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Id Subject Object Predicate Lexical cue
T1 0-102 Sentence denotes Adapting Policy Guidelines for Spine Surgeries During COVID-19 Pandemic in View of Evolving Evidences:
T2 103-161 Sentence denotes An Early Experience From a Tertiary Care Teaching Hospital
T3 163-171 Sentence denotes Abstract
T4 172-184 Sentence denotes Introduction
T5 185-285 Sentence denotes The recent novel coronavirus disease 2019 (COVID-19) pandemic has brought the world to a standstill.
T6 286-390 Sentence denotes This outbreak not only affected healthcare systems but the resultant economic losses were also enormous.
T7 391-639 Sentence denotes COVID-19 has demanded that the health care systems globally evolve, develop new strategies, identify new models of functioning, and at times, fall back on the old conservative methods of orthopedic care to decrease the risk of disease transmission.
T8 640-776 Sentence denotes Although, the majority of hospitals are refraining from performing elective surgeries, emergent and urgent procedures cannot be delayed.
T9 777-1001 Sentence denotes Various strategies have been developed at the institute level to reduce the risk of infection transmission among the theatre team from an unsuspected patient (asymptomatic and presymptomatic) during the perioperative period.
T10 1002-1022 Sentence denotes Material and methods
T11 1023-1174 Sentence denotes The present study is a part of an ongoing project which is being conducted in a tertiary level hospital after obtaining research review board approval.
T12 1175-1299 Sentence denotes All patients admitted either for vertebral fracture or spinal cord compression from February 2020 to May 2020 were included.
T13 1300-1514 Sentence denotes The present study included 13 patients (nine males and four females) with an average age of 35.4 years The oldest patient was of 63 years which is considered a risk factor for developing severe COVID-19 infection. 
T14 1515-1522 Sentence denotes Results
T15 1523-1670 Sentence denotes Eight patients (61.5%) presented with spinal cord injury (SCI) due to vertebral fracture with fall from height (87.5%) as the most common etiology.
T16 1671-2312 Sentence denotes Among the traumatic SCI patients, six (75%) were managed surgically with posterior decompression and instrumented fusion with pedicle screws while two patients (25%) were managed conservatively. There were four patients (30.8%) of tuberculosis of the spine of whom two (50%) were managed with posterior decompression, debridement, and stabilization with pedicle screws, samples for culture, biopsy, and cartridge-based nucleic acid amplification test (CBNAAT) were collected during the procedure; for the remaining two patients (50%), a trans-pedicular biopsy was performed to confirm the diagnosis for initiation of anti-tubercular therapy.
T17 2313-2668 Sentence denotes Prolapsed intervertebral disc causing cauda equina syndrome was the reason for emergency surgery in one patient (7.7%). COVID-19 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) reverse transcription-polymerase chain reaction (RT-PCR) test was performed in four patients (30.8%), in whom the most common symptom was fever (two patients (50%)).
T18 2669-2746 Sentence denotes These patients were residents of high prevalence area for COVID-19 infection.
T19 2747-2884 Sentence denotes Sore throat (25%), fatigue (25%), and low oxygen saturation (25%) were present in one patient which prompted us to get the COVID-19 test.
T20 2885-2934 Sentence denotes All patients were reported negative for COVID-19.
T21 2935-2945 Sentence denotes Conclusion
T22 2946-3149 Sentence denotes The structural organization and the management protocol we describe allowed us to reduce infection risk and ultimately hospital stay, thereby maximizing the already stretched available medical resources.
T23 3150-3285 Sentence denotes These precautions helped us to reduce transmission and exposure to COVID-19 in health care workers (HCW) and patients in our institute.
T24 3286-3423 Sentence denotes The aim of this article is that our early experience can be of value to the medical communities that will soon be in a similar situation.
T25 3425-3437 Sentence denotes Introduction
T26 3438-3538 Sentence denotes The recent novel coronavirus disease 2019 (COVID-19) pandemic has brought the world to a standstill.
T27 3539-3642 Sentence denotes This outbreak not only affected the healthcare systems but the resultant economic losses were enormous.
T28 3643-3891 Sentence denotes COVID-19 has demanded that the health care systems globally evolve, develop new strategies, identify new models of functioning, and at times, fall back on the old conservative methods of orthopedic care to decrease the risk of disease transmission.
T29 3892-3993 Sentence denotes The usual incubation period of the disease is 5-14 days but with reported outliers up to 24 days [1].
T30 3994-4181 Sentence denotes It is not just the contagiousness of the COVID-19 but the alarming fatality as well (approximately 3.6%), which far exceeds the other severe acute respiratory syndrome (SARS) viruses [1].
T31 4182-4361 Sentence denotes Although the recent World Health Organization (WHO) report suggests that the asymptomatic cases are less likely to transmit the virus, this is debatable with conflicting evidence.
T32 4362-4439 Sentence denotes Moreover, the presymptomatic cases are as likely to transmit the virus [2,3].
T33 4440-4577 Sentence denotes Infection among health care workers (HCWs) is further straining the already overburdened workforce due to a sudden spike in the caseload.
T34 4578-4714 Sentence denotes Although, the majority of hospitals are refraining from performing elective surgeries, emergent and urgent procedures cannot be delayed.
T35 4715-4945 Sentence denotes Various strategies have been developed at the institute level to reduce the risk of infection transmission among the theatre team from an unsuspected patient (asymptomatic and presymptomatic) during the perioperative period [2,3].
T36 4946-5245 Sentence denotes India has rapidly surged its capacity of reverse transcription-polymerase chain reaction (RT-PCR) testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) but with its 1.3 billion population and a rapidly increasing infection rate, a selective testing approach was adopted initially.
T37 5246-5423 Sentence denotes The policy regarding testing in India formulated by the Indian council of medical research (ICMR) has been revised with evolving evidence regarding the spread of infection [4]. 
T38 5424-5864 Sentence denotes Since testing could not be performed in all patients in need of surgical intervention due to time or resource constrain, nor an initial negative test can surely rule out infection, a “consider all positive” approach was adopted by the authors' institute to manage patients requiring emergent or urgent care including the available recommendations regarding reducing the risk of exposure to the surgical team during the perioperative period,
T39 5865-6003 Sentence denotes We developed a “caution at each step” model in an effort to minimize the risk of exposure to the theatre team from an unsuspected patient.
T40 6004-6126 Sentence denotes In this study, we elaborate on this model in detail along with our experience of its use in emergency spine surgery cases.
T41 6128-6149 Sentence denotes Materials and methods
T42 6150-6335 Sentence denotes The patients participating are also part of an ongoing prospective study on spine injuries at the authors' institute for which institutional ethics committee approval has been obtained.
T43 6336-6460 Sentence denotes All patients admitted either for vertebral fracture or spinal cord compression from February 2020 to May 2020 were included.
T44 6461-6689 Sentence denotes The spine conditions included were spinal cord injury (SCI), epidural abscess, epidural hematoma, close reduction of cervical facet dislocation, cauda equine syndrome, surgical spine tumor with spinal cord compression (Table 1).
T45 6690-6724 Sentence denotes No COVID-19 patients were treated.
T46 6725-6900 Sentence denotes The neurological status was assessed using the American Spinal Injury Association (ASIA) impairment scale as it can be used for traumatic [5] as well as non-traumatic SCI [6].
T47 6901-7262 Sentence denotes Thoracolumbar injury classification and severity score (TLICS) based on the morphology of the injury, the integrity of the posterior ligamentous complex, and neurological status of the patient was performed in which points are assigned for each category and the final total points suggest the possible treatment option for thoracolumbar vertebral fractures [7].
T48 7263-7305 Sentence denotes Table 1 Inclusion and exclusion criterias
T49 7306-7364 Sentence denotes A) Inclusion Criteria (Indications for emergency  surgery)
T50 7365-7412 Sentence denotes 1) Spinal Cord injury due to verbral fracture  
T51 7413-7432 Sentence denotes 2) Epidural Abscess
T52 7433-7454 Sentence denotes 3) Epidural Haematoma
T53 7455-7546 Sentence denotes 4) Surgical Spine tumour with Spinal Cord compression with progressive neurological deficit
T54 7547-7571 Sentence denotes 5) Cauda equina syndrome
T55 7572-7660 Sentence denotes 6) Infective pathology of spine (tubercular spondylodiscitis,bacterial spondylodiscitis)
T56 7661-7715 Sentence denotes B) Exclusion Criteria (Surgeries which can be delayed)
T57 7716-7772 Sentence denotes 1) Surgical lumbar disk herniation  with radiculopathy  
T58 7773-7795 Sentence denotes 2) Spondylolisthesis  
T59 7796-7832 Sentence denotes 3) Surgical cervical radiculopathy  
T60 7833-7863 Sentence denotes 4) Cervical myelopathy Methods
T61 7864-7958 Sentence denotes The detailed description of the steps which we took is mentioned below and briefly in Table 2.
T62 7959-8008 Sentence denotes Table 2 Brief description of precautionary steps
T63 8009-8013 Sentence denotes PPE:
T64 8014-8050 Sentence denotes Personal protective equipment; TOCC:
T65 8051-8255 Sentence denotes Travel to regions with a high prevalence of COVID-19, occupation with a high risk of COVID-19 infection, contact with people known to be infected with COVID-19, or proximity with a COVID-19 positive case.
T66 8256-8257 Sentence denotes  
T67 8258-8270 Sentence denotes Do’s Dont’s
T68 8271-8295 Sentence denotes 1.Preoperative period  
T69 8296-8397 Sentence denotes A) History, examination and screening Questinnare related to COVID 19 (Table 3) A) Entry to visitors
T70 8398-8460 Sentence denotes B) TOCC information (Table 3) B)  Allow unnecessary attendant
T71 8461-8576 Sentence denotes C) Explain the hospital’s protocol for COVID-19 Infection C) Overcrowing of patients in the ward and recovery room
T72 8577-8625 Sentence denotes D) Compulsory Mask for patient and attendant.  
T73 8626-8652 Sentence denotes 2.Intraoperative period  
T74 8653-8742 Sentence denotes A) Proper donning and doffing technique of prescribed PPE A)Avoid using High power tools
T75 8743-8884 Sentence denotes B) Limiting the number of people in the operating room   B) Unnecessary Crowd in  operation room especially during intubation and extubation
T76 8885-8971 Sentence denotes C) Reducing door opening in the operating room C) Cluttering of unnecessary equipment
T77 8972-9021 Sentence denotes D) Cautious use of electrocautery with suction  
T78 9022-9089 Sentence denotes E) Thorough cleaning of the operation room and all the equipment  
T79 9090-9092 Sentence denotes 3.
T80 9093-9116 Sentence denotes Postoperative period  
T81 9117-9174 Sentence denotes A) Mask for patient A) Overcrowding in the recovery room
T82 9175-9252 Sentence denotes B) Social distancing in the recovery room B) Keeping patient for longer time
T83 9253-9345 Sentence denotes C)Cleaning of bed and it's surface after the transfer of patient C)Prolong stay in hospital
T84 9346-9481 Sentence denotes D) Immediate Postoperative round by  Senior resident, Chief surgeon should be telephonically informed D)Change in antibiotic protocols
T85 9482-9576 Sentence denotes E) Prescribed PPE by health care personnel  E) Interdepartmental  Transfer for rehabilitation
T86 9577-9674 Sentence denotes F)Wound inspection and dressing – wear an N95 mask F) A frequent follow-up visit to the hospital
T87 9675-9727 Sentence denotes G) Early rehabilitation and physiotherapy program  
T88 9728-9789 Sentence denotes H) Teleconsultation for follow up   Precautions at admission
T89 9790-9863 Sentence denotes At presentation, history was recorded and clinical examination performed.
T90 9864-9941 Sentence denotes The temperature and oxygen saturation at room air recorded for every patient.
T91 9942-10403 Sentence denotes All patients were screened with a series of questions related to COVID-19 symptoms (fever, cough, fatigue, anorexia, shortness of breath, sputum production, loss of taste and smell, sore throat, diarrhea, nasal congestion) as well as TOCC information (travel to regions with a high prevalence of COVID-19, occupation with a high risk of COVID-19 infection, contact with people known to be infected with COVID-19, or proximity with a COVID-19 positive case) [8].
T92 10404-10501 Sentence denotes Information was also obtained regarding the previous infection and test for SARS-CoV-2 (Table 3).
T93 10502-10570 Sentence denotes Table 3 Coronavirus disease 2019 (COVID-19) screening questionnaire
T94 10571-10582 Sentence denotes SARS-CoV-2:
T95 10583-10639 Sentence denotes Severe acute respiratory syndrome coronavirus 2; RT-PCR:
T96 10640-10687 Sentence denotes Reverse transcription-polymerase chain reaction
T97 10688-10701 Sentence denotes S.no      
T98 10702-10722 Sentence denotes 1 Temperature    
T99 10723-10753 Sentence denotes 2 Pulse Oximetry (Spo2)    
T100 10754-10777 Sentence denotes 3 Travel History    
T101 10778-10797 Sentence denotes 4 Occupation    
T102 10798-10843 Sentence denotes 5 Contact with COVID positive  Patient    
T103 10844-10898 Sentence denotes 6 Close proximity to COVID 19 Positive patients    
T104 10899-10958 Sentence denotes 7 Symptoms Yes/ NO If Yes, when was the onset of symptom
T105 10959-10973 Sentence denotes a Fever    
T106 10974-10988 Sentence denotes b Cough    
T107 10989-11005 Sentence denotes c Fatigue    
T108 11006-11023 Sentence denotes d Anorexia    
T109 11024-11052 Sentence denotes e Shortness of breath    
T110 11053-11079 Sentence denotes f Sputum production    
T111 11080-11112 Sentence denotes g Loss of taste and smell    
T112 11113-11133 Sentence denotes h Sore throat    
T113 11134-11151 Sentence denotes i Diarrhea    
T114 11152-11177 Sentence denotes j Nasal Congestion    
T115 11178-11227 Sentence denotes 8) Previous history of COVID -19 infection    
T116 11228-11400 Sentence denotes 9) Previous SARS- COV2 RT PCR test (Date)   Result – Positive/Negative In the case of history or examination suggestive of COVID 19, the patient was isolated and tested.
T117 11401-11482 Sentence denotes However, none of the emergency surgeries was delayed while awaiting test results.
T118 11483-11592 Sentence denotes The sample was sent and surgery was conducted by donning full prescribed personal protective equipment (PPE).
T119 11593-11617 Sentence denotes Preoperative precautions
T120 11618-11876 Sentence denotes Preoperatively, patients and attendants explained about the precautions and measures (hand hygiene, wearing a mask, social distancing, restrictions of family members, and visitors in hospital) recommended by hospital authorities because of COVID-19 pandemic.
T121 11877-11961 Sentence denotes The patients were provided with a surgical mask throughout the perioperative period.
T122 11962-12076 Sentence denotes The patient was transferred to an operation theatre only on-call from the operation theatre to avoid overcrowding.
T123 12077-12193 Sentence denotes The individual operating rooms have separate air-handling units with high-efficiency particulate air (HEPA) filters.
T124 12194-12230 Sentence denotes Precautions in the operation theatre
T125 12231-12359 Sentence denotes Intraoperatively, the anesthesia team consisted of a consultant, senior resident, junior resident, and an anesthesia technician.
T126 12360-12754 Sentence denotes All preparation for general anesthesia was performed by the anesthesia team before shifting the patient to the operation table, during intubation either the consultant or the senior resident intubated the patient donning the prescribed PPE which consisted of Association for the Advancement of Medical Instrumentation (AAMI) level III gown, hood, N95 mask, face shield, boot covers, and gloves.
T127 12755-12853 Sentence denotes The junior resident or the anesthesia technician was available to assist during the procedure [8].
T128 12854-13021 Sentence denotes During intubation and extubation, the surgical team was outside the operating room to limit the number of persons inside and minimize the risk of disease transmission.
T129 13022-13112 Sentence denotes After intubation, the patient was handed over to the surgical team after about 20 minutes.
T130 13113-13213 Sentence denotes The surgical team consisted of the chief surgeon, senior resident, junior resident, and scrub nurse.
T131 13214-13347 Sentence denotes The entire surgical team was on hydroxychloroquine (HCQ) prophylaxis as advised by the Indian council of medical research (ICMR) [9].
T132 13348-13571 Sentence denotes The entire surgical team wore the prescribed PPE - N95 mask, hood with a face shield that wraps around the face and has an extension that can be placed inside the gown, AAMI level III gown, boot cover, and gloves [8,10,11].
T133 13572-13715 Sentence denotes The surgical knife was used for dissection and electrocautery was minimally used with suction wherever required to minimize aerosol generation.
T134 13716-13850 Sentence denotes Kerrison rongeur, nibblers, and osteotomes were used in place of burr or harmonic scalpel which decreased the aerosol generation [12].
T135 13851-13942 Sentence denotes Wound closure was done over the drain with staplers and the occlusive dressing was applied.
T136 13943-14122 Sentence denotes During extubation, theatre personnel was limited to the anesthesia team and the patient was allowed to recover in the operating room to minimize the shifting to the recovery room.
T137 14123-14236 Sentence denotes In case there was any other emergency case waiting for surgery the patient was shifted to the recovery room [13].
T138 14237-14448 Sentence denotes For the cases performed under local anesthesia like a transpedicular biopsy, the team inside the operating room was limited to surgeon, scrub nurse, and radiology technician to operate a C-arm image intensifier.
T139 14449-14511 Sentence denotes After the procedure, the patient directly shifted to the ward.
T140 14512-14735 Sentence denotes As per institutional policy, following the procedure. the surfaces of all equipment in the operating room (including computers, lead gowns, case carts, operation chair, and so on) were thoroughly wiped down after each case.
T141 14736-14801 Sentence denotes The surgeon and the surgical team changed scrubs after each case.
T142 14802-14868 Sentence denotes Respirators (N95) were not discarded after each use unless soiled.
T143 14869-14907 Sentence denotes A new respirator is required each day.
T144 14908-15002 Sentence denotes As per institutional policy, the N95 masks were reused up to five times unless visibly soiled.
T145 15003-15035 Sentence denotes Precautions in the recovery room
T146 15036-15145 Sentence denotes In the recovery room, patients were separated from each other by a minimum distance of two meters (six-feet).
T147 15146-15304 Sentence denotes Personnel taking care of the patient wore an N-95 mask as the patient is under the effect of general anesthesia, might not have control over cough and sneeze.
T148 15305-15407 Sentence denotes However, the patient’s stay in the recovery area was minimized while maintaining perioperative safety.
T149 15408-15492 Sentence denotes Patients were made to wear a triple-layer surgical mask in the postoperative period.
T150 15493-15559 Sentence denotes Over-crowding and non-essential personnel traffic were restricted.
T151 15560-15589 Sentence denotes Post-operative care protocols
T152 15590-15693 Sentence denotes Postoperative rounds were done by the senior resident and informed to the chief surgeon telephonically.
T153 15694-15829 Sentence denotes The surgical wound was inspected by the resident wearing an N95 mask on the third postoperative day and the drain, if any, was removed.
T154 15830-16016 Sentence denotes The patient was usually discharged on the same day if the wound was healthy after teaching physiotherapy and other precautions to the patient and attendant to minimize the hospital-stay.
T155 16017-16122 Sentence denotes For procedures that were performed under local anesthesia, the patients were discharged the next morning.
T156 16123-16181 Sentence denotes Suture removal was advised to be done at a local hospital.
T157 16182-16350 Sentence denotes Institute telemedicine number and the resident’s contact number was provided to the patient to consult in case of any surgery-related problem and to schedule follow up.
T158 16352-16359 Sentence denotes Results
T159 16360-16484 Sentence denotes The present study included 13 patients (nine males and four females) with an average age of 35.4 years (range- 42-63 years).
T160 16485-16611 Sentence denotes Eight patients (61.5%) presented with SCI due to vertebral fracture with fall from height (87.5%) as the most common etiology.
T161 16612-16686 Sentence denotes Road traffic accidents accounted for only one patient as the cause of SCI.
T162 16687-16881 Sentence denotes Among the traumatic SCI patients, six (75%) were managed surgically with posterior decompression and instrumented fusion with pedicle screws while two patients (25%) were managed conservatively.
T163 16882-17280 Sentence denotes There were four patients (30.8%) of tuberculosis of the spine of whom two (50%) were managed with posterior decompression, debridement, and stabilization with pedicle screws, samples for culture, biopsy, and CBNAAT were collected during the procedure; for the remaining two patients (50%), the trans-pedicular biopsy was performed to confirm the diagnosis for initiation of anti-tubercular therapy.
T164 17281-17401 Sentence denotes Prolapsed intervertebral disc causing cauda equina syndrome was the reason for emergency surgery in one patient (7.7%). 
T165 17402-17619 Sentence denotes COVID-19 (SARS-CoV-2 RT-PCR) test was done in four patients (30.8%), in whom the most common symptom was fever (two patients (50%)) and all these patients were residents of high prevalence area for COVID-19 infection.
T166 17620-17770 Sentence denotes Sore throat (25%), fatigue (25%), and low oxygen saturation (25%) were present in one patient each patient which prompted us to get the COVID-19 test.
T167 17771-17820 Sentence denotes All patients were reported negative for COVID-19.
T168 17821-17960 Sentence denotes Among the traumatic SCI patients, four were operated within 48 hours of injury as they were referred from other centers after primary care.
T169 17961-18016 Sentence denotes All patients were managed within 24 hours of admission.
T170 18017-18092 Sentence denotes The average hospital stay was 2.7 days (range four to five days) (Table 4).
T171 18093-18134 Sentence denotes Table 4 Patient demographics and results
T172 18135-18139 Sentence denotes RTA:
T173 18140-18166 Sentence denotes Road traffic accident; PF:
T174 18167-18185 Sentence denotes Pedicular fixation
T175 18186-18190 Sentence denotes Sno.
T176 18192-18340 Sentence denotes Age/sex Mode of trauma Diagnosis ASIA Score TLICS Score Surgery COVID testing Indication for COVID test Result Time interval Hospital Stay
T177 18341-18431 Sentence denotes 1 21/M RTA Burst # L1 A 7  Decompression and  PF  D12-L2 No NA NA 24 hrs 3 days
T178 18432-18494 Sentence denotes 2 40/M Fall #D8 E 2 Conservative No NA NA Na 1 days
T179 18495-18645 Sentence denotes 3 50/M Fall #D11 A 7 Decompression and PF D10 to D12 Yes 1)residence at High prevalence area 2)Spo2 – 88% on room air Negative 48 hrs 3 day
T180 18646-18772 Sentence denotes 4 30/M fall # L1 A 7 Decompression and PF D12to L2 Yes 1) Residence at High prevalence area Negative 48  hrs 3 days
T181 18773-18857 Sentence denotes 5 25/M Fall # L1 A 7 Decompression and PF D12to L2 NO NA NA 24 hrs 3 days
T182 18858-18920 Sentence denotes 6 22/F Fall # L2 E 2 Conservative No NA NA NA 1 day
T183 18921-19005 Sentence denotes 7 63/F Fall # L1 D 8 Decompression and PF D10 to L3 No NA NA 48hrs 3 days
T184 19006-19103 Sentence denotes 8 43/M Fall #Dislocation D6/D7 A 7 Decompression and PF D5to D8 No NA NA 48 hrs 3 days
T185 19104-19281 Sentence denotes 9 42/M Infective pathology Tuberculosis of spine from D8,D9,D12,L1,L2,L3 with paravertebral abscess E NA Transpedicular Biopsy from D12 vertebra No NA NA 24 hrs 1 day
T186 19282-19441 Sentence denotes 10 33/F Infective apthology Tuberculosis of spine L4-L5 with paravertbral abscess E NA Transpedicular Biopsy from L5  vertebra No NA NA 24 hrs 1 day
T187 19442-19657 Sentence denotes 11 25/M Infective apthology Tuberculosis of spine L2 to L3 with  paravertebral abscess C NA Decompression and PF D12to L5 Yes 1) Residence at High prevalence area 2)Fever 3) Fatigue Negative 24 hrs 5 days
T188 19658-19888 Sentence denotes 12 42/M Infective apthology Tuberculosis of spine L4-L5 vertebrae with paravertebral abscess D NA Decompression and PF from L3 to S1 Yes 1) Residence at High prevalence area 2)Fever 3)Sore throat Negative 24 days 5 days
T189 19889-20012 Sentence denotes 13 24/F Cauda Equina Syndrome Proloapsed intervertebral Disc L4-L5 B  NA Discectomy L4-L5 NO NA NA 24 hrs 3 days
T190 20014-20024 Sentence denotes Discussion
T191 20025-20124 Sentence denotes Covid-19 crisis has exhausted the capacity of national health services even in developed countries.
T192 20125-20258 Sentence denotes Most of the medical resources have been channeled for the management of this crisis and the elective services have been kept on hold.
T193 20259-20441 Sentence denotes Still, there would be some unavoidable surgical conditions when a delay in surgery would significantly increase the morbidity and warrants consideration for appropriate intervention.
T194 20442-20648 Sentence denotes 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.
T195 20649-20806 Sentence denotes We tried to develop a standard operating procedure for the management of patients needing emergent/urgent spine surgery taking input for the recent evidence.
T196 20807-20897 Sentence denotes The most common mode of injury in vertebral fractures is a motor vehicle accident [13,14].
T197 20898-20979 Sentence denotes However, in our study, fall from height (87.5%) was the commonest mode of trauma.
T198 20980-21390 Sentence denotes 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.
T199 21391-21509 Sentence denotes History should focus on the symptoms of COVID-19, travel to high prevalence area, or any contact with a known patient.
T200 21510-21737 Sentence denotes 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].
T201 21738-21828 Sentence denotes Secondly, it will also help in assessing if the patient might be in the incubation period.
T202 21829-21899 Sentence denotes However, in case of an emergency, the surgeries should not be delayed.
T203 21900-22014 Sentence denotes A sample can be sent for RT-PCR and surgery should be performed donning proper PPE without waiting for the result.
T204 22015-22306 Sentence denotes 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].
T205 22307-22462 Sentence denotes Trans-pedicular screw fixation is one of the main modalities of spinal instrumentation today and patients are stabilized with pedicle screws and rods [15].
T206 22463-22745 Sentence denotes 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].
T207 22746-22893 Sentence denotes In the operation theatre complex, it is mandatory to avoid overcrowding in all areas (patient waiting area, operating room, and the recovery room).
T208 22894-23254 Sentence denotes 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].
T209 23255-23342 Sentence denotes To decrease the risk of transmission from airborne droplets it is mandatory to use PPE.
T210 23343-23526 Sentence denotes 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].
T211 23527-23702 Sentence denotes 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.
T212 23703-23876 Sentence denotes 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].
T213 23877-23948 Sentence denotes At our institute, N-95 masks are reused unless they are visibly soiled.
T214 23949-24083 Sentence denotes 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.
T215 24084-24191 Sentence denotes After the duty shift, HCWs are supposed to put it in sealable plastic cover and next day use the next mask.
T216 24192-24376 Sentence denotes 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.
T217 24377-24454 Sentence denotes The masks are issued to the same user only after the fifth day of submission.
T218 24455-24496 Sentence denotes Each mask is used maximum for five times.
T219 24497-24549 Sentence denotes Subsequently, the mask is disposed of appropriately.
T220 24550-24697 Sentence denotes 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.
T221 24698-24895 Sentence denotes 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.
T222 24896-25020 Sentence denotes The rationale behind this is dry heat 70oC exposure for 60 minutes as an accepted method for decontaminating the N-95 masks.
T223 25021-25148 Sentence denotes Further, it is documented that the COVID-19 virus does not survive on inanimate surfaces beyond a period of five days [20,21]. 
T224 25149-25445 Sentence denotes 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.
T225 25446-25555 Sentence denotes This is followed by cleaning with water and then allowed to air dry completely and then store in clean cover.
T226 25556-25648 Sentence denotes The goggles are to be discarded if broken or rendered optically non-clear on repeated usage.
T227 25649-25707 Sentence denotes The recommended maximum reuse is for up to six times [22].
T228 25708-25856 Sentence denotes 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.
T229 25857-25972 Sentence denotes The proper and meticulous technique of donning and doffing should be practiced each time to prevent infection [23].
T230 25973-26126 Sentence denotes 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].
T231 26127-26304 Sentence denotes 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.
T232 26305-26548 Sentence denotes 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. 
T233 26549-26662 Sentence denotes It is not recommended for prophylaxis in children under 15 years of age and during pregnancy and lactation [24]. 
T234 26663-26872 Sentence denotes 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].
T235 26873-27043 Sentence denotes 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.
T236 27044-27220 Sentence denotes 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].
T237 27221-27290 Sentence denotes The postoperative length of stay in the hospital should be minimized.
T238 27291-27423 Sentence denotes The post-operative care (like dressing, intravenous antibiotics, etc.) can be managed at the patient’s home or the nearest hospital.
T239 27424-27640 Sentence denotes 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].
T240 27641-27801 Sentence denotes Before the COVID-19 pandemic, we were transferring the paraplegic patients to our hospital-based rehabilitation center where discharge time was about six weeks.
T241 27802-27941 Sentence denotes During this pandemic, we started teaching physiotherapy and care to attendants from day one which decreased the hospital stay to 3.7 days. 
T242 27942-28140 Sentence denotes 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).
T243 28141-28330 Sentence denotes 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].
T244 28331-28467 Sentence denotes 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].
T245 28468-28514 Sentence denotes We need to be vigilant and be prepared for it.
T246 28515-28613 Sentence denotes We should strictly adhere to infection control policy, use masks, and practice social distancing. 
T247 28614-28866 Sentence denotes 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.
T248 28867-28984 Sentence denotes An attempt is made to reduce infection transmission to health care workers without compromising the patient's safety.
T249 28985-29081 Sentence denotes We recognize that the small patient number is a limitation of this study and follow up is short.
T250 29082-29196 Sentence denotes We have not assessed the problem faced by a home-based rehabilitation program and is a subject of further research
T251 29198-29209 Sentence denotes Conclusions
T252 29210-29389 Sentence denotes In these unusual times of the COVID-19 pandemic, the healthcare institutions must adopt the emerging pieces of evidence on the safety of HCW’s into the existing hospital policies.
T253 29390-29532 Sentence denotes Usual theatre practices need to be modified to reduce the risk of virus transmission during surgical procedures to the operation theatre team.
T254 29533-29657 Sentence denotes The protocol we described has enabled our surgical team to work efficiently and safely without compromising on patient care.
T255 29659-29719 Sentence denotes The authors have declared that no competing interests exist.
T256 29720-29732 Sentence denotes Human Ethics
T257 29733-29788 Sentence denotes Consent was obtained by all participants in this study.
T258 29789-29904 Sentence denotes Institutional Human Ethics Committee, All India Institute Of Medical Scienecs ,Bhopal issued approval IHECPGRMD027.
T259 29905-29949 Sentence denotes The decision of the committee is as follows:
T260 29950-29958 Sentence denotes Approved
T261 29959-29972 Sentence denotes Animal Ethics
T262 29973-29989 Sentence denotes Animal subjects:
T263 29990-30075 Sentence denotes All authors have confirmed that this study did not involve animal subjects or tissue.