Case report (Precis): Two telemedicine consultants miss foot drop: When to see patients in person

Abstract

Background: Telemedicine has been rapidly adopted due to COVID-19. In the earliest days, most screenings were performed by primary care/internal medicine consultants; referrals to subspecialists were minimized. Now, as the pandemic has evolved over 6 months, secondary telemedicine consultations should be limited, and earlier involvement of appropriate subspecialists should be reconsidered to optimize patient management. Case Description: An older individual spoke to an on-call general medical physician with the chief complaint of the acute onset of low back pain after moderately strenuous activity, with severe unilateral radiculopathy. The telemedicine physician recommended a non-steroidal. anti-inflammatory agent without any specific recommendations regarding follow-up. A few days later, with progression of unilateral pain and numbness, a second telemedicine medical consultation was performed; a Medrol dose pack and muscle relaxant were now recommended, again without any follow-up recommendations. Days later, with increased unilateral pain/ near anesthesia in the foot, the patient was seen by a spinal surgeon who found; unilateral SLR positive at 20 degrees, a 0/5 foot drop, loss of the Achilles Response, and decreased pin appreciation in the L5 distribution. The patient's emergent lumbar MR showed a large unilateral disc herniation with inferior migration at the appropriate level, warranting surgical consideration. Conclusion: Here, we emphasized several points. First, telemedicine may be adequate for the initial screening, but further complaints would be better evaluated in person by either a medical or surgical subspecialist; here, both could have recognized the very clear unilateral foot drop. Second, the patient should have had a scheduled follow-up in-person consultation. Third, appropriate diagnostic studies should have been ordered at the time of the second telemedicine consultation to establish the correct diagnosis and direct treatment.