CDE Detailed Report
Subdomain Name: Therapies
CRF: Surgical and Procedural Interventions
Displaying 1 - 50 of 54
CDE ID | CDE Name | Variable Name | Definition | Short Description | 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 / Guidance) | Subdomain Name | Domain Name | Size | Input Restrictions | Min Value | Max Value | Measurement Type | External Id Loinc | External Id Snomed | External Id caDSR | External Id CDISC |
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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 |
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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-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 13:29:13.0 | Surgical and Procedural Interventions | Therapies | Treatment/Intervention Data |
Single Pre-Defined Value Selected |
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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 |
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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 |
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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; |
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 10:54:46.0 | Surgical and Procedural Interventions | Therapies | Treatment/Intervention Data |
Single Pre-Defined Value Selected |
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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 |
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 |
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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-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 13:32:07.0 | Surgical and Procedural Interventions | Therapies | Treatment/Intervention Data |
Single Pre-Defined Value Selected |
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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-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 10:32:56.0 | Surgical and Procedural Interventions | Therapies | Treatment/Intervention Data |
Single Pre-Defined Value Selected |
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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 availabl | 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 |
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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; |
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 10:57:52.0 | Surgical and Procedural Interventions | Therapies | Treatment/Intervention Data |
Single Pre-Defined Value Selected |
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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. |
Biering-SØrensen 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 |
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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-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 13:33:31.0 | Surgical and Procedural Interventions | Therapies | Treatment/Intervention Data |
Single Pre-Defined Value Selected |
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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-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 10:41:55.0 | Surgical and Procedural Interventions | Therapies | Treatment/Intervention Data |
Single Pre-Defined Value Selected |
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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 |
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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; |
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 10:59:33.0 | Surgical and Procedural Interventions | Therapies | Treatment/Intervention Data |
Single Pre-Defined Value Selected |
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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 procedur | Other, specify | Alphanumeric | Biering-SØrensen 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 |
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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-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 13:35:10.0 | Surgical and Procedural Interventions | Therapies | Treatment/Intervention Data |
Single Pre-Defined Value Selected |
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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-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 10:43:49.0 | Surgical and Procedural Interventions | Therapies | Treatment/Intervention Data |
Single Pre-Defined Value Selected |
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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 |
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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; |
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 11:01:19.0 | Surgical and Procedural Interventions | Therapies | Treatment/Intervention Data |
Single Pre-Defined Value Selected |
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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-SØrensen 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 |
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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 |
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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-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 10:45:15.0 | Surgical and Procedural Interventions | Therapies | Treatment/Intervention Data |
Single Pre-Defined Value Selected |
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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 |
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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; |
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 11:02:16.0 | Surgical and Procedural Interventions | Therapies | Treatment/Intervention Data |
Single Pre-Defined Value Selected |
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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 procedur | Other, specify | Alphanumeric | Krogh K, Perkash I, Stiens SA, Biering-SØrensen 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 |
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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 |
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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 |
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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-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 10:45:59.0 | Surgical and Procedural Interventions | Therapies | Treatment/Intervention Data |
Single Pre-Defined Value Selected |
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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. |
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 |
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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; |
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 13:18:07.0 | Surgical and Procedural Interventions | Therapies | Treatment/Intervention Data |
Single Pre-Defined Value Selected |
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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-SØrensen 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 |
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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 |
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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-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 10:47:52.0 | Surgical and Procedural Interventions | Therapies | Treatment/Intervention Data |
Single Pre-Defined Value Selected |
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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. |
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 |
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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; |
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 13:19:40.0 | Surgical and Procedural Interventions | Therapies | Treatment/Intervention Data |
Single Pre-Defined Value Selected |
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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-SØrensen 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 |
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C05106 | Surgical 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 | 3.20 | 2022-08-18 17:27:56.0 | Surgical and Procedural Interventions | Therapies | Treatment/Intervention Data |
Free-Form Entry |
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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-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 10:49:08.0 | Surgical and Procedural Interventions | Therapies | Treatment/Intervention Data |
Single Pre-Defined Value Selected |
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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. |
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 |
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C19118 | Upper extremity surgery left osteotomy wrist performed indicator | UPSurgLeftOsteoWristPerfrmdInd | The indicator for the surgical procedure of the restoration of the left wrist in an Osteotomy with or without rotation and/or Anthrodesis | The indicator for the surgical procedure of the restoration of the left wrist in an Osteotomy with or without rotation and/or Anthrodesis | Left 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; |
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 13:22:30.0 | Surgical and Procedural Interventions | Therapies | Treatment/Intervention Data |
Single Pre-Defined Value Selected |
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C19097 | Scoliosis surgical treatment indicator | ScoliosisSurgicalTreatmentInd | Indicator for surgical treatment of scoliosis | Indicator for surgical treatment of scoliosis | Surgical treatment of scoliosis | No;Yes;Unknown | No;Yes;Unknown | Alphanumeric | Biering-SØrensen F, Burns AS, Curt A, Harvey LA, Jane Mulcahey M, Nance PW, Sherwood AM, Sisto SA. International spinal cord injury musculoskeletal basic data set. Spinal Cord. 2012 Nov;50(11):797-802. doi: 10.1038/sc.2012.102. | Adult;Pediatric | Supplemental | 1.00 | 2014-05-27 15:41:39.0 | Surgical and Procedural Interventions | Therapies | Treatment/Intervention Data |
Single Pre-Defined Value Selected |
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C05453 | Hypotensive episode indicator | HypotnsnEpiInd | Indicator of hypotensive episode. In adults, hypotensive episode is defined as systolic blood pressure < 90 mmHg. In children, it is defined as systolic blood pressure < 5th percentile for age | Indicator of hypotensive episode. In adults, hypotensive episode is defined as systolic blood pressure < 90 mmHg. In children, it is defined as systolic blood pressure < 5th percentile for age | Did participant/subject experience hypotensive episode (systolic BP < 90 mm Hg for longer than 5 minutes)? | 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. | 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 |
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C19108 | Upper extremity surgery left soft tissue tendon lengthenings performed indicator | UPSurgLeftSTTendLngthPerfmdInd | The indicator for the surgical procedure of the restoration of left tendon/muscle releases or lengthenings in soft tissue reconstruction | The indicator for the surgical procedure of the restoration of left tendon/muscle releases or lengthenings in soft tissue reconstruction | Left tendon/muscle releases or lengthenings soft tissue reconstruction | Yes | Yes | Alphanumeric | 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 10:51:06.0 | Surgical and Procedural Interventions | Therapies | Treatment/Intervention Data |
Single Pre-Defined Value Selected |
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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 |
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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; |
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 |
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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 |
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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 |
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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-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 10:52:01.0 | Surgical and Procedural Interventions | Therapies | Treatment/Intervention Data |
Single Pre-Defined Value Selected |
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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 |