The coronavirus disease 2019 (COVID-19) pandemic has caused pronounced strain on global healthcare systems, forcing the streamlining of clinical activities and conservation of health resources. There is a pressing need for institutions to present discipline-specific strategies for the management of COVID-19 patients. We present the comprehensive considerations at the National University Hospital, Singapore from the surgeon’s and anesthetist’s perspectives in the performance of spinal surgery in COVID-19 patients. These are based on national guidelines and overarching principles of protection for the healthcare workers (HCWs) and efficiency in surgical planning. The workflow begins with the emergency department screening that has been adapted to the local epidemiology of COVID-19 in order to identify suspected/confirmed cases. If patient history cannot be obtained, demographic, clinical, and imaging data are used. Designated orthopedic “contaminated teams” are available 24/7 with an activation time of <30 minutes for review. In cases where sub-specialty spine surgeons were required, these professionals were inducted into the “contaminated team” and quarantined until cleared to return to work. Indications for emergency spine surgery were determined pre-emptively. Preoperative surgical considerations included the minimization of manpower, limited dissection, reduced operative time, and judicious use of equipment, leading to reduced aerosolization. Anesthesia considerations include preoperative screening for COVID-19–related concerns that influence surgery, operating room process planning and induction, intraoperative, reversal, recovery, and resuscitation considerations. Focused multi-disciplinary preoperative briefing facilitates familiarization. Surgical, anesthetic, and postoperative workflows were designed to reduce the risk of transmission and protect HCWs while effectively performing spinal surgery. The COVID-19 pandemic has necessitated paradigm shifts in healthcare planning, hospital workflows, and operative protocols. The viral burden does not discriminate between surgeons and physicians, and it is crucial that we, as medical professionals, adapt practices to be malleable and fluid to address the ever-changing developments.

STUDY DESIGN: A prospective observational study. PURPOSE: To evaluate the role of nucleoplasty in the management of discogenic axial back pain; to determine the influence of concordant pain during provocative discography, annular tear and loss of disc height on the outcome of nucleoplasty. OVERVIEW OF LITERATURE: The role of nucleoplasty in the management of radicular leg pain due to disc herniation is known. However, the data regarding its role in the management of discogenic axial back pain is scarce. METHODS: A prospective evaluation of 30 patients with discogenic axial back pain undergoing nucleoplasty was performed. Pain, functional disability and quality of life were assessed using the 100 mm visual analogue scale (VAS), Oswestry Disability Index (ODI) and Short Form-36 (SF-36), respectively. RESULTS: The mean reduction in VAS was 31.03 and 29.03; mean reduction in ODI was 24.53 and 20.60; and mean increment in SF-36 was 13.58 and 12.30, at 6 months and at 12 months, respectively. The differences were statistically significant (p <0.05). Concordant pain during provocative discography, annular tear and loss of disc height did not affect a clinically significant improvement in any of the three outcomes (p =0.882, 0.213, and 0.170; respectively). CONCLUSIONS: Nucleoplasty produced statistically significant improvements in pain, functional disability and quality of life in patients with discogenic low back pain at 6 months and at 12 months. Concordant pain during provocative discography, annular tear and loss of disc height did not influence any of the outcomes after nucleoplasty in patients with discogenic axial back pain.
Back Pain* ; Humans ; Leg ; Low Back Pain ; Quality of Life

Methods: We reviewed the evidence behind telemedicine and described our clinical protocol, patient selection criteria, and workflow for telemedicine. We discussed a simple methodology to convert pre-existing traditional clinic resources into telemedicine tools, along with future challenges. Results: Our methodology was successfully and easily applied in our clinical practice, with a streamlined workflow allowing our spine surgery service to implement telemedicine as a consultation modality in line with the national recommendations of social distancing. Conclusions Telemedicine was well incorporated into our outpatient practice using the above workflow. We believe that the use of telemedicine via videoconferencing can become part of the new normal and a safe strategy for healthcare systems as both a medical and an economic countermeasure against COVID-19.

Methods: We reviewed the evidence behind telemedicine and described our clinical protocol, patient selection criteria, and workflow for telemedicine. We discussed a simple methodology to convert pre-existing traditional clinic resources into telemedicine tools, along with future challenges. Results: Our methodology was successfully and easily applied in our clinical practice, with a streamlined workflow allowing our spine surgery service to implement telemedicine as a consultation modality in line with the national recommendations of social distancing. Conclusions Telemedicine was well incorporated into our outpatient practice using the above workflow. We believe that the use of telemedicine via videoconferencing can become part of the new normal and a safe strategy for healthcare systems as both a medical and an economic countermeasure against COVID-19.

Methods: We conducted a retrospective analysis of 288 patients (246 for final analysis) who underwent MSTS between 2005–2015. Data collected were demographics and peri/postoperative clinical and radiological features. Early and late radiological AsCF were defined as presentation before and after 3 months, respectively. We analyzed patients with AsCF for risk factors and survival duration by performing competing risk regression analyses where AsCF was the event of interest, with SF and death as competing events. Results: We observed AsCF in 41/246 patients (16.7%). The mean time to onset of AsCF after MSTS was 2 months (range, 1–9 months). Median survival of patients with AsCF was 20 and 41 months for early and late failures, respectively. Early AsCF accounted for 80.5% of cases, while late AsCF accounted for 19.5%. The commonest radiologically detectable AsCF mechanism was angular deformity (increase in kyphus) in 29 patients. Increasing age (p<0.02) and primary breast (13/41, 31.7%) (p<0.01) tumors were associated with higher AsCF rates. There was a non-significant trend towards AsCF in patients with a spinal instability neoplastic score ≥7, instrumentation across junctional regions, and construct lengths of 6–9 levels. None of the patients with AsCF underwent revision surgery. Conclusions AsCF after MSTS is a distinct entity. Most patients with early AsCF did not require intervention. Patients who survived and maintained ambulation for longer periods had late failure. Increasing age and tumors with a better prognosis have a higher likelihood of developing AsCF. AsCF is not necessarily an indication for aggressive/urgent intervention.