The L4-5 Case You Operated Six Months Ago
The patient is back in clinic. Her third visit. The post-op plain film is in the Postop Image field. The pre-op MRI is in MRI and MRI 2. The hardware is logged — pedicle screw system, specific implant details — in the Hardware field. The approach and operative findings from the day of surgery are in the Approach and Op Finding fields. The Lysholm score from last visit is in the Value field. You have the complete surgical narrative and outcome trajectory in front of you before the patient sits down.
Without this record, you're reconstructing a case from clinic notes scattered across whatever system the hospital uses, a paper operative dictation, and whatever the patient remembers.
The Imaging Matrix: PXR to MRI
The imaging fields are the most technically specific part of this template. PXR fields cover five projections: AP, Lateral, Axial, Oblique, and Other. This isn't generic radiology tracking — it's the specific projection set used for spinal assessment. An axial PXR at the lumbosacral junction gives you information that the lateral alone doesn't: rotational deformity, facet asymmetry, pedicle morphology. The oblique projection is the classic "Scottie dog" view for spondylolysis assessment. Having each projection as a separate image slot means the full pre-operative workup is stored per-projection, not compressed into a single file.
CT adds axial bone anatomy — pedicle dimensions for screw sizing, fusion mass assessment, hardware position confirmation post-operatively. MRI and MRI 2 capture the soft tissue pathology: disc herniation, stenosis, cord signal, neural compromise. A lumbar case involving multi-level disease with stenosis at L3-4 and spondylolisthesis at L4-5 needs separate MRI captures for each pathology; MRI 2 provides that slot without forcing the user to stack images into a single field.
Onset, Course, and Complaint: The Clinical Narrative Fields
Onset (Sudden, Acute, Chronic, Accidental, Insidious) and Course (Progressive, Regressive, Stationary, Recurrent) together establish the clinical trajectory before the surgical decision was made. A patient with insidious onset and progressive course who presents with lumbar stenosis is a different surgical candidate than one with sudden onset following a specific mechanism of injury.
Complaint is a multichoice covering eleven presentations: Pain, Swelling, Stiffness, Disability, Instability/Giving way, Deformity, Weakness, Tingling, Unable to bear weight, Locking, Limping. For spine, the combination of Pain + Weakness + Tingling points toward radiculopathy with motor compromise. Weakness alone, without pain, in a thoracic case raises cord compression as the primary concern. The multichoice captures the presenting syndrome rather than forcing it into a text field.
Region tags the spinal territory: Cervical, Thoracic, Lumbar, Scoliosis, Spondylolisthesis, Stenosis, Tumour, Pelvis, Trauma, Dorsal, Sacral, Sacroiliac. These are filterable — at year-end audit, grouping by Region shows case volume by spinal territory and reveals whether the practice case mix matches referral patterns and surgical capacity.
The Operative Record: Approach, Hardware, Audio Dictation
Approach captures the surgical corridor: posterior midline, posterolateral, TLIF, ALIF, lateral, anterior cervical. Op Finding records what was encountered intraoperatively — the extruded disc fragment, the degree of instability, the unexpected epidural fibrosis from prior surgery. Hardware records the implant used: specific pedicle screw system, interbody cage type and size, disc replacement system, osteobiologic material.
Two audio fields — Clinical Dictation and Operative Dict — store spoken recordings directly in the patient record. A surgeon who dictates post-operative notes immediately after closing has the intraoperative narrative captured with same-day accuracy. That dictation, linked to the same record as the imaging and hardware, is the complete case file.
Outcome Scoring: IKDC, ASES, Lysholm, Harris, Constant, Dash
The Score field selects from six validated outcome instruments. IKDC for knee, ASES for shoulder, Lysholm for knee ligament, Harris for hip, Constant for shoulder function, Dash for upper extremity disability — the presence of these instruments in a spine template reflects a practice that spans spinal and orthopaedic cases. Score website links directly to orthopedicscores.com, the calculator resource. Value stores the numeric result. Remarks captures previous scores for comparison — the longitudinal trajectory that determines whether surgical intervention produced measurable functional improvement.
The Linked file field attaches external documents — referral letters, pre-operative consent forms, insurance authorizations, pathology reports — to the patient record without requiring a separate document management system.