Table 1.

A standard tele-neurologic examination

Exam component		Assessment strategy and comments
Mental status		Can use normal examination methods
Cranial nerves
	II	Visual fields: can be evaluated using a shared screen or with the aid of an assistant.
		Visual acuity: can be measured with the aid of an assistant and/or the use of a pocket Snellen card. Online tools to measure visual acuity are available, but not yet validated. [49]
		Fundoscopic exam: currently difficult to accurately performed without an assistant. Can be reported by a trained assistant. New technologies allow assistant to send picture of fundoscopic exam directly to the neurosurgeon. [50] At-home technologies for fundoscopic exams are similarly in development. [51]
	III, IV, VI	EOM: can instruct patient which directions to look and observe eyes for deficits or nystagmus. Can also have patient fix eyes on camera and move head from side to site.
		Pupillary response: can have patient move eye closer to screen and observe response to light. If assistant is present, this can also be performed by assistant with response observed by neurosurgeon. Smart phone based technologies for measurement of pupillary light reflex are accurate, but still under development. [52]
	V	Facial sensation: can ask the patient to self-assess, although assistant help is required to accurately perform.
	VII	Facial strength: can assess symmetry and gross movements of the face on video.
	VIII	Hearing: can grossly assess.
	IX and X	Palate: can grossly evaluate palate and phonation of patient.
	XI	Shoulder shrug: can assess symmetry of shoulder shrug on video.
	XII	Tongue: can assess that tongue is midline on video examination.
Motor
	Upper extremities	Strength: see Fig. 3 for consensus-driven strength exam
	Lower extremities	Strength: see Fig. 3 for consensus-driven strength exam
		Straight leg raise: an assistant can aid by passively raising the leg while observed by the neurosurgeon with moderate accuracy. [53] The patient can also be asked to raise their own leg 20 cm above the table, with any changes in breathing counted as a positive exam. This has demonstrated good reliability. [54]
	Tone	Tone can be difficult to assess over telemedicine modalities, although it is possible to grossly assess. An assistant with the patient can also provide some insight into tone, albeit with poor reliability.
	Reflexes	Reflexes can be difficult to assess without a trained assistant. The patient or an untrained assistant can be taught how to assess plantar response while observed by neurosurgeon.
	Sensation	Frequently requires an assistant with the patient. Often possible to instruct an untrained assistant through a basic sensory examination. The patient can also roughly self-assess how they have been experiencing sensation in day-to-day life.
	Cerebellar function	Can ask patient to perform heel to shin test and rapid alternating movements while observed. Can observe patient’s gait and ask them to tandem walk if in a safe situation.
Additional spine-specific components
	Assessment of pain/disability	Disability and health-related quality of life: the Oswestry Disability Index and 12-item Short Form health survey can be used to measure disability successfully through telemedicine technologies. [54]
		Pain: a visual analogue scale and Tampa Scale of Kinesiophobia can both be successfully administered over during a telemedicine visit with good reliability. [54]
	Range of motion	Spinal range of motion can be observed by directing the patient through specific maneuvers and asking them bend/twist as far as possible. Studies have shown the assessment of lumbar lateral flexion range of motion to have acceptable reliability when performed in this manner. [54]