CDE Detailed Report

Disease: Spinal Cord Injury
Sub-Domain: Therapies
CRF: Surgical and Procedural Interventions

Displaying 1 - 50 of 54
CDE ID CDE Name Variable Name Definition Short Description Additional Notes (Question Text) Permissible Values Description Data Type Disease Specific Instructions Disease Specific Reference Population Classification (e.g., Core) Version Number Version Date CRF Name (CRF Module / Guideline) Sub Domain Name Domain Name Size Input Restrictions Min Value Max Value Measurement Type External Id Loinc External Id Snomed External Id caDSR External Id CDISC
C19087 Closure date & time ClosureDateTime Date and time the closure was performed by indicating the month, day, and year for the date and am, pm, or 24 hour clock for time Date and time the closure was performed by indicating the month, day, and year for the date and am, pm, or 24 hour clock for time Date and time of the intervention, completion or surgical closure Date or Date & Time

Record the date/time according to the ISO 8601, the International Standard for the representation of dates and times (http://www.iso.org/iso/home.html). The date/time should be recorded to the level of granularity known (e.g., year, year and month, complete date plus hours and minutes, etc.).

Dvorak MF, Itshayek E, Fehlings MG, Vaccaro AR, Wing PC, Biering-Sorensen F, Noonan VK. International Spinal Cord Injury: Spinal Interventions and Surgical Procedures Basic Data set. Spinal Cord. 2015 Feb;53(2):155-65. doi: 10.1038/sc.2014.182. Adult;Pediatric Supplemental 1.00 2014-05-27 14:36:51.0 Surgical and Procedural Interventions Therapies Treatment/Intervention Data

Free-Form Entry

C19119 Upper extremity surgery right osteotomy fingers/thumb performed indicator UPSurgRightOsteoFngrsPrfrmdInd The indicator for the surgical procedure of the restoration of the right fingers/thumb in an Osteotomy with or without rotation and/or Anthrodesis The indicator for the surgical procedure of the restoration of the right fingers/thumb in an Osteotomy with or without rotation and/or Anthrodesis Right fingers/thumb osteotomy with or without rotation and or Arthrodesis Yes Yes Alphanumeric

Osteotomy has been performed to position the extremity for function. In cases of internal rotation contracture of the shoulder and/or forearm supination contracture, a de-rotational osteotomy is performed to position the arm and forearm for function, respectively (Coulet et al 2010); these are usually done as a precursor to or in combination with tendon transfers. Fusion has been performed to stabilize a joint to improve function. The most common joints that are fused are in the thumb (House, et al 1992;
Waters 1985).

Biering-SØrensen F, Bryden A, Curt A, Friden J, Harvey LA, Mulcahey MJ, Popovic MR, Prochazka A, Sinnott KA, Snoek G. International spinal cord injury upper extremity basic data set. Spinal Cord. 2014 Sep;52(9):652-7. doi: 10.1038/sc.2014.87. Adult;Pediatric Supplemental 1.00 2014-05-28 13:24:05.0 Surgical and Procedural Interventions Therapies Treatment/Intervention Data

Single Pre-Defined Value Selected

C19098 Surgery scoliosis performed date SurgScoliosisPerformedDate Date of surgical treatment of scoliosis Date of surgical treatment of scoliosis If Yes: Date of surgery Date or Date & Time

Record the date/time according to the ISO 8601, the International Standard for the representation of dates and times (http://www.iso.org/iso/home.html). The date/time should be recorded to the level of granularity known (e.g., year, year and month, complete date plus hours and minutes, etc.).

No references available Adult;Pediatric Supplemental 1.00 2014-05-27 15:44:55.0 Surgical and Procedural Interventions Therapies Treatment/Intervention Data

Free-Form Entry

C05457 Hypoxic episode indicator HypxEpiInd Indicator of hypoxic episode. Hypoxic episode is defined as partial pressure of oxygen in the blood (paO2) < 8kPa (60mmHg) or oxygen saturation (SaO2) < 90% Indicator of hypoxic episode. Hypoxic episode is defined as partial pressure of oxygen in the blood (paO2) < 8kPa (60mmHg) or oxygen saturation (SaO2) < 90% Did participant/subject experience hypoxic episode [oxygen saturation (SpO2) less than 90% for > 5 min]? Yes;No;Unknown;Suspected Yes;No;Unknown;Suspected Alphanumeric

Choose one.

McHugh GS, Engel DC, Butcher I, et al. Prognostic value of secondary insults in traumatic brain injury: results from the IMPACT study. J Neurotrauma. Feb 2007;24(2):287-93. Silverstone P. Pulse oxymetry of at the road side: a study of pulse oxymetry in immediate care. BMJ. Mar 1989;298(6675):711-13. Stocchetti N, Furlan A, Volta F. Hypoxemia and arterial hypotension at the accident side in head injury. J Trauma. 1996;40:764-67. De Witt DS, Jenkins LW, Prough DS. Enhanced vulnerability to secondary ischemic insults after experimental traumatic brain injury. New Horizon. Aug 1995;3(3):376-383. Steyerberg EW, Mushkudiani N, Perel P, et al. Predicting outcome after traumatic brain injury: development and international validation of prognostic scores based on admission characteristics. PLoS Med. Aug 2008;5(8):e165. MRC CRASH Trial Collaborators. Predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of international patients. BMJ. Feb 2008;336(7641):425-429. Signorini DF, Andrews PJ, Jones PA, et al. Adding insult to injury: the prognostic value of early secondary insults for survival after traumatic brain injury. J Neurol Neurosurg Psychiatry. Jan 1999;66(1):26-31 Pediatric-specific reference(s): Adelson PD, Bratton SL, Carney, NA, Chesnut RM, du Coudray HE, Goldstein B, Kochanek PM, Miller HC, Partington MD, Selden NR, Warden CR, Wright DW. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents. Chapter 6. Threshold for treatment of intracranial hypertension. (2003a). Pediatr Crit Care Med 4:S25-S27. Adult;Pediatric Supplemental 3.00 2013-07-20 10:21:25.65 Surgical and Procedural Interventions Therapies Treatment/Intervention Data

Single Pre-Defined Value Selected

C19109 Upper extremity surgery right soft tissue other performed indicator UPSurgRightSTOtherPerformdInd The indicator for the surgical procedure of the restoration of something other on the right side in soft tissue reconstruction The indicator for the surgical procedure of the restoration of something other on the right side in soft tissue reconstruction Right other soft tissue reconstruction Yes Yes Alphanumeric

Other surgical soft tissue reconstruction to improve arm/hand function such as tenodesis procedures (Treanor 1992; Waters 1985).

Biering-S&Oslash;rensen F, Bryden A, Curt A, Friden J, Harvey LA, Mulcahey MJ, Popovic MR, Prochazka A, Sinnott KA, Snoek G. International spinal cord injury upper extremity basic data set. Spinal Cord. 2014 Sep;52(9):652-7. doi: 10.1038/sc.2014.87. Adult;Pediatric Supplemental 1.00 2014-05-28 10:52:01.0 Surgical and Procedural Interventions Therapies Treatment/Intervention Data

Single Pre-Defined Value Selected

C19088 Open reduction indicator OpenReductionInd Indicator for open reduction Indicator for open reduction Surgical procedure - open reduction No;Yes;Unknown No;Yes;Unknown Alphanumeric

Most commonly, open reduction is performed through a posterior surgical approach, but may, on occasion such as the anterior cervical discectomy which is followed by a reduction of a facet dislocation, be performed through an anterior approach.

Dvorak MF, Itshayek E, Fehlings MG, Vaccaro AR, Wing PC, Biering-Sorensen F, Noonan VK. International Spinal Cord Injury: Spinal Interventions and Surgical Procedures Basic Data set. Spinal Cord. 2015 Feb;53(2):155-65. doi: 10.1038/sc.2014.182. Adult;Pediatric Supplemental 1.00 2014-05-27 14:38:19.0 Surgical and Procedural Interventions Therapies Treatment/Intervention Data

Single Pre-Defined Value Selected

C19120 Upper extremity surgery left osteotomy fingers/thumb performed indicator UPSurgLeftOsteoFingrsPrfrmdInd The indicator for the surgical procedure of the restoration of the left fingers/thumb in an Osteotomy with or without rotation and/or Anthrodesis The indicator for the surgical procedure of the restoration of the left fingers/thumb in an Osteotomy with or without rotation and/or Anthrodesis Left fingers/thumb osteotomy with or without rotation and or Arthrodesis Yes Yes Alphanumeric

Osteotomy has been performed to position the extremity for function. In cases of internal rotation contracture of the shoulder and/or forearm supination contracture, a de-rotational osteotomy is performed to position the arm and forearm for function, respectively (Coulet et al 2010); these are usually done as a precursor to or in combination with tendon transfers. Fusion has been performed to stabilize a joint to improve function. The most common joints that are fused are in the thumb (House, et al 1992;
Waters 1985).

Biering-S&Oslash;rensen F, Bryden A, Curt A, Friden J, Harvey LA, Mulcahey MJ, Popovic MR, Prochazka A, Sinnott KA, Snoek G. International spinal cord injury upper extremity basic data set. Spinal Cord. 2014 Sep;52(9):652-7. doi: 10.1038/sc.2014.87. Adult;Pediatric Supplemental 1.00 2014-05-28 13:26:34.0 Surgical and Procedural Interventions Therapies Treatment/Intervention Data

Single Pre-Defined Value Selected

C19099 Upper extremity/hand reconstructive surgery indicator UpprExtrmtyHandRecnstveSurgInd Indicator for surgery on upper extremity/hand Indicator for surgery on upper extremity/hand Upper extremity/hand reconstructive surgery No;Yes;Unknown No;Yes;Unknown Alphanumeric

Choose one.
Yes: Includes any surgical procedures to the arms and/or hands to restore function, i.e. soft tissue reconstruction such as tendon transfers, lengthenings and releases; de-rotational osteotomies; implantation of a functional electrical stimulation system.
No: Excluded are: Surgical procedures to the arms or hands during initial management of the SCI for repair of concomitant brachial plexus injury or for treatment of concomitant upper extremity fractures, burns or other injuries.

Biering-S&Oslash;rensen F, Bryden A, Curt A, Friden J, Harvey LA, Mulcahey MJ, Popovic MR, Prochazka A, Sinnott KA, Snoek G. International spinal cord injury upper extremity basic data set. Spinal Cord. 2014 Sep;52(9):652-7. doi: 10.1038/sc.2014.87. Adult;Pediatric Supplemental 1.00 2014-05-28 08:48:57.0 Surgical and Procedural Interventions Therapies Treatment/Intervention Data

Single Pre-Defined Value Selected

C06005 Data collected date and time DataCollDateTime Date (and time, if applicable and known) the data were collected. This may be the date/time a particular examination or procedure was performed. Date (and time, if applicable and known) the data were collected. This may be the date/time a particular examination or procedure was performed. Date form completed Date or Date & Time

Record the date/time according to the ISO 8601, the International Standard for the representation of dates and times (http://www.iso.org/iso/home.html). The date/time should be recorded to the level of granularity known (e.g., year, year and month, complete date plus hours and minutes, etc.).

ISO 8601 - http://www.iso.org/iso/iso_catalogue.htm Adult;Pediatric Supplemental 3.00 2013-07-24 21:00:23.88 Surgical and Procedural Interventions Therapies Treatment/Intervention Data

Free-Form Entry

C19110 Upper extremity surgery left soft tissue other performed indicator UPSurgLeftSTOtherPerformedInd The indicator for the surgical procedure of the restoration of something other on the left side in soft tissue reconstruction The indicator for the surgical procedure of the restoration of something other on the left side in soft tissue reconstruction Left other soft tissue reconstruction Yes Yes Alphanumeric

Other surgical soft tissue reconstruction to improve arm/hand function such as tenodesis procedures (Treanor 1992; Waters 1985).

Biering-S&Oslash;rensen F, Bryden A, Curt A, Friden J, Harvey LA, Mulcahey MJ, Popovic MR, Prochazka A, Sinnott KA, Snoek G. International spinal cord injury upper extremity basic data set. Spinal Cord. 2014 Sep;52(9):652-7. doi: 10.1038/sc.2014.87. Adult;Pediatric Supplemental 1.00 2014-05-28 10:53:38.0 Surgical and Procedural Interventions Therapies Treatment/Intervention Data

Single Pre-Defined Value Selected

C19089 Neural element direct decompression indicator NeuralElmntDirectDecomprssnInd Indicator of direct decompression of neural elements Indicator of direct decompression of neural elements Direct decompression of neural elements No;Yes;Unknown No;Yes;Unknown Alphanumeric

This includes removing bone or disk that may be compressing one or more nerve roots. Direct surgical decompression does NOT include the indirect reduction that occurs with an open or closed reduction of neural elements, which may restore the spinal canal dimensions or restore the anatomy of neural foraminae. This may be performed through either an anterior or posterior surgical approach but requires direct visualization of the neural elements (dura). As such, it cannot be performed percutaneously.

Dvorak MF, Itshayek E, Fehlings MG, Vaccaro AR, Wing PC, Biering-Sorensen F, Noonan VK. International Spinal Cord Injury: Spinal Interventions and Surgical Procedures Basic Data set. Spinal Cord. 2015 Feb;53(2):155-65. doi: 10.1038/sc.2014.182. Adult;Pediatric Supplemental 1.00 2014-05-27 14:41:46.0 Surgical and Procedural Interventions Therapies Treatment/Intervention Data

Single Pre-Defined Value Selected

C19121 Upper extremity surgery right implantable FES performed indicator UPSurgRghtImpltbleFESPrfrmdInd The indicator for surgical procedure on the right side with an Implantable FES The indicator for surgical procedure on the right side with an Implantable FES Right implantable FES Yes Yes Alphanumeric

An FES system has been implanted in the upper extremity to restore stimulated arm and/or hand movement (Kilgore et al 2008; Peckham et al 2001; Mulcahey et al 1997).

Biering-S&Oslash;rensen F, Bryden A, Curt A, Friden J, Harvey LA, Mulcahey MJ, Popovic MR, Prochazka A, Sinnott KA, Snoek G. International spinal cord injury upper extremity basic data set. Spinal Cord. 2014 Sep;52(9):652-7. doi: 10.1038/sc.2014.87. Adult;Pediatric Supplemental 1.00 2014-05-28 13:29:13.0 Surgical and Procedural Interventions Therapies Treatment/Intervention Data

Single Pre-Defined Value Selected

C19100 Stabilization and fusion segment level StabilizationFusionSegmentLvl Level of stabilization and fusion segment in surgical procedure Level of stabilization and fusion segment in surgical procedure Stabilization & Fusion Segment Level Cervical;Lumbar;Sacral;Thoracic;Unknown Cervical;Unknown Level;Unknown Lumbar;Unknown Sacral;Unknown Thoracic Cervical;Lumbar;Sacral;Thoracic;Unknown Cervical;Unknown Level;Unknown Lumbar;Unknown Sacral;Unknown Thoracic Alphanumeric

This variable is used to document each of the level(s) of spinal fusion or instrumentation. For a single fused motion segment injury, such as a C5-6 anterior fusion and plating, both the cephalic and caudal of the two adjacent vertebrae are identified and separated by a dash (-). The prefix "v" references the fact that we are referring to a spinal column level (vertebral level) and helps distinguish the spinal column injury level from the neurological level. The cervical region is represented by vC00-vC07. The occiput is considered to be the most cephalic vertebral level and is designated by vC00. The thoracic region is represented by vT01-vT12.

Dvorak MF, Itshayek E, Fehlings MG, Vaccaro AR, Wing PC, Biering-Sorensen F, Noonan VK. International Spinal Cord Injury: Spinal Interventions and Surgical Procedures Basic Data set. Spinal Cord. 2015 Feb;53(2):155-65. doi: 10.1038/sc.2014.182. Adult;Pediatric Supplemental 1.00 2014-05-28 10:30:20.0 Surgical and Procedural Interventions Therapies Treatment/Intervention Data

Single Pre-Defined Value Selected

C06409 Skin thermoregulation pressure ulcer past year indicator SkiThermPressrUlcPstYrInd Indicator of the presence of a pressure ulcer during the last 12 months Indicator of the presence of a pressure ulcer during the last 12 months Has any other pressure ulcer been surgically treated during the last 12 months Yes;No;Unknown Yes;No;Unknown Alphanumeric International spinal cord injury skin and thermoregulation function basic data set. Spinal Cord. 2012 Jul;50(7):512-6. doi: 10.1038/sc.2011.167. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Surgical and Procedural Interventions Therapies Treatment/Intervention Data

Single Pre-Defined Value Selected

C19111 Upper extremity surgery right osteotomy humerus performed indicator UPSurgRightOsteoHumrsPerfmdInd The indicator for the surgical procedure of the restoration of the right humerus in an Osteotomy with or without rotation and/or Anthrodesis The indicator for the surgical procedure of the restoration of the right humerus in an Osteotomy with or without rotation and/or Anthrodesis Right humerus osteotomy with or without rotation and or Arthrodesis Yes Yes Alphanumeric

Osteotomy has been performed to position the extremity for function. In cases of internal rotation contracture of the shoulder and/or forearm supination contracture, a de-rotational osteotomy is performed to position the arm and forearm for function, respectively (Coulet et al 2010); these are usually done as a precursor to or in combination with tendon transfers. Fusion has been performed to stabilize a joint to improve function. The most common joints that are fused are in the thumb (House, et al 1992;
Waters 1985).

Biering-S&Oslash;rensen F, Bryden A, Curt A, Friden J, Harvey LA, Mulcahey MJ, Popovic MR, Prochazka A, Sinnott KA, Snoek G. International spinal cord injury upper extremity basic data set. Spinal Cord. 2014 Sep;52(9):652-7. doi: 10.1038/sc.2014.87. Adult;Pediatric Supplemental 1.00 2014-05-28 10:54:46.0 Surgical and Procedural Interventions Therapies Treatment/Intervention Data

Single Pre-Defined Value Selected

C19090 Stabilization and fusion segment number StablizationFusionSegmentNum The number of the stabilization and fusion segment in the surgical procedure The number of the stabilization and fusion segment in the surgical procedure Stabilization & Fusion Segment Number C0-C07;L1-L5;S1-S5;T1-T12 C0-C07;L1-L5;S1-S5;T1-T12 Alphanumeric

When a surgical procedure is performed it may or may not include the insertion of instrumentation to stabilize vertebral levels and may or may not involve a formal fusion procedure with or without insertion of local or distantly harvested structural or non-structural bone graft or substitutes. This variable encompasses any and all of the above in one single data point. This variable orders and assigns numbers to each region of the spine which has undergone a spinal instrumentation or fusion procedure beginning with the most cephalic region that has been instrumented and fused and progressing to the most caudal fused region regardless of which level of spinal column injury is the most severe or significant injury or which injury may or may not contribute to the patient's neurological
injury. If a patient has had a vC5-6 anterior fusion and also a vT12 to vL2 posterior instrumentation, then each of these non-contiguous instrumented and fused regions would receive a numerical score beginning with 1 for the vC5-6 fusion and 2 for the vT12-vL2 instrumentation.

Dvorak MF, Itshayek E, Fehlings MG, Vaccaro AR, Wing PC, Biering-Sorensen F, Noonan VK. International Spinal Cord Injury: Spinal Interventions and Surgical Procedures Basic Data set. Spinal Cord. 2015 Feb;53(2):155-65. doi: 10.1038/sc.2014.182. Adult;Pediatric Supplemental 1.00 2014-05-27 14:50:01.0 Surgical and Procedural Interventions Therapies Treatment/Intervention Data

Single Pre-Defined Value Selected

C19122 Upper extremity surgery left implantable FES performed indicator UPSurgLeftImpltbleFESPrfrmdInd The indicator for surgical procedure on the left side with an Implantable FES The indicator for surgical procedure on the left side with an Implantable FES Left implantable FES Yes Yes Alphanumeric

An FES system has been implanted in the upper extremity to restore stimulated arm and/or hand movement (Kilgore et al 2008; Peckham et al 2001; Mulcahey et al 1997).

Biering-S&Oslash;rensen F, Bryden A, Curt A, Friden J, Harvey LA, Mulcahey MJ, Popovic MR, Prochazka A, Sinnott KA, Snoek G. International spinal cord injury upper extremity basic data set. Spinal Cord. 2014 Sep;52(9):652-7. doi: 10.1038/sc.2014.87. Adult;Pediatric Supplemental 1.00 2014-05-28 13:32:07.0 Surgical and Procedural Interventions Therapies Treatment/Intervention Data

Single Pre-Defined Value Selected

C19101 Upper extremity surgery right soft tissue reconstruction tendon elbow performed indicator UPSurgRghtSTtendElbowPerfmdInd The indicator for the surgical procedure of the right tendon for elbow extension in soft tissue reconstruction The indicator for the surgical procedure of the right tendon for elbow extension in soft tissue reconstruction Right tendon for elbow extension soft tissue reconstruction Yes Yes Alphanumeric

Tendon transfer for elbow extension has been performed to restore/augment active elbow extension. The most common procedures to restore elbow extension in SCI are the deltoid-to-triceps transfer and biceps-to-triceps transfer (Kozin 2010; Leclerq 2008; Mulcahey 2003)

Biering-S&Oslash;rensen F, Bryden A, Curt A, Friden J, Harvey LA, Mulcahey MJ, Popovic MR, Prochazka A, Sinnott KA, Snoek G. International spinal cord injury upper extremity basic data set. Spinal Cord. 2014 Sep;52(9):652-7. doi: 10.1038/sc.2014.87. Adult;Pediatric Supplemental 1.00 2014-05-28 10:32:56.0 Surgical and Procedural Interventions Therapies Treatment/Intervention Data

Single Pre-Defined Value Selected

C18153 Data unknown text DataUnknwnTxt The free-text field to Mark an "X" in to record if data are unknown or not available. The free-text field to Mark an "X" in to record if data are unknown or not available. Or data. Time Performed Alphanumeric

Check box for Unknown

No references available Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Surgical and Procedural Interventions Therapies Treatment/Intervention Data 20

Free-Form Entry

C19112 Upper extremity surgery left osteotomy humerus performed indicator UPSurgLeftOsteoHumrusPerfmdInd The indicator for the surgical procedure of the restoration of the left humerus in an Osteotomy with or without rotation and/or Anthrodesis The indicator for the surgical procedure of the restoration of the left humerus in an Osteotomy with or without rotation and/or Anthrodesis Left humerus osteotomy with or without rotation and or Arthrodesis Yes Yes Alphanumeric

Osteotomy has been performed to position the extremity for function. In cases of internal rotation contracture of the shoulder and/or forearm supination contracture, a de-rotational osteotomy is performed to position the arm and forearm for function, respectively (Coulet et al 2010); these are usually done as a precursor to or in combination with tendon transfers. Fusion has been performed to stabilize a joint to improve function. The most common joints that are fused are in the thumb (House, et al 1992;
Waters 1985).

Biering-S&Oslash;rensen F, Bryden A, Curt A, Friden J, Harvey LA, Mulcahey MJ, Popovic MR, Prochazka A, Sinnott KA, Snoek G. International spinal cord injury upper extremity basic data set. Spinal Cord. 2014 Sep;52(9):652-7. doi: 10.1038/sc.2014.87. Adult;Pediatric Supplemental 1.00 2014-05-28 10:57:52.0 Surgical and Procedural Interventions Therapies Treatment/Intervention Data

Single Pre-Defined Value Selected

C19091 Urinary tract surgical procedure indicator UrinaryTractSurgProcedInd Indicator for surgical procedure on the urinary tract Indicator for surgical procedure on the urinary tract Surgical Procedures on the Urinary Tract No;Yes;Unknown No;Yes;Unknown Alphanumeric

Choose one.
Bladder stone or upper urinary tract stone removal includes any type of removal, including via endoscopy, extracorporal shock wave lithotripsy (ESWL), or open lithotomy.
The ileoureterostomy is corresponding to the formely ileal loop or ureteroileocutaneostomy (Bricker conduit). The continent catheterizable valves, include Monteand Mitrofanoff procedures. For other possible surgical procedures it is recommended to write them in a textfield, from which it will be possible to retrieve more detailed data when necessary. If there is more than one "other" surgical procedure, this field may be duplicated or triplicated, with the latest date given when the particular procedure has been performed. If the information has been documented once and noadditional surgical procedures on the urinary tract have been performed it is not necessary fill in this item again, to avoid redundant data.

Biering-S&Oslash;rensen F, Craggs M, Kennelly M, Schick E, Wyndaele JJ. International Lower Urinary Tract Function Basic Spinal Cord Injury Data Set. Spinal Cord 2008 May;46(5):325-30. Adult;Pediatric Supplemental 1.00 2014-05-27 15:00:45.0 Surgical and Procedural Interventions Therapies Treatment/Intervention Data

Single Pre-Defined Value Selected

C19123 Upper extremity surgery right other performed indicator UPSurgRightOtherPerformedInd The indicator for other surgical procedure on the right side The indicator for other surgical procedure on the right side Right other Yes Yes Alphanumeric

May include nerve transfer or other surgeries meant to restore arm and/or hand function.

Biering-S&Oslash;rensen F, Bryden A, Curt A, Friden J, Harvey LA, Mulcahey MJ, Popovic MR, Prochazka A, Sinnott KA, Snoek G. International spinal cord injury upper extremity basic data set. Spinal Cord. 2014 Sep;52(9):652-7. doi: 10.1038/sc.2014.87. Adult;Pediatric Supplemental 1.00 2014-05-28 13:33:31.0 Surgical and Procedural Interventions Therapies Treatment/Intervention Data

Single Pre-Defined Value Selected

C19102 Upper extremity surgery left soft tissue reconstruction tendon elbow performed indicator UPSurgLeftSTTendElbowPerfmdInd The indicator for the surgical procedure of the left tendon for elbow extension in soft tissue reconstruction The indicator for the surgical procedure of the left tendon for elbow extension in soft tissue reconstruction Left tendon transfer for elbow extension soft tissue reconstruction Yes Yes Alphanumeric

Tendon transfer for elbow extension has been performed to restore/augment active elbow extension. The most common procedures to restore elbow extension in SCI are the deltoid-to-triceps transfer and biceps-to-triceps transfer (Kozin 2010; Leclerq 2008; Mulcahey 2003)

Biering-S&Oslash;rensen F, Bryden A, Curt A, Friden J, Harvey LA, Mulcahey MJ, Popovic MR, Prochazka A, Sinnott KA, Snoek G. International spinal cord injury upper extremity basic data set. Spinal Cord. 2014 Sep;52(9):652-7. doi: 10.1038/sc.2014.87. Adult;Pediatric Supplemental 1.00 2014-05-28 10:41:55.0 Surgical and Procedural Interventions Therapies Treatment/Intervention Data

Single Pre-Defined Value Selected

C19080 Spinal intervention surgical procedure performance nonparticipating facility indicator SpnIntrvSrgProcPrfNoprtFcltInd Indicates performance of a spinal intervention or a surgical procedure at a nonparticipating facility Indicates performance of a spinal intervention or a surgical procedure at a nonparticipating facility Was a spinal intervention or a surgical procedure performed at a nonparticipating facility? No;Unknown;Yes Using available documentation, able to reliably determine intervention was NOT performed;Documentation not available or not complete, therefore unable to reliably determine if intervention was performed;Please complete the questions below Alphanumeric

Choose one.

No references available Adult;Pediatric Supplemental 1.00 2014-05-27 10:59:08.0 Surgical and Procedural Interventions Therapies Treatment/Intervention Data

Single Pre-Defined Value Selected

C19113 Upper extremity surgery right osteotomy radius performed indicator UPSurgRghtOsteoRadiusPerfmdInd The indicator for the surgical procedure of the restoration of the right radius in an Osteotomy with or without rotation and/or Anthrodesis The indicator for the surgical procedure of the restoration of the right radius in an Osteotomy with or without rotation and/or Anthrodesis Right radius osteotomy with or without rotation and or Arthrodesis Yes Yes Alphanumeric

Osteotomy has been performed to position the extremity for function. In cases of internal rotation contracture of the shoulder and/or forearm supination contracture, a de-rotational osteotomy is performed to position the arm and forearm for function, respectively (Coulet et al 2010); these are usually done as a precursor to or in combination with tendon transfers. Fusion has been performed to stabilize a joint to improve function. The most common joints that are fused are in the thumb (House, et al 1992;
Waters 1985).

Biering-S&Oslash;rensen F, Bryden A, Curt A, Friden J, Harvey LA, Mulcahey MJ, Popovic MR, Prochazka A, Sinnott KA, Snoek G. International spinal cord injury upper extremity basic data set. Spinal Cord. 2014 Sep;52(9):652-7. doi: 10.1038/sc.2014.87. Adult;Pediatric Supplemental 1.00 2014-05-28 10:59:33.0 Surgical and Procedural Interventions Therapies Treatment/Intervention Data

Single Pre-Defined Value Selected

C19092 Urinary tract surgical procedure other text UrinaryTractSurgProcedOTH The free text field related to "Urinary tract surgical procedures indicator" specifying the other text. The type of procedure. The free text field related to "Urinary tract surgical procedures indicator" specifying the other text. The type of procedure. Other, specify Alphanumeric Biering-S&Oslash;rensen F, Craggs M, Kennelly M, Schick E, Wyndaele JJ. International Lower Urinary Tract Function Basic Spinal Cord Injury Data Set. Spinal Cord 2008 May;46(5):325-30. Adult;Pediatric Supplemental 1.00 2014-05-27 15:15:49.0 Surgical and Procedural Interventions Therapies Treatment/Intervention Data 4000

Free-Form Entry

C19124 Upper extremity surgery left other performed indicator UPSurgLeftOtherPerformedInd The indicator for other surgical procedure on the left side The indicator for other surgical procedure on the left side Left other Yes Yes Alphanumeric

May include nerve transfer or other surgeries meant to restore arm and/or hand function.

Biering-S&Oslash;rensen F, Bryden A, Curt A, Friden J, Harvey LA, Mulcahey MJ, Popovic MR, Prochazka A, Sinnott KA, Snoek G. International spinal cord injury upper extremity basic data set. Spinal Cord. 2014 Sep;52(9):652-7. doi: 10.1038/sc.2014.87. Adult;Pediatric Supplemental 1.00 2014-05-28 13:35:10.0 Surgical and Procedural Interventions Therapies Treatment/Intervention Data

Single Pre-Defined Value Selected

C19103 Upper extremity surgery right soft tissue reconstruction tendon wrist performed indicator UPSurgRghtSTTendWristPerfmdInd The indicator for the surgical procedure of the right tendon for wrist extension in soft tissue reconstruction The indicator for the surgical procedure of the right tendon for wrist extension in soft tissue reconstruction Right tendon transfer for wrist extension soft tissue reconstruction Yes Yes Alphanumeric

Tendon transfer for wrist extension has been performed to restore/augment active wrist extension. The primary procedure for restoration of wrist extension in SCI is transfer of the brachioradialis to radial wrist extensors (FridÉn 2005)

Biering-S&Oslash;rensen F, Bryden A, Curt A, Friden J, Harvey LA, Mulcahey MJ, Popovic MR, Prochazka A, Sinnott KA, Snoek G. International spinal cord injury upper extremity basic data set. Spinal Cord. 2014 Sep;52(9):652-7. doi: 10.1038/sc.2014.87. Adult;Pediatric Supplemental 1.00 2014-05-28 10:43:49.0 Surgical and Procedural Interventions Therapies Treatment/Intervention Data

Single Pre-Defined Value Selected

C19081 Spinal intervention or surgical procedure performance study facility indicator SpnIntrvSrgProcPrfStdyFcltyInd Indicator for performance of a spinal intervention or a surgical procedure at the study facility Indicator for performance of a spinal intervention or a surgical procedure at the study facility Was a spinal intervention or surgical procedure performed at the study facility? No;Unknown;Yes No;Unknown;Please complete the questions below Alphanumeric

Choose one.

No references available Adult;Pediatric Supplemental 1.00 2014-05-27 11:14:21.0 Surgical and Procedural Interventions Therapies Treatment/Intervention Data

Single Pre-Defined Value Selected

C19114 Upper extremity surgery left osteotomy radius performed indicator UPSurgLeftOsteoRadiusPerfmdInd The indicator for the surgical procedure of the restoration of the left radius in an Osteotomy with or without rotation and/or Anthrodesis The indicator for the surgical procedure of the restoration of the left radius in an Osteotomy with or without rotation and/or Anthrodesis Left radius osteotomy with or without rotation and or Arthrodesis Yes Yes Alphanumeric

Osteotomy has been performed to position the extremity for function. In cases of internal rotation contracture of the shoulder and/or forearm supination contracture, a de-rotational osteotomy is performed to position the arm and forearm for function, respectively (Coulet et al 2010); these are usually done as a precursor to or in combination with tendon transfers. Fusion has been performed to stabilize a joint to improve function. The most common joints that are fused are in the thumb (House, et al 1992;
Waters 1985).

Biering-S&Oslash;rensen F, Bryden A, Curt A, Friden J, Harvey LA, Mulcahey MJ, Popovic MR, Prochazka A, Sinnott KA, Snoek G. International spinal cord injury upper extremity basic data set. Spinal Cord. 2014 Sep;52(9):652-7. doi: 10.1038/sc.2014.87. Adult;Pediatric Supplemental 1.00 2014-05-28 11:01:19.0 Surgical and Procedural Interventions Therapies Treatment/Intervention Data

Single Pre-Defined Value Selected

C19093 Gastrointestinal tract surgical procedure indicator GastroTractSurgProcedInd Indicator for surgical procedure on the gastrointestinal tract Indicator for surgical procedure on the gastrointestinal tract Surgical procedures on the gastrointestinal tract Appendicectomy, date performed YYYYMMDD;Cholecysectomy, date performed YYYYMMDD;Colostomy, date last performed YYYYMMDD;Ileostomy, date last performed YYYYMMDD;No;Other, specify:…date performed, YYYYMMDD;Unknown Appendicectomy, date performed YYYYMMDD;Cholecysectomy, date performed YYYYMMDD;Colostomy, date last performed YYYYMMDD;Ileostomy, date last performed YYYYMMDD;No;Other, specify:…date performed, YYYYMMDD;Unknown Alphanumeric

Choose one.

Krogh K, Perkash I, Stiens SA, Biering-S&Oslash;rensen F. International bowel function basic spinal cord injury data set. Spinal Cord. 2009 Mar;47(3):230-4. doi: 10.1038/sc.2008.102. Adult;Pediatric Supplemental 1.00 2014-05-27 15:25:02.0 Surgical and Procedural Interventions Therapies Treatment/Intervention Data

Single Pre-Defined Value Selected

C21668 ICD-10-CM code SurgTherapuProcICD10CMCode Code from the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) for the selected surgical procedure Code from the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) for the selected surgical procedure Surgical or therapeutic procedure ICD-10-CM code MB;C;T;S;G;Other, specify Muscle biopsy;Contracture Release;Tracheostomy;Scoliosis;Gastrostomy;Other specify Alphanumeric

Choose all that apply. Recommend collection during acute hospital care. Document information on a continuing basis and check/update on discharge/death from review of medical charts. Add date stamp for when assessed. In previous trials and studies, information on surgical procedures has typically been documented in free text format, thus often precluding any meaningful analysis. We therefore propose the use of ICD-10 coding.

International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM): http://www.cdc.gov/nchs/icd/icd10cm.htm#icd2016 Adult;Pediatric Supplemental 1.00 2013-08-28 16:08:00.453 Surgical and Procedural Interventions Therapies Treatment/Intervention Data

Multiple Pre-Defined Values Selected

C19104 Upper extremity surgery left soft tissue tendon wrist performed indicator UPSurgLeftSTTendWristPerfmdInd The indicator for the surgical procedure of the left tendon for wrist extension in soft tissue reconstruction The indicator for the surgical procedure of the left tendon for wrist extension in soft tissue reconstruction Left tendon transfer for wrist extension soft tissue reconstruction Yes Yes Alphanumeric

Tendon transfer for wrist extension has been performed to restore/augment active wrist extension. The primary procedure for restoration of wrist extension in SCI is transfer of the brachioradialis to radial wrist extensors (FridÉn 2005)

Biering-S&Oslash;rensen F, Bryden A, Curt A, Friden J, Harvey LA, Mulcahey MJ, Popovic MR, Prochazka A, Sinnott KA, Snoek G. International spinal cord injury upper extremity basic data set. Spinal Cord. 2014 Sep;52(9):652-7. doi: 10.1038/sc.2014.87. Adult;Pediatric Supplemental 1.00 2014-05-28 10:45:15.0 Surgical and Procedural Interventions Therapies Treatment/Intervention Data

Single Pre-Defined Value Selected

C19082 Interventionprocedure date IntervProcedDate Date (and time if applicable and known) intervention/procedure was performed Date (and time if applicable and known) intervention/procedure was performed Intervention/procedure date Date or Date & Time

Record the date/time according to the ISO 8601, the International Standard for the representation of dates and times (http://www.iso.org/iso/home.html). The date/time should be recorded to the level of granularity known (e.g., year, year and month, complete date plus hours and minutes, etc.).

Dvorak MF, Itshayek E, Fehlings MG, Vaccaro AR, Wing PC, Biering-Sorensen F, Noonan VK. International Spinal Cord Injury: Spinal Interventions and Surgical Procedures Basic Data set. Spinal Cord. 2015 Feb;53(2):155-65. doi: 10.1038/sc.2014.182. Adult;Pediatric Supplemental 1.00 2014-05-27 11:46:42.0 Surgical and Procedural Interventions Therapies Treatment/Intervention Data

Free-Form Entry

C19115 Upper extremity surgery right osteotomy ulnar performed indicator UPSurgRightOsteoUlnarPerfmdInd The indicator for the surgical procedure of the restoration of the right ulnar in an Osteotomy with or without rotation and/or Anthrodesis The indicator for the surgical procedure of the restoration of the right ulnar in an Osteotomy with or without rotation and/or Anthrodesis Right ulnar osteotomy with or without rotation and or Arthrodesis Yes Yes Alphanumeric

Osteotomy has been performed to position the extremity for function. In cases of internal rotation contracture of the shoulder and/or forearm supination contracture, a de-rotational osteotomy is performed to position the arm and forearm for function, respectively (Coulet et al 2010); these are usually done as a precursor to or in combination with tendon transfers. Fusion has been performed to stabilize a joint to improve function. The most common joints that are fused are in the thumb (House, et al 1992;
Waters 1985).

Biering-S&Oslash;rensen F, Bryden A, Curt A, Friden J, Harvey LA, Mulcahey MJ, Popovic MR, Prochazka A, Sinnott KA, Snoek G. International spinal cord injury upper extremity basic data set. Spinal Cord. 2014 Sep;52(9):652-7. doi: 10.1038/sc.2014.87. Adult;Pediatric Supplemental 1.00 2014-05-28 11:02:16.0 Surgical and Procedural Interventions Therapies Treatment/Intervention Data

Single Pre-Defined Value Selected

C19094 Gastrointestinal tract surgical procedure other text GastroTractSurgProcedOTH The free text field related to "Gastrointestinal tract surgical procedure indicator" specifying other text. Type of procedure. The free text field related to "Gastrointestinal tract surgical procedure indicator" specifying other text. Type of procedure. Other, specify Alphanumeric Krogh K, Perkash I, Stiens SA, Biering-S&Oslash;rensen F. International bowel function basic spinal cord injury data set. Spinal Cord. 2009 Mar;47(3):230-4. doi: 10.1038/sc.2008.102. Adult;Pediatric Supplemental 1.00 2014-05-27 15:28:08.0 Surgical and Procedural Interventions Therapies Treatment/Intervention Data 4000

Free-Form Entry

C21669 Surgical therapeutic procedure ICD-10-CM other text SurgTherapuProcICD10CMOthTxt The free-text field related to 'Surgical or therapeutic procedure ICD-10-CM code' specifying other text. Code from the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) for the selected surgical procedure The free-text field related to 'Surgical or therapeutic procedure ICD-10-CM code' specifying other text. Code from the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) for the selected surgical procedure Surgical or therapeutic procedure ICD-9-CM code other, specify Alphanumeric

Choose all that apply. Recommend collection during acute hospital care. Document information on a continuing basis and check/update on discharge/death from review of medical charts. Add date stamp for when assessed. In previous trials and studies, information on surgical procedures has typically been documented in free text format, thus often precluding any meaningful analysis. We therefore propose the use of ICD-9 coding.

International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) for permissible values: http://www.cdc.gov/nchs/icd/icd9cm.htm Adult;Pediatric Supplemental 1.00 2014-05-27 13:34:46.0 Surgical and Procedural Interventions Therapies Treatment/Intervention Data 4000

Free-Form Entry

C05104 Inpatient outpatient status InpatOutpatStatus Status describing whether the participant/subject was admitted to the hospital and stayed overnight Status describing whether the participant/subject was admitted to the hospital and stayed overnight Inpatient or Outpatient Inpatient;Outpatient;Home health Inpatient;Outpatient;Home health Alphanumeric

Choose one.

No references available Adult;Pediatric Supplemental 3.00 2013-07-20 10:21:25.65 Surgical and Procedural Interventions Therapies Treatment/Intervention Data

Single Pre-Defined Value Selected

C19105 Upper extremity surgery right soft tissue restoration pinch performed indicator UPSurgRghtSTRestPnchPerfmdInd The indicator for the surgical procedure of the restoration of right pinch and/or grasp in soft tissue reconstruction The indicator for the surgical procedure of the restoration of right pinch and/or grasp in soft tissue reconstruction Right restoration of pinch and or grasp soft tissue reconstruction Yes Yes Alphanumeric

Tendon transfer for pinch and\or grasp has been performed to restore/augment active hand function. The procedures used to restore hand function vary (Keith 2012; FridÉn 2011; Zancolli 2002; House 1985; Waters 1985).

Biering-S&Oslash;rensen F, Bryden A, Curt A, Friden J, Harvey LA, Mulcahey MJ, Popovic MR, Prochazka A, Sinnott KA, Snoek G. International spinal cord injury upper extremity basic data set. Spinal Cord. 2014 Sep;52(9):652-7. doi: 10.1038/sc.2014.87. Adult;Pediatric Supplemental 1.00 2014-05-28 10:45:59.0 Surgical and Procedural Interventions Therapies Treatment/Intervention Data

Single Pre-Defined Value Selected

C19083 Non-surgical bed rest external immobilization indicator NonSurgBedRestExterImmobilInd The indicator related to non-surgical bed rest and external immobilization The indicator related to non-surgical bed rest and external immobilization Non-Surgical bed rest and external immobilization Both enforced bed-rest and external immobilizing device;Enforced bed-rest;External immobilizing device;No;Unknown Both enforced bed-rest and external immobilizing device;Enforced bed-rest;External immobilizing device;No;Unknown Alphanumeric

Choose one.
This includes prescriptive bed-rest which usually involves more than 10 days of enforced bed-rest and does not include the normal recumbency which follows injury or surgery as a patient is slowly mobilized. The application of external spinal immobilization devices such as braces, casts, halo thoracic vests, etc. is also a specific spine intervention.

Dvorak MF, Itshayek E, Fehlings MG, Vaccaro AR, Wing PC, Biering-Sorensen F, Noonan VK. International Spinal Cord Injury: Spinal Interventions and Surgical Procedures Basic Data set. Spinal Cord. 2015 Feb;53(2):155-65. doi: 10.1038/sc.2014.182. Adult;Pediatric Supplemental 1.00 2014-05-27 12:21:35.0 Surgical and Procedural Interventions Therapies Treatment/Intervention Data

Single Pre-Defined Value Selected

C19116 Upper extremity surgery left osteotomy ulnar performed indicator UPSurgLeftOsteoUlnarPerfmdInd The indicator for the surgical procedure of the restoration of the left ulnar in an Osteotomy with or without rotation and/or Anthrodesis The indicator for the surgical procedure of the restoration of the left ulnar in an Osteotomy with or without rotation and/or Anthrodesis Left ulnar osteotomy with or without rotation and or Arthrodesis Yes Yes Alphanumeric

Osteotomy has been performed to position the extremity for function. In cases of internal rotation contracture of the shoulder and/or forearm supination contracture, a de-rotational osteotomy is performed to position the arm and forearm for function, respectively (Coulet et al 2010); these are usually done as a precursor to or in combination with tendon transfers. Fusion has been performed to stabilize a joint to improve function. The most common joints that are fused are in the thumb (House, et al 1992;
Waters 1985).

Biering-S&Oslash;rensen F, Bryden A, Curt A, Friden J, Harvey LA, Mulcahey MJ, Popovic MR, Prochazka A, Sinnott KA, Snoek G. International spinal cord injury upper extremity basic data set. Spinal Cord. 2014 Sep;52(9):652-7. doi: 10.1038/sc.2014.87. Adult;Pediatric Supplemental 1.00 2014-05-28 13:18:07.0 Surgical and Procedural Interventions Therapies Treatment/Intervention Data

Single Pre-Defined Value Selected

C19095 Pressure ulcer surgical treatment indicator PressrUlcSurgTreatmentInd Indicator for surgical treatment of pressure ulcer Indicator for surgical treatment of pressure ulcer Has the present pressure ulcer been surgically treated? No;Yes;Unknown No;Yes;Unknown Alphanumeric

Choose one.

Karlsson AK, Krassioukov A, Alexander MS, Donovan W, Biering-S&Oslash;rensen F. International spinal cord injury skin and thermoregulation function basic data set. Spinal Cord. 2012 Jul;50(7):512-6. doi: 10.1038/sc.2011.167. Adult;Pediatric Supplemental 1.00 2014-05-27 15:34:38.0 Surgical and Procedural Interventions Therapies Treatment/Intervention Data

Single Pre-Defined Value Selected

C05105 Surgical or therapeutic procedure end date and time SurgTherapuProcEndDateTime Date on which the surgical or therapeutic procedure ended Date on which the surgical or therapeutic procedure ended End Date Date or Date & Time

Record the date/time according to the ISO 8601, the International Standard for the representation of dates and times (http://www.iso.org/iso/home.html). The date/time should be recorded to the level of granularity known (e.g., year, year and month, complete date plus hours and minutes, etc.).

No references available Adult;Pediatric Supplemental 3.00 2013-07-24 21:00:23.88 Surgical and Procedural Interventions Therapies Treatment/Intervention Data

Free-Form Entry

C19106 Upper extremity surgery left soft tissue restoration pinch performed indicator UPSurgLeftSTRestPinchPerfmdInd The indicator for the surgical procedure of the restoration of left pinch and/or grasp in soft tissue reconstruction The indicator for the surgical procedure of the restoration of left pinch and/or grasp in soft tissue reconstruction Left restoration of pinch and or grasp soft tissue reconstruction Yes Yes Alphanumeric

Tendon transfer for pinch and\or grasp has been performed to restore/augment active hand function. The procedures used to restore hand function vary (Keith 2012; FridÉn 2011; Zancolli 2002; House 1985; Waters 1985).

Biering-S&Oslash;rensen F, Bryden A, Curt A, Friden J, Harvey LA, Mulcahey MJ, Popovic MR, Prochazka A, Sinnott KA, Snoek G. International spinal cord injury upper extremity basic data set. Spinal Cord. 2014 Sep;52(9):652-7. doi: 10.1038/sc.2014.87. Adult;Pediatric Supplemental 1.00 2014-05-28 10:47:52.0 Surgical and Procedural Interventions Therapies Treatment/Intervention Data

Single Pre-Defined Value Selected

C19084 Spinal elements close manipulation & reduction indicator SpnlElmntsClsdManipul&ReducInd The indicator related to closed manipulation and/or reduction of spinal elements in a spinal intervention The indicator related to closed manipulation and/or reduction of spinal elements in a spinal intervention SpnlInterv- Closed manipulation and/or reduction of spinal elements No;Yes;Unknown No;Yes;Unknown Alphanumeric

Choose one.
Performance of a closed reduction or manipulation may require application of pins, tongs, head halters, or various other forms of traction and then the subsequent manipulation. This may be performed over several hours or the patient may be left in traction for several days in an attempt to slowly effect a reduction.

Dvorak MF, Itshayek E, Fehlings MG, Vaccaro AR, Wing PC, Biering-Sorensen F, Noonan VK. International Spinal Cord Injury: Spinal Interventions and Surgical Procedures Basic Data set. Spinal Cord. 2015 Feb;53(2):155-65. doi: 10.1038/sc.2014.182. Adult;Pediatric Supplemental 1.00 2014-05-27 12:36:10.0 Surgical and Procedural Interventions Therapies Treatment/Intervention Data

Single Pre-Defined Value Selected

C19117 Upper extremity surgery right osteotomy wrist performed indicator UPSurgRightOsteoWristPrfrmdInd The indicator for the surgical procedure of the restoration of the right wrist in an Osteotomy with or without rotation and/or Anthrodesis The indicator for the surgical procedure of the restoration of the right wrist in an Osteotomy with or without rotation and/or Anthrodesis Right wrist osteotomy with or without rotation and or Arthrodesis Yes Yes Alphanumeric

Osteotomy has been performed to position the extremity for function. In cases of internal rotation contracture of the shoulder and/or forearm supination contracture, a de-rotational osteotomy is performed to position the arm and forearm for function, respectively (Coulet et al 2010); these are usually done as a precursor to or in combination with tendon transfers. Fusion has been performed to stabilize a joint to improve function. The most common joints that are fused are in the thumb (House, et al 1992;
Waters 1985).

Biering-S&Oslash;rensen F, Bryden A, Curt A, Friden J, Harvey LA, Mulcahey MJ, Popovic MR, Prochazka A, Sinnott KA, Snoek G. International spinal cord injury upper extremity basic data set. Spinal Cord. 2014 Sep;52(9):652-7. doi: 10.1038/sc.2014.87. Adult;Pediatric Supplemental 1.00 2014-05-28 13:19:40.0 Surgical and Procedural Interventions Therapies Treatment/Intervention Data

Single Pre-Defined Value Selected

C19096 Surgery performed date SurgPerformedDate Date of last surgical intervention Date of last surgical intervention Date of last surgical intervention Date or Date & Time

Record the date/time according to the ISO 8601, the International Standard for the representation of dates and times (http://www.iso.org/iso/home.html). The date/time should be recorded to the level of granularity known (e.g., year, year and month, complete date plus hours and minutes, etc.).

Karlsson AK, Krassioukov A, Alexander MS, Donovan W, Biering-S&Oslash;rensen F. International spinal cord injury skin and thermoregulation function basic data set. Spinal Cord. 2012 Jul;50(7):512-6. doi: 10.1038/sc.2011.167. Adult;Pediatric Supplemental 1.00 2014-05-27 15:38:10.0 Surgical and Procedural Interventions Therapies Treatment/Intervention Data

Free-Form Entry

C05106 Surgical or therapeutic procedure start date and time SurgTherapuProcStartDateTime Date (and time, if applicable and known) on which the surgical or therapeutic procedure started Date (and time, if applicable and known) on which the surgical or therapeutic procedure started Start Date Date or Date & Time

Record the date/time according to the ISO 8601, the International Standard for the representation of dates and times (http://www.iso.org/iso/home.html). The date/time should be recorded to the level of granularity known (e.g., year, year and month, complete date plus hours and minutes, etc.).

No references available Adult;Pediatric Supplemental 3.00 2013-07-25 08:54:08.2 Surgical and Procedural Interventions Therapies Treatment/Intervention Data

Free-Form Entry

C19107 Upper extremity surgery right soft tissue tendon lengthenings performed indicator UPSurgRghtSTTendLngthPerfmdInd The indicator for the surgical procedure of the restoration of right tendon/muscle releases or lengthenings in soft tissue reconstruction The indicator for the surgical procedure of the restoration of right tendon/muscle releases or lengthenings in soft tissue reconstruction Right tendon/muscle releases or lengthenings Yes Yes Alphanumeric Biering-S&Oslash;rensen F, Bryden A, Curt A, Friden J, Harvey LA, Mulcahey MJ, Popovic MR, Prochazka A, Sinnott KA, Snoek G. International spinal cord injury upper extremity basic data set. Spinal Cord. 2014 Sep;52(9):652-7. doi: 10.1038/sc.2014.87. Adult;Pediatric Supplemental 1.00 2014-05-28 10:49:08.0 Surgical and Procedural Interventions Therapies Treatment/Intervention Data

Single Pre-Defined Value Selected

C19085 Surgical procedure approach type SurgProcedApproachTyp The type of approach taken in surgical procedure The type of approach taken in surgical procedure SurgProced- Approach Anterior open surgical procedure;Both anterior and posterior open surgical procedures;No;Posterior open surgical procedure;Unknown Anterior open surgical procedure;Both anterior and posterior open surgical procedures;No;Posterior open surgical procedure;Unknown Alphanumeric

Choose one.
Anterior surgical approaches include all anterior and lateral cervical approaches as well as any thoracic or lumbar approach that visualizes the vertebral body or inter-vertebral disk such as thoracotomy, thoracoscopy, thoracoplasty, thoraco-abdominal, retro-peritoneal, trans-peritoneal, or variations of lateral lumbar approaches. A posterior approach includes midline posterior incisions, paraspinal and Wiltse type incisions that expose the lamina, facet joints, and/or the transverse processes. Also included in posterior approaches are percutaneous or minimally invasive surgical techniques that enable insertion of spinal implants through stab incisions.

Dvorak MF, Itshayek E, Fehlings MG, Vaccaro AR, Wing PC, Biering-Sorensen F, Noonan VK. International Spinal Cord Injury: Spinal Interventions and Surgical Procedures Basic Data set. Spinal Cord. 2015 Feb;53(2):155-65. doi: 10.1038/sc.2014.182. Adult;Pediatric Supplemental 1.00 2014-05-27 14:24:58.0 Surgical and Procedural Interventions Therapies Treatment/Intervention Data

Single Pre-Defined Value Selected

CSV