Background: The novel severe acute respiratory syndrome coronavirus 2 (COVID-19) pandemic has had a drastic effect on global healthcare with the UK amongst the countries most severely impacted. The aim of this study was to examine how COVID-19 challenged the neurosurgical delivery of care in a busy tertiary unit serving a socio-economically diverse population. We also describe the strategies we adopted to meet these challenges. Methods: A prospective single centre cohort study including all patients referred to the acute neurosurgical service or the subspecialty multi-disciplinary teams (MDT) as well as all emergency and elective admissions during COVID-19 (18th March 2020-15th May 2020) compared to pre-COVID-19 (18th of January 2020-17th March 2020). Data on demographics, diagnosis, operation, and treatment recommendation/outcome were collected and analysed. Findings: Overall, there was a reduction in neurosurgical emergency referrals by 33·6% and operations by 55·6% during the course of COVID-19. There was a significant increase in the proportion of emergency operations performed during COVID-19 (75·2% of total, n=155) when compared to pre-COVID-19 (n=198, 43·7% of total, p
