key: cord-0892985-eq8d49ow
authors: Figueroa, Javier M.; Boddu, James; Kader, Michael; Berry, Katherine; Kumar, Vignessh; Ayala, Veronica; Vanni, Steven; Jagid, Jonathan
title: The Effects of Lockdown During the SARS-CoV-2 Pandemic on Neuro-Trauma Related Hospital Admissions
date: 2020-08-19
journal: World Neurosurg
DOI: 10.1016/j.wneu.2020.08.083
sha: ff3c54f14b9401d3f3d958fc8ea1358765d2c01a
doc_id: 892985
cord_uid: eq8d49ow

Abstract Background The response to the global SARS-CoV-2 pandemic culminated in mandatory isolation throughout the world, with nation-wide confinement orders issued to decrease viral spread. These drastic measures were successful in “flattening the curve” and maintaining the prior rate of COVID-19 infections and deaths. To date, the effects of the COVID-19 pandemic on neuro-trauma has not been reported. Methods We retrospectively analyzed hospital admissions from Ryder Trauma Center at Jackson Memorial Hospital, during the months of March and April from 2016-2020. Specifically, we identified all patients who had cranial neuro trauma consisting of traumatic brain injury (TBI) and/or skull fractures, as well as spinal neuro trauma consisting of vertebral fractures and/or spinal cord injury (SCI). We then performed chart review to determine mechanism of injury and if emergent surgical intervention was required. Results Compared to previous years, we saw a significant decline in the number of neuro-traumas during the pandemic, with a 62% decline after the lockdown began. The number of emergent neuro-trauma surgical cases also significantly decreased by 84% in the month of April. Interestingly, while the number of vehicular traumas decreased by 77%, there was a significant 100% increase in the number of gunshot wounds. Conclusions Population seclusion had a direct effect on the frequency of neuro-trauma, while the change in relative proportion of certain mechanisms may be associated with the psychosocial effects of social distancing and quarantine.

The response to the global SARS-CoV-2 pandemic culminated in mandatory isolation throughout the world, with nation-wide confinement orders issued to decrease viral spread.

These drastic measures were successful in "flattening the curve" and maintaining the prior rate of COVID-19 infections and deaths. To date, the effects of the COVID-19 pandemic on neurotrauma has not been reported.

We retrospectively analyzed hospital admissions from Ryder Trauma Center at Jackson Memorial Hospital, during the months of March and April from 2016-2020. Specifically, we identified all patients who had cranial neuro trauma consisting of traumatic brain injury (TBI) and/or skull fractures, as well as spinal neuro trauma consisting of vertebral fractures and/or spinal cord injury (SCI). We then performed chart review to determine mechanism of injury and if emergent surgical intervention was required.

Compared to previous years, we saw a significant decline in the number of neuro-traumas during the pandemic, with a 62% decline after the lockdown began. The number of emergent neurotrauma surgical cases also significantly decreased by 84% in the month of April. Interestingly, while the number of vehicular traumas decreased by 77%, there was a significant 100% increase in the number of gunshot wounds.

As of June 1, 2020 the global incidence of COVID-19 was 6.05 million confirmed cases, with 371,000 related deaths. The U.S. had a major proportion of infections with 1.7 million confirmed cases and 102,000 related deaths. 1 Specific to our institution, Miami-Dade county had 18,139 confirmed cases with 702 associated deaths. The first case of COVID-19 in Miami-Dade county was confirmed on March 12, 2020, nearly 50 days after the initial case in the U.S., and 8 days after the initial case in Florida. 2 A subsequent state-wide closing of restaurants and bars on March 17, 2020 was then implemented to decrease viral spread. However, after a significant rise in infection rate over the next few weeks, the Governor of Florida issued an executive "stay-athome" order on April 1, 2020. 3 While the rate of viral spread improved, we also saw a decrease in both the number of accidents causing traumatic injuries and the number of emergent surgical procedures, secondary to a decline in both foot and automobile traffic. 4

After obtaining approval for this retrospective study from the University of Miami Institutional Review Board (IRB), we queried the registry at Ryder Trauma Center to obtain a list of patients from 2016-2020 who sustained neuro-trauma during the timeframe of March 1 to April 30.

Neuro-trauma was defined as patients with TBI, skull fractures, SCI, and vertebral fractures).

Chart review was then performed to obtain variables such as age, sex, mechanism of injury, type of injury, and need for emergent surgery. Mechanisms of injury included assaults, bicycle accidents, ground level falls (sitting, standing), falls from height (ladder, roof, multiple stories), 

Overall, we found a significant difference in the average number of monthly neuro-trauma consults from 2016-2019, with 83.5 ± 4.7 in March and 68.0 ± 8.8 in April (p = 0.048, student ttest). However, in March 2020 we saw a 20% decrease in total neuro-trauma consults, which was significantly lower (p = 0.036, Poisson analysis) than previous years ( Figure 1 ). This declining trend continued in April 2020, with the number of neuro-trauma consults decreasing significantly by 62% (p = 0.0001, Poisson analysis), after a state wide "stay-at-home" order was issued on to prior year averages, the relative proportion of each mechanism did not. As expected, the proportion of motorcycle collisions (MCC), motor-vehicle collisions (MVC), and bicycle accidents decreased by 4%, 10% and 3% respectively. Additionally, the proportion of ground level falls resulting in neuro-trauma decreased by 6%, while the proportion of falls from height increased by 6%. There was also non-significant 2% increase in the proportion of assaults.

Surprisingly, there was a 6% increase in the proportion of pedestrians hit by cars (PHBC) and a 12% significant increase (p = 0.034, chi-squared proportion analysis) in the proportion of gunshot wounds (GSW). There were no traumatic injuries caused by "other" mechanisms during the pandemic.

In the U.S., traumatic unintentional injuries are the leading cause of death in people less than 45 years old, and the third leading cause of death among all age groups combined. 5 An estimated J o u r n a l P r e -p r o o f 1.7 million people sustain traumatic brain injury (TBI) annually, with approximately 52,000 deaths. 6 Additionally, while not typically life threatening, an estimated 18,000 people sustain spinal cord injury (SCI) annually. 7 Importantly, the effects of the SARS-CoV-2 pandemic on the incidence of neuro-trauma has yet to be reported. While several hospitals found a decreasing trend in general trauma admissions from February to April 2020, none of these studies thoroughly evaluated the effects on emergent operative cases or changes in mechanisms of injury. [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] Here we found that the average number of neuro-trauma consults differed significantly between March and April, likely secondary to South Florida being a destination for Spring Break causing an influx of vacationers during that timeframe. During the pandemic however, travel restrictions in combination with less foot and vehicle traffic, lead to a decrease in all mechanisms of injury, except for GSW. Upon further investigation we found that the relative proportion of mechanisms of injury also changed after the lockdown in April 2020. With fewer citizens commuting on the streets, the proportion of vehicular trauma decreased as expected. Decreases in these types of traumas have been reported across the country, however not in correlation with specific events such as initiation of lockdown protocols. 8, 9, 12, 13 The proportion of ground level falls also decreased, however this may have been secondary to patients unwilling to take the risk of going to the emergency room after minor accidents for concern of contracting the virus. 18 Importantly, some businesses were deemed "essential" and allowed to continue operating, which some construction companies took advantage of. 1 This may explain the increase in the proportion of falls from height, in addition to people doing home repairs while "stay-at-home" orders were in place. With respect to increases in the proportions of assaults and GSWs during the pandemic, they may be secondary to the psychosocial effects of mandatory isolation. 19-20 Family and friends were forced to be in close proximity to one another which had the potential to ignite conflicts and violence leading to assault. 21 Finally, with prolonged confinement comes an increase in the risk of suicide, which may explain the increase in presumed self-inflicted PHBC and GSW. 22

While are results are compelling, there are several limitations that could be affecting the results of this study. For instance, ambulances may have avoided our hospital which had a high COVID census, and primary care physicians may have treated minor traumas rather than referring patients to the emergency room. These confounding variables are difficult to address during the pandemic and must be taken into account when referencing this observational study. 

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