OMR Form

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