A Comparative Study to Evaluate the Efficacy of Virtual Versus Direct Airway Assessment in the Preoperative Period in Patients Presenting for Neurosurgery: A Quest for Safer Preoperative Practice in Neuroanesthesia in the Backdrop of the COVID-19 Pandemic!

 Neurosurgical patients with cervical spine pathologies, craniofacial and craniovertebral junction anomalies, recurrent cervical spine, and posterior fossa surgeries frequently present with an airway that is anticipated to be difficult. Although the routine physical evaluation is nonaerosol-generating, Mallampati scoring, mouth opening, and assessment of lower cranial nerve function could potentially generate aerosols, imposing a greater risk of acquiring severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) infection. Moreover, airway evaluation requires the patient to remove the mask, thereby posing a greater risk to the assessing anesthesiologist. Thus, we designed this study to evaluate the efficacy of virtual airway assessment (VAA) done via telemedicine in comparison to direct airway assessment (DAA), and assess the feasibility of VAA as a part of the preanesthetic evaluation (PAE) of patients presenting for neurosurgery in the backdrop of the COVID-19 pandemic.  A total of 55 patients presenting for elective neurosurgical procedures were recruited in this prospective, observational study. The preoperative assessment of the airway was first done by a remote anesthetist via an encrypted video call, using a smartphone which served the purpose of telemedicine equipment, followed by a direct assessment by the attending anesthetist. The following parameters were assessed: mouth opening (MO), presence of any anomalies of tongue and palate, Mallampati classification (MPC) grading, thyromental distance (TMD), upper lip bite test (ULBT), neck movements, and Look-Evaluate-Mallampati-Obstruction-Neck mobility (LEMON) scoring system.  Demographic parameters were expressed as mean ± SD. Agreement between the values obtained by VAA and DAA parameters were analyzed with the Kappa test.  We observed a "perfect agreement" between the DAA and VAA with regard to MO. Assessment of ULBT, neck movements, and the LEMON score had an overall "almost perfect agreement" between the DAA and VAA. We also observed a "substantial agreement" between VAA and DAA during the assessment of MPC grading and TMD.  Our study shows that PAE and VAA via telemedicine can reliably be used as an alternative to direct physical preanesthetic consultation in the COVID-19 scenario. This could reduce unnecessary exposure of anesthesiologists to potential asymptomatic COVID-positive patients, thereby protecting the available skilled workforce, without any significant compromise to patient care.