Cervical Spine Evaluation by Telephone and Video Visit

As telecommunication technologies advance, efforts are being made to mitigate direct patient contact in the COVID-19 pandemic due to the risk of contagion. The ability to host telephone and video visits within patient portals within health care institutions will only become increasingly valuable. Neck pain, a common complaint seen in primary care clinics, is well-suited to telemedicine evaluation, as related etiologies are often comparatively straightforward. A good assessment of the cervical spine by telephone or video is possible with the right knowledge and practice. The purpose of this article is to propose questions and maneuvers that can be used to evaluate the cervical spine via telephone or video, as well as likely diagnoses that can be reached through these. Phone and video evaluation of the cervical spine can result in valuable data regarding symmetry, range of motion, functional movement patterns, modified strength testing, and provocative testing. The skill set necessary to do telephone and video visits should be included in the curriculum of physician learners.


Introduction And Background
Neck pain is among the most frequent complaints of patients seen in primary care clinics [1]. There are a myriad of possible diagnoses, but the common differentials include myofascial pain, degenerative disc disease, and muscle spasms [2]. These complaints often necessitate timely treatment, but evaluation of patients can become difficult during a pandemic. Fortunately, the technology needed for this type of evaluation already exists. During the coronavirus (COVID-19) pandemic, telephone and video visits have become increasingly useful. The success of these visits makes a compelling argument for their use during pandemics and by people who live far away from their physicians or are unable to travel for care [3]. The latter is especially relevant for patients suffering from neck pain, as a trip to the clinic could be a struggle. These patients may have difficulty turning their heads while driving [4] or may be taking medications that can cause drowsiness, making it difficult or dangerous to travel [5].
The goal of this article is to discuss how patients with neck pain can be evaluated using telephone and video visits and the specific details that need to be considered during these visits. While limitations exist, we believe that the use of telecommunication technologies to accurately evaluate and diagnose patients is possible.
Telecommunication and security technologies have become so advanced that it is possible to perform telephone and video visits within the patient portals that are tied to health care institutions [6]. In all likelihood, these portals will be widely used in the future, even after the end of the COVID-19 pandemic. The billing and coding for these visits and payment by insurance will also likely improve [7]. As such, the skills needed to hold telephone and video visits should be taught to physician learners as the way of the future, rather than as a momentary need due to the current pandemic.
Neck conditions lend themselves to telehealth evaluation, as their etiologies are often more straightforward than those of conditions that affect other joints. Additionally, red flags are easily identified through verbal history taking, and physical examination of the cervical spine by video is easier than that of smaller joints, such as the hands and wrists, or of more complex joints, like the shoulder.
As the availability of mobile applications increases, musculoskeletal evaluation by telemedicine will become accessible to a greater number of patients. The ability to connect with physicians through popular devices, 1 2, 3 4 4 1 such as a telephone or tablet, should only serve as an impetus to make telephone and video visits standard practice. This is likely to become a widely-used method for many patients with pain and disability, whether stemming from the cervical spine or from another source.

Review Evaluation of neck pain via telephone visit
As an actual physical examination cannot be done by telephone, each question posed by the physician should be aimed at uncovering a suspected injury or condition in order to narrow the differential diagnosis quickly and concisely. Furthermore, each response should be taken in the context of the patient's history.

Evaluation of neck pain via video visit
The neck and shoulders should be examined for asymmetry. The examiner should pay attention to the patient's head position in their natural neutral position. The patient should be asked to palpate around the neck: the patient can palpate the posterior midline (i.e., the spinous processes), posterior paraspinal musculature, and anterior musculature (Figure 1). The examiner can demonstrate the desired palpation or share an illustration with the patient. With guidance, the patient can report if they notice any cervical lymphadenopathy, bony tenderness, a step-off during palpation of the spinous processes, or tenderness or spasm during palpation of the paraspinous muscles.

FIGURE 1: Cervical spine inspection: anterior musculature (A); posterior paraspinal musculature and midline (B).
Range of motion tests should be performed next, and these can be quite easily estimated via video. Normal cervical flexion is about 50°; extension, 80°; right and left side bending, 45°; and right and left rotation, 85°( Figure 2).

FIGURE 2: Cervical spine range of motion: extension (A); right (B) and left (C) side rotation; left (D) and right (E) side-bending.
Testing the entire neck range of motion (i.e., flexion, extension, side bending, and rotation) is important to avoid missing important conditions. The patient can be asked to place their own hand against their head to resist motion and to assess if this causes pain (Figure 3). This maneuver can be used to assess if cervical motion causes pain when against a resistant force. Shoulder range of motion should also be evaluated (Figure 4).

FIGURE 4: Shoulder range of motion: forward flexion (A); external rotation (B); right (C) and left (D) internal rotation.
Strength can be assessed by asking the patient to lift a weight, such as a dumbbell or a book, while they describe any ensuing pain or differences beyond what would be expected for hand dominance ( Figure 5). The patient can be asked to give a thumbs-up, make an "OK" sign with their first finger and thumb, and cross their first and second fingers, to assess distal muscle function ( Figure 5).

FIGURE 5: Motor strength. Ask the patient to lift a weight with both arms, reporting differences or pain (A and B). Distal motor strength can be assessed by asking the patient to give a thumbs-up (C), make an "OK" sign (D), and cross their first and second fingers (E).
Signs of cervical nerve root irritation or impingement can be obtained with a forward flexion test: pain will be elicited when the patient is asked to turn their head to the side and then flex their neck forward ( Figure  6A). The patient can also be asked to turn and tilt their head backward toward the affected side to mimic an atlantoaxial compression test (Spurling test), or they can ask someone to apply an axial load to the top of their head while their neck is twisted ( Figure 6B). Reproduction of radicular pain to the shoulder and arm may suggest cervical nerve root irritation.

Cervical nerve root irritation can be assessed by performing the forward flexion test (A) and Spurling test (B).
Telephone and video visits should be considered important options for the evaluation of musculoskeletal conditions, such as neck pain. Patients with neck pain may have difficulty turning their heads while driving or may be taking medications related to previous neck pain episodes that may cause drowsiness, making it difficult or dangerous for them to travel or operate motor vehicles, and making virtual evaluation a valuable option. Previous literature has reported the use of telehealth visits prior to the COVID-19 pandemic for patients living in rural areas and for those who are older, blind, or disabled [8].

Conclusions
While telephone and video visits have their limitations, they can allow for the evaluation and accurate diagnosis of patients with neck pain. Questions and instructions can be given by telephone, and patient responses can give clinicians an idea of the etiology of the neck pain. Guided palpation is important, as is the patient's ability to perform certain movements, such as the thumbs-up or "OK" signs. Telephone and video visits may become valuable options for many patients with pain and disability, whether stemming from the cervical spine or from another source. The skill of managing telephone and video visits should be taught to physician learners as alternatives for future encounters. Scheduling these visits will likely continue, even after the resolution of the COVID-19 pandemic.

Conflicts of interest:
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