responses were obtained. Of the attending surgeons, 80% were located in Germany, 13% in Austria, and 7% in Switzerland. Most surgeons worked in cities with >200,000 inhabitants (42%) or smaller towns with <50,000 inhabitants (20%). Most the participants were men (88%). Most of the attending surgeons were aged between 45 and 54 years (33%) followed by 55 and 64 (29%) and 35 and 44 years (28%). The subspecialty of most of the surgeons was neurosurgery in 70%, and 30% of the respondees were orthopedic/trauma surgeons. Approximately 50% of the surgeons worked in public hospitals and 25% in university hospitals or private hospitals, respectively. Only a few surgeons worked in private practice.

The Influence of COVID-19 on Everyday Work Life
Of the respondees, 83% reported a reduced workload as a result of the restrictive measures at their hospital. The number of performed surgeries decreased in 95% of the participants' hospitals and led to more administrative work (or research) in 44%. The pandemic also had an impact on the training of surgical fellows, so that 41% of the specialists stated that teaching or training were suspended during the COVID-19 pandemic.
In approximately 50% of the surgeons, the sudden development of SARS-CoV2 led to the cancellation of all elective as well as semielective procedures ( Figure 2). Of surgeons, 6% performed only urgent or emergency operations, and 36% and 67% postponed lumbar disc or decompression surgery with minor symptoms (muscular deficit >3/5) and elective spinal instrumentations, respectively ( Figure 3). Surgical interventions for severe diseases (spinal tumors/vertebral body fracture with a sensorimotor deficit) were performed without any restriction in most participants.

COVID-19 and the Impact on Outpatient Clinic
Of the respondees, 45% reported that only patients with acute spinal diseases (fracture, infection, and neurologic deficits) were referred to an outpatient clinic and received a clinical examination. More than 50% of the centers implemented a screening questionnaire, if patients had visited COVID-19 hot spots or if flulike symptoms were present in recent weeks ( Table 1). If there was doubt, most institutes tested their patients for SARS-CoV2 before the outpatient clinical visit and especially in cases of hospitalization. Because of these circumstances, 90% of the participants noticed a reduced number of patients with degenerative spinal diseases in outpatient clinics. The same effect was found for degenerative disc disease in approximately 70% of participants. A clear reduction in emergencies was noticed by most surgeons, 70% of whom stated this as a consequence of the restrictive measures in public life ( Table 1). According to 62% of

ORIGINAL ARTICLE
the respondents, the number of nonemergent clinical presentations decreased significantly. This situation even meant that patients with a definite indication for surgical intervention did not visit the outpatient clinic because of concerns about infection (43%) or an additional burden for the hospital workload (20%) ( Table 1).
To ensure and to maintain the usual patient care, 73% of the respondees (20%) provided telephone consultation or offered video conferences for their patients ( Figure 4). Face-to-face clinical presentations were continued in approximately 35% of the participants.

Measures to Protect Patients and Staff
Systematic staff testing for SARS-CoV2 was carried out in 9% of the respondents' departments, whereas random sampling tests were provided in 14%. Of the participants, 69% reported already having treated SARS-CoV2epositive patients, whereas another 60% reported SARS-CoV2ecoworkers in the medical field and 25% had SARS-CoV2epositive nonmedical coworkers (e.g., administration) ( Figure 5). Of participants, 18% did not have any positive cases of SARS-CoV2 at their institution. The main problems of the COVID-19 pandemic were represented by a reduced supply of PPE or medical gear in general in 75% of the respondees (e.g., because of delivery problems), a lack of regular intensive care unit resources (27%), and reduced number of employees at their department (30%).
More than 70% of the respondents stated that they already had an individual COVID-19 screening outpatient clinic at their hospital as well as general wards and ICU beds for SARS-CoV2e positive patients at the time of the survey. In one third of the participants, an operating theater was kept free especially for COVID-19epositive patients. To ensure adequate patient care, 56% of the respondents reported specialized training for the treatment and management of SARS-CoV2epositive patients. What are the concrete effects of the COVID-19 pandemic on your outpatient clinics?
All patients are questioned about clinical symptoms and must complete a questionnaire before the examination 50 208 Only patients with acute symptoms (fracture, infection, neurological deficits) are examined in our outpatient clinic 45 189 Patients with clinical symptoms and/or positive screening are tested for SARS-CoV-2 37 153 No changes in our outpatient clinic 6 2 4 Other 14 59 Does the COVID-19 pandemic affect your regular business meetings?
Reduced staff in the meetings 48 201 No more meetings are held 20 84 All personnel participate in the meetings with the necessary distance from each other 12 48 Meetings take place exclusively online via video conferences 9 38 All personnel attend the meetings with protective clothing (masks, coats, etc.) 6 23 No impact on our department 3 1 2 What has changed in the emergency volume in your department?
Reduced number of cases due to burden/risk reduction due to the temporary restrictions in public life 70 290 Unnecessary ideas that otherwise occupy us are omitted 62 256 Necessary presentations are made by the patients out of fear of infection 43 180 Reduced number of cases due to lack of absorption capacity or keeping reserves free 32 135 Necessary conceptions on the part of the patients are not carried out due to concern for the load of the system 20 83 Face-to-face team meetings no longer took place for 20% of the respondees, and meetings with a reduced staff were performed in 50% ( Table 1). A medical split team was introduced in 60% of all spine surgeons' departments and all employees were equipped with individual protective clothing (surgical masks, protective coats, gloves, and shoes). Although the physicians reported that they were mainly provided with surgical masks and gloves on the general ward, the ICU was clearly better equipped with surgical caps and FFP2 and 3 masks as well as disposable coats.

The Influence of COVID-19 on Spinal Surgeons' Private Life
One of the biggest concerns of many surgeons is related to potential infections of close relatives. Of respondees, 71% reported more frequent hand disinfection and increased awareness at work in general, whereas 48% of the respondees did not take any additional precautions at home ( Table 1). Of the participants, 12% tried to avoid close contact with other family members at home and a few (2%) decided to live in a hotel/apartment/second residence during the COVID-19 pandemic to protect their family members.

DISCUSSION
The rapid development of the COVID-19 pandemic is partly responsible for the fact that many hospitals had to decide autonomously on their restrictive measures, because there were no available guidelines. In the initial phase, it could be assumed that spinal surgical practice, which includes both elective and emergency surgery as well as the management of inpatient and outpatient clinics, was put on individual and sometimes uncoordinated rapidly changing restrictive measures.
The results of our questionnaire show the significant impact of COVID-19 both in private life and in working life. Only 11% of the participants reported that they had no positive cases in their hospital or close environment. More frequent hand disinfection and a generally more cautious approach to potential sources of infection were typical behaviors seen in most respondents, although this should be part of our daily practice. In addition to the personal protective measures to prevent infection of patients or themselves, a clear change of private hygienic habits was also noticed. Most respondents stated that they minimized contact with their family members, reducing the risk of infection. Previous studies have shown increased concerns of safety at work in spinal surgical departments during the COVID-19 pandemic. 7 The lack of knowledge combined with weekly or even daily changes in political as well as medical facilities regarding the disease itself and preventive measures may arouse concerns in many employees. 8,9 This finding highlights the importance of information about the potential infection, with adequate preparation and structured training to maintain the self-confidence and safety of the team.
For capacity reasons, the availability of internal or neurologic COVID-19 ICU or general ward resources was often extended to surgical departments, so that isolation of surgical units took place. Consequently, operations could no longer be carried out. Because of the rapid spread of the disease, elective surgeries had to be cancelled or at least postponed and the operating room schedule was reduced to a minimum in about half of the respondents to create the necessary resources for SARS-CoV2epositive patients and to block the necessary anesthesiologic resources (Figure 2). 7,10 Further, surgical equipment such as masks or surgical gloves had to be saved because of a delivery bottleneck. 11 Many elective procedures without acute symptoms were postponed, whereas emergencies, such as vertebral body fractures with motor deficits, were still performed in most of the respondees' institutes. During the beginning of the pandemic or even during the stepwise lockdown of the operative program, it was recommended to perform smaller surgical (minimally invasive) interventions to keep the surgical time as short as possible to reduce the patient's hospitalization to a minimum. 12 Patients scheduled for spine surgery are typically older, with several comorbidities, often leading to an extended postoperative inpatient stay, which could increase the risk of nosocomial SARS-CoV2 infection. 13 A clear elaboration of the triage of patients for spinal surgery was developed during the COVID-19 pandemic, so that spinal diseases were categorized into 3 groups with different recommendations regarding the timing of surgery ( Figure 6). 14 Similar scenarios of surgical reduction and preventive measurements have also been reported for joint arthroplasty, musculoskeletal tumor surgery, and arthroscopic procedures. [15][16][17] The strict reduction of the elective surgical program and especially outpatient clinics has led to a "post-COVID-19 run," with an approximately 15%e20% increased patient presentation with spinal emergencies. As the questionnaire showed, patients with a clear indication for surgical intervention did not visit the outpatient clinic because of concerns of infection (43%) or additional burden for the hospital workload (20%). Most patients with a clear surgical indication did not receive an appointment in the outpatient department and had to come to the clinic as an emergency. As a result, many patients with true emergencies did not obtain an appointment and waited until reopening, so that in some cases, serious clinical symptoms worsened, with resultant progression of disease.
The outpatient clinics were reduced to a minimum in most departments. Approximately 50% of all respondees reported that they examined only acute emergencies. In general, a significantly reduced patient volume in the outpatient clinics during the strict lockdown as a result of a reduced number of accidents and the fear of SARS-CoV2 contamination was observed. To guarantee sufficient patient care despite the precarious situation, a screening questionnaire before the clinical visit in the outpatient clinic was introduced in our department. Patients with suspected SARS-CoV2 infection were potentially identified before any kind of physical contact.
Despite all precautionary measures and previous planning, the rapid increase of infections in Europe led to production difficulties and delivery bottlenecks of PPE, which was also present in our hospital at the time of the survey. 18 A shortage of PPE for medical staff means not only an additional threat to the health care system but also an increased risk for patients in outpatient clinics and general wards. The results of the survey showed that 60% of the participants already had positive cases in medical staff in their hospital. Because of the frequent mild or even asymptomatic course of a SARS-CoV2 infection, equipping medical staff is one of the key issues for successfully handling such a pandemic. 19,20 A recent study 21 has shown an increased number of infections among medical staff in Wuhan because of lack of or insufficient PPE.
In many departments, a split-team working plan with 2 groups, which usually changed every week, was introduced. 22 If there was a SARS-CoV2epositive case within 1 team, the other group could stand in and continue the clinical work. Additional measures led to a reduction of internal team meetings and clinical teaching. Therefore, alternative methods of teaching or team meetings (e.g., webinars and mail contact) were introduced. The same was true for public events, such as congresses. Nevertheless, COVID-19e specific training was performed for only 56% of the study participants, which is similar to recent results. 23 This fact does not only form additional psychological stress for health care workers but could also lead to increased infection rates among health care workers.
Not strictly necessary face-to-face contacts between patients and clinicians were replaced by telemedical renewals in most of the attending spine surgeons. The advantage of a well-developed telemedical network should be considered especially during pandemic crises. 24 In addition to telephone consultations, technological progress enables us to provide video conferences and online questionnaires to record the type and severity of the patient's symptoms and categorize the necessity of further clinical or imaging examination as well as the need for a clinical presentation in cases of an emergency. 25 This situation may provide alternative ways of patient contact to economize the medical system in future decades. 26 The purpose of this study was to capture the measures that have been adopted to reduce the intrahospital spread of COVID-19 and to prepare for a potential surge of patients with coronavirus during the first wave in 2020 in the DACH (Germany [D], Austria [A], and Switzerland [CH]) region. Although these countries have a similar management in everyday treatment of patients scheduled for spine surgery precisely because of their shared professional societies, the COVID-19 crisis was the first to show such divergence of individual measures, representing the surgical, inpatient, and outpatient settings. In addition to predictable reasons, such as the highly variable impact of COVID-19 on different regions, there is still no definite answer to some of the difficulties and problems that are shown in this study. The results of this study should serve as an incentive for German-speaking spinal surgical societies to develop guidelines based on studies such as ours to manage future pandemics in an even more optimized manner.

Limitations
This study has several weaknesses, which limit the validity of the results. First, because of the anonymization of the data, the questionnaire did not allow backtracking of the individual answers to a certain hospital or country, and hence, an in-depth analysis of country-specific or hospital-specific measures was not possible. Because of the high response rate of spine surgeons from Germany and the limitation of a country-specific analysis, the results may be distorted because most responses are from Germany.

CONCLUSIONS
Despite the lack of clear guidelines among spine centers during the initial pandemic peak, the results of this questionnaire study show a clear trend regarding the use of personal protective issues (hand disinfection and PPE), a lower incidence of nonemergency patients in outpatient departments, and a clear reduction of the surgical program, as well as the establishment of specific COVID-19 measures in high-volume spine centers across central Europe.

QUESTIONNAIRE COVID-19: SPINE
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We would like you to take about 6 minutes to complete an online survey about the COVID-19 pandemic and the impact on your patients and workplace.
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