By: 27 October 2020
Service delivery challenges in spine surgery during the COVID-19 pandemic

We are in the midst of the global pandemic. Consultant spine surgeon Manghattil Rajesh, of Royal London Hospital Barts Health NHS Trust, discusses how the working practices, day-to-day decision-making and leadership have evolved gradually and substantially. In other words, how COVID-19 has created the ‘new normal’.



This year, the arrival of COVID-19 has highlighted the need for service delivery optimisation in spine surgery more than ever before. The established clinical pathways are now replaced by emergency treatment protocols to deal with the current crisis. It also meant that spine surgeons with years of dedicated training and experience had to be deployed recently in areas of an immediate need to handle this pandemic effectively.


The ‘new normal’ is here to stay

The ‘new normal’ is the continuation of the seismic shift in our clinical practice, the way we think and organise our routines. It has forced us to learn so much in such a short space of time under testing conditions. It has given us the ability to think differently, innovate and come up with service delivery solutions that guide patient safety and our own.

Remote working is part of the ‘new normal’. We have adapted to hone our skills in listening to patients carefully over video and audio consultations. This practice in our line of work was quite unimaginable just a few months ago before the pandemic. We have learnt to prioritise and optimise our scarce resources including upskilling our ability in the use of information technology.


The challenges

The most significant challenge for the spine surgeon through this difficult time is to maintain his or her art of surgical proficiency and competency. Due to the decrease in the number of surgical episodes driven by the pandemic, there is a lack of sufficient opportunities to maintain clinical skills, surgical dexterity and thought leadership that is essential for efficient service delivery.

The explosion of the media platforms during this time must be leveraged to our advantage in delivering information for clinical training and education. The British Association of Spine Surgeons (BASS) is taking the lead in providing education, support leadership and maintaining morale among spine surgeons. But maintaining surgical skills and dexterity remains a challenge.


Role of virtual reality platforms

Surgical training through virtual reality platforms is becoming a new reality. These platforms allow surgical training to be run in ‘skills labs’ away from hospitals and ‘at risk’ clinical areas. The programme is similar to flight simulation modules that can cater to the continuous development and update of our surgical skills. The advantage is the repeatability, reproducibility, and skill synergy leading to well-calibrated skill enhancement. This reduces surgical time, improves surgeon confidence and ultimately patient safety.


Regional anaesthesia as a standard practice

With the advancement in regional anaesthesia, the potential to stretch the limits of day case surgery is ever greater than before [1]. Lumbar discectomy, decompression and single-level fusions can be safely and efficiently performed under regional anaesthesia. This type of anaesthesia reduces the risk of aerosols generation that is key in controlling the spread of the viral infection among staff and patients. It also contributes to a reduction in hospital stay during this pandemic, with sustained collateral advantages for patient and surgeon safety.

Endoscopic and minimally invasive spine surgery

The shorter the duration of hospital stays the greater will be the success of the service delivery in spine surgery. Endoscopic spine surgery, as well as minimally invasive spine surgery, affords the advantages of a shorter hospital stay, reduced post-operative pain, quicker return to daily activities and reduced risk of infection. Endoscopic surgery today matches the safety profile of open spine surgery [3].


Big data and the future of spine surgery

A recent nationwide survey among pain surgeons in the clinical decision-making for spinal fusion showed there is a lack of uniform evidence base in practice [4]. Rapid expansion in artificial intelligence and machine learning platforms has given us the potential to use big data for making cost-effective decisions in spine surgery. Data analysis can identify patients with a greater risk of failure from surgical interventions. These platforms can guide spine surgeons to recognise the best case and the worst-case scenarios in spinal fusion surgery that is cost-effective, resource optimised and pandemic proof.


The new reality

This pandemic is here to stay for some time. There will be a dawn of a new reality where our clinical practices and protocols will be altered to offer patients the best possible outcome within the confines thrown by this pandemic. The General Medical Council has stated that in the event of any regulatory concerns during the pandemic, the current working practices including resources available, guidelines and protocols will be taken into account [4].

Teaching and training with the use of virtual reality platforms, regional anaesthesia as a standard practice, use of endoscopic and minimally invasive surgery techniques to reduce hospital stay will become the ‘new reality’. Machine learning algorithms that predict and guide us on the best possible outcomes in spine surgery will be the future coming out of this pandemic.



Attari MA, Mirhosseini SA, Honarmand A, Safavi MR. Spinal anesthesia versus general anesthesia for elective lumbar spine surgery: A randomized clinical trial. J Res Med Sci. 2011;16(4):524-529.

Hasan S, Härtl R, Hofstetter CP. The benefit zone of full-endoscopic spine surgery. J Spine Surg. 2019;5(Suppl 1):S41-S56. doi:10.21037/jss.2019.04.19

Willems P, de Bie R, Öner C, et al
Clinical decision making in spinal fusion for chronic low back pain. Results of a nationwide survey among spine surgeons BMJ Open 2011;1:e000391. doi: 10.1136/bmjopen-2011-000391

The General Medical Council. How we will continue to regulate in light of Novel Coronavirus