Original Article

The Effects of Lockdown During the Severe Acute Respiratory Syndrome Coronavirus 2
(SARS-CoV-2) Pandemic on Neurotrauma-Related Hospital Admissions
Javier M. Figueroa, James Boddu, Michael Kader, Katherine Berry, Vignessh Kumar, Veronica Ayala, Steven Vanni,
Jonathan Jagid

- BACKGROUND: The response to the global severe acute associated with the psychosocial effects of social
respiratory syndrome coronavirus 2 pandemic culminated distancing and quarantine.
in mandatory isolation throughout the world, with nation-
wide confinement orders issued to decrease viral spread.
These drastic measures were successful in “flattening the
curve” and maintaining the previous rate of coronavirus INTRODUCTION
disease 2019 infections and deaths. To date, the effects of
the coronavirus disease 2019 pandemic on neurotrauma
has not been reported.
- METHODS: We retrospectively analyzed hospital ad-
A s of June 1, 2020, the global incidence of coronavirus
disease 2019 (COVID-19) was 6.05 million confirmed
cases, with 371,000 related deaths. The United States had
a major proportion of infections, with 1.7 million confirmed cases
and 102,000 related deaths.1 Specific to our institution, Miami-
missions from Ryder Trauma Center at Jackson Memorial Dade county had 18,139 confirmed cases with 702 associated
Hospital, during the months of March and April from 2016 to deaths. The first case of COVID-19 in Miami-Dade county was
2020. Specifically, we identified all patients who had cra- confirmed on March 12, 2020, nearly 50 days after the initial case
nial neurotrauma consisting of traumatic brain injury and/ in the United States and 8 days after the initial case in Florida.2 A
or skull fractures, as well as spinal neurotrauma consisting subsequent statewide closing of restaurants and bars on March 17,
2020, was then implemented to decrease viral spread. However,
of vertebral fractures and/or spinal cord injury. We then
after a significant increase in infection rate over the next few
performed chart review to determine mechanism of injury
weeks, the Governor of Florida issued an executive “stay-at-
and if emergent surgical intervention was required. home” order on April 1, 2020.3 Although the rate of viral spread
- RESULTS: Compared with previous years, we saw a improved, we also saw a decrease in both the number of
significant decline in the number of neurotraumas during accidents causing traumatic injuries and the number of
emergent surgical procedures, secondary to a decline in both
the pandemic, with a 62% decline after the lockdown
foot and automobile traffic.4
began. The number of emergent neurotrauma surgical
cases also significantly decreased by 84% in the month of
April. Interestingly, although the number of vehicular METHODS
traumas decreased by 77%, there was a significant 100% After obtaining approval for this retrospective study from the
increase in the number of gunshot wounds. University of Miami institutional review board, we queried the
registry at Ryder Trauma Center to obtain a list of patients from
- CONCLUSIONS: Population seclusion had a direct effect 2016 to 2020 who sustained neurotrauma during the time frame of
on the frequency of neurotrauma, whereas the change in March 1 to April 30, 2020. Neurotrauma was defined as patients
relative proportion of certain mechanisms may be with traumatic brain injury, skull fractures, spinal cord injury, and

Key words Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida,
- Admissions USA
- COVID-19 To whom correspondence should be addressed: Javier Figueroa, M.D., Ph.D.
- Lockdown [E-mail: Javier.Figueroa@jhsmiami.org]
- Neurotrauma Citation: World Neurosurg. (2020).
- Pandemic https://doi.org/10.1016/j.wneu.2020.08.083
Journal homepage: www.journals.elsevier.com/world-neurosurgery
Abbreviations and Acronyms
COVID-19: Coronavirus disease 2019 Available online: www.sciencedirect.com
GSW: Gunshot wound 1878-8750/$ - see front matter ª 2020 Published by Elsevier Inc.
PHBC: Pedestrian hit by car

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JAVIER M. FIGUEROA ET AL. SARS-COV-2 ON NEUROTRAUMA ADMISSIONS

Figure 1. Neurotrauma consults. The average number 0.036, Poisson analysis). There were 26 neurotrauma
of neurotrauma consults between 2016 and 2019 was consults in April 2020, which was significantly lower
151.5, with 83.5 in March and 68 in April. There were than the previous-year average (P ¼ 0.0001, Poisson
67 neurotrauma consults in March 2020, which was analysis). COVID-19, coronavirus disease 2019.
significantly lower than the previous-year average (P ¼

vertebral fractures. Chart review was then performed to obtain RESULTS

variables such as age, sex, mechanism of injury, type of injury, and Overall, we found a significant difference in the average number of
need for emergent surgery. Mechanisms of injury included as- monthly neurotrauma consults from 2016 to 2019, with 83.5
4.7
saults, bicycle accidents, ground-level falls (sitting, standing), falls in March and 68.0
8.8 in April (P ¼ 0.048, Student t test).
from height (ladder, roof, multiple stories), gunshot wounds However, in March 2020 we saw a 20% decrease in total neuro-
(GSWs), motorcycle collisions, motor vehicle collisions, pedes- trauma consults, which was significantly lower (P ¼ 0.036, Pois-
trian hit by car (PHBC), and other (boating, jet-ski, diving). son analysis) than previous years (Figure 1). This declining trend
Emergent surgery included procedures such as craniotomy, cra- continued in April 2020, with the number of neurotrauma
niectomy, elevation of depressed skull fracture, skull-base repair consults decreasing significantly by 62% (P ¼ 0.0001, Poisson
for leakage of cerebrospinal fluid, laminectomy for spinal analysis), after a statewide “stay-at-home” order was issued on
decompression, and instrumented fusions for spinal instability. April 1, 2020 (Figure 1). Further analysis demonstrated that the
Data sources included hospital charts and imaging studies. number of operative cases for neurotrauma also decreased
Data from the previous years 2016e2019 were used to establish significantly by 84% (P ¼ 0.0004, Poisson analysis) in April
baselines for statistical analysis. The absolute number of neuro- 2020 (Figure 2).
trauma consults, surgeries, and mechanisms of injury in 2020 We then evaluated the mechanisms of injury for monthly neu-
were compared with previous monthly averages and analyzed by rotrauma consults and found no significant difference from 2016
Poisson regression analysis. The relative differences in proportion to 2020. However, with only 28% of consults in 2020 coming in
of mechanisms of injury in 2020 were compared before monthly April, results may have been masked by normal proportions in
averages by c2 proportion analysis. All statistical analysis was March. When assessed individually, we found several differences
accomplished on GraphPad Prism 8 scientific software (GraphPad in mechanisms of injury between March and April 2020 (Figure 3).
Software, San Diego, California, USA). Although absolute numbers of nearly all mechanisms of injury

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Figure 2. Neurotrauma operative cases. The average previous year average (P ¼ 0.135, Poisson analysis).
number of neurotrauma operative cases between 2016 There were 2 neurotrauma surgeries in April 2020,
and 2019 was 29.25, with 17.0 in March and 12.25 in which was significantly lower than the previous year
April. There were 12 neurotrauma surgeries in March average (P ¼ 0.0004, Poisson analysis). COVID-19,
2020, which was not significantly lower than the coronavirus disease 2019.

declined compared with previous-year averages, the relative pro- although not typically life-threatening, an estimated 18,000 peo-
portion of each mechanism did not. As expected, the proportion ple sustain spinal cord injury annually.7 Importantly, the effects of
of motorcycle collisions, motor vehicle collisions, and bicycle ac- the severe acute respiratory syndrome coronavirus 2 pandemic on
cidents decreased by 4%, 10%, and 3% respectively. In addition, the incidence of neurotrauma has yet to be reported. While several
the proportion of ground-level falls resulting in neurotrauma hospitals found a decreasing trend in general trauma admissions
decreased by 6%, whereas the proportion of falls from height from February to April 2020, none of these studies thoroughly
increased by 6%. There was also a nonsignificant 2% increase in evaluated the effects on emergent operative cases or changes in
the proportion of assaults. Surprisingly, there was a 6% increase mechanisms of injury.8-18
in the proportion of PHBC and a 12% significant increase (P ¼ Here. we found that the average number of neurotrauma
0.034, c2 proportion analysis) in the proportion of GSWs. There consults differed significantly between March and April, likely
were no traumatic injuries caused by “other” mechanisms during secondary to South Florida being a destination for spring break,
the pandemic. causing an influx of vacationers during that time frame. During
the pandemic, however, travel restrictions in combination with
less foot and vehicle traffic led to a decrease in all mechanisms
DISCUSSION of injury, except for GSW. Upon further investigation, we found
In the United States, traumatic unintentional injuries are the that the relative proportion of mechanisms of injury also
leading cause of death in people younger than 45 years old and the changed after the lockdown in April 2020. With fewer citizens
third-leading cause of death among all age groups combined.5 An commuting on the streets, the proportion of vehicular trauma
estimated 1.7 million people sustain traumatic brain injury decreased, as expected. Decreases in these types of traumas have
annually, with approximately 52,000 deaths.6 In addition, been reported across the country, however, not in correlation

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JAVIER M. FIGUEROA ET AL. SARS-COV-2 ON NEUROTRAUMA ADMISSIONS

Figure 3. Effect of lockdown on neurotrauma (boating, jet-ski, diving) and increases in pedestrian hit
mechanisms. When comparing the relative proportions by car (PHBC), falls from height (ladders, roof, multiple
of mechanisms of injury between April 2020 and stories), assaults, and gunshot wounds (GSWs). Only
previous years, there were decreases in motor vehicle GSWs had a significant proportional increase from 3%
collisions (MVCs), motorcycle collisions (MCCs), to 15% (P ¼ 0.034, c2 proportion analysis).
bicycle accidents, and ground-level falls, and other

with specific events such as initiation of lockdown pro- during the pandemic and must be taken into account when
tocols.8,9,12,13 The proportion of ground-level falls also referencing this observational study.
decreased; however, this may have been secondary to patients
unwilling to take the risk of going to the emergency department CONCLUSIONS
after minor accidents for concern of contracting the virus.18
The severe acute respiratory syndrome coronavirus 2 pandemic
Importantly, some businesses were deemed “essential” and
significantly impacted the incidence of neurotraumas and asso-
allowed to continue operating, of which some construction
ciated emergent neurosurgical interventions, as lockdown orders
companies took advantage.1 This may explain the increase in
and apprehension of infection decreased the likelihood of certain
the proportion of falls from height, in addition to people
mechanisms of injury such as vehicular trauma. Conversely, the
doing home repairs while “stay-at-home” orders were in place.
psychosocial impact of sheltering at home increased the likelihood
With respect to increases in the proportions of assaults and
of interpersonal and self-inflicted trauma. These observations will
GSWs during the pandemic, they may be secondary to the
be helpful if another wave of the epidemic arises.
psychosocial effects of mandatory isolation.19,20 Family and
friends were forced to be in close proximity to one another,
which had the potential to ignite conflicts and violence leading CRediT AUTHORSHIP CONTRIBUTION STATEMENT
to assault.21 Finally, with prolonged confinement comes an Javier M. Figueroa: Conceptualization, Investigation, Formal
increase in the risk of suicide, which may explain the increase analysis, Writing - review & editing. James Boddu: Investigation,
in presumed self-inflicted PHBC and GSW.22 Formal analysis, Writing - review & editing. Michael Kader:
Although are results are compelling, there are several limita- Formal analysis, Writing - review & editing. Katherine Berry:
tions that could be affecting the results of this study. For instance, Formal analysis, Writing - review & editing. Vignessh Kumar:
ambulances may have avoided our hospital, which had a high Writing - review & editing. Veronica Ayala: Writing - review &
COVID-19 census, and primary care physicians may have treated editing. Steven Vanni: Conceptualization, Writing - review &
minor traumas rather than referring patients to the emergency editing. Jonathan Jagid: Conceptualization, Writing - review &
department. These confounding variables are difficult to address editing.

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JAVIER M. FIGUEROA ET AL. SARS-COV-2 ON NEUROTRAUMA ADMISSIONS

North Italy during the spread of COVID-19 County, California, March 2020. Trauma Surg Acute
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