Letter to the Editor. COVID-19 and chronic pain

Radek Kaiser MD, PhD
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  • Charles University and Military University Hospital Prague, Czech Republic
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TO THE EDITOR: I read with great interest the editorial by Ghogawala et al.1 (Ghogawala Z, Kurpad S, Falavigna A, et al. Editorial. COVID-19 and spinal surgery. J Neurosurg Spine. 2020;33[1]:1–3). The authors state that severe pain from nerve compression should be considered urgent in some cases, such as in patients at risk of using opioids or using valuable emergency room resources for pain control management in the outpatient setting. They admit, however, that the indication for such surgery during this time is questionable and that decisions regarding its urgency vary across health systems.

Most spine and orthopedic procedures are theoretically considered “elective” in that a patient is evaluated in an office setting and later provided an operative appointment date.2,3 However, some cases are not truly elective. In many situations, a significant delay can result in the progression of deformity, extremity weakness, and pain. Furthermore, conditions such as myelopathy can deteriorate over time and cause irreversible patient harm.3 Understandably, most of the literature about COVID-19 concentrates on the disease itself, on the management of acute medical or surgical cases in this situation, and on defining the elective cases that can be postponed. It is obvious that patients who need emergent surgical operations and trauma victims should still be hospitalized and managed. However, patients with chronic pain waiting in home isolation for their cancelled elective procedures seem to be outside the sphere of interest of both politicians and scientists. These patients can be affected not only by the cancellation of their surgeries but also by the suspension of outpatient services (pain clinics, physiotherapy).4,5

Pain management has not been traditionally considered a high priority in times of crisis.6 Nevertheless, even in the worst-affected areas, it is possible to manage patients with mild to moderate pain with relatively clear etiopathogenesis via telemedicine support while keeping them home and providing them with necessary medical services.7 However, this may be insufficient for cases suffering from severe pain requiring interventional pain procedures or surgical treatment.5 Such patients can suffer not only from inadequate treatment but also from the fact that they have no vision of the end of the restrictions.

Mental health disorders (depression, anxiety disorders, posttraumatic stress disorder, etc.) are common in patients with chronic pain. Such patients who have been denied assessment and treatment can worsen significantly. People waiting over 6 months for assessment experience deteriorating health-related quality of life, increased pain, and increased depression.8 Female sex, poor self-rated health status, and physical symptoms of myalgia or dizziness are significantly associated with greater levels of anxiety, depression, and stress.6 Containment measures, including self-isolation and social distancing, have a strong impact on the population’s daily life and can negatively affect psychological well-being. People’s emotional responses during massive infectious disease outbreaks are likely to include feelings of extreme fear and uncertainty that can eventually lead to a dramatic mental health burden.9 Moccia et al. found that 38% of the general population currently perceives a form of psychological distress.10 Moreover, after the COVID-19 crisis, patients will have the same (or even worse) economic, employment, and insurance concerns as those after the Great Recession of 2008, but patients may also be concerned about the risk of entering a healthcare facility. Older patients may be reluctant to undergo procedures given the high risk of infection. Younger patients may not be able to delay work for long periods in order to recover or may have insurance issues.11 All of these problems associated with the COVID-19 pandemic could exacerbate the pre-existing mental health conditions of patients with chronic pain, which in turn could adversely impact pain-related treatment outcomes.6

It can be assumed that not only patients suffering from severe pain from nerve compression, but also many others with osteoporotic fractures, spinal instability, or stenosis may suffer for months without adequate treatment, with the possibility of worsening symptoms or neurological deficit, and without seeing light at the end of the tunnel.

Disclosures

The author reports no conflict of interest.

References

  • 1

    Ghogawala Z, Kurpad S, Falavigna A, Editorial. COVID-19 and spinal surgery. J Neurosurg Spine. 2020;33(1):13.

  • 2

    Sarac NJ, Sarac BA, Schoenbrunner AR, A review of state guidelines for elective orthopaedic procedures during the COVID-19 outbreak. J Bone Joint Surg Am. 2020;102(11):942945.

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  • 3

    Donnally CJ III, Shenoy K, Vaccaro AR, Triaging spine surgery in the COVID-19 era. Clin Spine Surg. 2020;33(4):129130.

  • 4

    Khan F, Amatya B. Medical rehabilitation in pandemics: towards a new perspective. J Rehab Med. 2020;52(4):jrm00043.

  • 5

    Recommendations on chronic pain practice during the COVID-19 pandemic: a joint statement by American Society of Regional Anesthesia and Pain Medicine (ASRA) and European Society of Regional Anesthesia and Pain Therapy (ESRA). Accessed June 4, 2020. https://www.asra.com/content/documents/asra_esra_covid-19_and_chronic_pain.pdf

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  • 6

    Cohen SP, Baber ZB, Buvanendran A, Pain management best practices from multispecialty organizations during the COVID-19 pandemic and public health crises. Pain Med. Published online April 7, 2020. doi:10.1093/pm/pnaa127

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  • 7

    Song XJ, Xiong DL, Wang ZY, Pain management during the COVID-19 pandemic in China: lessons learned. Pain Med. Published online April 22, 2020. doi:10.1093/pm/pnaa143

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    • Export Citation
  • 8

    Eccleston C, Blyth FM, Dear BF, Managing patients with chronic pain during the COVID-19 outbreak: considerations for the rapid introduction of remotely supported (eHealth) pain management services. Pain. 2020;161(5):889893.

    • Search Google Scholar
    • Export Citation
  • 9

    Brooks SK, Webster RK, Smith LE, The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet. 2020;395(10227):912920.

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    • Export Citation
  • 10

    Moccia L, Janiri D, Pepe M, Affective temperament, attachment style, and the psychological impact of the COVID-19 outbreak: an early report on the Italian general population. Brain Behav Immun. Published online April 20, 2020. doi:10.1016/j.bbi.2020.04.048

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    • Export Citation
  • 11

    O’Connor CM, Anoushiravani AA, DiCaprio MR, Economic recovery after the COVID-19 pandemic: resuming elective orthopedic surgery and total joint arthroplasty. J Arthroplasty. Published online April 18, 2020. doi:10.1016/j.arth.2020.04.038

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Author: Zoher Ghogawala
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  • Lahey Hospital and Medical Center, Tufts University School of Medicine, Burlington, MA
Keywords:

Response

On behalf of my coauthors of the editorial, I would like to thank Dr. Kaiser for his letter. He points out the importance of understanding the impact of delaying procedures or surgery for patients who are experiencing severe pain during the COVID-19 pandemic, and he highlights the importance of mental health disorders (depression, anxiety, posttraumatic stress disorder, etc.) when considering the delay of spinal procedures and surgery aimed at reducing pain and suffering.

We agree that as a society we have had to make enormous sacrifices in order to accommodate the changes brought forward by the COVID-19 pandemic. The onslaught of patients with COVID-19 in our hospitals made it impossible to continue performing elective surgery in most parts of the world. Indeed, the delay of surgery aimed at relieving pain has been an important sacrifice that has affected thousands of patients. It is incumbent upon all of us in the spine community to do careful studies and report on the physical and psychological impact that postponement has had on the many patients with significant spinal disorders during this painful period in history.

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Contributor Notes

Correspondence Radek Kaiser: rkaiser@hotmail.cz.

INCLUDE WHEN CITING Published online June 26, 2020; DOI: 10.3171/2020.5.SPINE20849.

Disclosures The author reports no conflict of interest.

  • 1

    Ghogawala Z, Kurpad S, Falavigna A, Editorial. COVID-19 and spinal surgery. J Neurosurg Spine. 2020;33(1):13.

  • 2

    Sarac NJ, Sarac BA, Schoenbrunner AR, A review of state guidelines for elective orthopaedic procedures during the COVID-19 outbreak. J Bone Joint Surg Am. 2020;102(11):942945.

    • Search Google Scholar
    • Export Citation
  • 3

    Donnally CJ III, Shenoy K, Vaccaro AR, Triaging spine surgery in the COVID-19 era. Clin Spine Surg. 2020;33(4):129130.

  • 4

    Khan F, Amatya B. Medical rehabilitation in pandemics: towards a new perspective. J Rehab Med. 2020;52(4):jrm00043.

  • 5

    Recommendations on chronic pain practice during the COVID-19 pandemic: a joint statement by American Society of Regional Anesthesia and Pain Medicine (ASRA) and European Society of Regional Anesthesia and Pain Therapy (ESRA). Accessed June 4, 2020. https://www.asra.com/content/documents/asra_esra_covid-19_and_chronic_pain.pdf

    • Export Citation
  • 6

    Cohen SP, Baber ZB, Buvanendran A, Pain management best practices from multispecialty organizations during the COVID-19 pandemic and public health crises. Pain Med. Published online April 7, 2020. doi:10.1093/pm/pnaa127

    • Search Google Scholar
    • Export Citation
  • 7

    Song XJ, Xiong DL, Wang ZY, Pain management during the COVID-19 pandemic in China: lessons learned. Pain Med. Published online April 22, 2020. doi:10.1093/pm/pnaa143

    • Search Google Scholar
    • Export Citation
  • 8

    Eccleston C, Blyth FM, Dear BF, Managing patients with chronic pain during the COVID-19 outbreak: considerations for the rapid introduction of remotely supported (eHealth) pain management services. Pain. 2020;161(5):889893.

    • Search Google Scholar
    • Export Citation
  • 9

    Brooks SK, Webster RK, Smith LE, The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet. 2020;395(10227):912920.

    • Search Google Scholar
    • Export Citation
  • 10

    Moccia L, Janiri D, Pepe M, Affective temperament, attachment style, and the psychological impact of the COVID-19 outbreak: an early report on the Italian general population. Brain Behav Immun. Published online April 20, 2020. doi:10.1016/j.bbi.2020.04.048

    • Search Google Scholar
    • Export Citation
  • 11

    O’Connor CM, Anoushiravani AA, DiCaprio MR, Economic recovery after the COVID-19 pandemic: resuming elective orthopedic surgery and total joint arthroplasty. J Arthroplasty. Published online April 18, 2020. doi:10.1016/j.arth.2020.04.038

    • Search Google Scholar
    • Export Citation

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