Data Collection Form

Surgeon Name
Patient Code

Left Peak Removal Torque

Nm L1
Nm L2
Nm L3
Nm L4
Nm L5
Nm S1
Lower Spine Torque Measurements

Right Peak Removal Torque

L1 Nm
L2 Nm
L3 Nm
L4 Nm
L5 Nm
S1 Nm
 Fusion status
Fused    Nonunion    Unknown
Duration since hardware implantation
Explanted device product name
Explanted device manufacturer name
Explanted set screw material type
Rod material type
Interbody fusion device present at revised level(s)?
Yes    No
If yes, what type?
Explanted pedicle screw, set screw, and rod provided to sponsor?
Yes    No