Demand for Essential Nonambulatory Neurosurgical Care Decreased While Acuity of Care Increased During the Coronavirus Disease 2019 (COVID-19) Surge

Abstract

Background: In times of health resource reallocation, capacities must remain able to meet a continued demand for essential, nonambulatory neurosurgical acute care. This study sought to characterize the demand for and provision of neurosurgical acute care during the coronavirus disease 2019 (COVID-19) pandemic.

Methods: This single-center cross-sectional observational analysis compared nonambulatory neurosurgical consult encounters during the peri-surge period (March 9 to May 31, 2020) with those during an analogous period in 2019. Outcomes included consult volume, distribution of problem types, disease severity, and rate of acute operative intervention.

Results: A total of 1494 neurosurgical consults were analyzed. Amidst the pandemic surge, 583 consults were seen, which was 6.4 standard deviations below the mean among analogous 2016-2019 periods (mean 873; standard deviation 45, P = 0.001). Between 2019 and 2020, the proportion of degenerative spine consults decreased in favor of spinal trauma (25.6% vs. 34% and 51.9% vs. 41.4%, P = 0.088). Among aneurysmal subarachnoid hemorrhage cases, poor-grade (Hunt and Hess grades 4-5) presentations were more common (30% vs. 14.8%, P = 0.086). A greater proportion of pandemic era consults resulted in acute operative management, with an unchanged absolute frequency of acutely operative consults (123/583 [21.1%] vs. 120/911 [13.2%], P < 0.001).

Conclusions: Neurosurgical consult volume during the pandemic surge hit a 5-year institutional low. Amidst vast reallocation of health care resources, demand for high-acuity nonambulatory neurosurgical care continued and proportionally increased for greater-acuity pathologies. In our continued current pandemic as well as any future situations of mass health resource reallocation, neurosurgical acute care capacities must be preserved.

Keywords: Acute care neurosurgery; COVID-19 surge; Pandemic preparedness; Public health.

Figure 1

Volume of neurosurgical consults, 2016–2020. Line graphs of biweekly consult volume by year are plotted, scaled on the left-sided Y-axis (2020 in red). Vertical dotted lines indicate the instatement of lockdown measures on March 16, 2020, and Phase I Reopening on May 8, 2020, to contextualize data within the pandemic lockdown timeline. Line graphs of cumulative state coronavirus disease 2019 (COVID-19) cases (black) and state COVID-19 hospitalizations (brown) are overlaid to contextualize the data within the local pandemic surge (scaled on the right-sided Y-axis).

Figure 2

Breakdown of cranial and spine consults in 2019 versus 2020. There was an overall decrease in consult volume and a slight favoring of cranial consults over spine in 2020 (A). The distribution of cranial consults was largely unchanged between 2019 and 2020 cohorts (B). The distribution of spine consults showed a decrease in degenerative disc disease pathology in favor of spinal trauma (C).

Figure 3

Disease severity of traumatic brain injury (TBI) and aneurysmal subarachnoid hemorrhage (aSAH) consults in 2019 versus 2020. The severity of TBI consults did not vary between years (A), with Glasgow Coma Scale (GCS) score distribution remaining largely unchanged and continuing to involve mostly mild TBI (C). The severity of aSAH consults increased during the pandemic era (B), with a larger proportion of cases being rated poor-grade (Hunt and Hess [HH] 4–5) upon presentation (D).

Figure 4

Distribution of consult end points in 2019–2020. A larger proportion of consults resulted in acute operative management in the pandemic era, for both cranial (C) and spine (B) consults. The absolute frequency of acutely operative consults was unchanged between years. Note that (A) plots relative percentages of consults whereas panel (B) plots absolute numbers of consults with the corresponding percentages annotated.

Figure 5

A delayed presentation of giant pituitary adenoma resulting in pituitary apoplexy, hydrocephalus, and blindness. Computed tomography (CT) and magnetic resonance imaging (MRI) illustrates a case whose presentation was delayed in part due to the coronavirus disease 2019 (COVID-19) pandemic. In April of 2020, a 52-year-old male patient presented to an urgent care facility with a Glasgow Coma Scale (GCS) score of 15, reporting 1 week of progressively severe headache, blurry vision, somnolence, vomiting, dark urine, and fever refractory to antipyretics. He was swabbed for COVID-19, which was negative, and sent home. One week later, he presented to our emergency department with a GCS of 12, somnolent, and blind. Neurosurgery was consulted and workup revealed pituitary apoplexy and hydrocephalus due to a giant pituitary adenoma. Noncontrast CT brain (left) demonstrates a large hemorrhagic sellar mass obstructing the third ventricle, and resultant hydrocephalus. Postcontrast T1 MRI of the brain (right) demonstrates this mass to be compressing the hypothalamus and invading the cavernous and sphenoid sinus (ventricular system decompressed after interval external ventricular drain placement). The patient was taken for urgent surgery the same day and pathology confirmed giant pituitary adenoma, nonfunctioning, with apoplexy.