COVID-19 Saudi Arabia

Triage of Neurosurgery Cases During the COVID-19 Pandemic

Amro Al-Habib
President, Saudi Association of Neurological Surgery (SANS)
Associate Professor and Head, Division of Neurosurgery Department of Surgery, College of Medicine
King Saud University
Riyadh, Saudi Arabia

Epidemics secondary to spreading infections are known to present a challenge to healthcare systems. Providing adequate medical treatment to individuals falling sick to the new infection becomes a priority in many hospitals. On the other hand, providing medical care to sick people with illnesses other than the spreading infection could become a challenge. Since the newly identified COVID-19 virus became recognized as a pandemic on March 11, 2020, health care systems across the globe have taken measures to limit the spread of the virus.1

Given the unique nature of neurosurgical conditions, as many require an urgent or emergency intervention, it was necessary to have a system in place to triage neurosurgery cases. It will serve as a guide for health care providers to be able to provide the necessary care while limiting the spread of the infection to the patients and/or hospital staff. It is expected that the recommendations might differ from one country to another based on the local circumstances and disease conditions. The Saudi Association of Neurological surgeons (SANS), among many other neurosurgical societies worldwide,2,3 has commissioned a consortium of qualified and practicing neurosurgeons who developed a consensus statement to triage neurosurgery cases (Table1).4 Cases were classified into four color-coded categories based on the priority of the required neurosurgical intervention. It is recommended that healthcare providers would practice their judgment on individual cases while considering the triage recommendations as a guide.

It has to be emphasized that hospital recommendations for personal protective measures against the spread on the virus should be strictly followed. While social distancing recommendations are being followed, many neurosurgical services have developed a system of virtual online communication to ensure adequate and continuous patient care and education among team members are carried out.5 By sharing the triage statement, we hope that the readers would find it helpful and beneficial to their practice.


  1. World Health Organization. Coronavirus disease (COVID-19) pandemic, <> (2020).
  2. Cenzato, M., DiMeco, F., Fontanella, M., Locatelli, D. & Servadei, F. Editorial. Neurosurgery in the storm of COVID-19: suggestions from the Lombardy region, Italy (ex malo bonum). Journal of Neurosurgery, 1-2, doi:10.3171/2020.3.JNS20960 (2020).
  3. Germano, A., Raffa, G., Angileri, F. F., Cardali, S. M. & Tomasello, F. COVID-19 and Neurosurgery. Literature and Neurosurgical Societies Recommendations Update. World Neurosurgery, doi:10.1016/j.wneu.2020.04.181 (2020).
  4. Bajunaid, K. et al. Consensus Statement of the Saudi Association of Neurological Surgery (SANS) on Triage of Neurosurgery Patients During COVID-19 Pandemic in Saudi Arabia. Neurosciences 25, 148-151, doi:10.17712/nsj.2020.2.20200054 (2020).
  5. Carter, B. S. & Chiocca, E. A. Editorial. COVID-19 and academic neurosurgery. Journal of Neurosurgery, 1-2, doi:10.3171/2020.4.JNS201013 (2020).

Table 1. Prioritization of neurosurgical cases based on color domains and priority categories
* Patients must be treated as soon as possible, ** Patients can be treated up to/within 48 hours.

Priority Definition Procedure
Priority 1
(immediate or within 24 h)

Immediate: Acute life-threatenin condition that needs immediate attention*

Within 24 h: Loss of life or significant function that can be saved by intervention within 24 h


  • Acute TBI with EDH or SDH requiring surgery
  • Elevated ICP that cannot be controlled by medical/critical care
  • Insertion of an EVD or ICP monitoring for patients with severe injuries
  • Chronic SDH associated with neurological deficits
  • Open depressed skull fracture


  • Acute progressive neurologic deficits caused by trauma, tumor, infection, and other compressive pathologies interfering with the ability to perform activities of daily living


  • All intracranial tumours affecting consciousness or causing hemodynamic instability due to increased intracranial pressure, hydrocephalus, or herniation *
  • Tumors causing acute vision loss caused due to optic nerve/chiasm compression


  • Acute stroke thrombectomy*
  • Coiling or clipping of a ruptured saccular aneurysm with subarachnoid hemorrhage
  • Craniotomy or embolization of a ruptured AVM with pre-nidal/nidal aneurysms
  • Decompressive craniectomy or hematoma evacuation*


  • Patients with acute high ICP caused by hydrocephalus or mass effect
  • Shunt malfunction/infection
  • Open neural tube defect (encephalocele, myelomeningocele) **


  • Symptomatic intracranial or implant infections

Functional and epilepsy:

  • Implant replacement [intrathecal baclofen pump (ITP), vagal nerve stimulation (VNS) and implanted pulse generator (IPG)] due to malfunction, infection, or non-functioning devices, when associated with symptoms or signs of therapy/medications` debridement

Peripheral nerve:

  • Nerve repair for open sharp cut (clean) nerve injuries
  • Debridement and nerve tagging for open contaminated nerve injuries
Priority 2
(within 1 week)

Life or significant functional loss that can be saved by intervention within 1 week.


  • Subacute progressive neurologic deficit (developed over few weeks) due to degeneration, trauma, or tumors
  • Spinal instability without neurologic deficit due to trauma, tumor, or infection
  • Suspected cancer or infection that needs biopsy or resection


  • High grade primary brain tumors
  • Resection or biopsy for metastatic brain lesions
  • All intracranial brain tumors causing acute or subacute progressive neurological deficits and/or aggressive radiological features


  • Complex ruptured intracranial aneurysm requiring special preparation or equipment

Functional and epilepsy surgery:

  • Hardware replacement (ITP, VNS, and IPG) due to infection or malfunctioning or nonfunctioning devices, not associated with symptoms or signs of therapy or medications` debridement

Peripheral nerve surgery:

  • Malignant peripheral nerve sheet tumor
Priority 3
(from 1 to 4 weeks)
Life or significant functional loss that can be saved by intervention within 1 month.


  • Higher (worsening) chronic neurologic deficit or spinal instability (developed over few weeks) caused by degeneration, trauma, or tumors


  • Newly diagnosed low-grade primary brain tumors
  • Intracranial tumors with slowly progressive symptoms related to mass effect and/or radiological growth


  • Ruptured AVM with no nidal aneurysms
  • High grade dural AV fistulae with ICH
  • Carotid revascularization (endarterectomy or stenting) for symptomatic carotid stenosis


  • Hydrocephalus with chronically elevated ICP
  • Craniosynostosis with evidence of high ICP

Functional and epilepsy surgery:

  • Medically intractable severe epilepsy requiring urgent surgical intervention
  • Elective replacement of implants (ITP, VNS, and IPG)
Priority 4
(More than 1 month)

Cases where life or significant function would not be affected by waiting for more than 4 weeks

  • Any neurosurgical procedure that can be delayed for more than 1 month
  • The patient's condition requires re-evaluation on a regular basis and the priority will change depending on the change in the condition
August 2022