Formal guidelines to guide future public health concerns needed

The study predicts changes in clinical practice and establishment of Telemedicine.

The international study identifies regional variations, the infection rate, and raises awareness of the needs and challenges facing spine surgeons. It provides a foundation to establish interventions and guidelines for future public health crises. Almost 100% of the community are calling for formal guidelines. The study predicts changes in clinical practice and establishment of Telemedicine.

This is team science at its best and underscores the importance of this topic.

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Replies were received from a record number of over 900 surgeons worldwide. “This is team science at its best and underscores the importance of this topic," says Principal Investigator, AO Spine Research Commission Chair Dino Samartzis. "People are working together in synergy across borders, speaking the same language with a deeper appreciation for life during this period of immense uncertainly and challenging demands that mimic a war-time scenario."

"The rapid responses from the AO Spine community has been overwhelming," says AO Spine's Global Research Manager, Niccole Germscheid, "members eagerly sharing their insights and advice regarding the COVID-19 crisis amplifies the need for formal guidelines."

Many spine surgeons have multiple co-morbidities and report immense anxiety during this time.

The forgotten soldiers

Samartzis finds the preliminary data poignant and sobering and says, "In today’s climate, the surgeon is often the forgotten soldier." The survey notes a 1% infection rate of COVID-19 among spine surgeons. This might increase in time, but it shows surgeons are also vulnerable to this virus. "It underscores the fact that spine surgeons are not Teflon. Some surgeons noted they were conflicted that if infected with the virus, whether they should disclose such information to their patients," Samartzis adds.

As medical professionals that deal with delicate aspects of the body’s structure and function, spine surgeons have specific needs and concerns. Samartzis is alarmed with the finding that personal protective equipment (PPE) are not standard and available to all worldwide. In fact, the study further noted that many spine surgeons have multiple co-morbidities and report immense anxiety during this time, something that Samartzis further notes to be “a recipe for disaster if they ever do get infected with COVID-19 because they would fall into a high-risk group for complications.”    

"Most of us have never faced a pandemic like COVID-19," states Philip Louie, one of the study developers from New York City, USA. "The outbreak has resulted in widespread work stoppages, hospital-wide reorganizations, drastic changes in societal norms, and raised amounts of anxiety and uncertainty for everyone."

What are we looking at?

The survey looked specifically at six domains: demographics, COVID-19 observations, preparedness, personal impact, patient care, and future perceptions. It highlights the immediate reactions of authorities and how they impact treatment of patients. What will the outcomes be from postponing elective surgery, changing operating theaters into intensive care units, scarcity of PPE, or healthcare worker shortages? What changes will we see in the treatment of patients, in behavior, or through digitalization?

The survey also provides insights on what is going through the minds of spine surgeons, what are their greatest stressors, and what advice or encouragement they can give to their fellow colleagues and patients.

The survey provides insights on what is going through the minds of spine surgeons.

"Surgeons are not able to operate on patients they feel need surgery without considering the massive constraints on scarce resources and added risk of infection for their patients," Dan Sciubba from Johns Hopkins University, representing North America in the Research Commission says. "COVID-19 is not the only thing hurting patients. Those with cancer, heart disease, and other chronic illnesses still need our steadfast support. We cannot abandon these important and vulnerable patients."

Marcelo Valacco, from Buenos Aires, Argentina, Research Commission member representing Latin America, adds important considerations on how to propagate confidence to the entire surgical team, and how to avoid spreading the virus after being exposed to infected or potentially infected patients. "This puts surgeons and their families at risk in ways never experienced before. And then there are the economic issues, especially facing private practice."

Since Asia was hit first, Jason Cheung from Hong Kong, representing Asia Pacific in the Research Commission, has longer experience. "We could share experiences how we managed to stay afloat with our work while keeping our families safe and helping others." Cheung wants to better understand the cultural differences in the way we face this virus. "Are we actually over-reacting compared to others? Did others take on the same model as we did? Are we continuing to provide care for those in need of spine care?"

Going on, the AO Spine study seeks to learn about the financial impacts, how government leaderships and media have handled COVID-19, the transitions in patient care, and surgeons' personal well-being.

The world will change—but how?

This will change
the world.

The virus will have an unexpected long-term impact on our lives and work, economies, and international relationships. Different reactions from governments, hospitals, health authorities, local culture, and economies will all have an impact on the survival of people and on healthcare systems.

"This will change the world," Marko Neva, Research Commission member representing Europe and Southern Africa from Tampere, Finland, predicts. "That is why it is so important to do this study now and at various stages of the pandemic, to understand the impact to our spine surgeon community, treatment of patients, research, education of students and residents, and to compare outcomes of different reactions to it."

Mohammad El-Sharkawi, Chairperson AO Spine Middle East and Northern Africa from Assiut, Egypt, agrees that the pandemic will change every aspect of our lives. "It will affect how surgeons consult and treat their patients. Telemedicine must be established, regulated, and legalized, with fair compensation methods for doctors and surgeons."

Sciubba also thinks Telemedicine is here to stay. "Some have proposed the benefits of telemedicine for years, but now it is battle-tested and in many places, flourishing."

"The results can also aid conversations on how we could be a united healthcare profession when it comes time to restart and rebuild our medical practices and society as a whole," Louie says.

Similarities despite differences

While there are variations in societal restrictions imposed by governments, the initial results show similarities with the suspension of elective cases for an undefined time. The overall case volume has dramatically decreased for most spine surgeons and many are using more time for research and teaching. Lectures and seminars have been transferred online; the appeal for online education is astronomical.

The appeal for online education is astronomical.

On the other hand, one in four surgeons are taking on medical roles outside of their standard practice of care. Many are volunteering to work in "dirty wards", which means putting your family at risk.

Based on the survey, Louie says the number one stressor impacting surgeons' lives is health, on a personal, family, and community level. He further noted some interesting free-text responses in the survey whereby he summed up the statements as “heartwarming, soul searching, encouraging, and brutally honest." Other stressors include economic hardships, the uncertainty, and the timeline in which their lives and medical practices will even begin to resemble anything like a normal life.

This is a time-out to reconnect with family and for personal growth, as well as reassess priorities in life.

In this time of uncertainty, most surgeons are spending time with their families. "Overall, our spine community has expressed sentiments of optimism, perseverance, determination, and unity," Samartzis says. "They noted that this is a period of time-out to reconnect with family and for personal growth, as well as reassess their priorities in life. It was evident that in many aspects, we as a community have more in common than differences. There is an underling thread of humanity that crosses all borders."

AO Spine study assessing the impact of COVID-19 on spine surgeons around the world was developed by Dino Samartzis (PI, Chair, AO Spine International Research Commission), Philip Louie, Mike McCarthy, Howard S. An, Garrett Harada, Regional Research Chairs (Jason Cheung, Marko Neva, Marcelo Valacco, and Dan Sciubba), Norman Chutkan (Chair, AO Spine Community Development), and Niccole Germscheid (AO Spine Global Research Manager).

AO Spine thanks you all for taking the time to participate in the survey and for sharing your experiences. Follow-up surveys of the respondents may be circulated to address the long-term impact of COVID-19. Information gained will provide insight into the effects of such public health concerns upon the community. Results will be published in scientific journals, the AO Spine Newsletter, and on our website.