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HSS ID___________________ FOCOS DATABASE v3 Date of Evaluation_________
Pt Name__________________ Worksheet
D.O.B. ___________________
(decribe in the space
Medical History (check all that apply and describe) Famliy History provided)
GI □ Relationship
GU □
CVS □ Comments
Neurologic □
Psychiatric □ Chief compliant of patient:
Respiratory □
HEENT □
Gen. Musc. □
Other □
Other Treatment
Bracing □ Type Start date End date
Duration______ Purpose Status Comments
Non-bracing □ Type Start date End date
Duration______ Purpose Status Comments
Anthropometric Vital signs Pulmonary Function
Blood
Standing ht (in) Press. FVC ______ L ______ %
Sitting ht (in) Pulse FEV1 ______ L ______ %
Weight (lbs) Respiration FEV1/FVC ______ L ______ %
Armaspan (cm) Temp (°F) T score (L4) ______ L ______ %
T score
hip/neck ______ L ______ %
General Exam
Care au Lait Facial
spots yes □ no □ UNK □ Asymmetry yes □ no □ UNK □
Loss of hair/skin
pigmentation yes □ no □ UNK □ Arachnodactyl yes □ no □ UNK □
Hamstring
tightness yes □ no □ UNK □ Steinberg yes □ no □ UNK □
Asymmetry of Walker/
calves yes □ no □ UNK □ Murdock yes □ no □ UNK □
Asymmetry of
thighs yes □ no □ UNK □ Chest Deformity yes □ no □ UNK □
Skin
Pes cavus yes □ no □ UNK □ Hyperelasticity yes □ no □ UNK □
Joint hyperlaxity yes □ no □ UNK □ Cardiac findings Abnormal □ Normal □ UNK □
Musculoskeletal
Hypertonia yes □ no □ UNK □ findings Abnormal □ Normal □
Hypotonia yes □ no □ UNK □ Neurologic Abnormal □ Normal □
Pubic hair
Hypognadism yes □ no □ UNK □ development None □ Early □ Mature □
Shortness of Breast
breath yes □ no □ UNK □ development None □ Early □ Mature □
High arched plate yes □ no □ UNK □ Tanner sign 1□ 3□ 5 □ n/a □ UNK □
Notes:
page 1 of 5
Date of Evaluation_________
Radiographic Jacket Status Lenke class
EKM type
Pre Op □ King type
Post Op □ Nash Moe
Pedriolle (°)
Scoliosis Region Levels Right/Left Degrees Flexibility Degrees
_______ _______ _______ _______ _______ _______
Region Levels Right/Left Degrees Flexibility Degrees
_______ _______ _______ _______ _______ _______
Region Levels Right/Left Degrees Flexibility Degrees
_______ _______ _______ _______ _______ _______
Kyphosis Levels Degrees Flexibity Degrees T1-S1 length (cm)
_______ _______ _______ _______
Levels Degrees Flexibity Degrees Length of implant (CM)
_______ _______ _______ _______
Levels Degrees Flexibity Degrees Risser sign
_______ _______ _______ _______
Triradiate cartilage
Lordosis Levels Degrees Flexibity Degrees
_______ _______ _______ _______ sagittal Balance (cm)
Levels Degrees Flexibity Degrees
_______ _______ _______ _______ coronal balance (cm)
Levels Degrees Flexibity Degrees
_______ _______ _______ _______
Sacral
Listhesis Level Slip angle (°) inclination Grade Lung space ratio (SAL)
_______ _______ _______ _______
Sacral
Level Slip angle (°) inclination Grade CT Spine rotation (°)
_______ _______ _______ _______
Sacral Hemithoracic
Level Slip angle (°) inclination Grade symmetry ratio
_______ _______ _______ _______
Thoracic rotation (°)
Lumbar rotation (°)
Notes:
Questionnaires
SRS 22 □ Completed Today □ Not Completed Today
Oswestry □ Completed Today □ Not Completed Today
page 2 of 5
Neurologic Exam (if normal, skip page)
Gait normal □ abnormal □UNK □ Sensation normal □ abnormal □ UNK □
Bladder function normal □ abnormal □UNK □ If abnormal, explain
Bowel function normal □ abnormal □UNK □
Motor Exam
Grading options: Grading options:
0 -5 = normal, UNK, 0 -5 = normal, UNK,
Lower Extremity NA Upper extremity NA
Right Left Right Left
Hip flexion (L1, L2) _______ _______ Biceps _______ _______
Hip add (L2,3,4) _______ _______ Triceps _______ _______
Hip Abd (L5) _______ _______ Sup Abdominal _______ _______
Hip ext (S1) _______ _______ Reflexes Grading options:
Knee ext (L3, L4) _______ _______ Right Left
Knee flex (L5, S1) _______ _______ Patellar (L4) _______ _______
Ankle DF (L5) _______ _______ Achilles (S1) _______ _______
Ankle PF (S1, S2) _______ _______ Right Left
Babinski (grading
options: positive, negative,
Inver (L4) _______ _______ UNK) _______ _______
Clonus (grading options:
Ever (S1) _______ _______ positive, negative, UNK) _______ _______
EHL (L5) _______ _______ # of Beats _______ _______
Hoffman (grading
options: positive, negative,
Plantar flex _______ _______ UNK ) _______ _______
Diagnosis (check all that apply)
Age Group Region (check all
Deformity/Scoliosis (select one option) that apply )
Idiopathic Infatile Cv
Congenital Type: Juvenile P Th
Neuromuscular Type: Adolescent Th
Degenerative Scoliosis Type: Adult TLL
Kyphosis/Sagittal
Plane Deformity Lu
Scheurmann's LS
Congenital P
Neuromuscular Additional Notes:
Other Kyphosis/Sagittal
Plane Deformity Type
Degenerative Type:
Stenosis
Spondylolisthesis
Spondylo Region
Syndrome Type:
Complication Type:
Fracture Type:
page 3 of 5
Operative
DOS ASA Score DOS ASA Score
Primary surgeon Primary surgeon
Assisting surgeon Assisting surgeon
Anesthesiologist Anesthesiologist
Anterior (check all that apply) Levels Posterior (check all that apply) Levels
Decompression □ - Decompression □ -
- -
Discectomy □ - Laminectomy □
- Laminotomy □
Annulotomy □ - Foraminotomy □
Resection □ Microdiskectomy □
Corpectomy Nerve root exploration □
Resection □
Kyphectomy □
Osteotomy □ - Kyphoplasty/Vertebroplasty □
- Total Vertebrectomy □
ASF □ - PSF □ -
Apical Fusion - -
Disk athroplasty □ -
Total vertebrectomy □ PLIF □
Retroperitoneal □ TLIF
Transperitoneal □ Apical Fusion □
Laproscopic □ Pars defect repair □
Thoracotomy □ Lengthening □
VATS □ Thoracoplasty □ -
Thoracoplasty □ - Osteotomy type □
Rib Osteotomy □ - Osteotomy Levels □ -
Instrumentation Instrumentation
Metal type Metal type
Instrumentation levels Instrumentation levels
Instrumentation types Instrumentation types
Rod description Rod description
Screw/Hook fixation Screw/Hook fixation
Op Detail Op Detail
Time (min) Time (min)
Blood Loss (cc) Blood Loss (cc)
Transfusion (units) Transfusion (units)
Cell Saver (cc) Cell Saver (cc)
Bone graft type Bone graft type
Revision? yes □ no □ Revision? yes □ no □
Reason for revision Reason for revision
SC Monitoring yes □ no □ SC Monitoring yes □ no □
SC Monitoring type □ EMG □ SSEP □ MEP SC Monitoring type □ EMG □ SSEP □ MEP
Wake Up Test □ Normal □ Abnormal Wake Up Test □ Normal □ Abnormal
SCM Notes: SCM Notes:
Complications
□ Implant failure □ Pleural effusion □ Deep Vein Thrombosis
□ Implant other □ Severe Atelectasis □ Pseudoarthrosis
□ Dural Tear □ Pneumonia □ Decomensation
□ Nerve root injury □ Cardiac arrest □ Unrinary Tract Infection
□ Spinal cord injury □ Cardiac Other □ Deep Wound Infection
□ Neuro upper extremity □ Excessive blood loss □ Superficial Wound Infection
□ Neuro lower extremity □ Vascular injury □ Retained Instrument
□ Neuro Other □ Anesthesia related □ Death
□ Pulmonary embolism □ Retained sponge
Notes:
page 4 of 5
Name:___________________ Post Op Visit Date: ____________
Data Collection Sheet
MRN:____________________
Post Op
Interval □ Immediate □ 6 months □ 1 yr FU □ 2 yr FU □ 3+ yrs FU
_____# weeks s/p
Implant Status □ In tact □ Dislodged □ Other (describe)
Fusion Status □ Complete □ Incomplete □ Not sure
Post Op Radiographic Data T1-S1 length (cm)
Length of implant
Scoliosis Region Levels Right/Left Degrees (CM)
_______ _______ _______ _______ Risser sign
Region Levels Right/Left Degrees Triradiate cartilage
sagittal Balance
_______ _______ _______ _______ (cm)
coronal balance
Region Levels Right/Left Degrees (cm)
Lung space ratio
_______ _______ _______ _______ (SAL)
Kyphosis Levels Degrees CT Spine rotation (°)
Hemithoracic
_______ _______ symmetry ratio
Levels Degrees Thoracic rotation (°)
_______ _______ Lumbar rotation (°)
Listhesis
Slip angle Sacral
Levels Degrees Level (°) inclination Grade
_______ _______ _______ _______ _______ _______
Slip angle Sacral
Lordosis Levels Degrees Level (°) inclination Grade
_______ _______ _______ _______ _______ _______
Complications
□ Implant failure □ Pleural effusion □ Deep Vein Thrombosis
□ Implant other □ Severe Atelectasis □ Pseudoarthrosis
□ Dural Tear □ Pneumonia □ Decomensation
□ Nerve root injury □ Cardiac arrest □ Unrinary Tract Infection
□ Spinal cord injury □ Cardiac Other □ Deep Wound Infection
□ Neuro upper extremity □ Excessive blood loss □ Superficial Wound Infection
□ Neuro lower extremity □ Vascular injury □ Retained Instrument
□ Neuro Other □ Anesthesia related □ Death
□ Pulmonary embolism □ Retained sponge
Complication Notes:
Questionnaires
SRS 22 □ Completed Today □ Not Completed Today
Oswestry □ Completed Today □ Not Completed Today
page 5 of 5
ISSG Revision Surgery tab
Add New Tab
Additions
Date of index procedure
Previously fused levels
Existing implants
Revision Diagnosis
Bone/Implant Interface Failure check box
Implant Failure - Other check box
Infection - Deep check box
Infection - Superficial check box
Motor Deficit check box
Pain - Back check box
Pain - Radicular check box
Pain - Radicular and Back check box
Prominent Implant check box
Pseudarthrosis check box
Sagittal Plane Deformity - Flatback check box
Sensory Deficit check box
Transitional Syndrome - Crankshaft check box
Transitional Syndrome - Disc Degeneration check box
Transitional Syndrome - Junctional Kyphosis check box
Transitional Syndrome - Scoliosis check box
Other Complication check box
Revision Treatment
Decompression check box
Removal and Reinstrumentation check box
Removal of Instrumentation - Partial check box
Removal of Instrumentation - Total check box
Revision of Instrumentation check box
Extension of Fusion/Instrumentation check box
Elective Removal check box
Wound Revision check box
Other check box
Segmental Instrumentation INFO:
Right Left
Method: □ Transpedicular □ In/out/in C7 Method: □ Transpedicular □ In/out/in
Type: □ 1 Screw □ 2 Screws (□ Mono □ Uniplanar □ Poly ) □ n/a Type: □ 1 Screw □ 2 Screws (□ Mono □ Uniplanar □ Poly )
□ Hook (□ TP □ Supraliminar □ Claw □Pedicle ) □ Hook (□ TP □ Supraliminar □ Claw □Pedicle )
□ Wire □ Wire
Method: □ Transpedicular □ In/out/in T1 Method: □ Transpedicular □ In/out/in
Type: □ 1 Screw □ 2 Screws (□ Mono □ Uniplanar □ Poly ) □ n/a Type: □ 1 Screw □ 2 Screws (□ Mono □ Uniplanar □ Poly )
□ Hook (□ TP □ Supraliminar □ Claw □Pedicle ) □ Hook (□ TP □ Supraliminar □ Claw □Pedicle )
□ Wire □ Wire
Method: □ Transpedicular □ In/out/in T2 Method: □ Transpedicular □ In/out/in
Type: □ 1 Screw □ 2 Screws (□ Mono □ Uniplanar □ Poly ) □ n/a Type: □ 1 Screw □ 2 Screws (□ Mono □ Uniplanar □ Poly )
□ Hook (□ TP □ Supraliminar □ Claw □Pedicle ) □ Hook (□ TP □ Supraliminar □ Claw □Pedicle )
□ Wire □ Wire
Method: □ Transpedicular □ In/out/in T3 Method: □ Transpedicular □ In/out/in
Type: □ 1 Screw □ 2 Screws (□ Mono □ Uniplanar □ Poly ) □ n/a Type: □ 1 Screw □ 2 Screws (□ Mono □ Uniplanar □ Poly )
□ Hook (□ TP □ Supraliminar □ Claw □Pedicle ) □ Hook (□ TP □ Supraliminar □ Claw □Pedicle )
□ Wire □ Wire
Method: □ Transpedicular □ In/out/in T4 Method: □ Transpedicular □ In/out/in
Type: □ 1 Screw □ 2 Screws (□ Mono □ Uniplanar □ Poly ) □ n/a Type: □ 1 Screw □ 2 Screws (□ Mono □ Uniplanar □ Poly )
□ Hook (□ TP □ Supraliminar □ Claw □Pedicle ) □ Hook (□ TP □ Supraliminar □ Claw □Pedicle )
□ Wire □ Wire
Method: □ Transpedicular □ In/out/in T5 Method: □ Transpedicular □ In/out/in
Type: □ 1 Screw □ 2 Screws (□ Mono □ Uniplanar □ Poly ) □ n/a Type: □ 1 Screw □ 2 Screws (□ Mono □ Uniplanar □ Poly )
□ Hook (□ TP □ Supraliminar □ Claw □Pedicle ) □ Hook (□ TP □ Supraliminar □ Claw □Pedicle )
□ Wire □ Wire
Method: □ Transpedicular □ In/out/in T6 Method: □ Transpedicular □ In/out/in
Type: □ 1 Screw □ 2 Screws (□ Mono □ Uniplanar □ Poly ) □ n/a Type: □ 1 Screw □ 2 Screws (□ Mono □ Uniplanar □ Poly )
□ Hook (□ TP □ Supraliminar □ Claw □Pedicle ) □ Hook (□ TP □ Supraliminar □ Claw □Pedicle )
□ Wire □ Wire
Method: □ Transpedicular □ In/out/in T7 Method: □ Transpedicular □ In/out/in
Type: □ 1 Screw □ 2 Screws (□ Mono □ Uniplanar □ Poly ) □ n/a Type: □ 1 Screw □ 2 Screws (□ Mono □ Uniplanar □ Poly )
□ Hook (□ TP □ Supraliminar □ Claw □Pedicle ) □ Hook (□ TP □ Supraliminar □ Claw □Pedicle )
□ Wire □ Wire
Method: □ Transpedicular □ In/out/in T8 Method: □ Transpedicular □ In/out/in
Type: □ 1 Screw □ 2 Screws (□ Mono □ Uniplanar □ Poly ) □ n/a Type: □ 1 Screw □ 2 Screws (□ Mono □ Uniplanar □ Poly )
□ Hook (□ TP □ Supraliminar □ Claw □Pedicle ) □ Hook (□ TP □ Supraliminar □ Claw □Pedicle )
□ Wire □ Wire
Method: □ Transpedicular □ In/out/in T9 Method: □ Transpedicular □ In/out/in
Type: □ 1 Screw □ 2 Screws (□ Mono □ Uniplanar □ Poly ) □ n/a Type: □ 1 Screw □ 2 Screws (□ Mono □ Uniplanar □ Poly )
□ Hook (□ TP □ Supraliminar □ Claw □Pedicle ) □ Hook (□ TP □ Supraliminar □ Claw □Pedicle )
□ Wire □ Wire
Method: □ Transpedicular □ In/out/in T10 Method: □ Transpedicular □ In/out/in
Type: □ 1 Screw □ 2 Screws (□ Mono □ Uniplanar □ Poly ) □ n/a Type: □ 1 Screw □ 2 Screws (□ Mono □ Uniplanar □ Poly )
□ Hook (□ TP □ Supraliminar □ Claw □Pedicle ) □ Hook (□ TP □ Supraliminar □ Claw □Pedicle )
□ Wire □ Wire
Method: □ Transpedicular □ In/out/in T11 Method: □ Transpedicular □ In/out/in
Type: □ 1 Screw □ 2 Screws (□ Mono □ Uniplanar □ Poly ) □ n/a Type: □ 1 Screw □ 2 Screws (□ Mono □ Uniplanar □ Poly )
□ Hook (□ TP □ Supraliminar □ Claw □Pedicle ) □ Hook (□ TP □ Supraliminar □ Claw □Pedicle )
□ Wire □ Wire
Method: □ Transpedicular □ In/out/in T12 Method: □ Transpedicular □ In/out/in
Type: □ 1 Screw □ 2 Screws (□ Mono □ Uniplanar □ Poly ) □ n/a Type: □ 1 Screw □ 2 Screws (□ Mono □ Uniplanar □ Poly )
□ Hook (□ TP □ Supraliminar □ Claw □Pedicle ) □ Hook (□ TP □ Supraliminar □ Claw □Pedicle )
□ Wire □ Wire
Segmental Instrumentation INFO:
Right Left
Method: □ Transpedicular □ In/out/in L1 Method: □ Transpedicular □ In/out/in
Type: □ 1 Screw □ 2 Screws (□ Mono □ Uniplanar □ Poly ) □ n/a Type: □ 1 Screw □ 2 Screws (□ Mono □ Uniplanar □ Poly )
□ Hook (□ TP □ Supraliminar □ Claw □Pedicle ) □ Hook (□ TP □ Supraliminar □ Claw □Pedicle )
□ Wire □ Wire
Method: □ Transpedicular □ In/out/in L2 Method: □ Transpedicular □ In/out/in
Type: □ 1 Screw □ 2 Screws (□ Mono □ Uniplanar □ Poly ) □ n/a Type: □ 1 Screw □ 2 Screws (□ Mono □ Uniplanar □ Poly )
□ Hook (□ TP □ Supraliminar □ Claw □Pedicle ) □ Hook (□ TP □ Supraliminar □ Claw □Pedicle )
□ Wire □ Wire
Method: □ Transpedicular □ In/out/in L3 Method: □ Transpedicular □ In/out/in
Type: □ 1 Screw □ 2 Screws (□ Mono □ Uniplanar □ Poly ) □ n/a Type: □ 1 Screw □ 2 Screws (□ Mono □ Uniplanar □ Poly )
□ Hook (□ TP □ Supraliminar □ Claw □Pedicle ) □ Hook (□ TP □ Supraliminar □ Claw □Pedicle )
□ Wire □ Wire
Method: □ Transpedicular □ In/out/in L4 Method: □ Transpedicular □ In/out/in
Type: □ 1 Screw □ 2 Screws (□ Mono □ Uniplanar □ Poly ) □ n/a Type: □ 1 Screw □ 2 Screws (□ Mono □ Uniplanar □ Poly )
□ Hook (□ TP □ Supraliminar □ Claw □Pedicle ) □ Hook (□ TP □ Supraliminar □ Claw □Pedicle )
□ Wire □ Wire
Method: □ Transpedicular □ In/out/in L5 Method: □ Transpedicular □ In/out/in
Type: □ 1 Screw □ 2 Screws (□ Mono □ Uniplanar □ Poly ) □ n/a Type: □ 1 Screw □ 2 Screws (□ Mono □ Uniplanar □ Poly )
□ Hook (□ TP □ Supraliminar □ Claw □Pedicle ) □ Hook (□ TP □ Supraliminar □ Claw □Pedicle )
□ Wire □ Wire
