Letter to the Editor Regarding “Perioperative COVID-19 Incidence and Outcomes in Neurosurgical Patients at Two Tertiary Care Centers in Washington, DC, During a Pandemic: A 6-Month Follow-up”

Letter:

We read with great interest the article published in your respected journal by Sarpong et al.¹ entitled “Perioperative COVID-19 Incidence and Outcomes in Neurosurgical Patients at Two Tertiary Care Centers in Washington, DC, During a Pandemic: A 6-month Follow-up,” where the authors evaluated the perioperative incidence of coronavirus disease 2019 (COVID-19) in neurosurgery patients, as well as their respective evolution. During their study, they obtained a perioperative incidence of COVID-19 of 5.4% at the peak of the pandemic and 2.9% in the postpeak period. In addition, the authors found out that having an age younger than 65 years (odds ratio [OR] 7.027; 95% confidence interval [CI] 2.50–24.76; P = 0.0007), having an emergency procedure (OR 2.617; 95% CI 1.108–6.370; P = 0.0300), having a hospital stay longer than 7 days (OR 5.669; 95% CI 1.502–21.98; P = 0.0104), and non-domiciliary discharge (OR 13.12; 95% CI 3.494–64.38; P = 0.0005) are independent factors associated with positivity for COVID-19. In this way, innovative evidence was presented on factors linked to contagion during the in-hospital flow of neurosurgical patients, which must be taken into account for future decision-making. Finally, it was observed that incidence rates remain low despite the increase in the volume of patients, which supports the effectiveness of general and specialized measures adopted in the different centers to minimize the spread of this disease.¹ We thank Sarpong et al.¹ for providing this valuable information. However, we would like to add a few comments.

One of the major concerns in medical–surgical specialties during the current pandemic is the inherent contagion mechanism that can occur in the midst of invasive intervention, especially not being sure which patients are infected and asymptomatic and who are not. Because of this, various scientific societies have expressed themselves and have materialized proposals through clinical practice guidelines to provide guidance that safeguards the integrity of all participants in the different care scenarios.² Diaz et al.³ indicate that care centers are responsible for adapting their protection policies according to the needs of the population demand; this means that it is necessary to continue investigating the aspects that influence the prognosis of neurologic patients to guarantee their functional capacity, since those patients neuro-operated with COVID-19 or who develop this condition during the postoperative period tend to present complications.^{1 , 3} Recommendations such as those presented by Zheng et al.² emphasize that perioperative care measures should be extrapolated to other surgical fields, such as neurosurgery, due to the absence of personalized evidence but the imperative need to achieve the best clinical results. The authors state that there is greater mortality in patients who are diagnosed with COVID-19 after surgery than before. In addition, patients who are suspected or positive for severe acute respiratory distress syndrome coronavirus 2 infection have a longer period of surgery, a greater requirement for oxygen therapy and hospital stay, and a lower survival rate at 30 days.² In this sense, it can be said that at all times of neurointervention, personal protective equipment must be arranged, so that both doctors, assistants, and patients properly carry these instruments without hindering the procedure. It is also necessary to carry out screening tests on all patients who go to elective surgery to define the risk of surgery, medium-term prognosis, emergent management, and the individual's own needs during the perioperative and postoperative period.

In an attractive way, Tan et al.⁴ proposed recommendations adapted to the specialty of neurosurgery, such as to facilitate the movement of patients and the availability of the surgical field, expert neurosurgeons should be the ones who carry out the interventions, to shorten the time of surgery. For complex operations, 1 or 2 neurosurgeons must be found to back up rotations if necessary. Double gloves should be used to avoid infection in case of rupture of glove breaks, and it is suggested to decrease the speed of cranial perforation as to not generate bone aerosols. These researchers also performed a decision-making algorithm in which they define that every postoperative patient should be considered suspected of having COVID-19 and therefore should be isolated for at least 2 weeks and have at least 3 polymerase chain reaction tests and 3 chest computed tomography scans done within that time. Constant exposure to radiation by computed tomography scan is a debatable aspect where risk/benefit must be balanced, as well as cost/effectiveness, depending on each case. Another recommendation to mention is that of Eichberg et al.,⁵ who highlight that in regions in which there is a very high risk of contracting COVID-19 and there are difficulties in moving to care centers, the use of absorbable sutures should be made.

A valid approach in the context of neurointervention is the quantitative or qualitative calculation of the risk of contagion by severe acute respiratory distress syndrome coronavirus 2 since the neurotropic dynamics of this virus have been described⁶; plus, it has not been studied with certainty whether there are unknown mechanisms of propagation that specifically impact on the safety of neurosurgeons during the performance of an intervention. Despite the evidence that emerges rapidly on a daily basis, there are conditions outside the medical and administrative team of care centers that may limit the implementation of these recommendations. This is why it is necessary to carry out regional and local studies that allow designing and modifying organizational policies according to the demand and response capacity of each center. It is also essential to carry out multicenter studies that allow these results to be verified, especially in Latin America and the Caribbean, where the evidence is limited, with the purpose of identifying with certainty the magnitude of the association found between risk factors and clinical evolution to determine which strategies are the most effective and safe to guarantee the survival and functional capacity of neurologic patients.