Eligibility, p1 (1)

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 confrmdt Consent Form Sig Date

10 inc1 Inc Crit #1

0 Not checked

1 Yes

2 No

11 inc2 Inc Crit #2

0 Not checked

1 Yes

2 No

12 inc3 Inc Crit #3

0 Not checked

1 Yes

2 No

13 inc4 Inc Crit #4

0 Not checked

1 Yes

2 No

14 inc5 Inc Crit #5

0 Not checked

1 Yes

2 No

15 inc6 Inc Crit #6

0 Not checked

1 Yes

2 No

16 inc7 Inc Crit #7

0 Not checked

1 Yes

2 No

17 exc1 Excl Crit #1

0 Not checked

1 Yes

2 No

18 exc2 Excl Crit #2

0 Not checked

1 Yes

2 No

19 exc3 Excl Crit #3

0 Not checked

1 Yes

2 No

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20 exc4 Excl Crit #4

0 Not checked

1 Yes

2 No

21 exc5 Excl Crit #5

0 Not checked

1 Yes

2 No

22 exc6 Excl Crit #6

0 Not checked

1 Yes

2 No

23 exc7 Excl Crit #7

0 Not checked

1 Yes

2 No

24 exc8 Excl Crit #8

0 Not checked

1 Yes

2 No

25 exc9 Excl Crit #9

0 Not checked

1 Yes

2 No

26 payable$(plate) Payable0 Unchecked

1 Checked

27 LCUser$(plate) Last Change Username

28 LCDate$(plate) Last Change (Date)

29 LCTime$(plate) Last Change (Time)

Eligibility, p2 (2)

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 exc10 Excl Crit #10

0 Not checked

1 Yes

2 No

10 exc11 Excl Crit #11

0 Not checked

1 Yes

2 No

11 exc12 Excl Crit #12

0 Not checked

1 Yes

2 No

12 exc13 Excl Crit #130 Not checked

1 Yes

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2 No

13 exc14 Excl Crit #14

0 Not checked

1 Yes

2 No

3 NA

14 exc15 Excl Crit #15

0 Not checked

1 Yes

2 No

15 exc16 Excl Crit #16

0 Not checked

1 Yes

2 No

16 exc17 Excl Crit #17

0 Not checked

1 Yes

2 No

17 exc18 Excl Crit #18

0 Not checked

1 Yes

2 No

18 invagreeelig Investigator Agrees Eligibility0 Unchecked

1 Checked

19 LCUser$(plate) Last Change Username

20 LCDate$(plate) Last Change (Date)

21 LCTime$(plate) Last Change (Time)

SI Joint Injection (3)

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 sijinjdt$(plate) SI Joint Injectino Date

10 sijphys$(plate) SI Joint Inj Phys Name

11 bilatsijinj$(plate) Bilateral SI Joint Injection

0 Not checked

2 No

1 Yes

12 sijinjside$(plate) SIJ Injected Side

0 Not checked

1 Right

2 Left

13 arthrosucc$(plate) Arthrogram Successful

0 Not checked

1 Yes

2 No, could not access

3 No, other reason

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14 arthroreas$(plate) Reason Arthrog Not Successful

15 leakage$(plate) Leakage of Contrast

0 Not checked

1 No leakage

2 Minor leakage

3 Major leakage

16 aneslido$(plate) Anesthesia (Lidocaine)0 Unchecked

1 Checked

17 anesbup$(plate) Anesthesia (Bupivacaine)0 Unchecked

1 Checked

18 anesoth Anesthesia (Other)0 Unchecked

1 Checked

19 anesothsp$(plate) Other Anesthetic Used (Specify)

20 amtanes$(plate) Amount of Anesthetic

21 sterinj Steroids Injected

0 Not checked

2 No

1 Yes

22 stermedname Steroid Med Name

23 sterinjamt Steroid Injection Amt (cc)

24 sterinjconc Steroid Injection Concentration

25 sterinjtotaldose Steroid Injection (Total Dose)

26 sijimg$(plate) SIJ Images Forwarded to Sponsor

0 Not checked

1 Yes

2 No

27 nrspriorsij$(plate) NRS Prior to SIJ Injection

28 nrsposthalfsij$(plate) NRS 1/2 Hr After SIJ Injection

29 nrspostonesij$(plate) NRS 1 Hr Post SIJ Injection

30 sijpred50$(plate) SIJ Pain Reduced 50%

0 Not checked

1 Yes

2 No

31 LCUser$(plate) Last Change Username

32 LCDate$(plate) Last Change (Date)

33 LCTime$(plate) Last Change (Time)

SI Joint Injection (other side) (4)

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 sijinjdt$(plate) SI Joint Injectino Date

10 sijphys$(plate) SI Joint Inj Phys Name

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11 sijinjside$(plate) SIJ Injected Side

0 Not checked

1 Right

2 Left

12 arthrosucc$(plate) Arthrogram Successful

0 Not checked

1 Yes

2 No, could not access

3 No, other reason

13 arthroreas$(plate) Reason Arthrog Not Successful

14 leakage$(plate) Leakage of Contrast

0 Not checked

1 No leakage

2 Minor leakage

3 Major leakage

15 aneslido$(plate) Anesthesia (Lidocaine)0 Unchecked

1 Checked

16 anesbup$(plate) Anesthesia (Bupivacaine)0 Unchecked

1 Checked

17 anesoth Anesthesia (Other)0 Unchecked

1 Checked

18 anesothsp$(plate) Other Anesthetic Used (Specify)

19 amtanes$(plate) Amount of Anesthetic

20 sterinj Steroids Injected

0 Not checked

2 No

1 Yes

21 stermedname Steroid Med Name

22 sterinjamt Steroid Injection Amt (cc)

23 sterinjconc Steroid Injection Concentration

24 sterinjtotaldose Steroid Injection (Total Dose)

25 sijimg$(plate) SIJ Images Forwarded to Sponsor

0 Not checked

1 Yes

2 No

26 nrspriorsij$(plate) NRS Prior to SIJ Injection

27 nrsposthalfsij$(plate) NRS 1/2 Hr After SIJ Injection

28 nrspostonesij$(plate) NRS 1 Hr Post SIJ Injection

29 sijpred50$(plate) SIJ Pain Reduced 50%

0 Not checked

1 Yes

2 No

30 LCUser$(plate) Last Change Username

31 LCDate$(plate) Last Change (Date)

32 LCTime$(plate) Last Change (Time)

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Preop CT Scan (5)

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 ctnd CT Scan Not Done0 Unchecked

1 Checked

10 basectdate Baseline CT Date

11 basecttype Baseline CT Type

0 Not checked

1 Standard res

2 High res

12 basectosteo Baseline CT Osteophytes0 Unchecked

1 Checked

13 basectscler Baseline CT Sclerosis0 Unchecked

1 Checked

14 basectcyst Baseline CT Subchrondral Cysts0 Unchecked

1 Checked

15 basectvac Baseline CT Vacuum0 Unchecked

1 Checked

16 basectasymm Baseline CT Asymmetric Widening0 Unchecked

1 Checked

17 basectfindother Baseline CT Findings (Other)

18 ctprom CT Diagnosis More Prominent

0 Not checked

1 Degen more prominent

2 Disrup more prominent

19 basectsent Baseline CT Sent to Sponsor

0 Not checked

1 Yes

2 No

20 basectsentdt Baseline CT Sent Date

21 basectnotsentreas Baseline CT Not Sent Reason

22 LCUser$(plate) Last Change Username

23 LCDate$(plate) Last Change (Date)

24 LCTime$(plate) Last Change (Time)

Demographics / Pain Location (11)

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 basevisdt Baseline Visit Date

10 dob Date of Birth

11 consdt Consent Date

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12 gender Gender

0 Not checked

1 Male

2 Female

13 wtlbs Weight (lbs)

14 wtkg Weight (kg)

15 heightft Height (feet)

16 heightin Height (inches)

17 heightcm Height (cm)

18 ethnic Ethnicity

0 Not checked

1 Hispanic

2 Not Hispanic

19 race Race

0 Not checked

1 White

2 Hawaiian / Pac Isl

3 Black

4 Amer Indian

5 Asian

6 Other

20 raceother Race (Other)

21 painloc1 Pain Loc (Left Upper Lumbar)0 Unchecked

1 Checked

22 painloc2 Pain Loc (Right Upper Lumbar)0 Unchecked

1 Checked

23 painloc3 Pain Loc (L1 spine)0 Unchecked

1 Checked

24 painloc4 Pain Loc (Left Lower Lumbar)0 Unchecked

1 Checked

25 painloc5 Pain Loc (Right Lower Lumbar)0 Unchecked

1 Checked

26 painloc6 Pain Loc (L5 spine)0 Unchecked

1 Checked

27 painloc7 Pain Loc (Left PSIS)0 Unchecked

1 Checked

28 painloc8 Pain Loc (Right PSIS)0 Unchecked

1 Checked

29 painloc20 Pain Loc (Right ASIS)0 Unchecked

1 Checked

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30 painloc24 Pain Loc (Pubic Symphysis)0 Unchecked

1 Checked

31 painloc21 Pain Loc (Left ASIS)0 Unchecked

1 Checked

32 painloc22 Pain Loc (Right Lower Groin)0 Unchecked

1 Checked

33 painloc23 Pain Loc (Left Lower Groin)0 Unchecked

1 Checked

34 painloc11 Pain Loc (Left Hip)0 Unchecked

1 Checked

35 painloc9 Pain Loc (Left Buttock)0 Unchecked

1 Checked

36 painloc10 Pain Loc (Right Buttock)0 Unchecked

1 Checked

37 painloc12 Pain Loc (Right Hip)0 Unchecked

1 Checked

38 painloc25 Pain Loc (Right Upper Leg)0 Unchecked

1 Checked

39 painloc26 Pain Loc (Left Upper Leg)0 Unchecked

1 Checked

40 painloc13 Pain Loc (Left Upper Leg Post)0 Unchecked

1 Checked

41 painloc14 Pain Loc (Right Upper Leg Post)0 Unchecked

1 Checked

42 painloc27 Pain Loc (Right Lower Leg)0 Unchecked

1 Checked

43 painloc28 Pain Loc (Left Lower Leg)0 Unchecked

1 Checked

44 painloc15 Pain Loc (Left Lower Leg Post)0 Unchecked

1 Checked

45 painloc16 Pain Loc (Right Lower Leg Post)0 Unchecked

1 Checked

46 painloc29 Pain Loc (Right Knee)0 Unchecked

1 Checked

47 painloc30 Pain Loc (Left Knee)0 Unchecked

1 Checked

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48 painloc17 Pain Loc (Left Post Knee)0 Unchecked

1 Checked

49 painloc18 Pain Loc (Right Post Knee)0 Unchecked

1 Checked

50 payable$(plate) Payable0 Unchecked

1 Checked

51 LCUser$(plate) Last Change Username

52 LCDate$(plate) Last Change (Date)

53 LCTime$(plate) Last Change (Time)

SIJ History / Other Back Probs (12)

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 painstartmo Pain Start Month

10 painstartyr Pain Start Year

11 painperip Pain Began Peripartum

0 Not checked

1 Yes

2 No

3 NA

12 painradleg Pain Radiates Leg

0 Not checked

1 Yes

2 No

13 paingroin Pain in Groin

0 Not checked

1 Yes

2 No

14 painsit Pain Worse Sitting

0 Not checked

1 Yes

2 No

15 painris Pain Worse Rising

0 Not checked

1 Yes

2 No

16 painwalk Pain Worse Walking

0 Not checked

1 Yes

2 No

17 painclimb Pain Worse Climbing Stairs

0 Not checked

1 Yes

2 No

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18 paindesc Pain Worse Descending Stairs

0 Not checked

1 Yes

2 No

19 otherwors Other Activ That Worsen Pain

20 conscare6 Cons Care At Least 6 Mo

0 Not checked

1 Yes

2 No

21 priorpt Prior PT for SIJ

0 Not checked

2 No

1 Yes

22 numcourpt Number of Courses of PT in 2 Yrs

23 priorsterinj Prior Steroid Injection

0 Not checked

2 No

1 Yes

24 numsijinj Number of SIJ Injections Past 5 Yr

25 priorrfa Prior RFA

0 Not checked

2 No

1 Yes

26 numrfa Number of RFAs in 5 Yrs

27 hofusion History of Prior Fusion

0 Not checked

2 No

1 Yes

28 fus1desc Fusion 1 Desc

29 fus1mo Prior Fusion Mo 1

30 fus1year Prior Fusion Year 1

31 fus2desc Fusion 2 Desc

32 fus2mo Prior Fusion Mo 2

33 fus2year Prior Fusion Year 2

34 priorstenosis History of Lumbar Stenosis

0 Not checked

2 No

1 Yes

35 sten1desc Stenosis 1 Desc

36 sten1mo Prior Sten Mo 1

37 sten1year Prior Stenosis Year 1

38 sten2desc Stenosis 2 Desc

39 sten2mo Prior Sten Mo 2

40 sten2year Prior Stenosis Year 2

41 priorpiri History of Piriformis Syndrome

0 Not checked

2 No

1 Yes

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42 piri1desc Pirif 1 Desc

43 piri1mo Piri Treat Mo 1

44 piri1year Piri Treat Year 1

45 piri2desc Pirif 2 Desc

46 piri2mo Piri Treat Mo 2

47 piri2year Piri Treat Year 2

48 LCUser$(plate) Last Change Username

49 LCDate$(plate) Last Change (Date)

50 LCTime$(plate) Last Change (Time)

Ambulatory / Work Status (13)

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 hohip History of Hip Problems

0 Not checked

2 No

1 Yes

10 hipdiag Hip Diagnoses

11 hipright Hip Affected (R)0 Unchecked

1 Checked

12 hipleft Hip Affected (L)0 Unchecked

1 Checked

13 hip1desc Hip 1 Desc

14 hip1mo Hip Mo 1

15 hip1year Hip 1 Yr

16 hip2desc Hip 2 Desc

17 hip2mo Hip Mo 2

18 hip2year Hip 2 Yr

19 hosactra History of Sacral Trauma

0 Not checked

2 No

1 Yes

20 sactraum Sacral Trauma Description

21 sitrau1desc SI Trauma 1 Desc

22 sitrau1mo SI Trauma Mo 1

23 sitrau1year SI Trauma 1 Yr

24 sitrau2desc SI Trauma 2 Desc

25 sitrau2mo SI Trauma Mo 2

26 sitrau2year SI Trauma 2 Yr

27 hosif History of SI Fracture

0 Not checked

2 No

1 Yes

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28 sinsuffdesc Sac Insuf Fx Description

29 sif1desc Sac Insuff Fx 1 Desc

30 sif1mo Sac Insuff Fx Mo 1

31 sif1year Sac Insuff Fx Yr 1

32 sif2desc Sac Insuff Fx 2 Desc

33 sif2mo Sac Insuff Fx Mo 2

34 sif2year Sac Insuff Fx Yr 2

35 ambstat Ambulatory Status

0 Not checked

1 Fully ambulatory

2 Amb w assist

3 Cannot walk

36 smoker Smoking Status

0 Not checked

1 Current smoker

2 Former smoker

3 Never smoker

37 cigppd Cigarettes Pack Per Day

38 cigarppd Cigars Per Day

39 pipepd Pipes Per Day

40 bowlpd Bowls per Day

41 quityr Tob Quit Year

42 LCUser$(plate) Last Change Username

43 LCDate$(plate) Last Change (Date)

44 LCTime$(plate) Last Change (Time)

Medical Probs (14)

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 baseworkstat Baseline Work Status

0 Not checked

1 Working full time

2 Working part time

3 Not working, student

4 Not working, retired

5 Not working due to back pain

6 Not working other reason

10 painlimitwork Does Pain Prevent Working As Many Hrs

0 Not checked

1 Yes

2 No

11 basehrsprev Baseline Hrs Prevented Working/Week

12 worktype Work Type

0 Not checked

1 Manual

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2 Sedentary

3 NA

13 nomedhx No Medical History Checkbox0 Unchecked

1 Checked

14 medbs1 Med Body System 1

15 medcond1 Medical Condition 1

16 medbs2 Med Body System 2

17 medcond2 Medical Condition 2

18 medbs3 Med Body System 3

19 medcond3 Medical Condition 3

20 medbs4 Med Body System 4

21 medcond4 Medical Condition 4

22 medbs5 Med Body System 5

23 medcond5 Medical Condition 5

24 medbs6 Med Body System 6

25 medcond6 Medical Condition 6

26 medbs7 Med Body System 7

27 medcond7 Medical Condition 7

28 medbs8 Med Body System 8

29 medcond8 Medical Condition 8

30 medbs9 Med Body System 9

31 medcond9 Medical Condition 9

32 medbs10 Med Body System 10

33 medcond10 Medical Condition 10

34 medbs11 Med Body System 11

35 medcond11 Medical Condition 11

36 medbs12 Med Body System 12

37 medcond12 Medical Condition 12

38 medbs13 Med Body System 13

39 medcond13 Medical Condition 13

40 LCUser$(plate) Last Change Username

41 LCDate$(plate) Last Change (Date)

42 LCTime$(plate) Last Change (Time)

Medications (15)

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 basenotnarc Baseline Not Taking Narcotics0 Unchecked

1 Checked

10 narc1 Narcotic 1

11 narc1dose Narcotic 1 Dose (mg)

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12 narc2 Narcotic 2

13 narc2dose Narcotic 2 Dose (mg)

14 narc3 Narcotic 3

15 narc3dose Narcotic 3 Dose (mg)

16 basenotnsaid Baseline Not Taking NSAIDs0 Unchecked

1 Checked

17 nsaid1 NSAID 1

18 nsaid1dose NSAID 1 Dose (mg)

19 nsaid2 NSAID 2

20 nsaid2dose NSAID 2 Dose (mg)

21 nsaid3 NSAID 3

22 nsaid3dose NSAID 3 Dose (mg)

23 basenotacet Baseline Not Taking Acetaminophen0 Unchecked

1 Checked

24 acet Acetaminophen

25 acetdose Acetaminophen Dose (mg)

26 basenotmusc Baseline Not Musc Relax0 Unchecked

1 Checked

27 musc1 Musc Relax 1

28 musc1dose Musc Relax 1 Dose (mg)

29 musc2 Musc Relax 2

30 musc2dose Musc Relax 2 Dose (mg)

31 basenotster Baseline Not Taking Steroid0 Unchecked

1 Checked

32 ster Oral Steroid

33 sterdose Steroid Dose (mg)

34 othmed1 Other Pain Med 1

35 otrmed1dose Other Pain Med 1 Dose (mg)

36 othmed2 Other Pain Med 2

37 otrmed2dose Other Pain Med 2 Dose (mg)

38 basemed1 Base Med 1

39 basemedreas1 Base Med Reason 1

40 basemed2 Base Med 2

41 basemedreas2 Base Med Reason 2

42 basemed3 Base Med 3

43 basemedreas3 Base Med Reason 3

44 basemed4 Base Med 4

45 basemedreas4 Base Med Reason 4

46 basemed5 Base Med 5

47 basemedreas5 Base Med Reason 5

48 basemed6 Base Med 6

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49 basemedreas6 Base Med Reason 6

50 basemed7 Base Med 7

51 basemedreas7 Base Med Reason 7

52 basemed8 Base Med 8

53 basemedreas8 Base Med Reason 8

54 basemed9 Base Med 9

55 basemedreas9 Base Med Reason 9

56 basemed10 Base Med 10

57 basemedreas10 Base Med Reason 10

58 nomedsother No Meds BL Other Conditions0 Unchecked

1 Checked

59 LCUser$(plate) Last Change Username

60 LCDate$(plate) Last Change (Date)

61 LCTime$(plate) Last Change (Time)

Physical Exam (16)

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 faberl FABER (L)

0 Not checked

1 Positive

2 Negative

3 Not done

10 faberr FABER (R)

0 Not checked

1 Positive

2 Negative

3 Not done

11 compl Compression (L)

0 Not checked

1 Positive

2 Negative

3 Not done

12 compr Compression (R)

0 Not checked

1 Positive

2 Negative

3 Not done

13 thighl Thigh Thrust (L)

0 Not checked

1 Positive

2 Negative

3 Not done

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14 thighr Thigh Thrust (R)

0 Not checked

1 Positive

2 Negative

3 Not done

15 distracl Distraction (L)

0 Not checked

1 Positive

2 Negative

3 Not done

16 distracr Distraction (R)

0 Not checked

1 Positive

2 Negative

3 Not done

17 gaenl Gaensler's (L)

0 Not checked

1 Positive

2 Negative

3 Not done

18 gaenr Gaensrer's (R)

0 Not checked

1 Positive

2 Negative

3 Not done

19 provtestother1 Provocative Test Other 1

20 othr1l Other PE Finding 1 (L)

0 Not checked

1 Positive

2 Negative

3 Not done

21 othr1r Other PE Finding 1 (R)

0 Not checked

1 Positive

2 Negative

3 Not done

22 provtestother2 Provocative Test Other 2

23 othr2l Other PE Finding 2 (L)

0 Not checked

1 Positive

2 Negative

3 Not done

24 othr2r Other PE Finding 2 (R)

0 Not checked

1 Positive

2 Negative

3 Not done

25 kneeextl PE: Knee Extension (L)

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26 kneeextr PE: Knee Extension (R)

27 kneeflexl PE: Knee Flexion (L)

28 kneefrexr PE: Knee Frexion (R)

29 ankdorsl PE: Ankle Dorsiflexion (L)

30 ankdorsr PE: Ankre Dorsifrexion (R)

31 ankplanl PE: Ankle Plantarflexion (L)

32 ankplanr PE: Ankle Plantarflexion (R)

33 sensdefleft Sensory Deficit Left

0 Not checked

2 No

1 Yes

34 sensdefright Sensory Deficit Right

0 Not checked

2 No

1 Yes

35 sensltl1 Sens Deficit Left L10 Unchecked

1 Checked

36 sensltl2 Sens Deficit Left L20 Unchecked

1 Checked

37 sensltl3 Sens Deficit Left L30 Unchecked

1 Checked

38 sensltl4 Sens Deficit Left L40 Unchecked

1 Checked

39 sensltl5 Sens Deficit Left L50 Unchecked

1 Checked

40 senslts1 Sens Deficit Left S10 Unchecked

1 Checked

41 sensrtl1 Sens Deficit Right L10 Unchecked

1 Checked

42 sensrtl2 Sens Deficit Right L20 Unchecked

1 Checked

43 sensrtl3 Sens Deficit Right L30 Unchecked

1 Checked

44 sensrtl4 Sens Deficit Right L40 Unchecked

1 Checked

45 sensrtl5 Sens Deficit Right L50 Unchecked

1 Checked

46 sensrts1 Sens Deficit Right S10 Unchecked

1 Checked

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47 LCUser$(plate) Last Change Username

48 LCDate$(plate) Last Change (Date)

49 LCTime$(plate) Last Change (Time)

Phys Exam / QOL (17)

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 kneejerkl Knee Jerk L

10 kneejerkr Knee Jerk R

11 ankjerkl Ankle Jerk L

12 ankjerkr Ankre Jerk L

13 sf36done$(plate) SF36 Done

0 Not checked

1 Yes

2 No

14 eq5ddone$(plate) EQ5d Done

0 Not checked

1 Yes

2 No

15 LCUser$(plate) Last Change Username

16 LCDate$(plate) Last Change (Date)

17 LCTime$(plate) Last Change (Time)

Underlying Diagnosis (18)

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 priorlsf Prior Lumbosacral Fusion

0 Not checked

1 Yes

2 No

10 raddegen Radiographic Evidence of Degeneration

0 Not checked

1 Yes

2 No

3 Not Done

11 asymwid Asymmetric Widening

0 Not checked

1 Yes

2 No

3 Not Done

12 leakcont Leakage of Contrast

0 Not checked

1 Yes

2 No

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13 diagdegen Diagnosis: Degenerative Sacroiliitis0 Unchecked

1 Checked

14 diagdisrup Diagnosis: SI Joint Disruption0 Unchecked

1 Checked

15 diagpredomw Predominant Diagnosis

0 Not checked

1 Degeneration

2 Disruption

16 LCUser$(plate) Last Change Username

17 LCDate$(plate) Last Change (Date)

18 LCTime$(plate) Last Change (Time)

Procedure, p1 (21)

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 stagedpl Staged Proc Planned

0 Not checked

2 No

1 Yes

10 procdt Procedure Date

11 targsij Target SI Joint Side

0 Not checked

1 Right

2 Left

12 procstarthr Proc Start Hour

13 procstartmin Proc Start Min

14 procendhr Procedure End Hour

15 procendmin Proc End Min

16 fluoromin Fluoro Min

17 ebl Estim Blood Loss

18 impside1 Implant Side 1

0 Not checked

1 Right

2 Left

19 impdiam1 Implant Diam 1

0 Not checked

1 4 mm

2 7 mm

20 implen1 Implant Length 1

0 Not checked

1 30

2 35

3 40

4 45

5 50

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6 55

7 60

8 65

9 70

21 impside2 Implant Side 2

0 Not checked

1 Right

2 Left

22 impdiam2 Implant Diam 2

0 Not checked

1 4 mm

2 7 mm

23 implen2 Implant Length 2

0 Not checked

1 30

2 35

3 40

4 45

5 50

6 55

7 60

8 65

9 70

24 impside3 Implant Side 3

0 Not checked

1 Right

2 Left

25 impdiam3 Implant Diam 3

0 Not checked

1 4 mm

2 7 mm

26 implen3 Implant Length 3

0 Not checked

1 30

2 35

3 40

4 45

5 50

6 55

7 60

8 65

9 70

27 impside4 Implant Side 4

0 Not checked

1 Right

2 Left

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28 impdiam4 Implant Diam 4

0 Not checked

1 4 mm

2 7 mm

29 implen4 Implant Length 4

0 Not checked

1 30

2 35

3 40

4 45

5 50

6 55

7 60

8 65

9 70

30 payable$(plate) Payable0 Unchecked

1 Checked

31 LCUser$(plate) Last Change Username

32 LCDate$(plate) Last Change (Date)

33 LCTime$(plate) Last Change (Time)

Procedure, p2 (22)

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 pin1 Advance Pin 1

0 Not checked

1 Yes

2 No

10 drill1 Drill 1

0 Not checked

1 Yes

2 No

11 bro1 Broach 1

0 Not checked

1 Yes

2 No

12 deliv1 Deliver 1

0 Not checked

1 Yes

2 No

13 pin2 Advance Pin 2

0 Not checked

1 Yes

2 No

14 drill2 Drill 20 Not checked

1 Yes

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2 No

15 bro2 Broach 2

0 Not checked

1 Yes

2 No

16 deliv2 Deliver 2

0 Not checked

1 Yes

2 No

17 pin3 Advance Pin 3

0 Not checked

1 Yes

2 No

18 drill3 Drill 3

0 Not checked

1 Yes

2 No

19 bro3 Broach 3

0 Not checked

1 Yes

2 No

20 deliv3 Deliver 3

0 Not checked

1 Yes

2 No

21 pin4 Advance Pin 4

0 Not checked

1 Yes

2 No

22 drill4 Drill 4

0 Not checked

1 Yes

2 No

23 bro4 Broach 4

0 Not checked

1 Yes

2 No

24 deliv4 Deliver 4

0 Not checked

1 Yes

2 No

25 proccomp Procedure Complications

0 Not checked

2 No

1 Yes

26 compdesc Complication Description

27 procadv Procedure Adverse Events

0 Not checked

2 No

1 Yes

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28 LCUser$(plate) Last Change Username

29 LCDate$(plate) Last Change (Date)

30 LCTime$(plate) Last Change (Time)

Contralat Proced, p1 (23)

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 procdt2 Procedure Date

10 targsij$(plate) Target SI Joint Side

0 Not checked

1 Right

2 Left

11 procstarthr$(plate) Proc Start Hour

12 procstartmin$(plate) Proc Start Min

13 surgendhr$(plate) Surg End Hour

14 surgendmin$(plate) Surg End Min

15 fluoromin$(plate) Fluoro Min

16 ebl$(plate) Estim Blood Loss

17 impside1 Implant Side 1

0 Not checked

1 Right

2 Left

18 impdiam1 Implant Diam 1

0 Not checked

1 4 mm

2 7 mm

19 implen1 Implant Length 1

0 Not checked

1 30

2 35

3 40

4 45

5 50

6 55

7 60

8 65

9 70

20 impside2 Implant Side 2

0 Not checked

1 Right

2 Left

21 impdiam2 Implant Diam 2

0 Not checked

1 4 mm

2 7 mm

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22 implen2 Implant Length 2

0 Not checked

1 30

2 35

3 40

4 45

5 50

6 55

7 60

8 65

9 70

23 impside3 Implant Side 3

0 Not checked

1 Right

2 Left

24 impdiam3 Implant Diam 3

0 Not checked

1 4 mm

2 7 mm

25 implen3 Implant Length 3

0 Not checked

1 30

2 35

3 40

4 45

5 50

6 55

7 60

8 65

9 70

26 impside4 Implant Side 4

0 Not checked

1 Right

2 Left

27 impdiam4 Implant Diam 4

0 Not checked

1 4 mm

2 7 mm

28 implen4 Implant Length 4

0 Not checked

1 30

2 35

3 40

4 45

5 50

6 55

7 60

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8 65

9 70

29 LCUser$(plate) Last Change Username

30 LCDate$(plate) Last Change (Date)

31 LCTime$(plate) Last Change (Time)

Contralat Proc, p2 (24)

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 pin1 Advance Pin 1

0 Not checked

1 Yes

2 No

10 drill1 Drill 1

0 Not checked

1 Yes

2 No

11 bro1 Broach 1

0 Not checked

1 Yes

2 No

12 deliv1 Deliver 1

0 Not checked

1 Yes

2 No

13 pin2 Advance Pin 2

0 Not checked

1 Yes

2 No

14 drill2 Drill 2

0 Not checked

1 Yes

2 No

15 bro2 Broach 2

0 Not checked

1 Yes

2 No

16 deliv2 Deliver 2

0 Not checked

1 Yes

2 No

17 pin3 Advance Pin 3

0 Not checked

1 Yes

2 No

18 drill3 Drill 30 Not checked

1 Yes

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2 No

19 bro3 Broach 3

0 Not checked

1 Yes

2 No

20 deliv3 Deliver 3

0 Not checked

1 Yes

2 No

21 pin4 Advance Pin 4

0 Not checked

1 Yes

2 No

22 drill4 Drill 4

0 Not checked

1 Yes

2 No

23 bro4 Broach 4

0 Not checked

1 Yes

2 No

24 deliv4 Deliver 4

0 Not checked

1 Yes

2 No

25 proccomp$(plate) Procedure Complications

0 Not checked

2 No

1 Yes

26 compdesc Complication Description

27 procadv Procedure Adverse Events

0 Not checked

2 No

1 Yes

28 LCUser$(plate) Last Change Username

29 LCDate$(plate) Last Change (Date)

30 LCTime$(plate) Last Change (Time)

Discharge (31)

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 discxraydt Discharge X-Ray Date

10 discinlet Disch Inlet/Outlet/Lat View Done

0 Not checked

1 Yes

2 No

11 reasxrnd Reason DC X-Ray ND

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12 dcxraysponsor Discharge X-Ray Sent to Sponsor

0 Not checked

1 Yes

2 No

13 reasxrns Reason DC X-Ray Not Sent

14 aedisc AE Prior to DC

0 Not checked

2 No

1 Yes

15 hospdcdt Hospital DC Date

16 los Length of Stay (Nights)

17 fuvissched FU Visits Scheduled

0 Not checked

1 Yes

2 No

18 dischsameday Discharged Same Day0 Unchecked

1 Checked

19 LCUser$(plate) Last Change Username

20 LCDate$(plate) Last Change (Date)

21 LCTime$(plate) Last Change (Time)

Follow-Up Visit, p1 (41)

6 visitseq$(plate) Visit Sequence

0 Not checked

5 Month 1

6 Month 3

7 Month 6

8 Month 12

9 Month 18

10 Month 24

15 Month 1 (2)

16 Month 3 (2)

17 Month 6 (2)

18 Month 12 (2)

19 Month 18 (2)

20 Month 24 (2)

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 fuvisdt Follow-Up Visit Date

10 fuvasdone FU VAS Done

0 Not checked

1 Yes

2 No

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11 fuodidone FU ODI Done

0 Not checked

1 Yes

2 No

3 NA

12 fusf36done FU SF36 Done

0 Not checked

1 Yes

2 No

3 NA

13 fueq5ddone FU EQ5D Done

0 Not checked

1 Yes

2 No

3 NA

14 fupainvsbl FU Pain Vs. Baseline

0 Not checked

1 Improved

2 Same

3 Worse

15 fuadlvsbl FU ADL vs. Baseline

0 Not checked

1 Limited less

2 Same as baseline

3 Limited more

16 numptpiFuse Num PT Sessions After iFuse

17 reasptnd Reason PT Not Done (6 mo)

18 fuwalkstatus FU Ambulatory Status

0 Not checked

1 Ambulatory without assistance

2 Ambulatory with assistive device

3 Cannot walk

19 fullwalkdt Full Walking Date

20 notfullwalk Not Fully Walking / Still Needs Amb Dev0 Unchecked

1 Checked

21 LCUser$(plate) Last Change Username

22 LCDate$(plate) Last Change (Date)

23 LCTime$(plate) Last Change (Time)

Follow-Up Visit, p2 (42)

6 visitseq$(plate) Visit Sequence

0 Not checked

5 Month 1

6 Month 3

7 Month 6

8 Month 12

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9 Month 18

10 Month 24

15 Month 1 (2)

16 Month 3 (2)

17 Month 6 (2)

18 Month 12 (2)

19 Month 18 (2)

20 Month 24 (2)

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 fuworkstat FU Work Status

0 Not checked

1 Working full time

2 Working part time

3 Not working, student

4 Not working, retired

5 Not working due to back pain

6 Not working other reason

10 fupainprevwk FU Pain Prevents Working

0 Not checked

1 Yes

2 No

11 fuhrslimit FU Hours Limit Working

12 funarcnt FU Not Taking Narcotics0 Unchecked

1 Checked

13 narc1$(plate) Narcotic 1

14 narc1dose$(plate) Narcotic 1 Dose (mg)

15 narc2$(plate) Narcotic 2

16 narc2dose$(plate) Narcotic 2 Dose (mg)

17 narc3$(plate) Narcotic 3

18 narc3dose$(plate) Narcotic 3 Dose (mg)

19 funsaidnt FU Not Taking NSAIDs0 Unchecked

1 Checked

20 nsaid1$(plate) NSAID 1

21 nsaid1dose$(plate) NSAID 1 Dose (mg)

22 nsaid2$(plate) NSAID 2

23 nsaid2dose$(plate) NSAID 2 Dose (mg)

24 nsaid3$(plate) NSAID 3

25 nsaid3dose$(plate) NSAID 3 Dose (mg)

26 fuacetnt FU Not Taking Acetaminophen0 Unchecked

1 Checked

27 acet$(plate) Acetaminophen

28 acetdose$(plate) Acetaminophen Dose (mg)

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29 fumuscnt FU Not Taking Musc Relax0 Unchecked

1 Checked

30 musc1$(plate) Musc Relax 1

31 musc1dose$(plate) Musc Relax 1 Dose (mg)

32 musc2$(plate) Musc Relax 2

33 musc2dose$(plate) Musc Relax 2 Dose (mg)

34 fusternt FU Not Taking Steroids0 Unchecked

1 Checked

35 ster$(plate) Oral Steroid

36 sterdose$(plate) Steroid Dose (mg)

37 othmed1$(plate) Other Pain Med 1

38 otrmed1dose$(plate) Other Pain Med 1 Dose (mg)

39 othmed2$(plate) Other Pain Med 2

40 otrmed2dose$(plate) Other Pain Med 2 Dose (mg)

41 newmedst New Med Started vs. Baseline

0 Not checked

2 No

1 Yes

42 medstartbl New Med Started Since BL

43 oldmedstp Old Med Stopped Vs. BL

0 Not checked

2 No

1 Yes

44 medstpbl Old Med Stopped Since BL

45 LCUser$(plate) Last Change Username

46 LCDate$(plate) Last Change (Date)

47 LCTime$(plate) Last Change (Time)

Follow-Up Visit, p3 (43)

6 visitseq$(plate) Visit Sequence

0 Not checked

5 Month 1

6 Month 3

7 Month 6

8 Month 12

9 Month 18

10 Month 24

15 Month 1 (2)

16 Month 3 (2)

17 Month 6 (2)

18 Month 12 (2)

19 Month 18 (2)

20 Month 24 (2)

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7 ID$(plate) Patient number

8 initials$(plate) Initials

9 fukneeextnd FU Knee Ext ND (left)0 Unchecked

1 Checked

10 fukneeextl FU Knee Extent (L)

0 Not checked

1 Same

2 Better

3 Worse

11 fukneeextndr FU Knee Ext ND (Right)0 Unchecked

1 Checked

12 fukneeextr FU Knee Extent (R)

0 Not checked

1 Same

2 Better

3 Worse

13 fukneeflend FU Knee Flex ND (Left)0 Unchecked

1 Checked

14 fukneeflel FU Knee Flex (L)

0 Not checked

1 Same

2 Better

3 Worse

15 fukneeflendr FU Knee Flex ND (Right)0 Unchecked

1 Checked

16 fukneefler FU Knee Flex (R)

0 Not checked

1 Same

2 Better

3 Worse

17 fuankdflend FU Flex DFlex ND (Left)0 Unchecked

1 Checked

18 fuankdflel FU Ankle DFlex (L)

0 Not checked

1 Same

2 Better

3 Worse

19 fuankdflendr FU Flex DFlex ND (Right)0 Unchecked

1 Checked

20 fuankdfler FU Ankle DFlex (R)

0 Not checked

1 Same

2 Better

3 Worse

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21 fuankpflend FU Flex PFlex ND (Left)0 Unchecked

1 Checked

22 fuankpflel FU Ankle PFlex (L)

0 Not checked

1 Same

2 Better

3 Worse

23 fuankpflendr FU Flex PFlex ND (Right)0 Unchecked

1 Checked

24 fuankpfler FU Ankle PFlex (R)

0 Not checked

1 Same

2 Better

3 Worse

25 antthighnd Anterior Thigh Sensory ND0 Unchecked

1 Checked

26 antthighl Ant Thigh Sensory (L)

0 Not checked

1 Same

2 Better

3 Worse

27 antthighndL Anterior Thigh Sensory ND (Left)0 Unchecked

1 Checked

28 antthighr Ant Thigh Sensory (R)

0 Not checked

1 Same

2 Better

3 Worse

29 firstwsnd First WS Sensory ND0 Unchecked

1 Checked

30 firstwsl First WS Sensory (L)

0 Not checked

1 Same

2 Better

3 Worse

31 firstwsndL First WS Sensory ND (Left)0 Unchecked

1 Checked

32 firstwsr First WS Sensory (R)

0 Not checked

1 Same

2 Better

3 Worse

33 latcalfnd Lat Calf Sensory ND0 Unchecked

1 Checked

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34 latcalfl Lat Calf Sensory (L)

0 Not checked

1 Same

2 Better

3 Worse

35 latcalfndL Lat Calf Sensory ND (Left)0 Unchecked

1 Checked

36 latcalfr Lat Calf Sensory (R)

0 Not checked

1 Same

2 Better

3 Worse

37 latfootnd Lat Foot Sensory ND0 Unchecked

1 Checked

38 latfootl Lat Foot Sensory (L)

0 Not checked

1 Same

2 Better

3 Worse

39 latfootndL Lat Foot Sensory ND (Left)0 Unchecked

1 Checked

40 latfootr Lat Foot Sensory (R)

0 Not checked

1 Same

2 Better

3 Worse

41 postthighnd Posterior Thigh Sensory ND0 Unchecked

1 Checked

42 postthighl Posterior Thigh Sensory (L)

0 Not checked

1 Same

2 Better

3 Worse

43 postthighndL Posterior Thigh Sensory ND (Left)0 Unchecked

1 Checked

44 postthighr Posterior Thigh Sensory (R)

0 Not checked

1 Same

2 Better

3 Worse

45 kneejerknd Knee Jerk ND0 Unchecked

1 Checked

46 kneejerkl$(plate) Knee Jerk SBW (L)0 Not checked

1 Same

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2 Better

3 Worse

47 kneejerkndL Knee Jerk ND (Left)0 Unchecked

1 Checked

48 kneejerkr$(plate) Knee Jerk SBW (R)

0 Not checked

1 Same

2 Better

3 Worse

49 ankjerknd Ankle Jerk ND0 Unchecked

1 Checked

50 ankjerkl$(plate) Ankle Jerk SBW (L)

0 Not checked

1 Same

2 Better

3 Worse

51 ankjerkndL Ankle Jerk ND (Left)0 Unchecked

1 Checked

52 ankjerkr$(plate) Ankle Jerk SBW (R)

0 Not checked

1 Same

2 Better

3 Worse

53 fuxrdone FU X-Ray Done

0 Not checked

1 Yes

2 Not required

3 Not done

54 fuxrsentdt FU X-Ray Sent Date

55 reasxrnd$(plate) Reason FU X-Ray ND

56 hrctdone HR CT Done

0 Not checked

1 Yes

2 Not required

3 Not done

57 fuctsentdt FU CT Sent Date

58 reasctnd$(plate) Reason FU CT ND

59 aelastvis AE Since Last Visit

0 Not checked

2 No

1 Yes

60 LCUser$(plate) Last Change Username

61 LCDate$(plate) Last Change (Date)

62 LCTime$(plate) Last Change (Time)

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Study Exit (101)

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 exitdt Exit Date

10 exittp Study Exit

0 Not checked

1 Completed

2 Discont Premature

11 reasexit Reason Exit

0 Not checked

1 Withdrew consent

2 AE prevent participation

3 Death

4 LTFU

5 Other

12 reasexitother Reason Exit Other (Explain)

13 invrev Investigator Review of CRF0 Unchecked

1 Checked

14 LCUser$(plate) Last Change Username

15 LCDate$(plate) Last Change (Date)

16 LCTime$(plate) Last Change (Time)

Deviation (113)

6 devID Deviation ID

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 devtime Deviation Timing

0 Not checked

1 Elig

2 Baseline

3 Proc

4 Disch

5 Mo1

6 Mo3

7 Mo 6

8 Mo12

9 Mo 18

10 Mo 24

11 Exit

12 Adv Event

13 Unsch

14 Other

10 devtimothr Deviation Timing Other (Spec)

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11 devtype Deviation Type

0 Not checked

1 Cons form not signed

2 Not meet elig criteria

3 Test/proc not done

4 Test/proc not acc protocol

5 Test/proc outside window

6 Visit not done

7 Visit outside window

8 Other

12 devtypeother Deviation Type Other (Spec)

13 devdesc Deviation Description

14 invrevdev Investigator Reviewed Deviation0 Unchecked

1 Checked

15 LCUser$(plate) Last Change Username

16 LCDate$(plate) Last Change (Date)

17 LCTime$(plate) Last Change (Time)

18 fdevID$(plate) Deviation ID (Formatted)

Adverse Event, p1 (121)

6 AEID$(plate) Adverse Event ID

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 fAEID$(plate) Adverse Event ID (Formatted)

10 aestartdt AE Start Date

11 aedesc AE Description (Short)

12 aedesclong AE Descr Long

13 ifuseexp iFuse Explanted As Result of AE

0 Not checked

2 No

1 Yes

14 expreason Explant Reason

15 aesev AE Severity

0 Not checked

1 Mild

2 Moderate

3 Severe

16 aerelatdev AE Relatedness to iFuse

0 Not checked

1 Not related

2 Unlikely related

3 Possibly related

4 Probably related

5 Definitely related

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6 Not applicable

17 aerelatproc AE Relatedness to Procedure

0 Not checked

1 Not related

2 Unlikely related

3 Possibly related

4 Probably related

5 Definitely related

6 Not applicable

18 aerelatpre AE Relatedness to Prev Condition

0 Not checked

1 Not related

2 Unlikely related

3 Possibly related

4 Probably related

5 Definitely related

6 Not applicable

19 aerelatprocSIJ AE Relatedness to Proc for SIJ

0 Not checked

1 Not related

2 Unlikely related

3 Possibly related

4 Probably related

5 Definitely related

6 Not applicable

20 precond Previous Condition (Relatedness)

21 LCUser$(plate) Last Change Username

22 LCDate$(plate) Last Change (Date)

23 LCTime$(plate) Last Change (Time)

Adverse Event, p2 (122)

6 AEID$(plate) Adverse Event ID

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 fAEID$(plate) Adverse Event ID (Formatted)

10 aedeath AE Lead to Death0 Unchecked

1 Checked

11 issae SAE (Med Monitor)

0 Not checked

1 Yes

2 No

12 aethreat AE Caused Life-Threatening Problem0 Unchecked

1 Checked

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13 aeperm AE Caused Permanent Injury0 Unchecked

1 Checked

14 aeprol AE Prolonged Hosp0 Unchecked

1 Checked

15 aeinterv AE Required Intervention0 Unchecked

1 Checked

16 aenone AE Consequences None0 Unchecked

1 Checked

17 aenotreat AE Not Treatment0 Unchecked

1 Checked

18 aemed AE Medical Treatment0 Unchecked

1 Checked

19 aemedtreat Medical Treatment Provided

20 aeproc AE Procedure Treatment0 Unchecked

1 Checked

21 aeproctreat Procedure Treatment Provided

22 aesurg AE Surgical Treatment0 Unchecked

1 Checked

23 aesurgtreat Surgical Treatment Provided

24 aeoth AE Other Treat0 Unchecked

1 Checked

25 aeothtreat Other Treatment Provided

26 aeout AE Outcome

0 Not checked

1 Resolved

2 Ongoing

3 Death

4 Other

27 aeoutother AE Outcome Other (Spec)

28 aeoutdt AE Outcome Date

29 aerptirb AE Reported to IRB

0 Not checked

1 Yes

2 No

30 aeirbrptdt AE IRB Report Date

31 reasnotrep Reason Not Reported

32 invrevae Investigator Has Reviewed Adv Event0 Unchecked

1 Checked

33 LCUser$(plate) Last Change Username

34 LCDate$(plate) Last Change (Date)

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35 LCTime$(plate) Last Change (Time)

Medical Monitor Eval (123)

6 AEID$(plate) Adverse Event ID

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 aerptdt AE Reported to SI-B Date

10 mmaeshort Med Monitor: AE Brief Description

11 aecat AE Category

12 deathsi Death or Serious Injury

0 Not checked

2 No

1 Yes

13 devmalinj Device Malf Would Cause Injury

0 Not checked

2 No

1 Yes

14 serpub Serious Public Health Threat

0 Not checked

2 No

1 Yes

15 aelinkedmalf AE Linked to Malfunction

0 Not checked

2 No

1 Yes

16 defobv Deficiency Obvious?

0 Not checked

2 No

1 Yes

17 fsareq Field Safety Action Required

0 Not checked

2 No

1 Yes

18 addeventchar Additional Event Characteristics

0 Not checked

2 No

1 Yes

19 aeevalcomm AE Eval Comments

20 LCUser$(plate) Last Change Username

21 LCDate$(plate) Last Change (Date)

22 LCTime$(plate) Last Change (Time)

Revision (124)

6 AEID$(plate) Adverse Event ID

7 ID$(plate) Patient number

8 initials$(plate) Initials

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9 revisedside Revised Side

0 Not checked

1 Index

2 Contralateral

10 insurgdt Index surgery date

11 revsurgdt Revision Surgery Date

12 reasrev Reason for Revision

13 revdes Revision Description

Narrative (131)

6 narrID$(plate) Narrative ID

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 narr Narrative

10 LCUser$(plate) Last Change Username

11 LCDate$(plate) Last Change (Date)

12 LCTime$(plate) Last Change (Time)

Device Malfunction (141)

6 devmalID$(plate) Device Malfunction ID

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 devmalfdt Device Malfunction Date

10 malftype Malfunction Type

0 Not checked

1 Instrument broke

2 Broach did not create channel

3 Soft tissue dilator did not engage

4 Impactor did not direct

5 Pin damaged during drilling

6 Pin guide inadequate spacing

7 Drill bit stuck to pin

8 Removal tool did not engage

9 Other

11 malftypeother Malfunction Type Other

12 malfdet Malfunction Detailed Desc

13 aemalf AE Related to Malfunction

0 Not checked

2 No

1 Yes

14 LCUser$(plate) Last Change Username

15 LCDate$(plate) Last Change (Date)

16 LCTime$(plate) Last Change (Time)

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VAS (151)

6 visitseq$(plate) Visit Sequence

999 Not checked

1 Baseline

5 Month 1

6 Month 3

7 Month 6

8 Month 12

9 Month 18

10 Month 24

15 Month 1 (2)

16 Month 3 (2)

17 Month 6 (2)

18 Month 12 (2)

19 Month 18 (2)

20 Month 24 (2)

0 Eligibility

12 Prior to 2nd Proc

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 vaslb VAS Lower Back

10 vassij VAS Pelvis/buttocks

ODI (152)

6 visitseq$(plate) Visit Sequence

999 Not checked

1 Baseline

5 Month 1

6 Month 3

7 Month 6

8 Month 12

9 Month 18

10 Month 24

15 Month 1 (2)

16 Month 3 (2)

17 Month 6 (2)

18 Month 12 (2)

19 Month 18 (2)

20 Month 24 (2)

0 Eligibility

12 Prior to 2nd Proc

7 ID$(plate) Patient number

8 initials$(plate) Initials

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9 odi1 ODI 1

98 Not checked

0 0

1 1

2 2

3 3

4 4

5 5

10 odi2 ODI 2

98 Not checked

0 0

1 1

2 2

3 3

4 4

5 5

11 odi3 ODI 3

98 Not checked

0 0

1 1

2 2

3 3

4 4

5 5

12 odi4 ODI 4

98 Not checked

0 0

1 1

2 2

3 3

4 4

5 5

13 odi5 ODI 5

98 Not checked

0 0

1 1

2 2

3 3

4 4

5 5

14 odi6 ODI 6

98 Not checked

0 0

1 1

2 2

3 3

4 4

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5 5

15 odi7 ODI 7

98 Not checked

0 0

1 1

2 2

3 3

4 4

5 5

16 odi8 ODI 8

98 Not checked

0 0

1 1

2 2

3 3

4 4

5 5

99 Not answered

17 odi9 ODI 9

98 Not checked

0 0

1 1

2 2

3 3

4 4

5 5

18 odi10 ODI 10

98 Not checked

0 0

1 1

2 2

3 3

4 4

5 5

SF36 (153)

6 visitseq$(plate) Visit Sequence

999 Not checked

1 Baseline

5 Month 1

6 Month 3

7 Month 6

8 Month 12

9 Month 18

10 Month 24

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15 Month 1 (2)

16 Month 3 (2)

17 Month 6 (2)

18 Month 12 (2)

19 Month 18 (2)

20 Month 24 (2)

0 Eligibility

12 Prior to 2nd Proc

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 sf1 SF36-1

10 sf2 SF36-2

11 sf3a SF36-3a

12 sf3b SF36-3b

13 sf3c SF36-3c

14 sf3d SF36-3d

15 sf3e SF36-3e

16 sf3f SF36-3f

17 sf3g SF36-3g

18 sf3h SF36-3h

19 sf3i SF36-3i

20 sf3j SF36-3j

21 sf4a SF36-4a

22 sf4b SF36-4b

23 sf4c SF36-4c

24 sf4d SF36-4d

25 sf5a SF36-5a

26 sf5b SF36-5b

27 sf5c SF36-5c

28 sf6 SF36-6

29 sf7 SF36-7

30 sf8 SF36-8

31 sf9a SF36-9a

32 sf9b SF36-9b

33 sf9c SF36-9c

34 sf9d SF36-9d

35 sf9e SF36-9e

36 sf9f SF36-9f

37 sf9g SF36-9g

38 sf9h SF36-9h

39 sf9i SF36-9i

40 sf10 SF36-10

41 sf11a SF36-11a

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42 sf11b SF36-11b

43 sf11c SF36-11c

44 sf11d SF36-11d

EQ5D (154)

6 visitseq$(plate) Visit Sequence

999 Not checked

1 Baseline

5 Month 1

6 Month 3

7 Month 6

8 Month 12

9 Month 18

10 Month 24

15 Month 1 (2)

16 Month 3 (2)

17 Month 6 (2)

18 Month 12 (2)

19 Month 18 (2)

20 Month 24 (2)

0 Eligibility

12 Prior to 2nd Proc

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 eq1 EQ5D-1

0 Not checked

1 1

2 2

3 3

10 eq2 EQ5D-2

0 Not checked

1 1

2 2

3 3

11 eq3 EQ5D-3

0 Not checked

1 1

2 2

3 3

12 eq4 EQ5D-4

0 Not checked

1 1

2 2

3 3

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13 eq5 EQ5D-5

0 Not checked

1 1

2 2

3 3

14 eqvas EQ5D VAS

Satisfaction (155)

6 visitseq$(plate) Visit Sequence

999 Not checked

1 Baseline

5 Month 1

6 Month 3

7 Month 6

8 Month 12

9 Month 18

10 Month 24

15 Month 1 (2)

16 Month 3 (2)

17 Month 6 (2)

18 Month 12 (2)

19 Month 18 (2)

20 Month 24 (2)

0 Eligibility

12 Prior to 2nd Proc

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 satisf$(plate) Satisfaction w Treatment

0 Not checked

1 Very dissatisfied

2 Somewhat dissatisfied

3 Somewhat satisfied

4 Very satisfied

10 ifagain Undergo iFuse Again

0 Not checked

1 Not have

2 Might have

3 Definitely have

9 NA

Denver SIJ Questionnaire (156)

6 visitseq$(plate) Visit Sequence

999 Not checked

1 Baseline

5 Month 1

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6 Month 3

7 Month 6

8 Month 12

9 Month 18

10 Month 24

15 Month 1 (2)

16 Month 3 (2)

17 Month 6 (2)

18 Month 12 (2)

19 Month 18 (2)

20 Month 24 (2)

0 Eligibility

12 Prior to 2nd Proc

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 dq1 DSIJQ Q1

99 Not checked

0 0

1 1

2 2

3 3

4 4

5 5

10 dq2 DSIJQ Q2

99 Not checked

0 0

1 1

2 2

3 3

4 4

5 5

11 dq3 DSIJQ Q3

99 Not checked

0 0

1 1

2 2

3 3

4 4

5 5

12 dq4 DSIJQ Q4

99 Not checked

0 0

1 1

2 2

3 3

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4 4

5 5

13 dq5 DSIJQ Q5

99 Not checked

0 0

1 1

2 2

3 3

4 4

5 5

14 dq6 DSIJQ Q6

99 Not checked

0 0

1 1

2 2

3 3

4 4

5 5

15 dq7 DSIJQ Q7

99 Not checked

0 0

1 1

2 2

3 3

4 4

5 5

16 dq8 DSIJQ Q8

99 Not checked

0 0

1 1

2 2

3 3

4 4

5 5

17 dq9 DSIJQ Q9

99 Not checked

0 0

1 1

2 2

3 3

4 4

5 5

18 dq10 DSIJQ Q10

99 Not checked

0 0

1 1

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2 2

3 3

4 4

5 5

Payment (161)

6 payID Payment ID

0 Not checked

1 Baseline

5 Month 1

6 Month 3

7 Month 6

8 Month 12

9 Month 18

10 Month 24

7 ID$(plate) Patient number

8 cardID1 Card ID 1

9 cardsentdt1 Card Sent Date 1

10 cardptID1 Card Patient ID 1

11 payID1 Payment ID1

0 Not checked

1 Baseline

5 Month 1

6 Month 3

7 Month 6

8 Month 12

9 Month 18

10 Month 24

X-Ray (Reader 1), Radiol/Failure (171)

6 visitseq$(plate) Visit Sequence

99 Not checked

3 Discharge

6 Month 3

7 Month 6

10 Month 24

16 Month 3 (cross)

17 Month 6 (cross)

20 Month 24 (cross)

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 implantloc$(plate) Implant Location0 Not checked

1 Right

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2 Left

3 Bilateral

10 xradiolucr3 Radiolucency X-Ray (Right) Mo 3

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

5 Not available

11 xradiolucr6 Radiolucency X-Ray (Right) Mo 6

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

5 Not available

12 xradiolucr24 Radiolucency X-Ray (Right) Mo 24

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

5 Not available

13 xradiolucl3 Radiolucency X-Ray (Left) Mo 3

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

5 Not available

14 xradiolucl6 Radiolucency X-Ray (Left) Mo 6

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

5 Not available

15 xradiolucl24 Radiolucency X-Ray (Left) Mo 24

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

5 Not available

16 xradiocommr$(plate) Radiorucency X-Ray (Right) Comment

17 xradiocomml$(plate) Radiolucency X-Ray (Left) Comment

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18 xdevfailr3 Device Failure on X-Ray (Right) Mo 3

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

5 Not available

19 xdevfailr6 Device Failure on X-Ray (Right) Mo 6

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

5 Not available

20 xdevfailr24 Device Failure on X-Ray (Right) Mo 24

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

5 Not available

21 xdevfaill3 Device Failure X-Ray (Left) Mo 3

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

5 Not available

22 xdevfaill6 Device Failure X-Ray (Left) Mo 6

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

5 Not available

23 xdevfaill24 Device Failure X-Ray (Left) Mo 24

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

5 Not available

24 xdevfailcommr$(plate) Device Failure X-ray Comments (Right)

25 xdevfailcomml$(plate) Device Failure X-ray Comments (Left)

26 LCUser$(plate) Last Change Username

27 LCDate$(plate) Last Change (Date)

28 LCTime$(plate) Last Change (Time)

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X-Ray (Reader 1), Breach/Mig (172)

6 visitseq$(plate) Visit Sequence

99 Not checked

3 Discharge

6 Month 3

7 Month 6

10 Month 24

16 Month 3 (cross)

17 Month 6 (cross)

20 Month 24 (cross)

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 devmigr3 Device Migration X-Ray (Right) Mo 3

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

5 Not available

10 devmigr6 Device Migration X-Ray (Right) Mo 6

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

5 Not available

11 devmigr24 Device Migration X-Ray (Right) Mo 24

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

5 Not available

12 devmigl3 Device Migration X-Ray (Left) Mo 3

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

5 Not available

13 devmigl6 Device Migration X-Ray (Left) Mo 6

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

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5 Not available

14 devmigl24 Device Migration X-Ray (Left) Mo 24

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

5 Not available

15 xdevmigcommr$(plate) Device Migration X-Ray (Right) Comment

16 xdevmigcomml$(plate) Device Migration X-Ray (Left) Comment

17 LCUser$(plate) Last Change Username

18 LCDate$(plate) Last Change (Date)

19 LCTime$(plate) Last Change (Time)

X-Ray (Reader 1), Bone Rxn (173)

6 visitseq$(plate) Visit Sequence

99 Not checked

3 Discharge

6 Month 3

7 Month 6

10 Month 24

16 Month 3 (cross)

17 Month 6 (cross)

20 Month 24 (cross)

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 xadvbrr3 Adverse Bone Rxn X-ray (Right) Mo 3

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

5 Not available

10 xadvbrr6 Adverse Bone Rxn X-ray (Right) Mo 6

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

5 Not available

11 xadvbrr24 Adverse Bone Rxn X-ray (Right) Mo 24

0 Not checked

1 Absent

2 Present

3 Indeterminate

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4 Unable to assess

5 Not available

12 xadvbrcommr$(plate) Adv Bone Rxn X-Ray (Right) Comment

13 xadvbrl3 Adverse Bone Rxn X-ray (Left) Mo 3

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

5 Not available

14 xadvbrl6 Adverse Bone Rxn X-ray (Left) Mo 6

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

5 Not available

15 xadvbrl24 Adverse Bone Rxn X-ray (Left) Mo 24

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

5 Not available

16 xadvbrcomml$(plate) Adv Bone Rxn X-Ray (Left) Comment

17 xposbrr3 Pos Bone Remodel X-ray (Right) Mo 3

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

5 Not available

18 xposbrr6 Pos Bone Remodel X-ray (Right) Mo 6

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

5 Not available

19 xposbrr24 Pos Bone Remodel X-ray (Right) Mo 24

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

5 Not available

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20 xposbrcommr$(plate) Pos Bone Remodel X-ray Comm (Right)

21 xposbrl3 Pos Bone Remodel X-ray (Left) Mo 3

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

5 Not available

22 xposbrl6 Pos Bone Remodel X-ray (Left) Mo 6

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

5 Not available

23 xposbrl24 Pos Bone Remodel X-ray (Left) Mo 24

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

5 Not available

24 xposbrcomml$(plate) Pos Bone Remodel X-ray Comm (Left)

25 xaddobs$(plate) X-Ray Additional Observations

26 LCUser$(plate) Last Change Username

27 LCDate$(plate) Last Change (Date)

28 LCTime$(plate) Last Change (Time)

X-Ray (Reader 2), Radiol/Failure (174)

6 visitseq$(plate) Visit Sequence

99 Not checked

3 Discharge

6 Month 3

7 Month 6

10 Month 24

16 Month 3 (cross)

17 Month 6 (cross)

20 Month 24 (cross)

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 implantloc$(plate) Implant Location

0 Not checked

1 Right

2 Left

3 Bilateral

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10 xradiolucr$(plate) Radiolucency X-Ray (Right)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

11 xradiocommr$(plate) Radiorucency X-Ray (Right) Comment

12 xradiolucl$(plate) Radiolucency X-Ray (Left)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

13 xradiocomml$(plate) Radiolucency X-Ray (Left) Comment

14 xdevfailr$(plate) Device Failure on X-Ray (Right)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

15 xdevfailcommr$(plate) Device Failure X-ray Comments (Right)

16 xdevfaill$(plate) Device Failure X-Ray (Left)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

17 xdevfailcomml$(plate) Device Failure X-ray Comments (Left)

18 LCUser$(plate) Last Change Username

19 LCDate$(plate) Last Change (Date)

20 LCTime$(plate) Last Change (Time)

X-Ray (Reader 2), Breach/Mig (175)

6 visitseq$(plate) Visit Sequence

99 Not checked

3 Discharge

6 Month 3

7 Month 6

10 Month 24

16 Month 3 (cross)

17 Month 6 (cross)

20 Month 24 (cross)

7 ID$(plate) Patient number

8 initials$(plate) Initials

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9 xbreachr$(plate) Breach X-ray (Right)

0 Not checked

1 Absent

2 Present - sacral canal

3 Present sacral foramen

4 Present - anterior sacrum

5 Present - other

6 Indeterminate

7 Unable to assess

10 xbreachcommr$(plate) Beach X-Ray (Right) Comment

11 xbreachl$(plate) Breach X-ray (Left)

0 Not checked

1 Absent

2 Present - sacral canal

3 Present sacral foramen

4 Present - anterior sacrum

5 Present - other

6 Indeterminate

7 Unable to assess

12 xbreachcomml$(plate) Breach X-Ray (Left) Comment

13 devmigr$(plate) Device Migration X-Ray (Right)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

14 xdevmigcommr$(plate) Device Migration X-Ray (Right) Comment

15 devmigl$(plate) Device Migration X-Ray (Left)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

16 xdevmigcomml$(plate) Device Migration X-Ray (Left) Comment

17 LCUser$(plate) Last Change Username

18 LCDate$(plate) Last Change (Date)

19 LCTime$(plate) Last Change (Time)

X-Ray (Reader 2), Bone Rxn (176)

6 visitseq$(plate) Visit Sequence

99 Not checked

3 Discharge

6 Month 3

7 Month 6

10 Month 24

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16 Month 3 (cross)

17 Month 6 (cross)

20 Month 24 (cross)

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 xadvbrr$(plate) Adverse Bone Rxn X-ray (Right)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

10 xadvbrcommr$(plate) Adv Bone Rxn X-Ray (Right) Comment

11 xadvbrl$(plate) Adverse Bone Rxn X-ray (Left)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

12 xadvbrcomml$(plate) Adv Bone Rxn X-Ray (Left) Comment

13 xposbrr$(plate) Pos Bone Remodel X-ray (Right)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

14 xposbrcommr$(plate) Pos Bone Remodel X-ray Comm (Right)

15 xposbrl$(plate) Pos Bone Remodel X-ray (Left)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

16 xposbrcomml$(plate) Pos Bone Remodel X-ray Comm (Left)

17 xaddobs$(plate) X-Ray Additional Observations

18 LCUser$(plate) Last Change Username

19 LCDate$(plate) Last Change (Date)

20 LCTime$(plate) Last Change (Time)

X-Ray (Reader 3), Radiol/Failure (177)

6 visitseq$(plate) Visit Sequence

99 Not checked

3 Discharge

6 Month 3

7 Month 6

10 Month 24

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16 Month 3 (cross)

17 Month 6 (cross)

20 Month 24 (cross)

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 implantloc$(plate) Implant Location

0 Not checked

1 Right

2 Left

3 Bilateral

10 xradiolucr$(plate) Radiolucency X-Ray (Right)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

11 xradiocommr$(plate) Radiorucency X-Ray (Right) Comment

12 xradiolucl$(plate) Radiolucency X-Ray (Left)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

13 xradiocomml$(plate) Radiolucency X-Ray (Left) Comment

14 xdevfailr$(plate) Device Failure on X-Ray (Right)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

15 xdevfailcommr$(plate) Device Failure X-ray Comments (Right)

16 xdevfaill$(plate) Device Failure X-Ray (Left)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

17 xdevfailcomml$(plate) Device Failure X-ray Comments (Left)

18 LCUser$(plate) Last Change Username

19 LCDate$(plate) Last Change (Date)

20 LCTime$(plate) Last Change (Time)

X-Ray (Reader 3), Breach/Mig (178)

6 visitseq$(plate) Visit Sequence99 Not checked

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3 Discharge

6 Month 3

7 Month 6

10 Month 24

16 Month 3 (cross)

17 Month 6 (cross)

20 Month 24 (cross)

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 xbreachr$(plate) Breach X-ray (Right)

0 Not checked

1 Absent

2 Present - sacral canal

3 Present sacral foramen

4 Present - anterior sacrum

5 Present - other

6 Indeterminate

7 Unable to assess

10 xbreachcommr$(plate) Beach X-Ray (Right) Comment

11 xbreachl$(plate) Breach X-ray (Left)

0 Not checked

1 Absent

2 Present - sacral canal

3 Present sacral foramen

4 Present - anterior sacrum

5 Present - other

6 Indeterminate

7 Unable to assess

12 xbreachcomml$(plate) Breach X-Ray (Left) Comment

13 devmigr$(plate) Device Migration X-Ray (Right)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

14 xdevmigcommr$(plate) Device Migration X-Ray (Right) Comment

15 devmigl$(plate) Device Migration X-Ray (Left)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

16 xdevmigcomml$(plate) Device Migration X-Ray (Left) Comment

17 LCUser$(plate) Last Change Username

18 LCDate$(plate) Last Change (Date)

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19 LCTime$(plate) Last Change (Time)

X-Ray (Reader 3), Bone Rxn (179)

6 visitseq$(plate) Visit Sequence

99 Not checked

3 Discharge

6 Month 3

7 Month 6

10 Month 24

16 Month 3 (cross)

17 Month 6 (cross)

20 Month 24 (cross)

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 xadvbrr$(plate) Adverse Bone Rxn X-ray (Right)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

10 xadvbrcommr$(plate) Adv Bone Rxn X-Ray (Right) Comment

11 xadvbrl$(plate) Adverse Bone Rxn X-ray (Left)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

12 xadvbrcomml$(plate) Adv Bone Rxn X-Ray (Left) Comment

13 xposbrr$(plate) Pos Bone Remodel X-ray (Right)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

14 xposbrcommr$(plate) Pos Bone Remodel X-ray Comm (Right)

15 xposbrl$(plate) Pos Bone Remodel X-ray (Left)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

16 xposbrcomml$(plate) Pos Bone Remodel X-ray Comm (Left)

17 xaddobs$(plate) X-Ray Additional Observations

18 LCUser$(plate) Last Change Username

19 LCDate$(plate) Last Change (Date)

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20 LCTime$(plate) Last Change (Time)

X-Ray QC (181)

6 visitseq$(plate) Visit Sequence

99 Not checked

3 Discharge

6 Month 3

7 Month 6

10 Month 24

16 Month 3 (cross)

17 Month 6 (cross)

20 Month 24 (cross)

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 radtakendt$(plate) Date X-Ray Taken

10 imgnd$(plate) Images Not Done0 Unchecked

1 Checked

11 imgndreas Images Not Done Reason

12 qcdt CRL QC Date

13 qcrevAP QC Reviewed: AP (not required)0 Unchecked

1 Checked

14 qcrevInlet QC Reviewed: Inlet0 Unchecked

1 Checked

15 qcrevOutlet QC Reviewed: Outlet0 Unchecked

1 Checked

16 qcrevLateral QC Reviewed: Lateral0 Unchecked

1 Checked

17 qcxradiol QC X-Ray Radiolucency

0 Not checked

1 Sufficient

2 Insufficient

18 qcxfail QC X-Ray Device Failure

0 Not checked

1 Sufficient

2 Insufficient

19 qcxbreach QC X-Ray Device Breach

0 Not checked

1 Sufficient

2 Insufficient

20 qcxmig QC X-Ray Device Migration

0 Not checked

1 Sufficient

2 Insufficient

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21 qcxabr QC X-Ray Adverse Bone Rxn

0 Not checked

1 Sufficient

2 Insufficient

22 qcxpbmr QC X-Ray Pos Bone Remodeling Response

0 Not checked

1 Sufficient

2 Insufficient

23 qccommxrViews QC Comm (X-Ray): Views

24 qccommxrExpos QC Comm (X-Ray): Expos

25 qccommxrVisib QC Comm (X-Ray): Visib

26 qccommxrArtifact QC Comm (X-Ray): Artifact

27 qccommxrpos QC Comm (X-Ray): Positioningo

28 qccommxrOther QC Comm (X-Ray): Other

29 LCUser$(plate) Last Change Username

30 LCDate$(plate) Last Change (Date)

31 LCTime$(plate) Last Change (Time)

CT QC (182)

6 visitseq$(plate) Visit Sequence

0 Not checked

8 Month 12

18 Month 12 (Cross)

88 Other

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 radtakendt$(plate) Date CT Taken

10 imgnd$(plate) Images Not Done0 Unchecked

1 Checked

11 imgndreas$(plate) Images Not Done Reason

12 qcdt$(plate) CRL QC Date

13 qcctapp QC CT Apposition Bone

0 Not checked

1 Sufficient

2 Insufficient

14 qcctradiol QC CT Radiolucency

0 Not checked

1 Sufficient

2 Insufficient

15 qcctfail QC CT Dev Failure

0 Not checked

1 Sufficient

2 Insufficient

16 qcctbreach QC CT Dev Breach0 Not checked

1 Sufficient

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2 Insufficient

17 qcctmig QC CT Dev Migration

0 Not checked

1 Sufficient

2 Insufficient

18 qcctabr QC CT Adv Bone Rxn

0 Not checked

1 Sufficient

2 Insufficient

19 qcctbrid QC CT Bridging Bone

0 Not checked

1 Sufficient

2 Insufficient

20 qcctbridext QC CT Bridging Bone Extent

0 Not checked

1 Sufficient

2 Insufficient

21 qcctho QC CT Hetero Oss

0 Not checked

1 Sufficient

2 Insufficient

22 qcctpbmr QC CT Pos Bone Remod

0 Not checked

1 Sufficient

2 Insufficient

23 qccommctFOV QC Comm (CT): FOV

24 qccommctWindow QC Comm (CT): Window

25 qccommctSlice QC Comm (CT): Slice Thickness

26 qccommctArtifact QC Comm (CT): Artifact

27 qccommctOther QC Comm (CT): Other

28 LCUser$(plate) Last Change Username

29 LCDate$(plate) Last Change (Date)

30 LCTime$(plate) Last Change (Time)

Unsch Visit (201)

6 unsvisitID$(plate) Unscheduled Visit ID

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 unsvisdt Unscheduled Visit Date

10 reasvisit Reason for Unsc Visit

11 pefind Phys Exam Findings

0 Not checked

1 Normal

2 Not normal

12 pedesc Phys Exam Description

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13 uxrdone Unsc X-Ray Done0 Unchecked

1 Checked

14 uctdone Unsc CT Done0 Unchecked

1 Checked

15 umridone Unsc MRI Done0 Unchecked

1 Checked

16 uothdone Unsc Other Imaging Done0 Unchecked

1 Checked

17 uothimgspec Unsc Other Imaging Done (Spec)

18 imgres Imaging Results

19 LCUser$(plate) Last Change Username

20 LCDate$(plate) Last Change (Date)

21 LCTime$(plate) Last Change (Time)

Unsch Visit, p2 (202)

6 unsvisitID$(plate) Unscheduled Visit ID

7 ID$(plate) Patient number

8 initials$(plate) Initials

Sponsor Billing (301)

6 invoiceID$(plate) Invoice ID

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 servtp Service Type

0 Not checked

1 Diagnostic SI joint injection

2 iFuse procedure physician fee

3 iFuse procedure hospital fee

4 Therapeutic SI joint injection

5 RF ablation of SI joint

6 Phys therapy (eval)

7 Phys therapy (routine)

8 X-Ray of SI joint

9 CT scan of SI joint

10 Other

11 Anesthesia services

10 svccomm Service Comment

11 visitseq$(plate) Visit Sequence

99 Not checked

0 Screening

1 Baseline

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2 Procedure

3 Discharge

5 Month 1

6 Month 3

7 Month 6

8 Month 12

9 Month 18

10 Month 24

12 Proc (2)

13 Disch (2)

15 Month 1 (2)

16 Month 3 (2)

17 Month 6 (2)

18 Month 12 (2)

19 Month 18 (2)

20 Month 24 (2)

21 Miscellaneous

12 servdt1 Service Date (1)

13 servdt2 Service Date (2)

14 nocharges Payor Not Charged0 Unchecked

1 Checked

15 dispinvID Displayed Invoice ID

(R1) 12 Mo CT, apposition (311)

6 visitseq$(plate) Visit Sequence

0 Not checked

8 Month 12

18 Month 12 (Cross)

88 Other

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 implantloc$(plate) Implant Location (CT)

0 Not checked

1 Right

2 Left

3 Bilateral

10 appsac1r Appos Sacral 1 (Right)

0 Not checked

1 >30%

2 <30%

3 Indeterminate

4 Unable to assess

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11 appil1r Appos Ilial 1 (Right)

0 Not checked

1 >30%

2 <30%

3 Indeterminate

4 Unable to assess

12 appsac2r Appos Sacral 2 (Right)

0 Not checked

1 >30%

2 <30%

3 Indeterminate

4 Unable to assess

13 appil2r Appos Ilial 2 (Right)

0 Not checked

1 >30%

2 <30%

3 Indeterminate

4 Unable to assess

14 appsac3r Appos Sacral 3 (Right)

0 Not checked

1 >30%

2 <30%

3 Indeterminate

4 Unable to assess

15 appil3r Appos Ilial 3 (Right)

0 Not checked

1 >30%

2 <30%

3 Indeterminate

4 Unable to assess

16 appsac4r Appos Sacral 4 (Right)

0 Not checked

1 >30%

2 <30%

3 Indeterminate

4 Unable to assess

17 appil4r Appos Ilial 4 (Right)

0 Not checked

1 >30%

2 <30%

3 Indeterminate

4 Unable to assess

18 appsac1l Appos Sacral 1 (Left)

0 Not checked

1 >30%

2 <30%

3 Indeterminate

4 Unable to assess

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19 appil1l Appos Ilial 1 (Left)

0 Not checked

1 >30%

2 <30%

3 Indeterminate

4 Unable to assess

20 appsac2l Appos Sacral 2 (Left)

0 Not checked

1 >30%

2 <30%

3 Indeterminate

4 Unable to assess

21 appil2l Appos Ilial 2 (Left)

0 Not checked

1 >30%

2 <30%

3 Indeterminate

4 Unable to assess

22 appsac3l Appos Sacral 3 (Left)

0 Not checked

1 >30%

2 <30%

3 Indeterminate

4 Unable to assess

23 appil3l Appos Ilial 3 (Left)

0 Not checked

1 >30%

2 <30%

3 Indeterminate

4 Unable to assess

24 appsac4l Appos Sacral 4 (Left)

0 Not checked

1 >30%

2 <30%

3 Indeterminate

4 Unable to assess

25 appil4l Appos Ilial 4 (Left)

0 Not checked

1 >30%

2 <30%

3 Indeterminate

4 Unable to assess

26 ctcomm CT Comments

27 LCUser$(plate) Last Change Username

28 LCDate$(plate) Last Change (Date)

29 LCTime$(plate) Last Change (Time)

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(R1) 12 Mo CT, lucency (312)

6 visitseq$(plate) Visit Sequence

0 Not checked

8 Month 12

18 Month 12 (Cross)

88 Other

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 ctradiolucr CT Radiolucency (Right)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

10 ctradioluccommr CT Radiolucency Comment (Right)

11 ctradiolextr1 CT Radiol Extent (Right 1)

0 Not checked

1 None

2 <15%

3 15-50%

4 50-100%

5 Indeterminate

6 Unable to assess

7 No implant

12 ctradiolextr2 CT Radiol Extent (Right 2)

0 Not checked

1 None

2 <15%

3 15-50%

4 50-100%

5 Indeterminate

6 Unable to assess

7 No implant

13 ctradiolextr3 CT Radiol Extent (Right 3)

0 Not checked

1 None

2 <15%

3 15-50%

4 50-100%

5 Indeterminate

6 Unable to assess

7 No implant

14 ctradiolextr4 CT Radiol Extent (Right 4)

0 Not checked

1 None

2 <15%

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3 15-50%

4 50-100%

5 Indeterminate

6 Unable to assess

7 No implant

15 ctradlocilr1 CT Radioluc Location Ilial (Right 1)0 Unchecked

1 Checked

16 ctradlocsacr1 CT Radioluc Location Sacral (Right 1)0 Unchecked

1 Checked

17 ctradlocilr2 CT Radioluc Location Ilial (Right 2)0 Unchecked

1 Checked

18 ctradlocsacr2 CT Radioluc Location Sacral (Right 2)0 Unchecked

1 Checked

19 ctradlocilr3 CT Radioluc Location Ilial (Right 3)0 Unchecked

1 Checked

20 ctradlocsacr3 CT Radioluc Location Sacral (Right 3)0 Unchecked

1 Checked

21 ctradlocilr4 CT Radioluc Location Ilial (Right 4)0 Unchecked

1 Checked

22 ctradlocsacr4 CT Radioluc Location Sacral (Right 4)0 Unchecked

1 Checked

23 ctradiolucl CT Radiolucency (Left)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

24 ctradioluccomml CT Radiolucency Comment (Left)

25 ctradiolextl1 CT Radiol Extent (Left 1)

0 Not checked

1 None

2 <15%

3 15-50%

4 50-100%

5 Indeterminate

6 Unable to assess

7 No implant

26 ctradiolextl2 CT Radiol Extent (Left 2)

0 Not checked

1 None

2 <15%

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3 15-50%

4 50-100%

5 Indeterminate

6 Unable to assess

7 No implant

27 ctradiolextl3 CT Radiol Extent (Left 3)

0 Not checked

1 None

2 <15%

3 15-50%

4 50-100%

5 Indeterminate

6 Unable to assess

7 No implant

28 ctradiolextl4 CT Radiol Extent (Left 4)

0 Not checked

1 None

2 <15%

3 15-50%

4 50-100%

5 Indeterminate

6 Unable to assess

7 No implant

29 ctradlocill1 CT Radioluc Location Ilial (Left 1)0 Unchecked

1 Checked

30 ctradlocsacl1 CT Radioluc Location Sacral (Left 1)0 Unchecked

1 Checked

31 ctradlocill2 CT Radioluc Location Ilial (Left 2)0 Unchecked

1 Checked

32 ctradlocsacl2 CT Radioluc Location Sacral (Left 2)0 Unchecked

1 Checked

33 ctradlocill3 CT Radioluc Location Ilial (Left 3)0 Unchecked

1 Checked

34 ctradlocsacl3 CT Radioluc Location Sacral (Left 3)0 Unchecked

1 Checked

35 ctradlocill4 CT Radioluc Location Ilial (Left 4)0 Unchecked

1 Checked

36 ctradlocsacl4 CT Radioluc Location Sacral (Left 4)0 Unchecked

1 Checked

37 LCUser$(plate) Last Change Username

38 LCDate$(plate) Last Change (Date)

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39 LCTime$(plate) Last Change (Time)

(R1) 12 Mo CT, failure/breach (313)

6 visitseq$(plate) Visit Sequence

0 Not checked

8 Month 12

18 Month 12 (Cross)

88 Other

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 ctdevfailr CT Device Failure (Right)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

10 ctrdevfailcommr CT Dev Fail Comment (Right)

11 ctdevbreachr CT Device Breach (Right)

0 Not checked

1 Absent

2 Present - sacral canal

3 Present - sacral foramen

4 Present - anterior sacrum

5 Present - other

6 Indeterminate

7 Unable to assess

12 ctdevbreachcommr CT Device Breach Comment (Right)

13 ctdevfaill CT Device Failure (Left)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

14 ctrdevfailcomml CT Dev Fail Comment (Left)

15 ctdevbreachl CT Device Breach (Left)

0 Not checked

1 Absent

2 Present - sacral canal

3 Present - sacral foramen

4 Present - anterior sacrum

5 Present - other

6 Indeterminate

7 Unable to assess

16 ctdevbreachcomml CT Device Breach Comment (Left)

17 LCUser$(plate) Last Change Username

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18 LCDate$(plate) Last Change (Date)

19 LCTime$(plate) Last Change (Time)

(R1) 12 Mo CT, migration/bone rxn (314)

6 visitseq$(plate) Visit Sequence

0 Not checked

8 Month 12

18 Month 12 (Cross)

88 Other

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 ctdevmigr CT Device Migration (Right)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

10 devmigrcomm CT Dev Migration Comm (Right)

11 ctadvr CT Adverse Bone Rxn (Right)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

12 ctadvcommr CT Adv Bone Rxn Comm (Right)

13 ctdevmigl CT Device Migration (Left)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

14 devmiglcomm CT Dev Migration Comm (Left)

15 ctadvl CT Adverse Bone Rxn (Left)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

16 ctadvcomml CT Adv Bone Rxn Comm (Left)

17 LCUser$(plate) Last Change Username

18 LCDate$(plate) Last Change (Date)

19 LCTime$(plate) Last Change (Time)

(R1) 12 Mo CT, brid bone (315)

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6 visitseq$(plate) Visit Sequence

0 Not checked

8 Month 12

18 Month 12 (Cross)

88 Other

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 ctbridboner CT Bridging Bone (Right)

0 Not checked

1 Absent

2 Present - adjacent

3 Present - distant

4 Present - adj and dist

5 Indeterminate

6 Unable to assess

10 ctbridbonel CT Bridging Bone (Left)

0 Not checked

1 Absent

2 Present - adjacent

3 Present - distant

4 Present - adj and dist

5 Indeterminate

6 Unable to assess

11 ctbridbonecommr CT Bridging Bone Comm (Right)

12 ctblidbonecomml CT Bridging Bone Comm (Left)

13 ctbridboneextr1 CT Bridging Bone Extent (Right, 1)

0 Not checked

1 None

2 <5%

3 5-15%

4 15-30%

5 30-100%

6 Indeterminate

7 Unable to assess

14 ctbridboneextr2 CT Bridging Bone Extent (Right, 2)

0 Not checked

1 None

2 <5%

3 5-15%

4 15-30%

5 30-100%

6 Indeterminate

7 Unable to assess

15 ctbridboneextr3 CT Bridging Bone Extent (Right, 3)

0 Not checked

1 None

2 <5%

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3 5-15%

4 15-30%

5 30-100%

6 Indeterminate

7 Unable to assess

16 ctbridboneextr4 CT Bridging Bone Extent (Right, 4)

0 Not checked

1 None

2 <5%

3 5-15%

4 15-30%

5 30-100%

6 Indeterminate

7 Unable to assess

17 ctbridboneextl1 CT Bridging Bone Extent (Left, 1)

0 Not checked

1 None

2 <5%

3 5-15%

4 15-30%

5 30-100%

6 Indeterminate

7 Unable to assess

18 ctbridboneextl2 CT Bridging Bone Extent (Left, 2)

0 Not checked

1 None

2 <5%

3 5-15%

4 15-30%

5 30-100%

6 Indeterminate

7 Unable to assess

19 ctbridboneextl3 CT Bridging Bone Extent (Left, 3)

0 Not checked

1 None

2 <5%

3 5-15%

4 15-30%

5 30-100%

6 Indeterminate

7 Unable to assess

20 ctbridboneextl4 CT Bridging Bone Extent (Left, 4)

0 Not checked

1 None

2 <5%

3 5-15%

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4 15-30%

5 30-100%

6 Indeterminate

7 Unable to assess

21 bridboneprop Bridging Bone Proportion (%)

22 ctquantcomm CT Quantitative Comm Brid Bone

23 LCUser$(plate) Last Change Username

24 LCDate$(plate) Last Change (Date)

25 LCTime$(plate) Last Change (Time)

(R1) 12 Mo CT, bone remod (316)

6 visitseq$(plate) Visit Sequence

0 Not checked

8 Month 12

18 Month 12 (Cross)

88 Other

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 ctboneremr CT Bone Remodeling (Right)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

10 ctboneremcommr CT Bone Remod Comm (Right)

11 ctbonereml CT Bone Remodeling (Left)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

12 ctboneremcomml CT Bone Remod Comm (Left)

13 LCUser$(plate) Last Change Username

14 LCDate$(plate) Last Change (Date)

15 LCTime$(plate) Last Change (Time)

(R1) 12 Mo CT, HO/other (317)

6 visitseq$(plate) Visit Sequence

0 Not checked

8 Month 12

18 Month 12 (Cross)

88 Other

7 ID$(plate) Patient number

8 initials$(plate) Initials

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9 cthor CT Heterotopic Oss (Right)

0 Not checked

1 Absent

2 Present - islands

3 Present - spurs

4 Present - island & spurs

5 Unable to assess

10 hosaccanr HO: Sacral Canal (Right)0 Unchecked

1 Checked

11 hosacforr HO: Sacral Neural Foramen (Right)0 Unchecked

1 Checked

12 hointrapr HO: Intrapelvic (Right)0 Unchecked

1 Checked

13 hoextrapr HO: Extrapelvic (Right)0 Unchecked

1 Checked

14 hogt2r HO: >2 mm (Right)

0 Not checked

1 Yes

2 No

15 cthocommr HO: Comments (Right)

16 cthol CT Heterotopic Oss (Left)

0 Not checked

1 Absent

2 Present - islands

3 Present - spurs

4 Present - island & spurs

5 Unable to assess

17 hosaccanl HO: Saclal Canal (Left)0 Unchecked

1 Checked

18 hosacforl HO: Saclal Neural Foramen (Left)0 Unchecked

1 Checked

19 hointrapl HO: Intrapelvic (Left)0 Unchecked

1 Checked

20 hoextrapl HO: Extrapelvic (Left)0 Unchecked

1 Checked

21 hogt2l HO: >2 mm (Left)

0 Not checked

1 Yes

2 No

22 cthocomml HO: Comments (Left)

23 ctextracomm CT Extra Comments

24 LCUser$(plate) Last Change Username

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25 LCDate$(plate) Last Change (Date)

26 LCTime$(plate) Last Change (Time)

(R1) 12 Mo CT, Placement (318)

6 visitseq$(plate) Visit Sequence

0 Not checked

8 Month 12

18 Month 12 (Cross)

88 Other

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 impdepaxr1 Implant Depth Axial Right 1

10 impdepacor1 Implant Depth Coronal Right 1

11 depnoimpr1 No Implant Right 1 (Depth)0 Unchecked

1 Checked

12 impdepaxl1 Implant Depth Axial Left 1

13 impdepacol1 Implant Depth Coronal Left 1

14 depnoimpl1 No Implant Left 1 (Depth)0 Unchecked

1 Checked

15 impdepaxr2 Implant Depth Axial Right 2

16 impdepacor2 Implant Depth Coronal Right 2

17 depnoimpr2 No Implant Right 2 (Depth)0 Unchecked

1 Checked

18 impdepaxl2 Implant Depth Axial Left 2

19 impdepacol2 Implant Depth Coronal Left 2

20 depnoimpl2 No Implant Left 2 (Depth)0 Unchecked

1 Checked

21 impdepaxr3 Implant Depth Axial Right 3

22 impdepacor3 Implant Depth Coronal Right 3

23 depnoimpr3 No Implant Right 3 (Depth)0 Unchecked

1 Checked

24 impdepaxl3 Implant Depth Axial Left 3

25 impdepacol3 Implant Depth Coronal Left 3

26 depnoimpl3 No Implant Left 3 (Depth)0 Unchecked

1 Checked

27 impdepaxr4 Implant Depth Axial Right 4

28 impdepacor4 Implant Depth Coronal Right 4

29 depnoimpr4 No Implant Right 4 (Depth)0 Unchecked

1 Checked

30 impdepaxl4 Implant Depth Axial Left 4

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31 impdepacol4 Implant Depth Coronal Left 4

32 depnoimpl4 No Implant Left 4 (Depth)0 Unchecked

1 Checked

33 ctdepthcomm CT Depth Comments

(R2) 12 Mo CT, apposition (321)

6 visitseq$(plate) Visit Sequence

0 Not checked

8 Month 12

18 Month 12 (Cross)

88 Other

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 implantloc$(plate) Implant Location (CT)

0 Not checked

1 Right

2 Left

3 Bilateral

10 appsac1r Appos Sacral 1 (Right)

0 Not checked

1 >30%

2 <30%

3 Indeterminate

4 Unable to assess

11 appil1r Appos Ilial 1 (Right)

0 Not checked

1 >30%

2 <30%

3 Indeterminate

4 Unable to assess

12 appsac2r Appos Sacral 2 (Right)

0 Not checked

1 >30%

2 <30%

3 Indeterminate

4 Unable to assess

13 appil2r Appos Ilial 2 (Right)

0 Not checked

1 >30%

2 <30%

3 Indeterminate

4 Unable to assess

14 appsac3r Appos Sacral 3 (Right)

0 Not checked

1 >30%

2 <30%

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3 Indeterminate

4 Unable to assess

15 appil3r Appos Ilial 3 (Right)

0 Not checked

1 >30%

2 <30%

3 Indeterminate

4 Unable to assess

16 appsac4r Appos Sacral 4 (Right)

0 Not checked

1 >30%

2 <30%

3 Indeterminate

4 Unable to assess

17 appil4r Appos Ilial 4 (Right)

0 Not checked

1 >30%

2 <30%

3 Indeterminate

4 Unable to assess

18 appsac1l Appos Sacral 1 (Left)

0 Not checked

1 >30%

2 <30%

3 Indeterminate

4 Unable to assess

19 appil1l Appos Ilial 1 (Left)

0 Not checked

1 >30%

2 <30%

3 Indeterminate

4 Unable to assess

20 appsac2l Appos Sacral 2 (Left)

0 Not checked

1 >30%

2 <30%

3 Indeterminate

4 Unable to assess

21 appil2l Appos Ilial 2 (Left)

0 Not checked

1 >30%

2 <30%

3 Indeterminate

4 Unable to assess

22 appsac3l Appos Sacral 3 (Left)

0 Not checked

1 >30%

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2 <30%

3 Indeterminate

4 Unable to assess

23 appil3l Appos Ilial 3 (Left)

0 Not checked

1 >30%

2 <30%

3 Indeterminate

4 Unable to assess

24 appsac4l Appos Sacral 4 (Left)

0 Not checked

1 >30%

2 <30%

3 Indeterminate

4 Unable to assess

25 appil4l Appos Ilial 4 (Left)

0 Not checked

1 >30%

2 <30%

3 Indeterminate

4 Unable to assess

26 ctcomm CT Comments

27 LCUser$(plate) Last Change Username

28 LCDate$(plate) Last Change (Date)

29 LCTime$(plate) Last Change (Time)

(R2) 12 Mo CT, lucency (322)

6 visitseq$(plate) Visit Sequence

0 Not checked

8 Month 12

18 Month 12 (Cross)

88 Other

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 ctradiolucr CT Radiolucency (Right)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

10 ctradioluccommr CT Radiolucency Comment (Right)

11 ctradiolextr1 CT Radiol Extent (Right 1)

0 Not checked

1 None

2 <15%

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3 15-50%

4 50-100%

5 Indeterminate

6 Unable to assess

7 No implant

12 ctradiolextr2 CT Radiol Extent (Right 2)

0 Not checked

1 None

2 <15%

3 15-50%

4 50-100%

5 Indeterminate

6 Unable to assess

7 No implant

13 ctradiolextr3 CT Radiol Extent (Right 3)

0 Not checked

1 None

2 <15%

3 15-50%

4 50-100%

5 Indeterminate

6 Unable to assess

7 No implant

14 ctradiolextr4 CT Radiol Extent (Right 4)

0 Not checked

1 None

2 <15%

3 15-50%

4 50-100%

5 Indeterminate

6 Unable to assess

7 No implant

15 ctradlocilr1 CT Radioluc Location Ilial (Right 1)0 Unchecked

1 Checked

16 ctradlocsacr1 CT Radioluc Location Sacral (Right 1)0 Unchecked

1 Checked

17 ctradlocilr2 CT Radioluc Location Ilial (Right 2)0 Unchecked

1 Checked

18 ctradlocsacr2 CT Radioluc Location Sacral (Right 2)0 Unchecked

1 Checked

19 ctradlocilr3 CT Radioluc Location Ilial (Right 3)0 Unchecked

1 Checked

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20 ctradlocsacr3 CT Radioluc Location Sacral (Right 3)0 Unchecked

1 Checked

21 ctradlocilr4 CT Radioluc Location Ilial (Right 4)0 Unchecked

1 Checked

22 ctradlocsacr4 CT Radioluc Location Sacral (Right 4)0 Unchecked

1 Checked

23 ctradiolucl CT Radiolucency (Left)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

24 ctradioluccomml CT Radiolucency Comment (Left)

25 ctradiolextl1 CT Radiol Extent (Left 1)

0 Not checked

1 None

2 <15%

3 15-50%

4 50-100%

5 Indeterminate

6 Unable to assess

7 No implant

26 ctradiolextl2 CT Radiol Extent (Left 2)

0 Not checked

1 None

2 <15%

3 15-50%

4 50-100%

5 Indeterminate

6 Unable to assess

7 No implant

27 ctradiolextl3 CT Radiol Extent (Left 3)

0 Not checked

1 None

2 <15%

3 15-50%

4 50-100%

5 Indeterminate

6 Unable to assess

7 No implant

28 ctradiolextl4 CT Radiol Extent (Left 4)

0 Not checked

1 None

2 <15%

3 15-50%

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4 50-100%

5 Indeterminate

6 Unable to assess

7 No implant

29 ctradlocill1 CT Radioluc Location Ilial (Left 1)0 Unchecked

1 Checked

30 ctradlocsacl1 CT Radioluc Location Sacral (Left 1)0 Unchecked

1 Checked

31 ctradlocill2 CT Radioluc Location Ilial (Left 2)0 Unchecked

1 Checked

32 ctradlocsacl2 CT Radioluc Location Sacral (Left 2)0 Unchecked

1 Checked

33 ctradlocill3 CT Radioluc Location Ilial (Left 3)0 Unchecked

1 Checked

34 ctradlocsacl3 CT Radioluc Location Sacral (Left 3)0 Unchecked

1 Checked

35 ctradlocill4 CT Radioluc Location Ilial (Left 4)0 Unchecked

1 Checked

36 ctradlocsacl4 CT Radioluc Location Sacral (Left 4)0 Unchecked

1 Checked

37 LCUser$(plate) Last Change Username

38 LCDate$(plate) Last Change (Date)

39 LCTime$(plate) Last Change (Time)

(R2) 12 Mo CT, failure/breach (323)

6 visitseq$(plate) Visit Sequence

0 Not checked

8 Month 12

18 Month 12 (Cross)

88 Other

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 ctdevfailr CT Device Failure (Right)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

10 ctrdevfailcommr CT Dev Fail Comment (Right)

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11 ctdevbreachr CT Device Breach (Right)

0 Not checked

1 Absent

2 Present - sacral canal

3 Present - sacral foramen

4 Present - anterior sacrum

5 Present - other

6 Indeterminate

7 Unable to assess

12 ctdevbreachcommr CT Device Breach Comment (Right)

13 ctdevfaill CT Device Failure (Left)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

14 ctrdevfailcomml CT Dev Fail Comment (Left)

15 ctdevbreachl CT Device Breach (Left)

0 Not checked

1 Absent

2 Present - sacral canal

3 Present - sacral foramen

4 Present - anterior sacrum

5 Present - other

6 Indeterminate

7 Unable to assess

16 ctdevbreachcomml CT Device Breach Comment (Left)

17 LCUser$(plate) Last Change Username

18 LCDate$(plate) Last Change (Date)

19 LCTime$(plate) Last Change (Time)

(R2) 12 Mo CT, migration/bone rxn (324)

6 visitseq$(plate) Visit Sequence

0 Not checked

8 Month 12

18 Month 12 (Cross)

88 Other

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 ctdevmigr CT Device Migration (Right)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

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10 devmigrcomm CT Dev Migration Comm (Right)

11 ctadvr CT Adverse Bone Rxn (Right)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

12 ctadvcommr CT Adv Bone Rxn Comm (Right)

13 ctdevmigl CT Device Migration (Left)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

14 devmiglcomm CT Dev Migration Comm (Left)

15 ctadvl CT Adverse Bone Rxn (Left)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

16 ctadvcomml CT Adv Bone Rxn Comm (Left)

17 LCUser$(plate) Last Change Username

18 LCDate$(plate) Last Change (Date)

19 LCTime$(plate) Last Change (Time)

(R2) 12 Mo CT, brid bone (325)

6 visitseq$(plate) Visit Sequence

0 Not checked

8 Month 12

18 Month 12 (Cross)

88 Other

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 ctbridboner CT Bridging Bone (Right)

0 Not checked

1 Absent

2 Present - adjacent

3 Present - distant

4 Present - adj and dist

5 Indeterminate

6 Unable to assess

10 ctbridbonel CT Bridging Bone (Left)

0 Not checked

1 Absent

2 Present - adjacent

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3 Present - distant

4 Present - adj and dist

5 Indeterminate

6 Unable to assess

11 ctbridbonecommr CT Bridging Bone Comm (Right)

12 ctblidbonecomml CT Bridging Bone Comm (Left)

13 ctbridboneextr1 CT Bridging Bone Extent (Right, 1)

0 Not checked

1 None

2 <5%

3 5-15%

4 15-30%

5 30-100%

6 Indeterminate

7 Unable to assess

14 ctbridboneextr2 CT Bridging Bone Extent (Right, 2)

0 Not checked

1 None

2 <5%

3 5-15%

4 15-30%

5 30-100%

6 Indeterminate

7 Unable to assess

15 ctbridboneextr3 CT Bridging Bone Extent (Right, 3)

0 Not checked

1 None

2 <5%

3 5-15%

4 15-30%

5 30-100%

6 Indeterminate

7 Unable to assess

16 ctbridboneextr4 CT Bridging Bone Extent (Right, 4)

0 Not checked

1 None

2 <5%

3 5-15%

4 15-30%

5 30-100%

6 Indeterminate

7 Unable to assess

17 ctbridboneextl1 CT Bridging Bone Extent (Left, 1)

0 Not checked

1 None

2 <5%

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3 5-15%

4 15-30%

5 30-100%

6 Indeterminate

7 Unable to assess

18 ctbridboneextl2 CT Bridging Bone Extent (Left, 2)

0 Not checked

1 None

2 <5%

3 5-15%

4 15-30%

5 30-100%

6 Indeterminate

7 Unable to assess

19 ctbridboneextl3 CT Bridging Bone Extent (Left, 3)

0 Not checked

1 None

2 <5%

3 5-15%

4 15-30%

5 30-100%

6 Indeterminate

7 Unable to assess

20 ctbridboneextl4 CT Bridging Bone Extent (Left, 4)

0 Not checked

1 None

2 <5%

3 5-15%

4 15-30%

5 30-100%

6 Indeterminate

7 Unable to assess

21 bridboneprop Bridging Bone Proportion (%)

22 ctquantcomm CT Quantitative Comm Brid Bone

23 LCUser$(plate) Last Change Username

24 LCDate$(plate) Last Change (Date)

25 LCTime$(plate) Last Change (Time)

(R2) 12 Mo CT, bone remod (326)

6 visitseq$(plate) Visit Sequence

0 Not checked

8 Month 12

18 Month 12 (Cross)

88 Other

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7 ID$(plate) Patient number

8 initials$(plate) Initials

9 ctboneremr CT Bone Remodeling (Right)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

10 ctboneremcommr CT Bone Remod Comm (Right)

11 ctbonereml CT Bone Remodeling (Left)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

12 ctboneremcomml CT Bone Remod Comm (Left)

13 LCUser$(plate) Last Change Username

14 LCDate$(plate) Last Change (Date)

15 LCTime$(plate) Last Change (Time)

(R2) 12 Mo CT, HO/other (327)

6 visitseq$(plate) Visit Sequence

0 Not checked

8 Month 12

18 Month 12 (Cross)

88 Other

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 cthor CT Heterotopic Oss (Right)

0 Not checked

1 Absent

2 Present - islands

3 Present - spurs

4 Present - island & spurs

5 Unable to assess

10 hosaccanr HO: Sacral Canal (Right)0 Unchecked

1 Checked

11 hosacforr HO: Sacral Neural Foramen (Right)0 Unchecked

1 Checked

12 hointrapr HO: Intrapelvic (Right)0 Unchecked

1 Checked

13 hoextrapr HO: Extrapelvic (Right)0 Unchecked

1 Checked

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14 hogt2r HO: >2 mm (Right)

0 Not checked

1 Yes

2 No

15 cthocommr HO: Comments (Right)

16 cthol CT Heterotopic Oss (Left)

0 Not checked

1 Absent

2 Present - islands

3 Present - spurs

4 Present - island & spurs

5 Unable to assess

17 hosaccanl HO: Saclal Canal (Left)0 Unchecked

1 Checked

18 hosacforl HO: Saclal Neural Foramen (Left)0 Unchecked

1 Checked

19 hointrapl HO: Intrapelvic (Left)0 Unchecked

1 Checked

20 hoextrapl HO: Extrapelvic (Left)0 Unchecked

1 Checked

21 hogt2l HO: >2 mm (Left)

0 Not checked

1 Yes

2 No

22 cthocomml HO: Comments (Left)

23 ctextracomm CT Extra Comments

24 LCUser$(plate) Last Change Username

25 LCDate$(plate) Last Change (Date)

26 LCTime$(plate) Last Change (Time)

(R3) 12 Mo CT, apposition (331)

6 visitseq$(plate) Visit Sequence

0 Not checked

8 Month 12

18 Month 12 (Cross)

88 Other

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 implantloc$(plate) Implant Location (CT)

0 Not checked

1 Right

2 Left

3 Bilateral

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10 appsac1r Appos Sacral 1 (Right)

0 Not checked

1 >30%

2 <30%

3 Indeterminate

4 Unable to assess

11 appil1r Appos Ilial 1 (Right)

0 Not checked

1 >30%

2 <30%

3 Indeterminate

4 Unable to assess

12 appsac2r Appos Sacral 2 (Right)

0 Not checked

1 >30%

2 <30%

3 Indeterminate

4 Unable to assess

13 appil2r Appos Ilial 2 (Right)

0 Not checked

1 >30%

2 <30%

3 Indeterminate

4 Unable to assess

14 appsac3r Appos Sacral 3 (Right)

0 Not checked

1 >30%

2 <30%

3 Indeterminate

4 Unable to assess

15 appil3r Appos Ilial 3 (Right)

0 Not checked

1 >30%

2 <30%

3 Indeterminate

4 Unable to assess

16 appsac4r Appos Sacral 4 (Right)

0 Not checked

1 >30%

2 <30%

3 Indeterminate

4 Unable to assess

17 appil4r Appos Ilial 4 (Right)

0 Not checked

1 >30%

2 <30%

3 Indeterminate

4 Unable to assess

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18 appsac1l Appos Sacral 1 (Left)

0 Not checked

1 >30%

2 <30%

3 Indeterminate

4 Unable to assess

19 appil1l Appos Ilial 1 (Left)

0 Not checked

1 >30%

2 <30%

3 Indeterminate

4 Unable to assess

20 appsac2l Appos Sacral 2 (Left)

0 Not checked

1 >30%

2 <30%

3 Indeterminate

4 Unable to assess

21 appil2l Appos Ilial 2 (Left)

0 Not checked

1 >30%

2 <30%

3 Indeterminate

4 Unable to assess

22 appsac3l Appos Sacral 3 (Left)

0 Not checked

1 >30%

2 <30%

3 Indeterminate

4 Unable to assess

23 appil3l Appos Ilial 3 (Left)

0 Not checked

1 >30%

2 <30%

3 Indeterminate

4 Unable to assess

24 appsac4l Appos Sacral 4 (Left)

0 Not checked

1 >30%

2 <30%

3 Indeterminate

4 Unable to assess

25 appil4l Appos Ilial 4 (Left)

0 Not checked

1 >30%

2 <30%

3 Indeterminate

4 Unable to assess

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26 ctcomm CT Comments

27 LCUser$(plate) Last Change Username

28 LCDate$(plate) Last Change (Date)

29 LCTime$(plate) Last Change (Time)

(R3) 12 Mo CT, lucency (332)

6 visitseq$(plate) Visit Sequence

0 Not checked

8 Month 12

18 Month 12 (Cross)

88 Other

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 ctradiolucr CT Radiolucency (Right)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

10 ctradioluccommr CT Radiolucency Comment (Right)

11 ctradiolextr1 CT Radiol Extent (Right 1)

0 Not checked

1 None

2 <15%

3 15-50%

4 50-100%

5 Indeterminate

6 Unable to assess

7 No implant

12 ctradiolextr2 CT Radiol Extent (Right 2)

0 Not checked

1 None

2 <15%

3 15-50%

4 50-100%

5 Indeterminate

6 Unable to assess

7 No implant

13 ctradiolextr3 CT Radiol Extent (Right 3)

0 Not checked

1 None

2 <15%

3 15-50%

4 50-100%

5 Indeterminate

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6 Unable to assess

7 No implant

14 ctradiolextr4 CT Radiol Extent (Right 4)

0 Not checked

1 None

2 <15%

3 15-50%

4 50-100%

5 Indeterminate

6 Unable to assess

7 No implant

15 ctradlocilr1 CT Radioluc Location Ilial (Right 1)0 Unchecked

1 Checked

16 ctradlocsacr1 CT Radioluc Location Sacral (Right 1)0 Unchecked

1 Checked

17 ctradlocilr2 CT Radioluc Location Ilial (Right 2)0 Unchecked

1 Checked

18 ctradlocsacr2 CT Radioluc Location Sacral (Right 2)0 Unchecked

1 Checked

19 ctradlocilr3 CT Radioluc Location Ilial (Right 3)0 Unchecked

1 Checked

20 ctradlocsacr3 CT Radioluc Location Sacral (Right 3)0 Unchecked

1 Checked

21 ctradlocilr4 CT Radioluc Location Ilial (Right 4)0 Unchecked

1 Checked

22 ctradlocsacr4 CT Radioluc Location Sacral (Right 4)0 Unchecked

1 Checked

23 ctradiolucl CT Radiolucency (Left)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

24 ctradioluccomml CT Radiolucency Comment (Left)

25 ctradiolextl1 CT Radiol Extent (Left 1)

0 Not checked

1 None

2 <15%

3 15-50%

4 50-100%

5 Indeterminate

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6 Unable to assess

7 No implant

26 ctradiolextl2 CT Radiol Extent (Left 2)

0 Not checked

1 None

2 <15%

3 15-50%

4 50-100%

5 Indeterminate

6 Unable to assess

7 No implant

27 ctradiolextl3 CT Radiol Extent (Left 3)

0 Not checked

1 None

2 <15%

3 15-50%

4 50-100%

5 Indeterminate

6 Unable to assess

7 No implant

28 ctradiolextl4 CT Radiol Extent (Left 4)

0 Not checked

1 None

2 <15%

3 15-50%

4 50-100%

5 Indeterminate

6 Unable to assess

7 No implant

29 ctradlocill1 CT Radioluc Location Ilial (Left 1)0 Unchecked

1 Checked

30 ctradlocsacl1 CT Radioluc Location Sacral (Left 1)0 Unchecked

1 Checked

31 ctradlocill2 CT Radioluc Location Ilial (Left 2)0 Unchecked

1 Checked

32 ctradlocsacl2 CT Radioluc Location Sacral (Left 2)0 Unchecked

1 Checked

33 ctradlocill3 CT Radioluc Location Ilial (Left 3)0 Unchecked

1 Checked

34 ctradlocsacl3 CT Radioluc Location Sacral (Left 3)0 Unchecked

1 Checked

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35 ctradlocill4 CT Radioluc Location Ilial (Left 4)0 Unchecked

1 Checked

36 ctradlocsacl4 CT Radioluc Location Sacral (Left 4)0 Unchecked

1 Checked

37 LCUser$(plate) Last Change Username

38 LCDate$(plate) Last Change (Date)

39 LCTime$(plate) Last Change (Time)

(R3) 12 Mo CT, failure/breach (333)

6 visitseq$(plate) Visit Sequence

0 Not checked

8 Month 12

18 Month 12 (Cross)

88 Other

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 ctdevfailr CT Device Failure (Right)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

10 ctrdevfailcommr CT Dev Fail Comment (Right)

11 ctdevbreachr CT Device Breach (Right)

0 Not checked

1 Absent

2 Present - sacral canal

3 Present - sacral foramen

4 Present - anterior sacrum

5 Present - other

6 Indeterminate

7 Unable to assess

12 ctdevbreachcommr CT Device Breach Comment (Right)

13 ctdevfaill CT Device Failure (Left)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

14 ctrdevfailcomml CT Dev Fail Comment (Left)

15 ctdevbreachl CT Device Breach (Left)

0 Not checked

1 Absent

2 Present - sacral canal

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3 Present - sacral foramen

4 Present - anterior sacrum

5 Present - other

6 Indeterminate

7 Unable to assess

16 ctdevbreachcomml CT Device Breach Comment (Left)

17 LCUser$(plate) Last Change Username

18 LCDate$(plate) Last Change (Date)

19 LCTime$(plate) Last Change (Time)

(R3) 12 Mo CT, migration/bone rxn (334)

6 visitseq$(plate) Visit Sequence

0 Not checked

8 Month 12

18 Month 12 (Cross)

88 Other

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 ctdevmigr CT Device Migration (Right)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

10 devmigrcomm CT Dev Migration Comm (Right)

11 ctadvr CT Adverse Bone Rxn (Right)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

12 ctadvcommr CT Adv Bone Rxn Comm (Right)

13 ctdevmigl CT Device Migration (Left)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

14 devmiglcomm CT Dev Migration Comm (Left)

15 ctadvl CT Adverse Bone Rxn (Left)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

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16 ctadvcomml CT Adv Bone Rxn Comm (Left)

17 LCUser$(plate) Last Change Username

18 LCDate$(plate) Last Change (Date)

19 LCTime$(plate) Last Change (Time)

(R3) 12 Mo CT, brid bone (335)

6 visitseq$(plate) Visit Sequence

0 Not checked

8 Month 12

18 Month 12 (Cross)

88 Other

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 ctbridboner CT Bridging Bone (Right)

0 Not checked

1 Absent

2 Present - adjacent

3 Present - distant

4 Present - adj and dist

5 Indeterminate

6 Unable to assess

10 ctbridbonel CT Bridging Bone (Left)

0 Not checked

1 Absent

2 Present - adjacent

3 Present - distant

4 Present - adj and dist

5 Indeterminate

6 Unable to assess

11 ctbridbonecommr CT Bridging Bone Comm (Right)

12 ctblidbonecomml CT Bridging Bone Comm (Left)

13 ctbridboneextr1 CT Bridging Bone Extent (Right, 1)

0 Not checked

1 None

2 <5%

3 5-15%

4 15-30%

5 30-100%

6 Indeterminate

7 Unable to assess

14 ctbridboneextr2 CT Bridging Bone Extent (Right, 2)

0 Not checked

1 None

2 <5%

3 5-15%

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4 15-30%

5 30-100%

6 Indeterminate

7 Unable to assess

15 ctbridboneextr3 CT Bridging Bone Extent (Right, 3)

0 Not checked

1 None

2 <5%

3 5-15%

4 15-30%

5 30-100%

6 Indeterminate

7 Unable to assess

16 ctbridboneextr4 CT Bridging Bone Extent (Right, 4)

0 Not checked

1 None

2 <5%

3 5-15%

4 15-30%

5 30-100%

6 Indeterminate

7 Unable to assess

17 ctbridboneextl1 CT Bridging Bone Extent (Left, 1)

0 Not checked

1 None

2 <5%

3 5-15%

4 15-30%

5 30-100%

6 Indeterminate

7 Unable to assess

18 ctbridboneextl2 CT Bridging Bone Extent (Left, 2)

0 Not checked

1 None

2 <5%

3 5-15%

4 15-30%

5 30-100%

6 Indeterminate

7 Unable to assess

19 ctbridboneextl3 CT Bridging Bone Extent (Left, 3)

0 Not checked

1 None

2 <5%

3 5-15%

4 15-30%

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5 30-100%

6 Indeterminate

7 Unable to assess

20 ctbridboneextl4 CT Bridging Bone Extent (Left, 4)

0 Not checked

1 None

2 <5%

3 5-15%

4 15-30%

5 30-100%

6 Indeterminate

7 Unable to assess

21 bridboneprop Bridging Bone Proportion (%)

22 ctquantcomm CT Quantitative Comm Brid Bone

23 LCUser$(plate) Last Change Username

24 LCDate$(plate) Last Change (Date)

25 LCTime$(plate) Last Change (Time)

(R3) 12 Mo CT, bone remod (336)

6 visitseq$(plate) Visit Sequence

0 Not checked

8 Month 12

18 Month 12 (Cross)

88 Other

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 ctboneremr CT Bone Remodeling (Right)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

10 ctboneremcommr CT Bone Remod Comm (Right)

11 ctbonereml CT Bone Remodeling (Left)

0 Not checked

1 Absent

2 Present

3 Indeterminate

4 Unable to assess

12 ctboneremcomml CT Bone Remod Comm (Left)

13 LCUser$(plate) Last Change Username

14 LCDate$(plate) Last Change (Date)

15 LCTime$(plate) Last Change (Time)

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(R3) 12 Mo CT, HO/other (337)

6 visitseq$(plate) Visit Sequence

0 Not checked

8 Month 12

18 Month 12 (Cross)

88 Other

7 ID$(plate) Patient number

8 initials$(plate) Initials

9 cthor CT Heterotopic Oss (Right)

0 Not checked

1 Absent

2 Present - islands

3 Present - spurs

4 Present - island & spurs

5 Unable to assess

10 hosaccanr HO: Sacral Canal (Right)0 Unchecked

1 Checked

11 hosacforr HO: Sacral Neural Foramen (Right)0 Unchecked

1 Checked

12 hointrapr HO: Intrapelvic (Right)0 Unchecked

1 Checked

13 hoextrapr HO: Extrapelvic (Right)0 Unchecked

1 Checked

14 hogt2r HO: >2 mm (Right)

0 Not checked

1 Yes

2 No

15 cthocommr HO: Comments (Right)

16 cthol CT Heterotopic Oss (Left)

0 Not checked

1 Absent

2 Present - islands

3 Present - spurs

4 Present - island & spurs

5 Unable to assess

17 hosaccanl HO: Saclal Canal (Left)0 Unchecked

1 Checked

18 hosacforl HO: Saclal Neural Foramen (Left)0 Unchecked

1 Checked

19 hointrapl HO: Intrapelvic (Left)0 Unchecked

1 Checked

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20 hoextrapl HO: Extrapelvic (Left)0 Unchecked

1 Checked

21 hogt2l HO: >2 mm (Left)

0 Not checked

1 Yes

2 No

22 cthocomml HO: Comments (Left)

23 ctextracomm CT Extra Comments

24 LCUser$(plate) Last Change Username

25 LCDate$(plate) Last Change (Date)

26 LCTime$(plate) Last Change (Time)

Quality Control Report (501)

7 DFControlNum DataFax Control #

8 DFSiteNum DFSiteNum

9 DFReportDate DFReportDate

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