Telehealth Spine Exam: Step-by-Step (Gallon of Milk Included!)

How close can you get to a real spine exam during a telemedicine visit? With the help of a few household items, says new research, quite close. Citing a lack of a framework for conducting such exams, a team from Columbia University Irving Medical Center in New York has developed one.

Their study, “The Telehealth Spine Physical Examination: A Practical Approach Learned During the COVID-19 Pandemic,” appears in the July 6, 2021 edition of World Neurosurgery.

Zeeshan M. Sardar, M.D., M.Sc., assistant professor of Orthopedic Surgery (in Neurological Surgery) at Columbia University, attending spine surgeon at the Och Spine Hospital at New York Presbyterian/The Allen Hospital and study co-author explained his interest in this topic to OTW, “New York was amongst the first cities in the U.S. to be impacted by the Covid-19 pandemic. With the sudden surge of the virus in the beginning of the pandemic most outpatient offices had to be closed and clinical practices had to transition to telehealth visits without much advance preparation.”

“In the field of spine surgery, practitioners typically rely heavily on the physical examination of a patient to formulate the appropriate diagnosis and treatment plan. We observed that many practitioners were omitting the physical examination portion of the clinical evaluation and we were concerned that this could lead to delayed diagnosis or incorrect diagnosis in some select cases.”

Before the visit, patients were asked to arrange for someone to be present with them during the telehealth visit. Examples of the items that should be available during the appointment were: a piece of paper, a pen, a rubber band or hair tie, and a heavy object such as a gallon of water or milk, a bag, or a heavy book.

A sample of the telehealth visit is as follows: The physical examination starts in a sitting position, with the physician observing the range of motion in the patient’s neck. The physician would then move to evaluate strength and sensation of the patient’s upper and lower extremities (for the purpose of assessing neurologic status). When motor strength is addressed, the patient uses a piece of paper, a pen, a rubber band or hair tie, and a heavy object to perform various maneuvers.

In determining lower extremity sensation, the physician first asks the patient to palpate the greater trochanters for tenderness and then asks the patient to stand and walk on their toes, heels, and with a tandem gait. The patient then raises their shirt to assess the back, and then turns around so that the shoulder and chest symmetry can be evaluated.

Dr. Sardar told OTW, “We observed that a very thorough physical examination can be carried out during a telehealth visit and hence allow practitioners to continue to obtain all the necessary information for them to make a timely and accurate diagnosis. In this manuscript we give a detailed step-by-step description of how an excellent physical evaluation can be performed for a patient with suspected spinal pathology during a video visit. Assessment of range of motion, spinal deformity, and sensation is performed in a precise manner. Simple household objects can be used to grade a patient’s muscle strength objectively instead of relying on a patient’s subjective feeling of weakness.”

“This provides a strong framework for a full physical examination of a patient during a virtual telehealth meeting. Such guidelines allow physicians to make accurate and timely diagnosis similar to what can be done during an in-person visit with a patient.”