Impact of SARS-Cov2 on Endoscopic Trans-Nasal Skull Base Surgeries

The COVID-19 pandemic is currently an evolving situation. Operating rooms (OR) are high-risk areas for the transmission of any respiratory infection with multiple personnel involved, in close proximity. Of concern to neurosurgeons, is the high-risk of aerosol generating procedures (AGPs) like transsphenoidal and endonasal surgery. Endonasal AGPs theoretically present a higher risk of viral exposure due to the longer duration of exposure and aggressive disruption of potentially virus-containing mucosa.

The current review discusses potential strategies to neuro-surgeons to avoid transmission of COVID 19 during endo-nasal and trans-sphenoidal surgeries.

We searched PubMed using the search terms "COVID-19", "SARS-CoV-2", "coronavirus" in combination with "neurosurgery", and identified 13 relevant articles. A pre-surgical risk assessment score is proposed based on the risk of transmission. A flow chart of patient selection and care has been formulated.

In all emergency patients, it is preferable to consider transcranial surgery or a sub-labial approach avoiding exposure to mucosa. Due to laboratory constraints routine swabs is not always available. Therefore, routine preoperative screening computed tomography (CT) chest is performed in all patients. Based on risk of transmission of infection to others, we propose a classification of patients for skull-based surgery into low, high and very high risk groups and suggest suitable personal protective equipment. Additionally, we discuss avoiding use of powered drills in or any AGP. However, cold procedures involving shavers and microdebriders generate lesser amounts of aerosol. Post-operatively, the length of stay could be reduced with a multidisciplinary approach.