SPINE TANGO SURGERY Directions Internal Use Only / Not read by scanner 2011 Use a #2 soft pencil for marking. Last name First name Gender Text answers must be entered with the web interface. All questions must be answered unless otherwise indicated. Street M.R.N. )I Completely fill in boxes to record answers. Question types Country code Zip code City I only 1 answer allowed Format J multiple answers allowed I minimal Social security number Birthdate (DD.MM.YYYY) mandatory questions Icomplete ...... please specify Level of intervention I upper cervical I cervicothoracic I thoracic I thoraco-lumbo-sacral I lumbo-sacral I coccyx I mid lower cervical I cervico-thoraco-lumbar I thoracolumbar I lumbar I sacral Admission / Pathology Day IIIIIIIIIIIIIIIIIIIIIIIIIIIIIII12345678910111213141516171819202122232425262728293031 MonthIIIIIIIIIIII123456789101112 Year IIIIIIIIII11 12 13 14 15 16 17 18 19 20 Main pathology I degenerative disease I fracture/trauma I spondylolisthesis (non degen.) I infection I repeat surgery I non degen. deformity I pathological fracture I inflammation I tumor I other: specify .......................... Specification of Main Pathology Only answer questions related to Main Pathology (Main Pathology "other" requires no specification.). Type of degeneration Specify grade of spondyl. Grade of J disc herniat./protrusion J degen. spondylolisthesis Type of spondylolisthesis spondylolisthesis J central stenosis J other instability I Type I (congenital, dysplastic) I Grade 0 J lateral stenosis J myelopathy I Type II (isthmic) I Grade I J foraminal stenosis J facet joint arthrosis Type III see type of degeneration I Grade II J degen. disc disease J other ........................... I Type IV (traumatic) I Grade III Degen. disease J degen. deformity Specify type of deformity below I Type V (pathologic) I Grade IV Type VI (postsurgical) Spondyloptosis (V) Spondylolisthesis I I Type of deformity Also specify type of degenerative deformity I scoliosis I combined I kyphosis I other ............ Type of inflammation Type of scoliosis I inflammatory arthritis (seropos) I single curve I double curve I seronegative arthritis Predominant etiology I ankylosing spondylitis (M. Bechterew) idiopathic posttraumatic Inflammation other .......... Deformity I I I I congenital I M. Scheuermann I neuromuscular I other .......... Infection specification Affected structure(s) I pyogenic I fungal J spondylitis J paravertebral Additional fractures w/different treatments require separate forms I parasitic I other J discitis infection Type of (pathological) fracture/trauma Infection I tuberculotic ................... J epidural space J other ............... I condylar (C0) I C2 other fracture I C0/1 dissociation I soft tissue injury neck Type of tumor Localization I C1 fracture I fracture C3-L5/S1 I primary malignant J extraosseous soft tissues I C1/2 instability I sacrum fracture I primary benign J intraosseous (superficial) I C2 dens fracture I other .......... I secondary malignant J intraosseous (deep) I tumor like lesion J extrasosseous (extradural) Dens fracture type C3-L5/S1 AO fracture type Tumor I other .......... J extraosseous (intradural) I I Type I A I B I C J other .......... I II Group I 1 I 2 I 3 Specify type of tumor ....................................................... I III SubgroupI 1 I 2 I 3 Pathological Type or reason of repeat surgery fracture due to ... Fracture age J hardware removal J neurocompression J implant failure I osteoporosis I fresh fracture J non-union J postop. infection J sagittal imbalance (Pathological) Fracture/Trauma I tumor I old fracture J instability superficial J adjac. segment I other .......... In case of tumor, answer questions "Type of J failure to reach J postop. infect. deep pathology tumor" and "Localization" in section "TUMOR" Repeat surg. therapeutic goals J implant malposition J other .......... Comments regarding main pathology: ..................................................................................................................................................................... In segments, mark cranial VB SA = sacrum (S2-5) / CO = coccyx Most severely affected I segment I vertebral body Extent of lesion (segments/vertebral bodies) IC0 IC1 IC2 IC3 IC4 IC5 IC6 IC7 IT1 IT2 IT3 IT4 IT5 IT6 I1 I2 I3 I4 I5 I6 I7 I8 I9 I10 I11 I12 I13 IT7 IT8 IT9 IT10 IT11 IT12 IL1 IL2 IL3 IL4 IL5 IS1 ISA ICO I14 I15 I16 I17 I18 I19 I20 I21 I22 I23 I24 I>24 Additional pathology (Answer to question "Main pathology" is excluded.) J none J non-degen. deformityJ pathological fracture J inflammation J tumor J other: J degen. disease J fracture/trauma J spondylolisthesis (non-degen.) J infection J repeat surgery specify .................. Number of previous spine surgeries Previous surgeries at same level Previous treatment for main pathology (by specialist) IIIIIII012345>5 I no I yes I partially J none J 3-6 mon. conservative Answer "0" excludes both "Previous surgery" Prev. surg. same hospital or surgeon J surgical J 6-12 mon. conservative questions ("at same level" and "at same hospital".) I no I yes I partially J < 3 mon. conservative J > 12 mon. conservative Current Red: Biomedical Factors; serious spinal pathology BMI smoker Presence of flags - low back pain Yellow: Psychosocial or behavioral factors I < 20 I 31-35 I yes J none J orange J not Orange: Abnormal psychological processes indicating I 20-25 I >35 I no J red J blue assessable/ psychatric disorders 26-30 unknown unknown yellow black applicable Blue: Socioeconomic/work factors Risk factors I I I J J Black: Occupational and societal factors SA = sacrum / CO = coccyx Copyright MEMdoc, 2011 All rights reserved 31.12.2011 / Version v1 SPINE TANGO Internal Use Only - Not read by scanner SURGERY Page 2 of 2 Surgeon ........................... Assistant ........................... Surgery DayIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII12345678910111213141516171819202122232425262728293031 MonthIIIIIIIIIIII123456789101112 Year IIIIIIIIII11 12 13 14 15 16 17 18 19 20 Therapeutic goals Anterior access J axial pain relief J spinal stabilization I no anterior access I thoracotomy J peripheral pain relief J stop deformity progression I transoral I thoracoabdominal J functional improvement J prophylactic decompression I anterolateral I retroperitoneal J motor improvement J cosmetic improvement I cervicothorac. anterolat. I transperitoneal J sensory improvement J diagnostic measures I cervicothorac. I trans-psoas (XLIF) J bladder/sex function improv. J other .............. w/sternotomy I other ............... Components Description not needed if SEDICO implant tracking is used. Posterior access I none Supplier: ............................................................... I no posterior access I percutaneous I with description I midline I para-coccygeal (AxiALIF) I w/o description Article name: ......................................................... I paramedian I other For article numbers or multiple implants use form "Implant documentation" posterolateral .................... @ www.eurospine.org I Surgeon credentials Morbidity state Technology Operation time I specialized spine I unknown J conventional J CASS I unknown I 4-5 hrs. I board certif. orthopaedic I ASA1 (no disturbance) J MISS/LISS J microscope I < 1 hr. I 5-6 hrs. I board certified neuro I ASA2 (mild/moderate) J loops J neuromonitoring I 1-2 hrs. I 6-8 hrs. I orthopaedic in training I ASA3 (severe) J endoscope J other ................ I 2-3 hrs. I 8-10 hrs. I neuro in training I ASA4 (life threatening) I 3-4 hrs. I > 10 hrs. I other .................... I ASA5 (moribund) Blood loss Prophylaxis I unknown I 500 - 1000 ml Blood transfusion J none J thrombembolism J other I < 100 ml I 1000 - 2000 ml J none J >=2 units J J infection J ossification ................ I 100 - 500 ml I > 2000 ml J <2 unitsJ cell saver unknown Surgical Measures Note: "anterior" / "posterior" refers to location of MEASURES in the spine, NOT to access! Decompression J none J discectomy partial/total J laminotomy J facet joint resection full J foraminotomy anterior vertebrectomy partial hemi-laminectomy sequestrectomy laminoplasty J specify ... J J J J J posterior } J vertebrectomy full J laminectomy J flavectomy J uncoforaminotomy Location in spine, choose at least one! J osteotomy J facet joint resec. partial J flavotomy J other ................. Fusion promoting measu. Fusion material J none J interbody fusion (A-IF) J other interbody fusion J none J bone subst. anterior interbody fusion (PLIF) posterolat. fusion autol. bone harvested cement J specify ... J J J J J posterior } J interbody fusion (TLIF) J posterior fusion J autol. bone locally procured J BMP or similar Location in spine, choose at least one! J interbody fusion (XLIF) J other ................ J allog. bone J other ............. Stabilization rigid J interbody stabil. with cage J pedicle screws with rod J lateral mass screw with rod J none J interbody stabil. with auto-/allograft J facet screws J odontoid screws anterior vertebral body replacement by cage transarticular screw C1-C2 laminar screws J specify ... J J J J posterior } J vertebral body replacment by auto-/allograft J laminar hooks with rod J other Location in spine, choose at least one! J plates J pedicle hooks with rod ............................ Stabil. motion preservingJ disc replacement Percutan. measuresJ facet block J kyphoplasty Other surgical measures J none J dynamic stabilizat. I none J root block J epidural I no I yes anterior interspin. spacer post. J specify ... J I } specify ... J