Discussion
Covid-19 crisis has exhausted the capacity of national health services even in developed countries. Most of the medical resources have been channeled for the management of this crisis and the elective services have been kept on hold. Still, there would be some unavoidable surgical conditions when a delay in surgery would significantly increase the morbidity and warrants consideration for appropriate intervention. Since there is a difference in the burden of disease, availability of resources, and the ability to surge capacity in a short span, the policy to deal with this crisis must be individualized to some extent. We tried to develop a standard operating procedure for the management of patients needing emergent/urgent spine surgery taking input for the recent evidence.
The most common mode of injury in vertebral fractures is a motor vehicle accident [13,14]. However, in our study, fall from height (87.5%) was the commonest mode of trauma. The possible explanation is that due to the nationwide lockdown, there was a significant reduction in surface transportation and people were generally refraining from traveling for non-essential work. Due to the limited capacity for SARS-Cov-2 RT-PCR testing and the centers performing COVID tests, comprehensive screening history, and physical examination becomes important to triage the patient for the test. History should focus on the symptoms of COVID-19, travel to high prevalence area, or any contact with a known patient. It is also important to enquire whether the patient had been infected with COVID-19 earlier or ever been tested as there are reports of individuals who got infected with COVID-19, recovered, and then again tested positive [14]. Secondly, it will also help in assessing if the patient might be in the incubation period. However, in case of an emergency, the surgeries should not be delayed. A sample can be sent for RT-PCR and surgery should be performed donning proper PPE without waiting for the result. As asymptomatic patients can transmit the infection it becomes prudent to assume that all patients requiring orthopedic intervention as COVID-19 positive and they should be managed accordingly from their admission into the hospital to their exit from the hospital during their discharge [1].
Trans-pedicular screw fixation is one of the main modalities of spinal instrumentation today and patients are stabilized with pedicle screws and rods [15].
Patient and attendant education regarding the administrative policies to prevent contracting/transmitting infection while in hospital as well as education regarding wearing a mask, hand hygiene, social distancing serves the purpose of making patients aware of their safety [4,7,10].
In the operation theatre complex, it is mandatory to avoid overcrowding in all areas (patient waiting area, operating room, and the recovery room). Inside operation theatre it is important to limit the number of staff allowed as SARS-CoV-2 is mainly transmitted via aerosolized droplets, so by decreasing the air turbulence and the number of air particles decreases the disease transmission; it will help in implementing the social distancing concept while also decreasing the demand for PPE [8,10,11,16-18].
To decrease the risk of transmission from airborne droplets it is mandatory to use PPE. The surgical team must wear PPE which includes AAMI III gowns, gloves, face masks, and N95 with face shield/goggles to minimize the risk of transmission and cross-infection [8,11,12]. Association for the Advancement of Medical Instrumentation (AAMI) ratings are based on the level of fluid protection in the critical zone or chest region of the surgical gown. Surgical gowns AAMI-level-III (typically those found in operating rooms) are recommended for use during surgical and aerosolized blood-generating procedures [8,11,12,17-19].
At our institute, N-95 masks are reused unless they are visibly soiled. Each HCW is given a set of five N-95 masks that are numbered from 1 to 5 and HCWs are supposed to write their name and number over it. After the duty shift, HCWs are supposed to put it in sealable plastic cover and next day use the next mask. The masks are deposited at the designated place from where the infection control nurse (ICN) collects them for drying under the sun on two consecutive days for at least nine hours/day. The masks are issued to the same user only after the fifth day of submission. Each mask is used maximum for five times. Subsequently, the mask is disposed of appropriately. Single-use of the N-95 mask is recommended if it is contaminated with blood, respiratory or nasal secretions, or other bodily fluids from patients. It should be discarded following close contact with or exit from, the care area of any patient co-infected with an infectious disease requiring contact precautions, and if it is damaged or clogged. The rationale behind this is dry heat 70oC exposure for 60 minutes as an accepted method for decontaminating the N-95 masks. Further, it is documented that the COVID-19 virus does not survive on inanimate surfaces beyond a period of five days [20,21]. 
As per the advisory issued by the Ministry of health and family welfare on re-processing and re-use of eye-protection (goggles), the goggles are to be reused; after each use, the goggles are cleaned with soap and water and then immersed in freshly prepared 1% sodium hypochlorite for ten minutes. This is followed by cleaning with water and then allowed to air dry completely and then store in clean cover. The goggles are to be discarded if broken or rendered optically non-clear on repeated usage. The recommended maximum reuse is for up to six times [22]. These methods devised to reuse N-95 and goggles are very helpful in the judicious use of limited resources without increasing the risk of infection. The proper and meticulous technique of donning and doffing should be practiced each time to prevent infection [23].
Our surgical team was on HCQ prophylaxis as recommended by the ICMR in a dose of 400 mg twice a day on day one and 400 mg once a week for seven days [9]. HCQ has antiviral efficacy and has shown a reduction of infectivity/log reduction in viral RNA copy of SARs-CoV2 and has a low incidence of infection to those who are taking it. The drug is contraindicated in persons with a known case of retinopathy, hypersensitivity to HCQ or 4-aminoquinoline compounds, glucose-6-phosphate dehydrogenase (G6PD) deficiency, and pre-existing cardiomyopathy and cardiac rhythm disorders. 
It is not recommended for prophylaxis in children under 15 years of age and during pregnancy and lactation [24]. 
The aerosols generating procedures in orthopedic surgery include the use of electrocautery, high-speed burr, ultrasonic devices, and power tools like an oscillating saw, drills, reamers, and pulse lavage [12]. While it is unknown if the COVID-19 particles can survive electrocautery, minimizing the amount of smoke in the operating room helps in decreasing potential transmission. Similarly, it is unknown that a virus can spread through body fluids, soft tissue, or bone particulate, it is wise to avoid harmonic scalpels and high-speed burrs [8,11,12,18].
The postoperative length of stay in the hospital should be minimized. The post-operative care (like dressing, intravenous antibiotics, etc.) can be managed at the patient’s home or the nearest hospital. The patient is instructed to perform self-directed physical therapy at home and transfer to inpatient rehabilitation should be minimized which can significantly reduce the length of hospital stay [10,11,16,17,19,25]. Before the COVID-19 pandemic, we were transferring the paraplegic patients to our hospital-based rehabilitation center where discharge time was about six weeks. During this pandemic, we started teaching physiotherapy and care to attendants from day one which decreased the hospital stay to 3.7 days. 
Post-discharge visits to the hospital have been minimized with the majority of the follow-up by the surgical team through telemedicine or remote consultations (e.g. telephone or video consultation). The hospital visits were limited to those who are having issues/complications such as wound healing problems, suspected fracture, stiffness, and non-compliance to physiotherapy [4,7,11-13].
There are chances of a “second wave” which were seen in SARS and Spanish flu which may lead to a sudden increase in COVID-19 cases [10]. We need to be vigilant and be prepared for it. We should strictly adhere to infection control policy, use masks, and practice social distancing. 
The above structural organization and management protocol helped us to provide efficient care to emergency spine conditions, without undue stretching the resources of a tertiary care center which is also catering to a large number of COVID-19 patients. An attempt is made to reduce infection transmission to health care workers without compromising the patient's safety.
We recognize that the small patient number is a limitation of this study and follow up is short. We have not assessed the problem faced by a home-based rehabilitation program and is a subject of further research