RESUMEN
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.
RESUMEN
PURPOSE: 'Low back pain' (LBP) is a prevalent condition with a majority showing no specific organic pathology. Distinguishing 'secondary gain motives (SGM)' from organic causes is imperative in clinical practice. We describe here, three new tests-resistive straight leg raise test (rSLRT), resistive forward bend test (rFBT) and heel compression test (HCT) to help differentiate patients with 'SGM' from those without. We conducted a prospective study to validate the above tests in predicting non-organic causes as a reason for LBP. METHODS: 200 patients presenting with low back pain at the senior author's outpatient orthopaedic clinic from Jan 2009 to Nov 2010 were studied. Patients were separated into two groups-'SGM group' (n = 100) and 'non-SGM group' (n = 100). 'SGM group' patients had a history of work-related accidents, road traffic accidents or assault, with a background of ongoing litigation issues or compensation benefits. rSLRT, rFBT, HCT, Schober's test and Waddell's five signs were performed on them. Statistical analysis was done to identify correlations between test results, MRI findings and 'SGM' status. RESULTS: Statistically significant differences were observed between the SGM and non-SGM group (p < 0.0005) for all tests studied. In predicting SGM status, rSLRT showed highest specificity (0.94) and highest positive predictive value (0.925) while HCT showed the highest negative predictive value (0.859). Positive rSLRT was found to be strongly correlated with ≥3 positive Waddell's signs. SGM patients with positive rSLRT tended to show resistance ≤45°. CONCLUSIONS: rSLRT, rFBT and HCT (NK triad) are highly practical tests which strongly predict SGM status in patients.
