- All patients undergoing surgery should be considered positive for COVID-19 unless proven otherwise, and appropriate PPE should be used. - For elective surgeries, a chest CT scan and COVID test are recommended pre-operatively. Surgeries should be postponed for COVID-positive patients or those with unknown status. - Special precautions are outlined for endoscopic or endonasal surgeries on COVID-positive patients due to risk of transmission, including use of PAPRs by all OR staff or choosing alternative surgical approaches if possible.

1. Change of Neurosurgical
planning during COVID
Pandemic and Endemic era
DR AMIT KUMAR GHOSH
INSTITUTE OF NEUROSCIENCES KOLKATA
INDIA

2. All patient of unknown COVID status should be considered COVID POSITIVE unless
proven. Use Standard PPE for all surgeries and use PAPR for high risk surgeries(
surgery around nose, nasopharyx, oral cavity, lungs etc)
Test RT-PCR for SARS-CoV-2 for all these operated patients after surgery and treat
accordingly.
For all elective surgeries—
Pre-operative --
Chest CT scan (reported to have a high sensitivity (97%) for COVID-19 screening,
but lower specificity and accuracy)
Most guidelines recommend single RT-PCR for SARS-CoV-2 from upper respiratory
nasopharyngeal swab
1) CDC. Coronavirus Disease 2019 (COVID-19). Centers for Disease Control and Prevention.https://www.cdc.gov/coronavirus/2019-
ncov/lab/guidelines-clinical-specimens.html. Published February 11, 2020. Accessed April 11, 2020.
2) COVID-19 in Neurosurgery News, Guidelines and Discussion Forum.
https://www.eans.org/page/covid-19. Accessed April 13, 2020.
3) Caruso D, Zerunian M, Polici M, et al. Chest CT Features of COVID-19 in Rome, Italy.
Radiology. April 2020. doi:https://doi.org/10.1148/radiol.2020201237
4) Correlation of Chest CT and RT-PCR Testing in Coronavirus Disease 2019 (COVID-19) in China: A Report of 1014 Cases | Radiology.
https://pubs.rsna.org/doi/full/10.1148/radiol.2020200642. Accessed April 16, 2020.
SUGGESTED PROTOCOL FOR SURGERY

3. Procrastinating elective procedures has been one of the crucial indications
delivered by
international societies with many important aims:
A. To contain the spread of SARS-CoV-2, by reducing visits to hospitals by people with no
urgent medical issue
B. To reduce the patient load on
Intensive Care Units with non-COVID-19 patients
C. To reduce the possibility of treating asymptomatic SARS-CoV-2
patients, who would be at high risk of deteriorating due to the
surgical stress and would increase the risk of infecting health
professionals.
Fontanella MM, De Maria L, Zanin L, Saraceno G, Terzi di Bergamo L,
Servadei F, Chaurasia B, Olivi A, Vajkoczy P, Schaller K, Cappabianca P, Doglietto F,
Neurosurgical practice during the SARS-CoV-2 pandemic: a worldwide survey, World
Neurosurgery (2020), doi: https:// doi.org/10.1016/j.wneu.2020.04.204.

4. COVIDSurg Collaborative. Mortality and pulmonary complications in patients
undergoing surgery with perioperative SARS-CoV-2 infection: an international
cohort study [published online ahead of print, 2020 May 29] [published correction
appears in Lancet. 2020 Jun 9;:]. Lancet. 2020;S0140-6736(20)31182-X.
doi:10.1016/S0140-6736(20)31182-X
Postoperative pulmonary complications occur in half of
patients with perioperative SARS-CoV-2 infection and are
associated with high mortality.
Consideration should be given for postponing non-urgent
procedures and promoting non-operative treatment to delay or
avoid the need for surgery.

5. •Consider alternatives to general anesthesia whenever possible to minimize
the risk of aerosolization associated with endotracheal intubation and
extubation
• For awake surgeries, use a facemask
• If intubation is required, keep all unnecessary personnel outside of
the room during the induction
• Use intubation tent and use appropriate PPE or PAPR
• If intubation is required, use neuromuscular blockers to avoid cough
•Consider surgical approaches avoiding the sinuses and mastoids
• If exposing the nasal or oral mucosa, consider intranasal povidone
iodine preparation (especially in endonasal approaches) and
chlorhexidine or hydrogen peroxide mouth rinse
• Avoid postoperative nasal endoscopy and nasal spays
SUGGESTED PROTOCOL for COVID POSITIVE OR SUSPECTED
COVID PATIENT---

6. Given the current uncertainty on the potential of viral
transmission through aerosolized blood or other particles such as
bone, consider limiting the use of aerosol-generating
instruments:
Avoid using drills whenever possible:
Choose rongeurs, curettes, or chisels instead of burrs,
especially when in the vicinity of sinuses or mastoid cells
Perform burr holes using a Hudson brace or twist drill rather
than a perforator
For spinal decompression and stabilization, perform bony
removal using rongeurs rather than a burr and use manual,
tactile pedicle probes to facilitate the placement of pedicle
screws

7. When drilling is required:
Consider drilling at lower speed
Stop the drill when irrigating
Use large suctions to try and aspirate all airborne particles
Try isolating the drilled area using a transparent adherent film
(eg, OpsiteTM) “tent” or gauzes to limit the spread of airborne
particles
Try minimizing the amount of drilling required in spine
procedures by using navigation and
Considering minimally invasive approaches, such as
endoscopic procedures and percutaneous instrumentation

8. Avoid using unnecessary electrocautery
Avoid using lasers
Avoid using ultrasonic aspirators
Consider performing VP shunts open rather than
laparoscopically to minimize pneumoperitoneum-induced
aerosolization
Protect the surgical field with towels when hammering to
minimize aerosolization
Irrigate with large volumes at low pressure rather than low
volumes at high pressure

9. If the test, RT-PCR for SARS-CoV-2 is positive, we defer surgery
if at all possible until the infection is cleared, verified by repeat
testing.
When endonasal surgery cannot be postponed in a COVID-19 positive patient, based
on guidelines now being used in China, we have recommended to our institutional
officials that we utilize full PAPR (an enclosed powered system
with HEPA filter).
Alternatively, a trans-cranial approach should be considered
whenever possible.
Because endo-nasal surgery creates clouds of droplets and
aerosols which may permeate the operating environment,
anyone in the operating theatre requires the same protection
when operating on known COVID-19 positives.

10. For unavoidable (or emergent) surgeries in patients positive for COVID-19 or in
whom the status is undetermined, the surgeon and all OR personnel in the surgical
suite should use powered air purifying respirators (PAPR), which filter the air being
breathed in addition to face shields and other standard personal protective
equipment (PPE).
Another reasonable approach is to treat patients who cannot be safely delayed
through a transcranial approach, or through the head or skull, instead of approaching
through the nose.
the American College of Surgeons (ACS), as well as Center for Medicare and
Medicaid Services (CMS), have published guidelines for the triage, or ranking in
order of priority, of surgical patients
Specifically, there are concerns that transsphenoidal surgeries (surgery of the brain
through the nose) on patients who have the virus have a higher risk of transmission to
operating room staff than other surgeries, based on preliminary reports out of China.
At this time some authors recommend cancelling elective cases for at least one
month or for urgent cases, performing two COVID-19 tests separated by 24 hours
with the patient quarantined in the interval between tests before the surgery, with
the surgery proceeding only if the results are negative for both tests

11. PAPR consists of
Some kind of headgear (mask or
hood),
A powered (motor-
driven) fan which forces incoming
air into the device
A filter (or multiple filters) for
delivery to the user for breathing,
and
A battery or other power source.
Powered air-purifying respirator

12. FULL ISOLATION PRECAUTIONS FOR OT
1. Consider all patients undergoing surgery as being Covid-19 positive
2. Consent for greater risk of surgery and Covid related complications
3. PPE + visors + N95 mask for all O.T staff & staff handling biologic material
4. Patient wearing only disposable gown and mask while entering O.T
5. Minimum staff in OT
6. All intubation and extubation done only in OT
7. Stop positive pressure ventilation in OT
8. 100% fresh air exchange in OT with no recycled air
9. AC to be based on air handling unit and separate from other OT
10.Proper disposal facility for discarded disposable gowns and other waste
11.Proper transport of biologic material to laboratory immediately after surgery
12.Laparoscopic/endoscopic procedures should not be generally carried out

13. No clear guidelines are available for SARS-CoV-2 positive,
asymptomatic health professionals whether they should
work or not, resulting in heterogeneity of recommendations
Guidelines for risk assessment and management of exposure of healthcare
workers vary according to the risk of SARS-CoV-2 infection (categorized as
high or low) and recommend COVID-19 testing only for workers at a high
risk of infection.
Some Institutes (26%) declared that SARS-CoV-2 positive health
professionals kept working if asymptomatic and a large portion of these
respondents were from Italy .

14. Published by Oxford University Press.
PRECAUTIONS FOR ENDOSCOPIC TRANSNASAL SKULL BASE
SURGERY DURING THE COVID-19 PANDEMIC
Zara M. Patel, MD; Juan Fernandez-Miranda, MD; Peter H. Hwang, MD; Jayakar V.
Nayak, MD, PhD; Robert Dodd, MD, PhD; Hamed Sajjadi, MD; Robert K. Jackler, MD
Stanford University School of Medicine Departments of Otolaryngology-Head & Neck
Surgery and Neurosurgery

15. Neurosurgery. 2020 Apr 26 : nyaa157.
Published online 2020 Apr 26. doi: 10.1093/neuros/nyaa157
Letter: The Risk of COVID-19 Infection During
Neurosurgical Procedures: A Review of Severe Acute
Respiratory Distress Syndrome Coronavirus 2 (SARS-
CoV-2) Modes of Transmission and Proposed
Neurosurgery-Specific Measures for Mitigation
Christian Iorio-Morin, MD, PhD, FRCSC,1,2 Mojgan Hodaie, MD, MSc, FRCSC,2 Can
Sarica, MD,2 Nicolas Dea, MD, MSc, FRCSC,3 Harrison J Westwick, MD, MSc,
FRCSC,4 Sean D Christie, MD, FRCSC,5 Patrick J McDonald, MD, MHSc,
FRCSC,6 Moujahed Labidi, MD, FRCSC,7 Jean-Pierre Farmer, MD, CM, FRCSC,
DABPNS,8 Simon Brisebois, MD, MSc, FRCSC,9 Frédérick D’Aragon, MD, MSc,
FRCPC,10 Alex Carignan, MD, MSc, FRCPC,11 and David Fortin, MD, MSc1

16. Conclusions
SARS-CoV-2 pandemic has consistently changed medical practice, with an
enormous impact on all specialties, regardless of their contribution in
facing the disease itself.
Neurosurgeons worldwide have changed their surgical planning and
activity, in most cases following national and international guidelines.
Dedicated routes were put in place for SARS-CoV-2 patients in most cases
and surgical activity was limited to procedures that could not be
postponed, resulting in an overall reduction of surgeries by more than
70%.
The lockdown will be soon followed by the rebuilding phase, when
delayed elective procedures will need to be performed, thus opening a
new challenge that to be addressed, possibly by sharing current
knowledge and experience worldwide

17. THANK YOU