Introduction

With the World Health Organization declaring the COVID19 pandemic in March 2020, there have been various strategies to cut off the viral transmission [8, 22, 40, 44]. Of these, lockdown and social distancing have been the major ones. Post lockdown, a global change in admission pattern and patient care, has been noted across multiple medical domains [1, 4, 17, 32, 36]. Neurosurgical patients remain no exception, and COVID19 has impacted all facets of neurosurgery, including neurotrauma [3, 19, 21, 23, 25, 28, 32]. The latter, however, has been less evaluated. While a few studies on the Western population have attempted to look upon the COVID19 influence on neurotrauma patterns, the comparable data from low- and middle-income countries (LMIC) is minimal [16, 26, 37]. This assumes importance, as there is a considerable difference in head injury epidemiology between high-income and LMIC [18, 30, 39]. Therefore, understanding the sectoral changes in neurotrauma following COVID19 could better prepare for the ongoing pandemic and an unprecedented catastrophe in the future. Many European nations have already started experiencing the COVID19 second wave [27].

The COVID19 viral surge in India was relatively late; however, the volume has exponentially escalated to approximately 9.7 million, with the country emerging as a significant epicenter [6, 33]. As of this writing, although the spread of the contagion seems to be stabilized with a reducing trend in the number of new active cases, the effect of forthcoming winters on the viral spread is currently uncertain [2, 15, 33]. Soon after 11 Mar 2020, when the World Health Organization declared COVID19 as a pandemic and with few sporadic cases reported in the country, the Indian Government, on 25 Mar, imposed a strict nationwide lockdown. This was staged in 4 phases with gradual unlock in sequence. Neurotrauma trends have likely changed during these periods due to more extraordinary travel restrictions. Besides, the COVID19 pandemic has forced a reshuffle of the existing resources to focus mainly on COVID19 patients [3, 28, 32]. The care may have consequently altered for a non-COVID cohort such as neurotrauma. We intended to perform a comparative analysis on the effect of COVID19 on the volume and admission patterns of head injury (HI) in our level 1 tertiary trauma care center and compare the mortality for severe HI, which can act as a surrogate indicator of the collateral fallout of COVID19 restrictions.

Methods and materials

This comparative study of prospectively acquired data was carried out in our level 1 central tertiary referral trauma center catering to north-west India (Fig. 1). The overall study data represent approximately 12-month HI admissions between 16 Sept 2019 and 30 Sept 2020.

Fig. 1
figure 1

Our catchment areas (states of India as of September 2019), showing the population density according to the 2011 census and the proportion of patient inflow from each state

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Patient cohort

In India, the lockdown was imposed in phases from 25 Mar 2020, with the following timeline: phase 1 (25 Mar–14 Apr), phase 2 (15 Apr–3 May), phase 3 (4–17 May), and phase 4 (18–31 May). Similarly, the phases of unlocking were as follows: unlock 1.0 (1–30 June), unlock 2.0 (1–31 July), unlock 3.0 (1–31 August), and unlock 4.0 (1–30 September) [35]. The study cohort involved three distinct periods in analyzing the significant change in trends and patient characteristics. The patients admitted with HI during the lock phases (68 days, 25 Mar to 31 May) and unlock phases (122, 1 Jun to 30 Sept) were compared to those admitted during 190 days from 16 Sept to 24 Mar, an equivalent time frame just before COVID19 restrictions. The latter served as a control group before the onset of the COVID19 pandemic. The data were evaluated in each phase of the lockdown and unlock period.

Data collection

The basic clinico-demographics, mechanism of injury, hospital arrival time since the time of injury, admission Glasgow coma scale (GCS), significant computed tomography (CT) imaging findings, and surgical intervention were prospectively entered into a pre-planned database. The mortality among patients with severe HI was compared during the pre-COVID period and lock phases.

Statistical analysis

The pre-COVID and post-COVID groups were compared using standard descriptive measures such as percentages and the mean number. The chi-square method tested significance for categorical variables, while the independent samples t test tested the difference in means for continuous variables. p < 0.05 was considered significant.

Results

Head injury admissions

The trends in number and pattern of head injury admissions are detailed in Fig. 2 and Table 1. Overall, the study identified 3372 HI admissions (2259 in pre-COVID19, 320 in lock phases, and 720 during unlocking phases of COVID19). There were 83 head injury admissions per week before COVID19. The numbers decreased to 33 per week during the lock phases (60% less). Although the unlock period saw a rise in the number of patients (46 per week), it was still only 55% of the pre-COVID19 period.

Fig. 2
figure 2

Admission trend in head injury after COVID19

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Table 1 Comparative data of pre- and COVID19 period
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Demography and referral

After COVID19 restrictions, there was a significant increase in the proportion of patients arriving directly without initial resuscitation at peripheral centers (15% vs. 11%, p = 0.002). Though the patients’ mean age did not change, more female admissions were noted post restrictions.

Time of arrival

After COVID19, the proportion of patients reaching later than 6 h increased significantly from 66 to 74% (p < 0.001) (Table 1). Interestingly, it showed a continuing trend from lock phases to even the unlock phases (Fig. 3).

Fig. 3
figure 3

Injury to the arrival time among HI patients

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Mode and severity of injury

Regarding the mechanism of injury, motor vehicular accidents remained the most common cause overall. There was a significant rise in admissions secondary to assault (4.5% vs. 8%) after the onset of COVID19. The percentage of fall exceeded vehicular accidents (48% vs. 42%). Despite lockdown measures, vehicular accidents in the later phases contributed to almost 50% of injuries, increasing up to 71% in the last phase. Though the percentage of vehicular accidents returned to pre-COVID19 status during unlocks phases, assaults were still relatively high. During the COVID19 period, there was a significant decrease in HI under alcohol influence (21% vs. 17%, P=0.02) and with comorbid illnesses (10% vs. 2%, p < 0.001). The proportions of patients with associated ophthalmic and faciomaxillary injuries were lower with COVID19. However, according to GCS, there was no change in patients’ distribution as mild, moderate, and severe head injury (Table 1).

Neuroimaging, treatment, and mortality

The common imaging findings were contusions, subdural hematoma (SDH), skull fractures, subarachnoid hemorrhage (SAH), and pneumocephalus in decreasing order of frequency. The proportion of SDH, SAH, and pneumocephalus decreased during COVID19, compared to the pre-COVID19 period (p < 0.05). There was, however, a marginal increase in concurrent spinal injuries (Table 1). The majority of the patients were managed conservatively. Operative intervention was undertaken among 27% and 29% of patients before and during COVID19, respectively. The severe head injury mortality was significantly more during the lock phases than before COVID19 (59% vs. 47%, p = 0.02).

Discussion

Head injury like any acute brain insult, initiates a cascade of secondary pathophysiological events, potentially influenced by the COVID19 constraints, possibly widening the economic divide between the developed and LMIC [9, 12, 13, 43]. By contrast to the cancelation of non-emergency admissions, our neurotrauma wing has been functioning throughout COVID19, offering its regular services, amidst a tight situation of these pandemic-related constraints. We considered the following perspectives for this study: First, how the pandemic has influenced the HI epidemiology in LMIC trauma center, and second, has there been any difference in care because of the significant ongoing rearrangement of health resources. As of this writing, India has experienced substantial COVID19 case-volume and its consequences [6, 33]. Therefore, it is imperative to understand the changes in the HI profile from the standpoint of LMIC.

Effect of lockdown/COVID on neurotrauma patterns

Regional variations in the HI profile are established [18, 30]. For instance, while fall predominates the HI etiology in high-income countries secondary to a growing geriatric population and better adaptation of traffic practices, vehicular accidents remain the most typical cause of HI in LMIC [18, 24, 30, 34]. After COVID19 and lockdown began, reports across countries have documented a decrease in overall hospital admissions [17, 23, 25, 28, 32, 36]. This trend owes restricted freedom of movement consequent to lockdown, social distancing, and possibly a COVID19 fear with hesitancy in reaching hospital premises. However, the neurotraumatological aspects have been relatively less studied.

As evident from this study and others from developed nations, the lockdown has changed HI patterns and care [16, 26, 37]. The proportion of vehicular HI decreased, while the relative percentage secondary to assault rose during COVID19. In contrast to the pre-COVID19 period, when vehicular accidents were the most common, the injury after fall and vehicular accidents were nearly the same during the first phase of lockdown. Less commutation, traffic, and strict vigilance during the initiation of the lockdown explain this change. With more people residing at home and a few hailing from hilly terrains of the hospital catchment area has possibly led to the rise in fall-associated HI. However, in the subsequent lockdown phases, vehicular accidents showed an increasing trend, suggesting lockdown fatigue and perhaps complacency. The psychosocial stress of staying at home, interpersonal conflict, and financial crisis has been implicated in increased assault-related injuries [16, 26, 37]. Interestingly, the percentage of female HI also increased after COVID19. This could be due to an increase in the non-vehicular mode of injuries than pre-COVID conditions when males were more frequently involved in a substantial proportion of road traffic accidents.

After the COVID19 outbreak, the percentage of patients referred to our center after resuscitation has decreased. With a rise in direct admissions, this is possibly due to fewer intermediate hospitals fully functional or effectively delivering early care during this pandemic. Some have suggested a higher proportion of severe HI after COVID19 due to mild HI patients’ reluctance to attend hospitals. However, we observed that mild HI continued to occupy a significant share of our hospital admissions. Despite being a tertiary referral center, our institute has continuously been overburdened due to a higher proportion of mild HI that can be effectively managed at peripheral centers. Although this demand could be met by stretching the hospital resources during the standard pre-COVID19 period, at this point, with the pandemic taking the upper hand and with significant infrastructure shifted towards COVID19 care, this trend appears to sustain excess stress on the limited resources. A lack of fall in the proportion of mild HI (approximately 50% in both periods) hints that peripheral facilities are less prepared to manage this cohort of neurotrauma. Upgrading these intermediate facilities with a long-term outlook may permit better care for patients who legitimately require advanced care while avoiding strain on health resources.

Timely transportation to an appropriate trauma care facility is an essential component that affects the final HI outcomes [14, 20, 29, 41]. We noted that during COVID19, the proportion of patients who reached our hospital within optimal time has decreased. This can be explained by factors such as hindrance in arranging transport and transfer-related delays due to disruption of the routine transfer services compared to that of typical time frame. The findings imply that interhospital transfer coordination is a domain that needs a relook.

With the gradual lifting of lockdown restrictions, the absolute volume of HI admissions demonstrated a rising trend. Also, few authors have noted the emergency neurosurgical load remained the same despite the ongoing pandemic [3]. While the COVID19 may continue to stay longer, our findings hint that it is time to reconsider mobilizing sufficient health resources for treating non-COVID conditions such as neurotrauma, which has a significant social and economic impact. As expected, owing to the initial fall in admissions, the surgical volume of neurotrauma decreased during the lockdown.

After COVID19, some positive effects were noticed, such as decreased HI patients under alcohol influence. Lockdown restrictions with restricted access to alcohol availability can explain this trend. A decline in HI patients with comorbid illness was also seen after this pandemic. With the awareness that comorbidities constitute a significant risk factor for COVID19 infection, there is probably a natural tendency for persons with preexisting illnesses not to venture out of the home during COVID19.

Mortality of severe HI

We attempted to evaluate whether the COVID19 outbreak has influenced the overall HI patient care. Hence the mortality of severe HI was chosen as a proxy variable. In a severe HI cohort, there are many determinants such as prehospital resuscitation, timely transfer, and dedicated nursing care that influence the hypoxemic morbidity after head injury [5, 20, 42]. While improvements in services have been shown to result in better neurosurgical outcomes in LMICS, COVID19 has caused a redistribution of resources, with less emphasis on non-COVID19 cases [10, 11, 38]. These patients likely received care that is less optimal than during the pre-COVID19 period. Apprehensions among healthcare workers to care for the airway and breathing could also have contributed to poorer outcomes.

We acknowledge that this is a single-center study, and hence the observations may not be generalized. We have not assessed the long-term functional outcome, influenced by rehabilitation limitations [7, 31]. Yet, the findings, by and large, represent the prevailing scenario in an LMIC trauma center. Hospital referral bias and seasonal bias are some of the other potential concerns. This hospital-based study may not reflect the overall HI prevalence in the community during the COVID19 pandemic. Many mild injured patients may not have been brought to the hospital because of the fear of being infected. Even in severe HI cases, a few might have died before reaching the hospital due to longer transit and suboptimal conditions during the COVID19 lockdown.

Conclusions

In summary, COVID19 has influenced HI care overall. A definitive delay in patient arrival has occurred. The severe head injury mortality was significantly greater during lock phases than before COVID19, highlighting the collateral fallout of lockdown. Pandemic control measures in the future should not ignore the concerns of trauma emergency care.