Eleven spine surgeons and one physical medicine and rehabilitation specialist discuss how their patient evaluation considerations have changed during the pandemic and how their practice has evolved to telemedicine.
Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. We invite all spine surgeon and specialist responses.
Next week's question: Do you use patient-reported outcome measures (PROMs)? If so, how have they affected your practice?
Please send responses to Alan Condon at email@example.com by 5 p.m. CDT Wednesday, Sept. 2.
Note: The following responses were lightly edited for style and clarity.
Question: How have your patient evaluation considerations changed since the onset of the COVID-19 pandemic?
Richard Kim, MD. DISC Sports & Spine Center (Newport Beach, Calif.): Of course, all elective surgeries were put on hold at the beginning of the pandemic. There was a high threshold for what was considered 'urgent,' meaning impending neurologic compromise or permanent disability if surgery was delayed by eight weeks. Now in our area, the COVID-19 cases are sufficiently under control and elective surgeries resumed several months ago. A coronavirus PCR test is now part of the preoperative testing on all patients.
There has been a positive response to telemedicine by most of my patients, whom I’m continuing to see via videoconference. Exceptions are postop visits, wound checks and the like. Many initial consultations are remote and it's usually at the patient's request. However, I usually bring the patient back for an in-person visit if I need to check for neurologic deficits, reflexes, gait, etc prior to any final decision to proceed with surgery. I have a telehealth service that patients find easy to use. Telehealth will definitely continue to be a part of my practice going forward beyond the pandemic.
Grant Shifflett, MD. DISC Sports & Spine Center (Newport Beach, Calif.): I have had to do more ahead of time to screen and evaluate patients to identify who really needs a live physical exam and who can be adequately evaluated virtually. Then, when making treatment decisions, I have to be more thoughtful about the patient’s underlying medical status and the attendant risks of a variety of both nonsurgical and surgical treatment modalities.
Kenan Aksu, DO. Premier Orthopaedics (Exton, Pa.): The biggest change regarding patient evaluation is the way I perform physical exams of patients. It is impossible to social distance, but before I evaluate the patient I wash my hands and obviously wear a mask. Afterwards I wash my hands again and social distance. Telemedicine appointments are a challenge as well. I have patients do various exercises to gauge pain response and weakness, if present.
Brian Gantwerker, MD. Craniospinal Center of Los Angeles: Now, I spend some time educating patients on what the latest issues are with the pandemic. Many times, I have to tell them my level of comfort doing their surgery in the hospital vs. the surgery center. I am agnostic in most cases, unless it's a bigger case and must be done in the hospital. In some ways, the hospital or center is a known quantity because all the patients are tested prior to admission. For any fragile patient, we try to postpone if possible, but with all patients I am straightforward when it comes to the risk of getting ill from COVID-19.
Jeffrey Wang, MD. USC Spine Center (Los Angeles): The pandemic has impacted the way we interact with our patients in so many ways. We are reserving face-to-face visits for those who really need a physical examination or a live interaction that we are not able to do via telemedicine. We are definitely using telemedicine for those who are at high-risk or fear coming into the office, and we try to do as much as possible remotely. We have learned to adapt and have enabled the ability to actually perform a very reasonable and accurate physical examination through video. Although nothing can replace the face-to-face interactions and a live physical examination, certainly we have adapted. We also realize that we can accomplish quite a bit through telemedicine.
Ehsan Jazini, MD. Virginia Spine Institute (Reston): Through this extraordinary pandemic, I have recognized two critical components of patient evaluation that needed to be addressed. First is the safety of my patients and the medical team. Secondly, many patients with spinal conditions cannot wait weeks to months to be seen or until the current situation changes. It is challenging to deal with excruciating back or neck pain under normal circumstances — much more so while in isolation. Arm or leg pain, numbness or weakness can become permanent if not promptly addressed. Difficulty with balance, coordination or urinary incontinence may point to a worsening spinal condition that shouldn't be neglected.
To address these two factors, we instituted a rigorous pre-screening of our patients and offer a telehealth visit if they are of high risk. We also instituted stringent guidelines for our medical team that include daily temperature checks, a mask mandate for staff and patients, thorough cleaning of exam rooms between patients and limiting in-office work to essential staff, while the remainder had been deployed remotely. For surgical patients, we instituted COVID-19 testing three days before surgery with a period of quarantining until the day of surgery.
Ram Mudiyam MD. Hoag Orthopedic Institute (Irvine, Calif.): I have a 100 percent elective surgical practice and therefore better control over patient evaluation considerations. We did experience a temporary slowdown during the latter part of March and all of April. However, as of May, the volume has equaled pre-COVID numbers and sometimes exceeded it. All my elective surgical patients, in addition to routine preop screening, undergo COVID-19 testing five days prior to the date of surgery and self-quarantine at home until the day of surgery.
For urgent cases, rapid testing is available on the day of surgery. Patients answer a questionnaire on COVID symptoms and travel history and have their temperature taken prior to being admitted. In our clinics, patients, staff and providers follow social distancing in the waiting rooms and to the extent possible in exam rooms, along with mandatory mask-wearing and frequent handwashing. In spite of these requirements, our clinics and surgical case loads are functioning at full capacity.
Todd Lanman, MD. Lanman Spinal Neurosurgery (Beverly Hills, Calif.): During the COVID outbreak, we have been gradually seeing an increased number of people complaining of neck and low back pain, mostly because they've been sedentary in bed and working from home. Some have been sitting on couches or laying in bed while working, which is not ergonomically sufficient to prevent back pain. Additionally, most gyms are closed, so people have been unable to exercise and maintain core strengthening exercises and good posture.
We've been doing more telemedicine evaluations, but at some point patients still need to have a hands-on evaluation. I still review their films via telemedicine and show the patients these studies. When they are ready, I examine the patient and proceed with our standard procedure of treating the patients respectively.
Our hospitals have rigorous policies for preventing the spread of COVID-19. All patients are tested within 24 hours of their surgical hospitalization for the virus to be sure they are not infected. The spine surgical area and recovery wings of the hospital are separated from the coronavirus patients, so it is very safe to proceed with inpatient surgery at this time.
Vladimir Sinkov, MD. Sinkov Spine Center (Las Vegas): The pandemic has caused the decrease in overall patient volume, but it is starting to pick up. It has also led to wider acceptance and insurance coverage for telemedicine visits. I find that most patients still prefer in-person appointments. A proper spine physical exam is certainly easier to perform in-person as well. The telemedicine visits are a great option for patients who cannot get to the office or for those who have concerns about potential infection exposure. I find it very helpful to be able to provide both options to my patients to expand their access to care.
Alexander Satin, MD. Texas Back Institute (Plano): The pandemic led to a rapid rise in telemedicine patient evaluations. This allowed us to remain available to our patients during the initial shutdown. Since our office reopened, we have maintained a telemedicine program to expand access to care and limit in-person interactions. Through various research initiatives, we were able to identify patient and visit factors associated with patient satisfaction and telemedicine.
We are fortunate to have access to a number of surgical facilities without COVID inpatients. When appropriate, we have moved surgical cases to these centers. This has been critical to delivering timely care and has been greatly appreciated by patients and their families. Patient safety and satisfaction remain our top priorities.
Peter Derman, MD. Texas Back Institute (Plano): I continue to offer telemedicine as a safe means of evaluating patients during this pandemic. I have found it to be extremely effective in the vast majority of cases. I can obtain the patient's history, perform a physical exam (a grown-up version of 'Simon Says') and review images with the patient. Clearly those who lack the requisite technology require in-person visits, but most people can otherwise be well served by telehealth. Notable exceptions include potential myelopathic patients and those in whom hip pathology is a possibility — I find these two issues can be difficult to diagnose with confidence without an in-person exam.
Another challenge has been obtaining and accessing imaging. As a result, I have been preferentially utilizing third-party imaging centers that allow me to directly import images from their web portal to our picture archiving and communication system. I plan to continue to offer telemedicine as an option into the future as many patients now prefer the convenience of visiting with a physician from the comfort of their homes.
Nayan Patel, MD. PM&R at Texas Back Institute (Plano): Since we have transitioned to a significant increase in telemedicine visits, the patient's detail on the clinical history has become increasingly more important. Since there is not as thorough a physical examination during the telehealth visit, l spend more time with the patient getting the answers I need, so I can tailor a treatment plan to the patient. Not all patients are adept at providing a problem-specific clinical history via telemedicine; those patients need to be safely and reliably evaluated in person.