Remote Virtual Spinal Evaluation in the Era of COVID-19

INTRODUCTION

The COVID-19 pandemic has swept through the world, and its full impact has yet to be realized.¹ Although its immediate and short-term effects on the field of medicine have been tremendously disruptive, one potential benefit has been the increased use of telemedicine for outpatient clinical visits.^2–4 Using a platform that allows for the real-time synchronous transmission of video and audio information, spine surgeons are able to communicate with their patients and effectively collect pertinent history.⁵ There is not yet a standardized and established protocol to perform a comprehensive spinal evaluation using telemedicine alone. We have developed a novel protocol for remote spinal examinations for use in clinical practice through which spine care providers can perform consistent and reliable remote examinations for office-based exams.

TELEMEDICINE PORTAL

There are multiple telemedicine portals available for conducting HIPAA-compliant telemedicine spine visits, including but not limited to Zoom (San Jose, California), BlueJeans (San Jose, California), Teams (Redmond, Washington), Doxy.me (Rochester, New York), and EPIC (Verona, Wisconsin). Here, we describe the typical work flow of using these portals to conduct spine clinics virtually. Prior to the initiation of the clinic, the physician and patient will need to download the relevant application onto their computers or smart phones. After scheduling the telemedicine clinic visit, the physician and patient are given a passcode to access the portal, and they are then connected via the telemedicine portal (Figure 1). Patients are asked to send their CD with their imaging studies to the office prior to the clinic visit, or to electronically load the results through their patient portal. Physicians can review the radiographic studies such as magnetic resonance, computed tomography, and x-ray images, prior to or concurrent with the telemedicine examination.

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Figure 1

An example of a telemedicine clinic visit with a patient. The patient's EMR record can be reviewed by physician on the same computer screen.

The electronic medical record (EMR) is populated prior to the clinic visit by the patient with an intake form that shows all of that patient's medical history, including medications, allergies, past medical and surgical history, family medical history, and social history. The EMR is also populated with imaging results and neurophysiologic studies.

At the opening of the visit, it is incumbent on the provider or his or her staff to ask the patient for identification, and it is also good practice for the provider to wear an ID badge that is visible to confirm their identity. It is also important to discuss the inherent limitations of a video visit with the patient.

Once the patient is connected via the portal, a screen sharing option is available in some telemedicine portals that allows the physician to review the images with the patient. The physician can point out pertinent pathology to the patient via his computer cursor through the screen sharing function (Figure 2). Orders such as physical therapy, further imaging studies, pain management, and medications can be entered via the EMR portal. Medications are sent directly to the pharmacy of choice entered by the patient for pickup.

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Figure 2

(A) Sagittal and (B) axial contrast-enhanced magnetic resonance image, and (C) radiographic report reviewed with a patient via shared screen option of telemedicine portal showing a lesion at the T1 level of spine.

Following this protocol, one computer can be used to perform the telemedicine clinic visit, and other providers, such as residents, fellows, or advanced practice providers, can join the meeting in real time if they have been invited into the meeting. Coding for the visit can be performed via the EMR system, with entering the modifier GT to indicate that the visit was done via telemedicine. This system is very useful for following up on postoperative patients who do not require staple or suture removal. Additionally, this system has been useful in evaluating patients who have difficulty traveling to the office due to medical or logistical expense, inconvenience, or exposure during the current COVID-19 pandemic. In this manner, many patients have been effectively evaluated, treated nonoperatively, and/or scheduled for surgery.

Prior to the COVID-19 shutdown, approximately 1500 patients per month (750 new patient visits and 750 return visits) were seen at the Department of Neurosurgery at the University of Pennsylvania outpatient clinics. Since the onset of pandemic and shutdown order, in-person clinic visits have only been done on an emergency basis, which comprised fewer than 50 visits. However, with the rapid adoption and expansion of our telemedicine program, 695 telemedicine visits were completed during a period of 4 weeks from the middle of March to the beginning of April of 2020, enabling us to continue delivering spine care to patients remotely throughout the pandemic.

RECOMMENDATIONS FOR REMOTE EXAMINATIONS

Remote spinal examinations should be conducted via videoconference using a platform that conforms to each individual institution's policies for patient communication. Even though non–HIPAA-compliant platforms may be temporarily acceptable, these platforms will be expected to adhere to HIPAA compliance in the long term.⁶

It is imperative that a detailed history be obtained to help guide and augment the telemedicine examination. It is recommended that physicians provide instructions to the patient in advance, including videos and diagrams, so that the patient can efficiently perform the exercises during their telemedicine visit (see Supplemental Methods). Because the maneuvers are performed in a choreographed sequence, these videos promote the efficiency of the exam. Note that unless considered standard of care by an institution, Institutional Review Board approval may be required when providing these videos to patients. Furthermore, the exam itself is facilitated by having an assistant available, such as a family member,⁷ and physicians are encouraged during the exam to share their screen with patients to show them their pertinent radiographic studies. The examination can be more carefully guided by the patients' complaints reviewed below, including but not limited to dermatomal distribution of pain, dysesthesias, specific muscular weakness, and gait difficulties.

GENERAL EXAMINATION

The patient is asked to stand upright, and posture is assessed in anteroposterior and lateral planes. Cervical and lumbar movements and range of motion can also be assessed and recorded. Ambulation status can be assessed with the patient performing a natural walk and a “heel-toe” tandem gait.

GAIT EXAMINATION

The patient is asked to walk normally, and gait is examined for abnormalities, including wide or narrow base, spasticity, shuffling, steppage, waddling, and magnetic traits, in addition to sagittal and/or coronal plane deformity and antalgia.⁸

SENSORY EXAMINATION

A dermatomal pain diagram may be included for reference as well as a video demonstrating the examination technique. As applicable, the patient should complete any self-assessments, such as marking problematic areas. During the exam, the physician should ask the patient or assistant to lightly touch each dermatome on the patient with a pin or end of a paper clip; one extremity should be compared to the other side for reference.

UPPER EXTREMITY SENSORY EXAMINATION

• Specific areas that the patient may be asked to examine with a safety pin or open paper clip for each dermatome include the following:

  • ○ C2, C3: Back of the head

  • ○ C4: Trapezius

  • ○ C5: Shoulder

  • ○ C6: Biceps

  • ○ C7: Triceps

  • ○ C8: Ulnar side of hand

  • ○ T1: Middle of forearm (flexor side)

LOWER EXTREMITY SENSORY EXAMINATION

• Specific areas that the patient may be asked to examine for each dermatome include the following::

  • ○ L1: Just above iliac crest

  • ○ L2: Upper anterior thigh

  • ○ L3: Lower anterior thigh

  • ○ L4: Anterior/lateral aspect of thigh/shin/medial lower leg

  • ○ L5: Lateral calf/top of foot/dorsal space between first and second toes

  • ○ S1: Lateral aspect of foot/bottom of foot/calf

MOTOR EXAMINATION

Prior to motor testing, we suggest counseling the patients with regard to safety while performing maneuvers in the video and emphasizing that not all movements need to be attempted if too difficult given their functional status. For example, examinations should be tailored to each patient's ambulatory ability and need for assistive devices, because walking ability may inform selection and safety of the tests. In addition to the specific maneuvers described below, gait observation may additionally be indicative of motor deficits if an abnormal gait is apparent (e.g., gastrocnemius/soleus weakness, foot-drop, or Trendelenburg gait). Direct video examination using a commercial platform may also reveal muscle atrophy.

UPPER EXTREMITY MOTOR EXAMINATION

LOWER EXTREMITY MOTOR STRENGTH EXAMINATION

REFLEXES

We have not identified a reliable method of reproducing the reflex examination, with the exception of the Babinski response, which can be assessed by having the assistant stimulate the bottom of the patient's foot and observing for fanning of the toes and extension of the great toe. Most patients with significant myelopathy have difficulty performing tandem walk (i.e., heel to toe walking). This examination can be useful in identifying patients with significant cervical or thoracic cord compression causing myelopathy. If a family member is present, a gentle tap below the knee hitting the patellar tendon can also elicit a significant knee jerk indicating possible myelopathy.

TENSION SIGNS

To elicit tension signs from the patient, an active assistant is required in order to complete this portion of the examination. If an assistant is not available, the patients can be directed to palpate over bilateral sacroiliac (SI) joint and spinous processes, and these can be documented separately.

KEY TAKEAWAYS

Telemedicine helps to establish a working patient-provider relationship prior to the in-person visit. The telemedicine visit effectively gathers necessary information, including pertinent patient history and physical examination findings. The examining physician can then direct the patient for further studies or for an emergency visit if significant or progressive neurologic deficits are identified. The use of telemedicine for spinal examinations should reduce the number of patient examination rooms required in the outpatient setting because physicians have the ability to remotely screen patients. Furthermore, telemedicine will make postoperative visits more convenient for patients because of the economic benefits in saving time and money. Lastly, telemedicine will ease the process of recording postoperative visits, helping to meet the Center for Medicare & Medicaid Services' global surgery code requirements.

The main drawbacks with spine telemedicine visits include the loss of direct physical examination, the potential for not detecting subtle neurologic deficits, and technical software or hardware difficulties. These technical shortfalls may be ameliorated by improving network speed, accessibility, and upgrading software usability. Synchronizing EMRs with a telemedicine application could also improve upon currently existing telemedicine platforms.

DISCUSSION

In times of national health care emergencies, the complex web of social needs, health care availability, and accessibility to technology is dynamic. For example, nonurgent and nonemergent spinal surgeries are being deferred in some geographic areas until the crisis abates. However, it is difficult to determine the degree of neurologic urgency without performing an examination. This protocol is designed to incorporate accepted neurologic and spinal examination principles via telemedicine and establish a guideline to facilitate the examination process. The reasons for difficulty in establishing a strict guideline lie in the art of history-taking and physical examination for patients with spine disease. Variations in the practice of spine care are magnified when the provider cannot talk to or examine the patient in person. Because there is no standard method to accurately, reliably, and consistently perform a spine examination through telemedicine, this paper suggests a formal spinal examination that is both user-friendly and nearly comprehensive.

The psychologic effect of the COVID-19 pandemic for patients who are in unrelenting pain or who have progressive neurologic deficits cannot be understated. For this subset of spine patients, in-person evaluation in an emergency room may be more appropriate rather than in an office setting. Prior to scheduling a patient for a telemedicine visit, a triage system is needed to screen patients to determine if they are deemed safe and appropriate to undergo telemedicine evaluation electively or if they need to be seen in the emergency room. At the conclusion of the visit, a spine provider should decide if a patient would need an emergent or an urgent surgery based on Elective Surgery Acuity Scale recommended by the American College of Surgeons.^10(p19) By no means can telemedicine replace all in-person visits, but it can be a valuable tool to reach most spine patients during this crisis. Data privacy is a huge concern with telemedicine software, which has garnered much interest in the media recently.¹¹ The breach of personal health information can occur despite multiple layers of security that are built into these telemedicine portals. However, given the situation, these are the risks that both the providers and the patients must discuss and acknowledge before proceeding with telemedicine visits.

The use of telemedicine in outpatient settings across a variety of medical and surgical specialties is increasing given the need for social distancing in the era of COVID-19.¹² As more physicians adopt telemedicine into their clinical practice, patients will become more comfortable interacting with their physicians via an online platform. Even after the current pandemic recedes, we expect that telemedicine will become more widely used because of its economic benefits for patients, efficiency for practitioners, and facilitation of postoperative care. By presenting a standardized remote spinal examination in this manuscript, we hope that spine care providers will be able to use this methodology to perform full spine evaluations through telemedicine.

SUPPLEMENTAL METHODS

• Cervical exam: https://youtu.be/HvkLssBFzkU

• Lumbar exam: https://youtu.be/tyDXVaqygKA