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 only 1 answer allowedILevel of procedureupper cervicalmid lower cervicalJ multiple answers allowedmandatory questionsIcervicothoraciccervico-thoraco-lumbarInternal Use OnlyNot read by scannerILast nameStreetCountry codeOccupationthoracicthoracolumbarFirst nameZip codeCityBirthdate (DD.MM.YYYY)Ithoraco-lumbo-sacrallumbarSURGERYI2006GenderStagedM.R.N.Telephonelumbo-sacralsacralIcoccyxAdmissionDay 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 31Month IIIIIIIIIIII1 2 3 4 5 6 7 8 9 10 11 12 YearIIIIIIIIIIIIIIIII00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16IIIMain pathology Answer "same as stage I surgery" excludes questions "Specification of Main Pathology" and "Previous treatment for main pathology"same as stage I surgery deformitypathological fracture inflammation tumorI degenerative disease I fracture / trauma I spondylolisthesis I infection I failed surgery I otherSpecification of Main PathologyDegenerativeDiseaseDeformity(Pathological) Fracture/TraumaIIIIJType of degenerationblack discJ disc degenerationdisc herniationJ spondylosisIType of deformityscoliosisI kyphosisType of scoliosisI single curvePredominant etiologyI idiopathiccongenitalI neuromusculardegenerativeJJIIIIIspondylarthrosisspinal stenosisadjacent segment degen.other ..........combinedother ..........double curveposttraumaticM. Scheuermannother ..........Additional fractures w/different treatments require separate forms.Type of (pathological) fracture/traumaI condylar (C0) I C2 other fractureC0/1 dissoziationsoft tissue injury neckI C1 fracture I fracture C3-L5/S1C1/2 instabilitysacrum fractureI C2 dens fracture I other ..........Dens fracture type C3-L5/S1 AO fracture typeI I I A1 I B1 I C1IIA2B2C2I III I A3 I B3 I C3PathologicalFracture agefracture due to ... I fresh fractureI osteoporosisold fracturetumor (In case of tumor, answer questions "Type of tumor"I other .......... and "Localization" in section "TUMOR"Most severely affected segment/vertebral bodynot applicable/assessable C3unknown I C3 / 4C0C4C0 / 1I C4 / 5C1C5C1 / 2I C5 / 6C2C6C2 / 3I C6 / 7IIIIC7C7 / Th1Th1Th1 / 2Th2Th2 / 3Th3Th3 / 4IIIIITh4Th4 / 5Th5Th5 / 6Th6Th6 / 7Th7Th7 / 8IOnly answer questions related to Main Pathology (Main Pathology "other" requires no specification.).SpondylolisthesisInflammationInfectionTumorFailed surg.IIIIIIType of spondylolisthesisType I (congenital, dysplastic)I Type II (isthmic)Type III (degenerative)I Type IV (traumatic)Type V (pathologic)I Type VI (postsurgical)Type of inflammationinflammatory arthritis (seropos)I seronegative arthritisankylosing spondylitis (M. Bechterew)I other ..........IInfection specificationpyogenicfungalI parasitic I other ..........tuberculoticIIType of tumorprimary malignantI primary benignsecondary malignantI tumor like lesionother ..........Specify type of tumorJType of failed surgerynon-unionJ instabilityneurocompressionJJJTh8Th8 / 9Th9Th9 / 10Th10Th10 / 11Th11Th11 / 12IGrade of spondylolisthesisGrade 0I Grade IGrade III Grade IIIGrade IVI Spondyloptosis (V)IAffected structure(s)spondylitisI discitisspondylodiscitisLocalizationvertebral bodyJ posterior bony elementsextraduralJ intradural extramedullaryintradural intramedullaryJ other .................................................................postop. infectionimplant failuresagittal imbalanceIIIIJTh12Th12 / L1L1L1 / 2L2L2 / 3L3L3 / 4frontal imbalanceother ..........Comments regarding main pathology: .............................................................................................................................................................IIIIL4L4 / 5L5L5 / S1S1sacrum(S2-5)coccyxIExtent of lesion1 segment/vertebral bodyI2-3 segments/vertebral bodiesI4-5 segments/vertebral bodiesI>5 segments/vertebral bodiesJJJPrevious treatment for main pathologynone surgical < 3 mon. conservativeJ3-6 mon. conservativeJ6-12 mon. conservativeJ> 12 mon. conservativeCopyright MEMdoc, 2008All rights reserved15.05.2008

SPINE TANGOStagedInternal Use Only - Not read by scannerSURGERYPage 2 of 2SurgeryDayMonthSurgeon ........................... 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 31IIIIIIIIIIII1 2 3 4 5 6 7 8 9 10 11 12 IIIIIIIIIIIIIIIII00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16YearSURGICAL PROCEDUREIISurgeon credentialsspecialized spineboard certif. orthopaedicboard certified neuroIMorbidity stateunknownI ASA1 (no disturbance)ASA2 (mild/moderate)I ASA3 (severe)ASA4 (life threatening)I ASA5 (moribund)JJTechnologyconventionalMISS/LISSloopsmicroscopeIComponentsyesI noComponentdescriptionIIIIIAnterior accessno anterior accesstransoralanterioranterolateralcervicothorac. anterolat.cervicothorac. a.lat. w/sternotomyJJBlood lossendoscope unknownCASS I noneother< 500 ml................Not needed if SEDICO implant tracking is used.Supplier:Article name:orthopaedic in trainingneuro in trainingother ....................IIIJJIII.................................................................Goal of surgerypain relieffunctional improvementneurological improvementcervicothor. a.lat. w/ thoracot.thoracotomythoraco-phrenico-lumbotomyretroperitonealtransperitonealother ....................500 - 1000 ml1000 - 2000 ml> 2000 mlIIOperation timeunknown< 1 hr.1-2 hrs.2-3 hrs.JJIIIPosterior accessno posterior accessmidlineparamedianposterolateralother ....................IIcosmetic improvementdiagnostic measuresother ....................3-4 hrs.4-5 hrs.5-6 hrs.II6-8 hrs.8-10 hrs.> 10 hrs.Article No: ..................................................................................................................................................................................................................................JJDecompressionnoneanteriorspecify ...posterior}Location in spine,choose at least one!JFusionnoneJ anteriorspecify ...posterior}Location in spine,choose at least one!JStabilization rigidnoneJ anteriorposterior}specify ...Location in spine,choose at least one!JJJJSurgical complicationsnonewrong levelnerve root damagecauda equina damagespinal cord damageJJSurgical MeasuresDischargeJJJJJJJJJ(Answer "none" in both "Surgical" and "General complications" excludes all remaining questions.)JJJMeasures takennoneintervention during surgeryre-intervention after surgeryconservative medicalComments regarding dischargediscectomyvertebrectomy partialvertebrectomy fullother ....................bleeding in spinal canalbleeding outside spinal canalmalposition of implantduralesionwound infectionJJNote: "anterior" / "posterior" refers to location of MEASURES in the spine, NOT to access!JJconservative functionalextended hospital stayother ..........osteotomylaminotomyhemi-laminectomyinterbody stabil. with cage (ant. approach)interbody stabil. with cage (post. approach)vertebral body replacement by cageplatespedicle screws with rodJJJJJJinterbody fusion between adjct. vertebrae (ant. appr.)interbody fusion between adjct. vertebrae (post. appr.)interbody fusion between dist. vertebrae (ant. appr.)interbody fusion between dist. vertebrae (post. appr.)Iimplant failureother ..........laminectomyfacet joint resection partialfacet joint resection fullJJposterolat. fusionposterior fusionother ................pedicle screws with platefacet screwstransarticular screwlaminar hooks with rodpedicle hooks with rodJJJJJJJJGeneral complicationsnoneanaesthesiologicalcardiovascularpulmonarySurgical intervention/re-interventionnonemetal removalJ hematoma evacuation J re-implantationabscess drainagerefusionflavectomyforaminotomysequestrectomyFusion materialnoneautol. boneallog. bonelateral mass screw with rodlateral mass screw with plateodontoid screwsother ............................JJJJJbone subst.cementother................Stabil. motion preservingPercutan. measuresnonedisc replacement nonefacet block discographykyphoplastyJ anteriordynamic stabilizat. I post. } specify ... J root block J vertebroplasty J other ............posterior}specify ... other ............ Choose one!Location in spine, choose at least one!Other surgical measuresSurgical notes ....................................................................................................................I noyes } specify ... ...........................................................................................................................................................................................Choose one!JJJcerebralkidney/urinaryliver/GIdeathother ..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................JJJsutureother .......Abbreviations:MISS = Minimally Invasive Spine Surgery; LISS = Less Invasive Spine Surgery; CASS = Computer-Assisted Spine SurgeryCopyright MEMdoc, 2008All rights reserved15.05.2008