====== Personal protection equipment ======

If local circumstances permit, the [[Society of British Neurological Surgeons]] ([[SBNS]]) strongly advocates [[personal protection equipment]] (PPE) for all [[procedure]]s during this time. However, [[COVID-19]] appears to be principally spread, either directly or via fomites, through droplets from respiratory epithelium— especially the upper respiratory tract. Blood is not at this point a recognized vehicle; if the significant [[virus]] were present in the blood, we would be able to do a blood test for the disease. Similarly, it does not seem to concentrate in the cerebrospinal fluid. Thus, most [[neurosurgical procedure]]s to the spine and head should be safe with routine face and eye protection if PPE is unavailable. This includes cranial and spinal [[drilling]], though we should all be more rigorous than usual with the irrigation of drills to prevent aerosol formation. Care would clearly be needed with anterior skull base procedures, which might breach an air sinus. Endonasal procedures, by contrast, are a very significant risk. Use of debriders and [[drill]]s within the nasal cavity will produce a droplet aerosol, which is highly dangerous. In [[Wuhan]], ENT surgeons are amongst the worst affected—and [[N95 mask]]s did not prevent infection. The majority of pituitary patients present subacutely, and can hopefully wait, but it would be unforgivable to allow a patient to go blind during this period. With patients for whom surgery cannot be deferred, consideration should be given to alternatives to endoscopic surgery: 1. Craniotomy 2. Microscope-based trans-sphenoidal surgery, with a submucosal approach and entry to the sella using nondrill techniques. Available PPE should be employed BY ALL THEATRE STAFF and care taken with nasal secretions. If these are unavailable in a particular unit, or there is insufficient experience, networking should be employed. Preoperative COVID-19 testing should be employed when available. The small number of patients presenting in an endocrine crisis should be managed medically if at all possible. If there is no alternative to trans-sphenoidal surgery, it is the strong feeling of the SBNS that this should be discussed at a national level
((Jenkins A. Letter: Transmission of COVID-19 During Neurosurgical
Procedures-Some Thoughts From the United Kingdom. Neurosurgery. 2020 Apr 18. pii:
nyaa126. doi: 10.1093/neuros/nyaa126. [Epub ahead of print] PubMed PMID:
32304212.
)).