Cervical Spine Treatment Record (v. 2)
Complete for All Procedures
Patient’s study number ______________
Today’s date ___________________
Patient’s initials _______________________
Patient’s DOB: _________________
A. Date of surgery _____ /_____ /_____
B. Surgical time (skin to skin) _____________________minutes
C.
Estimated blood loss _________________________________cc.
D.
Transfused unit
E.
F.
Spinal Cord Monitoring
Type of immobilization
0
1
2
3
4
5
autologous blood
0
1
2
3
4
5
cell saver
0
1
2
3
4
5
banked blood
0
1
2
3
4
5
FP/platelets etc.
None
o1
Other
o
None
o1
SSEP
o2
MEP
specify type
Soft collar
o2
o3
EMG
o4
Wake up
o5
_______________________________
Rigid collar
o3
Halo
o4
CTO
o5
Recommended duration of immobilization: ______________ weeks
G.
Immediate complications (prior to hospital discharge) _____________________________________________________
__________________________________________________________________________________________________________
H.
Hospital length of stay _____________days
Complete for Anterior Procedures
A.
Decompression
a. Discectomy
C
2-3
o
C
3-4
o
C
4-5
o
C
5-6
o
C
6-7
o
C 7-T
1
o
b. Osteophyte removal
C
2-3
o
C
3-4
o
C
4-5
o
C
5-6
o
C
6-7
o
C 7-T
1
o
c. Corpectomy
d. PLL removal
B.
C.
2
o
4
o
1-2
o
3-4
o
o
None o
None o
N/A o
N/A o
o
Removed with burr o
Strut o
Autograft o
Iliac o
o1
Atlantis o5
None o
None o1
Other o4
o2
Equinox o6
Unicortical o
Harms’ Cage o2
C
C
3
o
2-3
o
C
o
C
C
C
C
5
o
C
4-5
o
C
C
4-5
o
C
C
6
o
5-6
o
C
6-7
o
o
Perforated o
Interbody o
Allograft o
Fibula o
C
6-7
o
C
C
7
o
T
1
o
o
C 7-T
Reconstruction
a.
Fusion
b.
Endplate preparation
c.
Graft
d.
Type of graft used
e.
Source of graft used
C
1-2
C
2-3
3-4
5-6
1
o
Local Cancellous
o
C 7-T
Instrumentation
a. Plates
b. Screws
c. Interbody device
None
Orion
ACLP/Synthes
Other
o7
o3
PEAK
o4
specify type: ___________________
o
NOVUS CT cage o3
Bicortical
Odontoid
o
specify type: ________________________
Cervical Spine Research Society Plate Study
JHU Spine Outcomes Research Center
Copyright (1998 , 2000) The Johns Hopkins University. All rights reserved. Limited permission to copy and use: You may copy and use this document to assess
outcomes in a research setting (not to be used for the generation of profits). You may not make modifications to this document or distribute this document
to others. The Johns Hopkins University reserves the right to withdraw this permission at any time