COVID-19’s Impact on Elective Spine Surgery: What Happened? What Comes Next?

The COVID-19 pandemic has brought elective spine surgery to a grinding halt in nations around the world. The results have been dramatic. Surgeons have been unable to perform surgeries, patients have gone without needed operative care, and many medical device and biologic companies have seen their sales “fall off a cliff.”

Many communities across the globe are now taking tentative steps to reopen and build toward a return to everyday life. For the medical community, returning to “normal” is an essential but complex process. To better understand the impact of the shutdown on spine surgeons, and to learn when surgeons expect elective spine surgeries to return to full capacity, the Society for Minimally Invasive Spine Surgery (SMISS) surveyed more than 230 spine surgeons worldwide.

SMISS’s survey was conducted via email in the last week of April. We asked Juan Uribe, MD, president of SMISS, and Jean-Pierre Mobasser, MD, president-elect of SMISS, to comment on some of the most interesting findings.

Table 1
Demographics of Survey Respondents Specialty %a
Orthopedic surgeon 57%
Neurological surgeon 39%
Other 5%
Geographic Region
Africa <1%
Asia/Pacific 27%
Europe 31%
Middle East 2%
North America 27%
South America 10%
Other 3%
Type of Practice
Employed (e.g., hospital or government healthcare system) 46%
Private (e.g., owner or partner in a practice) 31%
Hybrid 22%

a Percentages do not total 100 due to rounding.

Date of Last Elective Surgery

Table 2
When did you perform your last elective surgery? %
January or February 13%
March 51%
April 16%
Currently performing elective surgeries 20%

According to the survey, 64% of respondents had not performed elective surgery since March or earlier. These findings were to be expected. Asian countries started shutting down in January and February, while the March figure matches the subsequent shutdown in many other countries.

However, Dr. Uribe expressed surprise that 20% of surgeons reported that they were currently performing surgeries. “I think it is fair to surmise that the 20% of surgeons still performing elective surgeries are not doing so in large urban areas that are—or might become—big centers of COVID-19.”

Elective Surgery Timeline Expectations

Table 3
When do you expect to perform your next elective surgery? %
Currently performing elective surgeries 20%
May 39%
June 26%
July 10%
Later than July 5%

In the survey, 85% of respondents expect to be performing elective surgeries by the end of June. Clearly, surgery is ramping up. What isn’t clear, however, is how many elective surgeries will be performed. Will the number of surgeries be limited by hospital constraints such as the availability of operating rooms? Or will some surgeons perform more surgeries than is typical due to a backlog of cases?

In considering these questions, Dr. Mobasser noted, “I think we can say that spine surgeons believe it’s time to get back to elective surgery and caring for patients. However, the speed with which we return will vary from hospital to hospital and from nation to nation. The variety of measures being taken to re-open is incredibly varied. At this point, we are all trying to find the best path forward, and this will be a trial and error process for the foreseeable future.”

Annual Case Load Expectations, 2019 vs. 2020

Table 4
I expect to perform fewer elective surgeries in 2020 compared to 2019 %
Reduction of at least 21% of cases 42%
Reduction of 11-20% of cases 20%
Other 38%a

a “Other” Due to the wording of this question, it appears that a language comprehension issue among some surgeons outside of the US may have inflated the “Other” responses, and diminished the actual number of responses that would have shown a reduction in elective surgeries.

Compared with the number of elective surgeries performed in 2019, 42% of respondents expect to perform at least 21% fewer elective surgeries in 2020. This predicted reduction of cases is due to numerous reasons. Dr. Uribe noted that, in addition to reasons resulting from government orders, hospital decisions, and other limiting factors, “Many patients are in a holding pattern due to unemployment or the threat of unemployment, which will mean the loss of health insurance. Frankly, even with insurance, when it comes to elective procedures, patients are inclined to avoid surgery now because of the copay.” Of course, he continued, patients may have other concerns: “Patients may also be wary of undergoing a procedure in a hospital where COVID-19 has been present.”

Income Expectations, 2020 vs. 2019

Table 5
I expect my income to decline by more than 20% in 2020 %
Surgeons in private practice 43%
Surgeons employed by a hospital, government
institution, etc.
22%
Surgeons in a hybrid practice 26%

According to the survey findings, 43% of respondents in private practice expect to see their income decline by more than 20% in 2020 compared with 2019. Dr. Mobasser observed that surgeons employed by hospitals will have greater certainty in their responses compared to those in private practices, who need to run predictive financial modeling, with an unpredictable ramp-up schedule.

Dr. Uribe, who is part of a large private practice, noted, “At the worst point, my colleagues and I were seeing a major reduction in our incomes. However, over the past three weeks, it’s coming back.” He added, “My colleagues and I typically travel quite a bit for meetings. Because there has been no travel lately, there is more time for surgeries.”

Survey Takeaways

Findings from this SMISS survey indicate that while elective surgeries are resuming, the total number that will be performed in 2020 is expected to be significantly lower than it was in 2019. Likewise, many surgeon’s incomes will likely be significantly reduced in 2020.

The survey provides fascinating insights, but it represents only one point in time—i.e., the last week of April. The remainder of the year is impossible to predict. How will governments and medical institutions respond to a second wave of COVID-19 infections? How will macro issues such as unemployment impact the number of patients seeking elective spine surgery? The future is unclear, but let’s hope that the impact of COVID-19 will diminish through the second half of 2020 and that soon we’ll start to return to normal life—albeit a “new” normal.

Interviews conducted by: Elizabeth Hofheinz, M.P.H., M.ED.