As the world’s healthcare communities continue to lead efforts to tackle the COVID-19 pandemic, non-essential procedures in a number of fields, including spine care, have been scaled back to preserve resources and protect patients. Speaking to Spinal News International, North American Spine Society (NASS) president William J Sullivan (Vanderbilt University, Nashville, USA) reflects on the impact that the pandemic has had on the spine community to date, and what its lasting legacy could be.
“The COVID-19 outbreak has impacted everything in spine care, including pain procedures and surgery, but also everything in medicine,” Sullivan tells Spinal News International, commenting on the emotional, physical and economic toll that the virus has across the healthcare profession. The curtailment of elective surgeries in countries including the USA and more widely, has been well documented. However, Sullivan notes that while this is an important step to help mitigate the spread of the virus it presents challenges of its own. The reduction of elective procedures is one he sees a lasting potential impact from the COVID-19 pandemic in spine care.
“The difficulty is that it depends what your definition of “essential” is,” he says. “When people first started talking about what is considered elective surgery, there were questions such as whether or not to do outpatient elective surgery on someone when they may have a lot of pain, but is not life or limb threatening. Does that count as elective if the procedure allows them to function better?
“Certainly, someone who has trauma or metastatic disease need to be treated and surgery or procedures for these conditions are essential. Some things are very clear, but in many of the situations there are grey zones. The grey zones and how people interpret the guidelines is one of the difficulties because of the various factors to be considered. You may have someone who is looking at their practice and thinking ‘I have got 50 people that I am employing, and if I continue to see patients I can keep these 50 people employed for the next week’. These are very difficult decisions that people are being asked to make,” Sullivan adds.
In terms of lasting impacts for spine care, Sullivan muses that there are likely to be two “parallel paths” regarding patient outcomes. “The first is that we are kicking the can down the road and that these problems that we have will still be there when we get back. A certain percentage of people, if they wait long enough will decide that they don’t need surgery or injections for their condition. They potentially got better doing other things, for example by resting or exercising more.
“The other patients who would normally be treated “now” may become a longer-standing chronic pain patient who may now be dependent on opioid medications for a longer period of time. That will be difficult for us to deal with, but the reality is there is no way around it anyway. We are going to have a backlog, and that backlog is going to necessitate the need to stratify people and triage people appropriately when we go back to doing elective procedures.
“You can’t see everybody on that first day that we go back. I think that kicking the can down the road problem is going to exist, and that there are going to be people who don’t have as good outcomes as we would have hoped they would have had.
However, within this challenge, Sullivan also sees an opportunity for some vital learning to be taken from the current slowdown in the number of procedures being performed, something that he sees as being a possibility in both patient sets described.
“If it is a year from now, and those people say ‘yes, I do need surgery’ we have another opportunity for data that from those people who really wanted to do surgery but had to wait an extra year, let’s see what the outcomes were,” he meditates. “I would hope that people [within the spine field] would think about those things when they do outcome assessment related to this, that will be part of the information to come out of it. Maybe it will provide some answers down the road about what is the sweet spot, what is long enough but not too long. “
Another potential takeaway from the pandemic for the spine community will be the increased use of telehealth in patient consultations, as well as other forms of digital communication. “Because we are doing it in this scenario it might may lead to more openness to have these types of visits for people who otherwise would not have access to care based in a different environment,” says Sullivan, whose own practice has sought to move towards digital working where possible. However, he notes that this is itself not entirely without challenge, with concerns about data security being an important consideration if these practices are to last. “Maybe this will provide an opportunity for improved security and use of technology.
“These are opportunities to think about how we provide care, and there is no one way for everybody, but it is definitely an opportunity to think about how we deliver different aspects of patient care.”