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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

				
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posted:7/24/2011
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