OMR Form

SPINE TANGODirectionsUse a #2 soft pencil for marking.Text answers must be entered with the web interface.All questions must be answered unless otherwise indicated.)I Completely fill in boxes to record answers.Question typesI Jonly 1 answer allowedmultiple answers allowedmandatory questionsLevel of main pathologyI upper cervicalmid lower cervicalAdmission / PathologyDayMonthIIcervicothoraciccervico-thoraco-lumbarIthoracicthoracolumbarIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31IIIIIIIIIIIIIthoraco-lumbo-sacrallumbar1 2 3 4 5 6 7 8 9 10 11 12 Year IIIIIIIIII11 12 13 14 15 16 17 18 19 20Main pathologydegenerative diseasenon degen. deformityISpecification of Main PathologyDegen. disease(Pathological) Fracture/Trauma DeformityJType of degenerationdisc herniat./protrusionJ central stenosislateral stenosisJ foraminal stenosisdegen. disc diseaseJ degen. deformityIType of deformityscoliosisType of scoliosisIIIPredominant etiologyidiopathicI congenitalneuromuscularfracture/traumapathological fractureJJJISpecify grade of spondyl.degen. spondylolisthesisother instabilitymyelopathyfacet joint arthrosisother ...........................Specify type of deformity belowIAlso specify type of degenerative deformitykyphosis combinedIIposttraumaticM. Scheuermannother ..........Additional fractures w/different treatments require separate formsType of (pathological) fracture/traumaI condylar (C0) I C2 other fractureC0/1 dissociationsoft tissue injury neckI C1 fracture I fracture C3-L5/S1C1/2 instabilitysacrum fractureI C2 dens fracture I other ..........IDens fracture typeII IIIIIPathologicalfracture due to ...I osteoporosistumorI other ..........single curveIIIC3-L5/S1 AO fracture typeType A B CGroup123SubgroupI 1 I 2 I 3IFracture agefresh fractureI old fracturespondylolisthesis (non degen.)inflammationIIinfectiontumorISURGERY2011IType of inflammationinflammatory arthritis (seropos)I seronegative arthritisankylosing spondylitis (M. Bechterew)I other ..........IJlumbo-sacralsacralIcoccyxrepeat surgeryother: specify ..........................Only answer questions related to Main Pathology (Main Pathology "other" requires no specification.).Idouble curveIn case of tumor, answer questions "Type oftumor" and "Localization" in section "TUMOR"Internal Use Only / Not read by scannerLast nameFirst nameStreetCountry code Zip codeSocial security numberSpondylolisthesisInflammationInfectionTumorRepeat surg.IType of spondylolisthesisType I (congenital, dysplastic)I Type II (isthmic)Type III see type of degenerationI Type IV (traumatic)Type V (pathologic)I Type VI (postsurgical)IIInfection specificationpyogenic fungalI parasitic I othertuberculotic ...................JJGrade ofspondylolisthesisI Grade 0Grade II Grade IIGrade IIII Grade IVSpondyloptosis (V)JJAffected structure(s)spondylitis paravertebraldiscitisinfectionepidural space other ...............Type of tumorLocalizationprimary malignantextraosseous soft tissuesI primary benign J intraosseous (superficial)secondary malignantintraosseous (deep)I tumor like lesion J extrasosseous (extradural)other ..........extraosseous (intradural)J other ..........Specify type of tumor .......................................................JJType or reason of repeat surgeryhardware removal neurocompressionJ non-union J postop. infectioninstabilitysuperficialJ failure to reach J postop. infect. deeptherapeutic goalsimplant malpositionJJJimplant failuresagittal imbalanceadjac. segmentpathologyother ..........Comments regarding main pathology: .....................................................................................................................................................................In segments, mark cranial VBSA = sacrum / CO = coccyxMost severely affected I segment I vertebral body Extent of lesion (segments/vertebral bodies)IIIIIIIIIIIIIIC0 C1 C2 C3 C4 C5 C6 C7 T1 T2 T3 T4 T5 T6 IIIIIIIIIIIII1 2 3 4 5 6 7 8 9 10 11 12 13IIIIIIIIIIIIIIT7T8T9 T10 T11 T12 L1L2L3FormatI minimalcompleteL4L5S1SACOCityIIIIIIIIIIII1415161718192021222324>24M.R.N.GenderBirthdate (DD.MM.YYYY)JJJAdditional pathology (Answer to question "Main pathology" is excluded.)nonen. degen. deformity pathological fracturedegen. disease fracture/trauma spondylolisthesis (non-degen.)JinflammationinfectionJtumorrepeat surgeryJother:specify ..................Number of previous spine surgeriesIIIIIII0 1 2 3 4 5 >5Answer "0" excludes both "Previous surgery"questions ("at same level" and "at same hospital".)Risk factorsBMIII< 2020-2526-30II31-35>35unknownIIIPrevious surgeries at same levelno yes partiallyPrev. surg. same hospital or surgeonI no I yes I partiallyCurrentsmoker Presence of flagsI yes J none J orange J unable tonoredblue assessI unknown J yellow J blackJJPrevious treatment for main pathology (by specialist)none3-6 mon. conservativeJ surgical J 6-12 mon. conservative< 3 mon. conservative> 12 mon. conservativeRed: Biomedical Factors; serious spinal pathologyYellow: Psychosocial or behavioral factorsOrange: Abnormal psychological processes indicatingBlue:Black:psychatric disordersSocioeconomic/work factorsOccupational and societal factorsSA = sacrum / CO = coccyxCopyright MEMdoc, 2011All rights reserved20.05.2011

SPINE TANGOSurgeryInternal Use Only - Not read by scannerSurgeon ........................... Assistant ...........................IIIIIIIIIIIIIIIIIIIIIIIIIIIIIII1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31IIIIIIIIIIIIDayMonth 1 2 3 4 5 6 7 8 9 10 11 12 YearIIIIIIIIII11 12 13 14 15 16 17 18 19 20SURGERYPage 2 of 2JJJTherapeutic goalsaxial pain reliefperipheral pain relieffunctional improvementmotor improvementsensory improvementbladder/sex function improv.JJJspinal stabilizationstop deformity progressionprophylactic decompressioncosmetic improvementdiagnostic measuresother ..............IIIAnterior accessno anterior accesstransoralanterolateralcervicothorac. anterolat.cervicothorac.w/sternotomyIIIthoracotomythoracoabdominalretroperitonealtransperitonealextreme lateral (e.g. XLIF)other ......................................IComponents Description not needed if SEDICO implant tracking is used. Posterior accessnoneSupplier: no posterior accessI...............................................................with descriptionmidlinew/o description Article name: ......................................................... paramedianFor article numbers or multiple implants use form "Implant documentation"posterolateral@ www.eurospine.orgSurgeon credentials Morbidity stateTechnologyI specialized spine I unknown J conventional J endoscopeboard certif. orthopaedicASA1 (no disturbance)MISS/LISSmicroscopeI board certified neuro I ASA2 (mild/moderate) J loops J neuromonitoringorthopaedic in trainingASA3 (severe)CASSother ................I neuro in training I ASA4 (life threatening)other ....................ASA5 (moribund) Blood lossProphylaxisI unknown I 500 - 1000 mlJ none J thrombembolism J other< 100 ml1000 - 2000 mlinfectionossification................ I 100 - 500 ml I > 2000 mlJJSurgical MeasuresDecompressionnoneanteriorspecify ...posterior}Location in spine, choose at least one!JFusion promoting measu.noneJ anteriorposterior}specify ...Location in spine, choose at least one!JJStabilization rigidnoneanteriorspecify ...posterior}Location in spine, choose at least one!JJJJJJJJJJdiscectomy partial/totalvertebrectomy partialvertebrectomy fullosteotomyinterbody fusion (ALIF)interbody fusion (PLIF)interbody fusion (TLIF)interbody fusion (XLIF)JJinterbody stabil. with cageinterbody stabil. with auto-/allograftvertebral body replacement by cageplatespedicle screws with rodIlaminotomyhemi-laminectomylaminectomyfacet joint resec. partialJJother interbody fusionposterolat. fusionposterior fusionother ................Postop surgic compl. before dischargePostop general compl. before dischargenoneimplant malpositionnonekidney / urinary other .............J epidural hematoma J implant failure J cardiovascular J liver / GI J not documentedother hematomawrong levelpulmonarythrombembolismJ radiculopathy J other ............. J cerebral J deathCSF leak / pseudomeningocelenot documentedJ motor dysfunctionRe-intervention after index surgerysensory dysfunctionJ none J hardware J other ............J bowel / bladder dysfunctionhematoma evacuation re-implantationnot documentedwound infection superficialJ suture / glue J abscess drainageJ wound infection deephardware removal(further) decompressionHospital stayStatus of surg. complications Therapeutic goals upon discharge FU foreseenJ uneventful J extended stay I resolved I persisting I achieved I not achieved I noICU > 2 daysimprovedpartially achievedyesDay 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31DischargeMonth IIIIIIIIIIII1 2 3 4 5 6 7 8 9 10 11 12 Year IIIIIIIIII11 12 13 14 15 16 17 18 19 20JJJJJJJJJfacet joint resection fullsequestrectomyflavectomyflavotomyFusion materialnoneautol. bone harvestedautol. bone locally procuredallog. bonefacet screwstransarticular screw C1-C2laminar hooks with rodpedicle hooks with rodlateral mass screw with rodJJJJJJforaminotomylaminoplastyuncoforaminotomyother .................bone subst.cementBMP or similarother .............odontoid screwslaminar screwsother............................Stabil. motion preserving disc replacement Percutan. measures facet block kyphoplasty Other surgical measuresnonedynamic stabilizat. noneroot block epiduralno yesJ anteriorinterspin. spacer I post.specify ...} specify ... discography injectionsposterior}other ............JChoose one!vertebroplasty other .............. Specify yes: ........................Location in spine, choose at least one!IExtent of surgery - indicate as:segments from C0 C1I vertebral bodies toIC0C1JJIIJIIpercutaneoustrans-sacral (e.g. AxiaLIF)other....................Note: "anterior" / "posterior" refers to location of MEASURES in the spine, NOT to access!SA = sacrum / CO = coccyxIIIIIIIIIIIIIIIIIIIIIIIIIIIIC2 C3 C4 C5 C6 C7 T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 L1 L2 L3 L4 L5 S1 SA COIIIIIIIIIIIIIIIIIIIIIIIIIIIJJIntraop surgical complicationsnonevascular injurynerve root damage fx spinal structuresspinal cord damage other ..................dura lesionnot documentedJHospital stayC2JC3C4C5C6C7Surgical measuresduring index surgeryJJT1T2T3T4nonesuture/glueother ............JT5T6T9 T10 T11 T12 L1IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIT7T8JJL2IL3JJL4L5IIntraop general complicationsnonethrombembolismanaesthesiological deathcardiovascularother ..................pulmonarynot documentedJIIIOperation timeunknown< 1 hr.1-2 hrs.2-3 hrs.3-4 hrs.JJIIIJ4-5 hrs.5-6 hrs.6-8 hrs.8-10 hrs.> 10 hrs.Blood transfusionnone >=2 units