Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
CEREBROVASCULAR ADULT
Board Reporting Term
Aneurysm clipping
Bypass of carotid artery by
anastomosis of superficial temporal
artery to middle cerebral artery
Carotid endarterectomy
Terms that roll up to the Board
Reporting Term
 Clipping of aneurysm of circle of Willis
 Clipping of intracranial aneurysm
 Craniotomy and clipping of intracranial
aneurysm
Procedure Reporting Field
Procedure Reporting Field Values
Site
 Anterior
 Posterior
 Endarterectomy and angioplasty of
external carotid artery
 Endarterectomy and angioplasty of
internal carotid artery
 Endarterectomy and angioplasty of
internal carotid artery with prosthesis
 Endarterectomy and angioplasty of
internal carotid artery with vein
 Endarterectomy of carotid artery and
patch repair of carotid artery
 Endarterectomy of common carotid
artery
 Endarterectomy of external carotid
artery
 Endarterectomy of internal carotid
artery
 Endarterectomy of internal carotid
artery with eversion and end-to-end
anastomosis
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Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
CEREBROVASCULAR ADULT
Board Reporting Term
Creation of external-internal carotid
bypass
Embolisation of aneurysm using
transluminal coil
Embolisation of vein of Galen
Encephalo-duro-arterio-synangiosis
Evacuation of intracerebral
haematoma
Evacuation of intracranial extradural
haematoma
Excision of arteriovenous
malformation
Excision of intracranial cavernous
haemangioma
Percutaneous balloon angioplasty of
intracranial artery
Terms that roll up to the Board
Reporting Term
 Percutaneous endarterectomy of
common carotid artery
 Percutaneous endarterectomy of
external carotid artery
 Percutaneous endarterectomy of
internal carotid artery
 Thromboendarterectomy with graft of
carotid artery by neck incision
Procedure Reporting Field
Procedure Reporting Field Values
 Evacuation of haematoma from
cerebellum
 Evacuation of haematoma from
temporal lobe of brain
 Excision of intracranial arteriovenous
malformation
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Page 2 of 57
Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
CEREBROVASCULAR ADULT
Board Reporting Term
Percutaneous embolisation of
arteriovenous fistula using
fluoroscopic guidance
Percutaneous embolisation of
cerebral neoplasm using
fluoroscopic guidance
Repair of aneurysm
Revascularisation of brain tissue
Terms that roll up to the Board
Reporting Term
Procedure Reporting Field
Procedure Reporting Field Values
Procedure Reporting Field
Procedure Reporting Field Values
Site
 Anterior
 Posterior
 Encephalo-duro-arterio-myosynangiosis
 Pial synangiosis
Stereotactic radiosurgery of
intracranial arteriovenous
malformation
Trapping of intracranial aneurysm
CEREBROVASCULAR PAEDIATRIC
Board Reporting Term
Aneurysm clipping
Terms that roll up to the Board
Reporting Term
 Clipping of aneurysm of circle of Willis
 Clipping of intracranial aneurysm
 Craniotomy and clipping of intracranial
aneurysm
Bypass of carotid artery by
anastomosis of superficial temporal
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Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
CEREBROVASCULAR PAEDIATRIC
Board Reporting Term
artery to middle cerebral artery
Carotid endarterectomy
Terms that roll up to the Board
Reporting Term
Procedure Reporting Field
Procedure Reporting Field Values
 Endarterectomy and angioplasty of
external carotid artery
 Endarterectomy and angioplasty of
internal carotid artery
 Endarterectomy and angioplasty of
internal carotid artery with prosthesis
 Endarterectomy and angioplasty of
internal carotid artery with vein
 Endarterectomy of carotid artery and
patch repair of carotid artery
 Endarterectomy of common carotid
artery
 Endarterectomy of external carotid
artery
 Endarterectomy of internal carotid
artery
 Endarterectomy of internal carotid
artery with eversion and end-to-end
anastomosis
 Percutaneous endarterectomy of
common carotid artery
 Percutaneous endarterectomy of
external carotid artery
 Percutaneous endarterectomy of
internal carotid artery
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Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
CEREBROVASCULAR PAEDIATRIC
Board Reporting Term
Creation of external-internal carotid
bypass
Embolisation of aneurysm using
transluminal coil
Embolisation of vein of Galen
Encephalo-duro-arterio-synangiosis
Evacuation of intracerebral
haematoma
Evacuation of intracranial extradural
haematoma
Excision of arteriovenous
malformation
Excision of intracranial cavernous
haemangioma
Percutaneous balloon angioplasty of
intracranial artery
Percutaneous embolisation of
aneurysm malformation of great
cerebral vein of Galen using
fluoroscopic guidance
Percutaneous embolisation of
arteriovenous fistula using
Terms that roll up to the Board
Reporting Term
 Thromboendarterectomy with graft of
carotid artery by neck incision
Procedure Reporting Field
Procedure Reporting Field Values
 Evacuation of haematoma from
cerebellum
 Evacuation of haematoma from
temporal lobe of brain
 Excision of intracranial arteriovenous
malformation
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Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
CEREBROVASCULAR PAEDIATRIC
Board Reporting Term
fluoroscopic guidance
Percutaneous embolisation of
cerebral neoplasm using
fluoroscopic guidance
Repair of aneurysm
Revascularisation of brain tissue
Terms that roll up to the Board
Reporting Term
Procedure Reporting Field
Procedure Reporting Field Values
Procedure Reporting Field
Procedure Reporting Field Values
 Encephalo-duro-arterio-myosynangiosis
 Pial synangiosis
Stereotactic radiosurgery of
intracranial arteriovenous
malformation
Trapping of intracranial aneurysm
CRANIO-CERVICAL JUNCTION ADULT
Board Reporting Term
Terms that roll up to the Board
Reporting Term
Arthrodesis by anterior transoral
technique, clivus-C1-C2, with bone
graft and excision of odontoid
process
Excision of cranio-cervical tumour
Transoral excision of odontoid peg
Transoral fusion of atlantoaxial joint
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Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
CRANIO-CERVICAL JUNCTION PAEDIATRIC
Board Reporting Term
Terms that roll up to the Board
Reporting Term
Procedure Reporting Field
Procedure Reporting Field Values
Terms that roll up to the Board
Reporting Term
 Frontal advancement - fixed
 Frontal advancement - floating
 Cranioplasty with synchronous repair of
encephalocele
 Repair of meningoencephalocele
Procedure Reporting Field
Procedure Reporting Field Values
Type
 Single
 Multiple
Arthrodesis by anterior transoral
technique, clivus-C1-C2, with bone
graft and excision of odontoid
process
Excision of cranio-cervical tumour
Transoral excision of odontoid peg
Transoral fusion of atlantoaxial joint
CRANIOFACIAL ADULT
Board Reporting Term
Frontofacial advancement
Repair of encephalocele
Sutural craniectomy
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Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
CRANIOFACIAL PAEDIATRIC
Board Reporting Term
Frontofacial advancement
Repair of encephalocele
Terms that roll up to the Board
Reporting Term
 Frontal advancement - fixed
 Frontal advancement - floating
 Cranioplasty with synchronous repair of
encephalocele
 Repair of meningoencephalocele
Sutural craniectomy
Procedure Reporting Field
Procedure Reporting Field Values
Type
 Single
 Multiple
Procedure Reporting Field
Procedure Reporting Field Values
EPILEPSY ADULT
Board Reporting Term
Callosotomy
Cerebral hemispherectomy
Corticectomy
Craniotomy with elevation of bone
flap and excision of epileptogenic
focus
Electrocorticography
Implantation of electrode into brain
Terms that roll up to the Board
Reporting Term
 Complete callosotomy
 Partial callosotomy
 Excision of lesion of cerebral cortex
 Excision of part of frontal cortex
 Electrocorticogram during surgery
 Electrocorticogram with photic
stimulation
 Implantation of electrode into brain
using stereotactic guidance
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Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
EPILEPSY ADULT
Board Reporting Term
Insertion of vagal nerve stimulator
Lobectomy of brain
Temporal lobectomy
Terms that roll up to the Board
Reporting Term
 Implantation of electronic stimulator in
brain
 Placement of brain surface electrode
for electroencephalography
 Placement of depth electrode into
brain for electroencephalography
Procedure Reporting Field
Procedure Reporting Field Values
Procedure Reporting Field
Procedure Reporting Field Values
 Excision of lesion of temporal lobe of
brain
EPILEPSY PAEDIATRIC
Board Reporting Term
Callosotomy
Cerebral hemispherectomy
Corticectomy
Craniotomy with elevation of bone
flap and excision of epileptogenic
focus
Electrocorticography
Terms that roll up to the Board
Reporting Term
 Complete callosotomy
 Partial callosotomy
 Excision of lesion of cerebral cortex
 Excision of part of frontal cortex
 Electrocorticogram during surgery
 Electrocorticogram with photic
stimulation
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Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
EPILEPSY PAEDIATRIC
Board Reporting Term
Implantation of electrode into brain
Insertion of vagal nerve stimulator
Lobectomy of brain
Temporal lobectomy
Terms that roll up to the Board
Reporting Term
 Implantation of electrode into brain
using stereotactic guidance
 Implantation of electronic stimulator in
brain
 Placement of brain surface electrode
for electroencephalography
 Placement of depth electrode into
brain for electroencephalography
Procedure Reporting Field
Procedure Reporting Field Values
Terms that roll up to the Board
Reporting Term
Procedure Reporting Field
Procedure Reporting Field Values
 Creation of lumbar subarachnoidperitoneal shunt with laminectomy
Revision
 Creation of ventriculo-auricular shunt
Revision






 Excision of lesion of temporal lobe of
brain
HYDROCEPHALUS ADULT
Board Reporting Term
Cauterisation of choroid plexus
Creation of lumboperitoneal shunt
Creation of ventriculo-atrial shunt
Yes
No
Unknown
Yes
No
Unknown
CSF shunt removal
Diagnostic endoscopic examination
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Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
HYDROCEPHALUS ADULT
Board Reporting Term
of ventricle of brain and biopsy of
lesion of ventricle of brain
Endoscopic extirpation of lesion of
ventricle of brain
Endoscopic third ventriculostomy
Revision of cerebral ventricular
shunt
Terms that roll up to the Board
Reporting Term
Procedure Reporting Field Values
Revision
 Yes
 No
 Unknown
 Yes
 No
 Unknown
 Conversion of ventricular shunt
 Revision of more than one component
of ventricular shunt
Revision of ventriculoperitoneal
shunt
Therapeutic endoscopic operations
on ventricle of brain
Ventriculoperitoneal shunt
Ventriculo-pleural shunt
Procedure Reporting Field
 Ventriculopleural shunt with valve
Revision
Terms that roll up to the Board
Reporting Term
Procedure Reporting Field
Procedure Reporting Field Values
 Creation of lumbar subarachnoidperitoneal shunt with laminectomy
Revision
 Yes
 No
HYDROCEPHALUS PAEDIATRIC
Board Reporting Term
Cauterisation of choroid plexus
Creation of lumboperitoneal shunt
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Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
HYDROCEPHALUS PAEDIATRIC
Board Reporting Term
Terms that roll up to the Board
Reporting Term
Procedure Reporting Field
Creation of ventriculo-atrial shunt
 Creation of ventriculo-auricular shunt
Revision
CSF shunt removal
Diagnostic endoscopic examination
of ventricle of brain and biopsy of
lesion of ventricle of brain
Endoscopic extirpation of lesion of
ventricle of brain
Endoscopic third ventriculostomy
Revision of cerebral ventricular
shunt
 Unknown
 Yes
 No
 Unknown
 Conversion of ventricular shunt
 Revision of more than one component
of ventricular shunt
Revision of ventriculoperitoneal
shunt
Therapeutic endoscopic operations
on ventricle of brain
Ventriculoperitoneal shunt
Ventriculo-pleural shunt
Procedure Reporting Field Values
Revision
 Ventriculopleural shunt with valve
Revision
 Yes
 No
 Unknown
 Yes
 No
 Unknown
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Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
INFECTION ADULT
Board Reporting Term
Terms that roll up to the Board
Reporting Term
Procedure Reporting Field
Procedure Reporting Field Values
Terms that roll up to the Board
Reporting Term
Procedure Reporting Field
Procedure Reporting Field Values
Procedure Reporting Field
Procedure Reporting Field Values
Aspiration of brain abscess
Focal excision of brain abscess
Trephination of cranium and
drainage of empyema of subdural
space
INFECTION PAEDIATRIC
Board Reporting Term
Aspiration of brain abscess
Focal excision of brain abscess
Trephination of cranium and
drainage of empyema of subdural
space
MINOR/MISCELLANEOUS PROCEDURES ADULT
Board Reporting Term
Biopsy of brain meninges
Terms that roll up to the Board
Reporting Term
 Biopsy of lesion of meninges of brain
 Closed excisional biopsy of cerebral
meninges
 Excisional biopsy of cerebral meninges
 Excisional biopsy of cerebral meninges,
percutaneous, needle
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Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
MINOR/MISCELLANEOUS PROCEDURES ADULT
Board Reporting Term
Biopsy of muscle
Evacuation of haematoma
External drainage procedure from
ventricle of brain
Fenestration of cyst of arachnoid
Implantation of Rickham reservoir
Insertion of intracranial pressure
monitor
Insertion of Ommaya reservoir
Irrigation of wound
Removal of foreign body from brain
Surgical debridement of wound
Terms that roll up to the Board
Reporting Term
 Incisional biopsy of cerebral meninges
 Needle biopsy of cerebral meninges
 Open excisional biopsy of meninges
Procedure Reporting Field
Procedure Reporting Field Values
 Craniotomy and evacuation of
traumatic haematoma
 Diagnostic drainage from ventricle of
brain
 Therapeutic drainage from ventricle of
brain
Post Op
 Yes
 No
 Removal of foreign body from brain
with incision into brain
 Removal of foreign body from brain
without incision into brain
 Removal of foreign body from ventricle
of brain
 Excisional debridement of wound for
infection
 Shave debridement of skin wound
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Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
MINOR/MISCELLANEOUS PROCEDURES ADULT
Board Reporting Term
Tracheostomy
Terms that roll up to the Board
Reporting Term
 Anterior tracheostomy
 Emergency tracheostomy
 Non-emergency tracheostomy
Procedure Reporting Field
Procedure Reporting Field Values
Terms that roll up to the Board
Reporting Term
 Biopsy of lesion of meninges of brain
 Closed excisional biopsy of cerebral
meninges
 Excisional biopsy of cerebral meninges
 Excisional biopsy of cerebral meninges,
percutaneous, needle
 Incisional biopsy of cerebral meninges
 Needle biopsy of cerebral meninges
 Open excisional biopsy of meninges
Procedure Reporting Field
Procedure Reporting Field Values
 Craniotomy and evacuation of
traumatic haematoma
 Diagnostic drainage from ventricle of
brain
 Therapeutic drainage from ventricle of
brain
Post Op
 Yes
 No
MINOR/MISCELLANEOUS PROCEDURES PAEDIATRIC
Board Reporting Term
Biopsy of brain meninges
Biopsy of muscle
Evacuation of haematoma
External drainage procedure from
ventricle of brain
Excision of dermoid anterior
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Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
MINOR/MISCELLANEOUS PROCEDURES PAEDIATRIC
Board Reporting Term
fontanelle region
Fenestration of cyst of arachnoid
Implantation of Rickham reservoir
Insertion of intracranial pressure
monitor
Insertion of Ommaya reservoir
Irrigation of wound
Removal of foreign body from brain
Surgical debridement of wound
Tracheostomy
Terms that roll up to the Board
Reporting Term
Procedure Reporting Field
Procedure Reporting Field Values
 Removal of foreign body from brain
with incision into brain
 Removal of foreign body from brain
without incision into brain
 Removal of foreign body from ventricle
of brain
 Excisional debridement of wound for
infection
 Shave debridement of skin wound
 Anterior tracheostomy
 Emergency tracheostomy
 Non-emergency tracheostomy
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Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
NEUROENDOSCOPY ADULT
Board Reporting Term
Terms that roll up to the Board
Reporting Term
Procedure Reporting Field
Procedure Reporting Field Values
Procedure Reporting Field
Procedure Reporting Field Values
Biopsy of brain tissue tumour
Endoscopic fenestration of cyst of
arachnoid
Endoscopic fenestration of septum
pellucidum for isolated ventricular
hydrocephalus
Endoscopic placement of ventricular
shunt
Neuroendoscopy
Ventriculostomy
NEUROENDOSCOPY PAEDIATRIC
Board Reporting Term
Terms that roll up to the Board
Reporting Term
Biopsy of brain tissue tumour
Endoscopic fenestration of cyst of
arachnoid
Endoscopic fenestration of septum
pellucidum for isolated ventricular
hydrocephalus
Endoscopic placement of ventricular
shunt
Neuroendoscopy
Ventriculostomy
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Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
PAIN & SPASTICITY ADULT
Board Reporting Term
Decompression of trigeminal nerve
(V)
DREZ lesion destruction
Insertion of implantable intrathecal
pump
Insertion of spinal neurostimulator
Spinal cordotomy
Spinal rhizotomy
Terms that roll up to the Board
Procedure Reporting Field
Reporting Term
 Decompression of trigeminal nerve root Microvascular
Procedure Reporting Field Values
 Yes
 No
 Nashold needling of substantia
gelatinosa of cervical cord
 Implantation of neuropacemaker in
spine
 Anterior spinal cordotomy
 Anterolateral cordotomy
 Bilateral spinal cordotomy
 One stage myelotomy
 Percutaneous cervical anterolateral
cordotomy
 Posterior spinal cordotomy
 Spinal cord tractotomy
 Spinal percutaneous cordotomy
 Spinothalamic cordotomy
 Stereotactic cordotomy
 Two stage myelotomy
 Anterior spinal rhizotomy
 Intraspinal nerve root division
 Radiculectomy
 Transection of dorsal spinal nerve root
at entry zone
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Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
PAIN & SPASTICITY ADULT
Board Reporting Term
Trigeminal rhizotomy
Terms that roll up to the Board
Reporting Term
 Pancoast operation
Procedure Reporting Field
Procedure Reporting Field Values
Technique
 Balloon compression
 Injection
 Radiofrequency
 Unknown
PAIN & SPASTICITY PAEDIATRIC
Board Reporting Term
Decompression of trigeminal nerve
(V)
DREZ lesion destruction
Insertion of implantable intrathecal
pump
Insertion of spinal neurostimulator
Spinal cordotomy
Terms that roll up to the Board
Procedure Reporting Field
Reporting Term
 Decompression of trigeminal nerve root Microvascular
Procedure Reporting Field Values
 Yes
 No
 Nashold needling of substantia
gelatinosa of cervical cord
 Implantation of neuropacemaker in
spine
 Anterior spinal cordotomy
 Anterolateral cordotomy
 Bilateral spinal cordotomy
 One stage myelotomy
 Percutaneous cervical anterolateral
cordotomy
 Posterior spinal cordotomy
 Spinal cord tractotomy
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Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
PAIN & SPASTICITY PAEDIATRIC
Board Reporting Term
Spinal rhizotomy
Trigeminal rhizotomy
Terms that roll up to the Board
Reporting Term
 Spinal percutaneous cordotomy
 Spinothalamic cordotomy
 Stereotactic cordotomy
 Two stage myelotomy
 Anterior spinal rhizotomy
 Intraspinal nerve root division
 Radiculectomy
 Transection of dorsal spinal nerve root
at entry zone
 Pancoast operation
Procedure Reporting Field
Procedure Reporting Field Values
Technique
 Balloon compression
 Injection
 Radiofrequency
 Unknown
Procedure Reporting Field
Procedure Reporting Field Values
PERIPHERAL NERVE SURGERY ADULT
Board Reporting Term
Biopsy of sural nerve
Carpal tunnel decompression
Terms that roll up to the Board
Reporting Term
 Carpal tunnel decompression
 Endoscopic carpal tunnel release
 Neuroplasty and transposition of
median nerve at carpal tunnel
 Neuroplasty of median nerve at carpal
tunnel
 Re-release of carpal tunnel
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Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
PERIPHERAL NERVE SURGERY ADULT
Board Reporting Term
Decompression of thoracic outlet by
myotomy of scalenus anticus muscle
Exploration of Brachial Plexus
Implantation of stimoceiver into
peripheral nerve
Neurolysis of ulna nerve
Operative procedure on peripheral
nerve
Peripheral nerve neurectomy
Terms that roll up to the Board
Reporting Term
Procedure Reporting Field
Procedure Reporting Field Values
 Excision of Morton's neuroma of
peripheral nerve
 Excision of nerve of posterior thigh
muscle
 Excision of neuroma of cutaneous
nerve
 Ganglionectomy of coeliac nerve plexus
 Gasserian ganglionectomy
 Incisional biopsy of peripheral nerve
 Inferior maxillary neurectomy
 Intercostal neurectomy
 Paracervical spinal neurectomy
 Partial sacrifice of peripheral nerve
 Popliteal neurectomy
 Tenotomy of adductor of hip,
subcutaneous, open, with obturator
neurectomy
 Total sacrifice of peripheral nerve
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Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
PERIPHERAL NERVE SURGERY ADULT
Board Reporting Term
Repair of nerve
Terms that roll up to the Board
Reporting Term
 Transantral neurectomy of vidian nerve
using sublabial approach
 Transantral vidian nerve neurectomy
 Trigeminal neurectomy
 Tympanosympathectomy
 Vidian Neurectomy
 Biopsy of sural nerve
 Cranial neuroanastomosis
 Cranial neuroplasty
 Cranial neurorrhaphy
 Delayed suture of nerve
 Epineural suture technique
 Epineural suturing of peripheral nerve
 Epiperineural suture technique
 Epiperineural suturing of peripheral
nerve
 Microsurgical repair of peripheral nerve
 Nerve closure
 Nerve reconstruction
 Neuroanastomosis
 Neuroplasty and transposition of
cranial nerve
 Neuroplasty and transposition of ulnar
nerve at elbow
 Neuroplasty of major peripheral nerve
branch of sciatic nerve
Procedure Reporting Field
Procedure Reporting Field Values
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Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
PERIPHERAL NERVE SURGERY ADULT
Board Reporting Term
Terms that roll up to the Board
Reporting Term
 Neuroplasty of major peripheral nerve
of arm
 Neuroplasty of major peripheral nerve
of brachial plexus
 Neuroplasty of major peripheral nerve
of leg
 Neuroplasty of major peripheral nerve
of lumbar plexus
 Neuroplasty of nerve of hand
 Neuroplasty of old injury
 Neuroplasty of ulnar nerve at elbow
 Neuroplasty of ulnar nerve at wrist
 Neurorrhaphy
 Old nerve injury repair
 Perineural suture technique
 Perineural suturing of peripheral nerve
 Peripheral neuroanastomosis
 Peripheral neuroplasty
 Peripheral neurorrhaphy
 Phrenoplasty
 Primary approximation of peripheral
nerve
 Primary microsurgical graft to
peripheral nerve
 Reattachment of nerve
 Repair of abducens nerve (VI)
Procedure Reporting Field
Procedure Reporting Field Values
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Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
PERIPHERAL NERVE SURGERY ADULT
Board Reporting Term
Terms that roll up to the Board
Reporting Term
 Repair of accessory nerve (XI)
 Repair of acoustic nerve (VIII)
 Repair of digital nerve
 Repair of facial nerve (VII)
 Repair of ganglion
 Repair of glossopharyngeal nerve (IX)
 Repair of hypoglossal nerve (XII)
 Repair of oculomotor nerve (III)
 Repair of old traumatic injury of cranial
nerve
 Repair of old traumatic injury of major
peripheral nerve
 Repair of old traumatic injury of
peripheral nerve
 Repair of optic nerve (II)
 Repair of peripheral nerve by
tubulation
 Repair of sympathetic nerve
 Repair of trigeminal nerve (V)
 Repair of trochlear nerve (IV)
 Secondary repair and mobilisation of
peripheral nerve
 Suture of brachial plexus
 Suture of common plantar digital nerve
of foot
 Suture of digital nerve of foot
Procedure Reporting Field
Procedure Reporting Field Values
Prepared by the Royal Australasian College of Surgeons, February 2017
Page 24 of 57
Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
PERIPHERAL NERVE SURGERY ADULT
Board Reporting Term
Sympathectomy
Terms that roll up to the Board
Reporting Term
 Suture of digital nerve of hand
 Suture of facial nerve, extracranial
 Suture of facial nerve, intratemporal,
with grafting
 Suture of lumbar plexus
 Suture of major peripheral nerve of
arm including transposition
 Suture of motor branch of ulnar nerve
 Suture of nerve of hand
 Suture of nerve with mobilisation
 Suture of posterior tibial nerve
 Suture of sciatic nerve
 Suture of sympathetic ganglion
 Suture of sympathetic nerve
 Suture of thenar branch of median
nerve
 Suturing of nerve plexus
 Abdominal sympathectomy
 Cervical sympathectomy
 Cervicothoracic sympathectomy
 Endoscopic transaxillary cervical
sympathectomy
 Excision of cervical rib for outlet
compression syndrome with
sympathectomy
 Excision of lesion of sympathetic nerve
Procedure Reporting Field
Procedure Reporting Field Values
Prepared by the Royal Australasian College of Surgeons, February 2017
Page 25 of 57
Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
PERIPHERAL NERVE SURGERY ADULT
Board Reporting Term
Terms that roll up to the Board
Reporting Term
 Excisional biopsy of sympathetic nerve
ganglion
 Ganglionectomy of sympathetic nerve
 Laparoscopic uterosacral nerve ablation
 Lower limb sympathectomy
 Lumbar sympathectomy
 Lumbar sympathetic ganglionectomy
 Periarterial sympathectomy
 Presacral sympathectomy
 Renal sympathectomy
 Splanchnic surgical sympathectomy
 Splanchnicectomy
 Supraclavicular cervical sympathectomy
 Sympathectomy of digital artery
 Sympathectomy of radial artery
 Sympathectomy of superficial palmar
arch
 Sympathectomy of ulnar artery
 Thoracic surgical sympathectomy
 Thoracolumbar sympathectomy
 Thoracoscopic splanchnicectomy
 Upper limb sympathectomy
 Uterine suspension with presacral
sympathectomy
 Visceral sympathectomy
Procedure Reporting Field
Procedure Reporting Field Values
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Page 26 of 57
Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
PERIPHERAL NERVE SURGERY PAEDIATRIC
Board Reporting Term
Biopsy of sural nerve
Carpal tunnel decompression
Decompression of thoracic outlet by
myotomy of scalenus anticus muscle
Exploration of Brachial Plexus
Implantation of stimoceiver into
peripheral nerve
Neurolysis of ulna nerve
Operative procedure on peripheral
nerve
Peripheral nerve neurectomy
Terms that roll up to the Board
Reporting Term
Procedure Reporting Field
Procedure Reporting Field Values
 Carpal tunnel decompression
 Endoscopic carpal tunnel release
 Neuroplasty and transposition of
median nerve at carpal tunnel
 Neuroplasty of median nerve at carpal
tunnel
 Re-release of carpal tunnel
 Excision of Morton's neuroma of
peripheral nerve
 Excision of nerve of posterior thigh
muscle
 Excision of neuroma of cutaneous
nerve
 Ganglionectomy of coeliac nerve plexus
 Gasserian ganglionectomy
 Incisional biopsy of peripheral nerve
 Inferior maxillary neurectomy
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Page 27 of 57
Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
PERIPHERAL NERVE SURGERY PAEDIATRIC
Board Reporting Term
Repair of nerve
Terms that roll up to the Board
Reporting Term
 Intercostal neurectomy
 Paracervical spinal neurectomy
 Partial sacrifice of peripheral nerve
 Popliteal neurectomy
 Tenotomy of adductor of hip,
subcutaneous, open, with obturator
neurectomy
 Total sacrifice of peripheral nerve
 Transantral neurectomy of vidian nerve
using sublabial approach
 Transantral vidian nerve neurectomy
 Trigeminal neurectomy
 Tympanosympathectomy
 Vidian Neurectomy
 Biopsy of sural nerve
 Cranial neuroanastomosis
 Cranial neuroplasty
 Cranial neurorrhaphy
 Delayed suture of nerve
 Epineural suture technique
 Epineural suturing of peripheral nerve
 Epiperineural suture technique
 Epiperineural suturing of peripheral
nerve
 Microsurgical repair of peripheral nerve
 Nerve closure
Procedure Reporting Field
Procedure Reporting Field Values
Prepared by the Royal Australasian College of Surgeons, February 2017
Page 28 of 57
Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
PERIPHERAL NERVE SURGERY PAEDIATRIC
Board Reporting Term
Terms that roll up to the Board
Reporting Term
 Nerve reconstruction
 Neuroanastomosis
 Neuroplasty and transposition of
cranial nerve
 Neuroplasty and transposition of ulnar
nerve at elbow
 Neuroplasty of major peripheral nerve
branch of sciatic nerve
 Neuroplasty of major peripheral nerve
of arm
 Neuroplasty of major peripheral nerve
of brachial plexus
 Neuroplasty of major peripheral nerve
of leg
 Neuroplasty of major peripheral nerve
of lumbar plexus
 Neuroplasty of nerve of hand
 Neuroplasty of old injury
 Neuroplasty of ulnar nerve at elbow
 Neuroplasty of ulnar nerve at wrist
 Neurorrhaphy
 Old nerve injury repair
 Perineural suture technique
 Perineural suturing of peripheral nerve
 Peripheral neuroanastomosis
 Peripheral neuroplasty
Procedure Reporting Field
Procedure Reporting Field Values
Prepared by the Royal Australasian College of Surgeons, February 2017
Page 29 of 57
Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
PERIPHERAL NERVE SURGERY PAEDIATRIC
Board Reporting Term
Terms that roll up to the Board
Reporting Term
 Peripheral neurorrhaphy
 Phrenoplasty
 Primary approximation of peripheral
nerve
 Primary microsurgical graft to
peripheral nerve
 Reattachment of nerve
 Repair of abducens nerve (VI)
 Repair of accessory nerve (XI)
 Repair of acoustic nerve (VIII)
 Repair of digital nerve
 Repair of facial nerve (VII)
 Repair of ganglion
 Repair of glossopharyngeal nerve (IX)
 Repair of hypoglossal nerve (XII)
 Repair of oculomotor nerve (III)
 Repair of old traumatic injury of cranial
nerve
 Repair of old traumatic injury of major
peripheral nerve
 Repair of old traumatic injury of
peripheral nerve
 Repair of optic nerve (II)
 Repair of peripheral nerve by
tubulation
 Repair of sympathetic nerve
Procedure Reporting Field
Procedure Reporting Field Values
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Page 30 of 57
Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
PERIPHERAL NERVE SURGERY PAEDIATRIC
Board Reporting Term
Sympathectomy
Terms that roll up to the Board
Reporting Term
 Repair of trigeminal nerve (V)
 Repair of trochlear nerve (IV)
 Secondary repair and mobilisation of
peripheral nerve
 Suture of brachial plexus
 Suture of common plantar digital nerve
of foot
 Suture of digital nerve of foot
 Suture of digital nerve of hand
 Suture of facial nerve, extracranial
 Suture of facial nerve, intratemporal,
with grafting
 Suture of lumbar plexus
 Suture of major peripheral nerve of
arm including transposition
 Suture of motor branch of ulnar nerve
 Suture of nerve of hand
 Suture of nerve with mobilisation
 Suture of posterior tibial nerve
 Suture of sciatic nerve
 Suture of sympathetic ganglion
 Suture of sympathetic nerve
 Suture of thenar branch of median
nerve
 Suturing of nerve plexus
 Abdominal sympathectomy
Procedure Reporting Field
Procedure Reporting Field Values
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Page 31 of 57
Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
PERIPHERAL NERVE SURGERY PAEDIATRIC
Board Reporting Term
Terms that roll up to the Board
Reporting Term
 Cervical sympathectomy
 Cervicothoracic sympathectomy
 Endoscopic transaxillary cervical
sympathectomy
 Excision of cervical rib for outlet
compression syndrome with
sympathectomy
 Excision of lesion of sympathetic nerve
 Excisional biopsy of sympathetic nerve
ganglion
 Ganglionectomy of sympathetic nerve
 Laparoscopic uterosacral nerve ablation
 Lower limb sympathectomy
 Lumbar sympathectomy
 Lumbar sympathetic ganglionectomy
 Periarterial sympathectomy
 Presacral sympathectomy
 Renal sympathectomy
 Splanchnic surgical sympathectomy
 Splanchnicectomy
 Supraclavicular cervical sympathectomy
 Sympathectomy of digital artery
 Sympathectomy of radial artery
 Sympathectomy of superficial palmar
arch
 Sympathectomy of ulnar artery
Procedure Reporting Field
Procedure Reporting Field Values
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Page 32 of 57
Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
PERIPHERAL NERVE SURGERY PAEDIATRIC
Board Reporting Term
Terms that roll up to the Board
Reporting Term
 Thoracic surgical sympathectomy
 Thoracolumbar sympathectomy
 Thoracoscopic splanchnicectomy
 Upper limb sympathectomy
 Uterine suspension with presacral
sympathectomy
 Visceral sympathectomy
Procedure Reporting Field
Procedure Reporting Field Values
Terms that roll up to the Board
Reporting Term
Procedure Reporting Field
Procedure Reporting Field Values
Canal stenosis
 Yes
 No
Instrumentation
 With
 Without
 Unknown
SPINE ADULT
Board Reporting Term
Aspiration of cyst
Cervical discectomy
 Osteotomy and discectomy of cervical
spine by anterior approach
 Primary excision of cervical
intervertebral disc
Cervical foraminotomy
Cervical laminectomy
Cervical laminoplasty with
decompression of spinal cord
Cranial decompression, posterior
fossa
 Primary decompression of posterior
fossa and upper cervical spinal cord and
instrumentation
Creation of connection from spinal
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Page 33 of 57
Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
SPINE ADULT
Board Reporting Term
syrinx
Evacuation of spinal extradural
abscess
Evacuation of spinal extradural
haematoma
Excision of lesion of intramedullary
spinal cord
Excision of spinal arteriovenous
malformation
Excision of spinal cord cyst
Excision of thoracic intervertebral
disc
Excision of vertebra
Freeing of spinal tether
Fusion of joint of lumbar spine by
anterior approach
Fusion of joint of thoracic spine by
anterior approach
Fusion of occipitocervical junction
Lumbar discectomy
Lumbar Laminectomy
Percutaneous embolisation of spinal
arteriovenous malformation using
fluoroscopic guidance
Posterior spinal rhizotomy
Primary anterior excision of cervical
Terms that roll up to the Board
Reporting Term
Procedure Reporting Field
Procedure Reporting Field Values
Plate
 With
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Page 34 of 57
Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
SPINE ADULT
Board Reporting Term
intervertebral disc and interbody
fusion of joint of cervical spine
Prosthetic replacement of cervical
intervertebral disc
Prosthetic replacement of lumbar
intervertebral disc
Prosthetic replacement of thoracic
intervertebral disc
Removal of Lipomyelomeningocele
Removal of spinal extradural tumour
Removal of spinal intradural
extramedullary tumour
Repair of diastematomyelia
Repair of Lipomyelomeningocele
Repair of myelomeningocele
Spinal arthrodesis
Terms that roll up to the Board
Reporting Term
Procedure Reporting Field
Procedure Reporting Field Values
 Without
 Unknown
Posterior
 Alar-transverse fusion
 Anterior epiphysiodesis of spine for
correction of deformity
 Arthrodesis by anterior extraoral
technique, clivus-C1-C2, with bone graft
and excision of odontoid process
 Arthrodesis by anterior interbody
technique of cervical region below C2
with bone graft
 Arthrodesis by posterior technique of
atlas-axis with bone graft
 Instrumented
 Non-instrumented
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Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
SPINE ADULT
Board Reporting Term
Terms that roll up to the Board
Procedure Reporting Field
Reporting Term
 Arthrodesis by posterior technique of
atlas-axis with internal fixation
 Back fusion
 Bosworth operation on lumbar spine
 Cervical arthrodesis
 Cervical arthrodesis by anterior
technique
 Cervical arthrodesis by posterior
technique
 Cervical spinal fusion for
pseudoarthrosis
 Combined anterior and posterior
epiphysiodesis of spine for correction
of deformity
 Craniocervical spinal fusion
 Craniocervical spinal fusion for
pseudoarthrosis
 Dorsal and dorsolumbar fusion by
anterior technique
 Dorsal and dorsolumbar fusion by
posterior technique
 Dorsal spinal fusion for pseudoarthrosis
 Dorsolumbar fusion
 Dorsolumbar fusion for pseudoarthrosis
 Dorsolumbar spinal fusion with
Harrington rod
Procedure Reporting Field Values
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Page 36 of 57
Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
SPINE ADULT
Board Reporting Term
Terms that roll up to the Board
Reporting Term
 Fusion of atlantooccipital joint with
internal fixation by posterior approach
 Fusion of cervicothoracic joint by
anterior approach
 Fusion of cervicothoracic joint by
posterior approach
 Fusion of cervicothoracic region of
spine by anterior approach
 Fusion of cervicothoracic region of
spine by posterior approach
 Fusion of cervicothoracic region of
spine with internal fixation by anterior
approach
 Fusion of cervicothoracic region of
spine with internal fixation by posterior
approach
 Fusion of joint of cervical spine with
internal fixation by anterior approach
 Fusion of joint of cervical spine with
internal fixation by posterior approach
 Fusion of joint of lumbar spine with
internal fixation by posterior approach
 Fusion of joint of thoracic spine with
internal fixation by posterior approach
 Fusion of joints of spine from T5
through L1 by posterior approach
Procedure Reporting Field
Procedure Reporting Field Values
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Page 37 of 57
Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
SPINE ADULT
Board Reporting Term
Terms that roll up to the Board
Reporting Term
 Fusion of lumbosacral region of spine
by anterior approach
 Fusion of lumbosacral region of spine
by posterior approach
 Fusion of lumbosacral region of spine
with internal fixation by anterior
approach
 Fusion of lumbosacral region of spine
with internal fixation by posterior
approach
 Fusion of posterior lumbar spine
 Fusion of thoracic spine
 Fusion of thoracolumbar region of
spine
 Fusion of thoracolumbar region of
spine by anterior approach
 Fusion of thoracolumbar region of
spine by posterior approach
 Fusion of thoracolumbar region of
spine with internal fixation by anterior
approach
 Fusion of thoracolumbar region of
spine with internal fixation by posterior
approach
 Laminectomy with spinal fusion
 Lumbar and lumbosacral fusion by
Procedure Reporting Field
Procedure Reporting Field Values
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Page 38 of 57
Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
SPINE ADULT
Board Reporting Term
Terms that roll up to the Board
Reporting Term
lateral transverse process technique
 Lumbar and lumbosacral fusion by
posterior technique
 Lumbar spinal fusion
 Lumbar spinal fusion for
pseudoarthrosis
 Lumbosacral arthrodesis
 Lumbosacral spinal fusion for
pseudoarthrosis
 Posterior epiphysiodesis of spine for
correction of deformity
 Posterior fusion of atlantoaxial joint
 Posterior fusion of atlantoaxial joint
using pedicle screw
 Posterior fusion of atlantoaxial joint
using transarticular screw
 Primary decompression of thoracic
spinal cord and fusion of joint of
thoracic spine
 Primary fusion of cervical spine
 Primary intertransverse fusion of
lumbar spine
 Primary posterior decompression
lumbar spine and fusion
 Primary posterior fusion of lumbar
spine
Procedure Reporting Field
Procedure Reporting Field Values
Prepared by the Royal Australasian College of Surgeons, February 2017
Page 39 of 57
Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
SPINE ADULT
Board Reporting Term
Terms that roll up to the Board
Reporting Term
 Primary posterior fusion of thoracic
spine
 Primary posterior interbody fusion of
joint of lumbar spine
 Primary posterolateral fusion lumbar
spine
 Primary transforaminal interbody
fusion of joint of lumbar spine
 Refusion of spine
 Revision posterior fusion of lumbar
spine
 Revision posterolateral fusion lumbar
spine
 Revisional fusion of cervical spine
 Revisional fusion of joint of spine
 Revisional fusion of occipitocervical
junction
 Revisional posterior fusion of
atlantoaxial joint using pedicle screw
 Revisional posterior fusion of
atlantoaxial joint using transarticular
screw
 Revisional posterior fusion of joint of
thoracic spine
 Spinal epiphysiodesis
 Spinal fusion for kyphosis
Procedure Reporting Field
Procedure Reporting Field Values
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Page 40 of 57
Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
SPINE ADULT
Board Reporting Term
Terms that roll up to the Board
Reporting Term
 Spinal fusion for spondylolysis
 Spinal fusion of atlas-axis
 Spinal fusion of atlas-axis for
pseudoarthrosis
 Spinal fusion with graft
 Spinal fusion without reduction of
spinal deformity
Procedure Reporting Field
Procedure Reporting Field Values
Terms that roll up to the Board
Reporting Term
Procedure Reporting Field
Procedure Reporting Field Values
Canal stenosis
 Yes
 No
Instrumentation
 With
 Without
 Unknown
Thoracic laminectomy
SPINE PAEDIATRIC
Board Reporting Term
Aspiration of cyst
Cervical discectomy
 Osteotomy and discectomy of cervical
spine by anterior approach
 Primary excision of cervical
intervertebral disc
Cervical foraminotomy
Cervical laminectomy
Cervical laminoplasty with
decompression of spinal cord
Cranial decompression, posterior
fossa
 Primary decompression of posterior
fossa and upper cervical spinal cord and
instrumentation
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Page 41 of 57
Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
SPINE PAEDIATRIC
Board Reporting Term
Terms that roll up to the Board
Reporting Term
Procedure Reporting Field
Procedure Reporting Field Values
Creation of connection from spinal
syrinx
Evacuation of spinal extradural
abscess
Evacuation of spinal extradural
haematoma
Excision of lesion of intramedullary
spinal cord
Excision of spinal arteriovenous
malformation
Excision of spinal cord cyst
Excision of thoracic intervertebral
disc
Excision of vertebra
Freeing of spinal tether
Fusion of joint of lumbar spine by
anterior approach
Fusion of joint of thoracic spine by
anterior approach
Fusion of occipitocervical junction
Lumbar discectomy
Lumbar Laminectomy
Percutaneous embolisation of spinal
arteriovenous malformation using
fluoroscopic guidance
Posterior spinal rhizotomy
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Page 42 of 57
Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
SPINE PAEDIATRIC
Board Reporting Term
Primary anterior excision of cervical
intervertebral disc and interbody
fusion of joint of cervical spine
Prosthetic replacement of cervical
intervertebral disc
Prosthetic replacement of lumbar
intervertebral disc
Prosthetic replacement of thoracic
intervertebral disc
Removal of Lipomyelomeningocele
Removal of spinal extradural tumour
Removal of spinal intradural
extramedullary tumour
Repair of diastematomyelia
Repair of Lipomyelomeningocele
Repair of myelomeningocele
Spinal arthrodesis
Terms that roll up to the Board
Reporting Term
Procedure Reporting Field
Procedure Reporting Field Values
Plate
 With
 Without
 Unknown
Posterior
 Alar-transverse fusion
 Anterior epiphysiodesis of spine for
correction of deformity
 Arthrodesis by anterior extraoral
technique, clivus-C1-C2, with bone graft
and excision of odontoid process
 Arthrodesis by anterior interbody
technique of cervical region below C2
with bone graft
 Arthrodesis by posterior technique of
 Instrumented
 Non-instrumented
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Page 43 of 57
Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
SPINE PAEDIATRIC
Board Reporting Term
Terms that roll up to the Board
Procedure Reporting Field
Reporting Term
atlas-axis with bone graft
 Arthrodesis by posterior technique of
atlas-axis with internal fixation
 Back fusion
 Bosworth operation on lumbar spine
 Cervical arthrodesis
 Cervical arthrodesis by anterior
technique
 Cervical arthrodesis by posterior
technique
 Cervical spinal fusion for
pseudoarthrosis
 Combined anterior and posterior
epiphysiodesis of spine for correction
of deformity
 Craniocervical spinal fusion
 Craniocervical spinal fusion for
pseudoarthrosis
 Dorsal and dorsolumbar fusion by
anterior technique
 Dorsal and dorsolumbar fusion by
posterior technique
 Dorsal spinal fusion for pseudoarthrosis
 Dorsolumbar fusion
 Dorsolumbar fusion for pseudoarthrosis
 Dorsolumbar spinal fusion with
Procedure Reporting Field Values
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Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
SPINE PAEDIATRIC
Board Reporting Term
Terms that roll up to the Board
Reporting Term
Harrington rod
 Fusion of atlantooccipital joint with
internal fixation by posterior approach
 Fusion of cervicothoracic joint by
anterior approach
 Fusion of cervicothoracic joint by
posterior approach
 Fusion of cervicothoracic region of
spine by anterior approach
 Fusion of cervicothoracic region of
spine by posterior approach
 Fusion of cervicothoracic region of
spine with internal fixation by anterior
approach
 Fusion of cervicothoracic region of
spine with internal fixation by posterior
approach
 Fusion of joint of cervical spine with
internal fixation by anterior approach
 Fusion of joint of cervical spine with
internal fixation by posterior approach
 Fusion of joint of lumbar spine with
internal fixation by posterior approach
 Fusion of joint of thoracic spine with
internal fixation by posterior approach
 Fusion of joints of spine from T5
Procedure Reporting Field
Procedure Reporting Field Values
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Page 45 of 57
Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
SPINE PAEDIATRIC
Board Reporting Term
Terms that roll up to the Board
Reporting Term
through L1 by posterior approach
 Fusion of lumbosacral region of spine
by anterior approach
 Fusion of lumbosacral region of spine
by posterior approach
 Fusion of lumbosacral region of spine
with internal fixation by anterior
approach
 Fusion of lumbosacral region of spine
with internal fixation by posterior
approach
 Fusion of posterior lumbar spine
 Fusion of thoracic spine
 Fusion of thoracolumbar region of
spine
 Fusion of thoracolumbar region of
spine by anterior approach
 Fusion of thoracolumbar region of
spine by posterior approach
 Fusion of thoracolumbar region of
spine with internal fixation by anterior
approach
 Fusion of thoracolumbar region of
spine with internal fixation by posterior
approach
 Laminectomy with spinal fusion
Procedure Reporting Field
Procedure Reporting Field Values
Prepared by the Royal Australasian College of Surgeons, February 2017
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Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
SPINE PAEDIATRIC
Board Reporting Term
Terms that roll up to the Board
Reporting Term
 Lumbar and lumbosacral fusion by
lateral transverse process technique
 Lumbar and lumbosacral fusion by
posterior technique
 Lumbar spinal fusion
 Lumbar spinal fusion for
pseudoarthrosis
 Lumbosacral arthrodesis
 Lumbosacral spinal fusion for
pseudoarthrosis
 Posterior epiphysiodesis of spine for
correction of deformity
 Posterior fusion of atlantoaxial joint
 Posterior fusion of atlantoaxial joint
using pedicle screw
 Posterior fusion of atlantoaxial joint
using transarticular screw
 Primary decompression of thoracic
spinal cord and fusion of joint of
thoracic spine
 Primary fusion of cervical spine
 Primary intertransverse fusion of
lumbar spine
 Primary posterior decompression
lumbar spine and fusion
 Primary posterior fusion of lumbar
Procedure Reporting Field
Procedure Reporting Field Values
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Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
SPINE PAEDIATRIC
Board Reporting Term
Terms that roll up to the Board
Reporting Term
spine
 Primary posterior fusion of thoracic
spine
 Primary posterior interbody fusion of
joint of lumbar spine
 Primary posterolateral fusion lumbar
spine
 Primary transforaminal interbody
fusion of joint of lumbar spine
 Refusion of spine
 Revision posterior fusion of lumbar
spine
 Revision posterolateral fusion lumbar
spine
 Revisional fusion of cervical spine
 Revisional fusion of joint of spine
 Revisional fusion of occipitocervical
junction
 Revisional posterior fusion of
atlantoaxial joint using pedicle screw
 Revisional posterior fusion of
atlantoaxial joint using transarticular
screw
 Revisional posterior fusion of joint of
thoracic spine
 Spinal epiphysiodesis
Procedure Reporting Field
Procedure Reporting Field Values
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Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
SPINE PAEDIATRIC
Board Reporting Term
Terms that roll up to the Board
Reporting Term
 Spinal fusion for kyphosis
 Spinal fusion for spondylolysis
 Spinal fusion of atlas-axis
 Spinal fusion of atlas-axis for
pseudoarthrosis
 Spinal fusion with graft
 Spinal fusion without reduction of
spinal deformity
Procedure Reporting Field
Procedure Reporting Field Values
Terms that roll up to the Board
Reporting Term
Procedure Reporting Field
Procedure Reporting Field Values
Type
 Frame based
 Frameless
Spinal fusion for scoliosis
Thoracic laminectomy
STEREOSTATIC ADULT
Board Reporting Term
Deep brain stimulation
Needle biopsy
Pallidotomy
Stereotactic radiosurgery
 Chemopallidectomy
 Pallidoamygdalotomy
 Stereotactic ablation of globus pallidus
tissue
 Stereotactic focused gamma
radiosurgery of cerebrum
 Stereotactic focused proton beam on
cerebrum
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Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
STEREOSTATIC ADULT
Board Reporting Term
Terms that roll up to the Board
Procedure Reporting Field
Reporting Term
 Stereotactic radiosurgery of brain tissue
Procedure Reporting Field Values
Terms that roll up to the Board
Reporting Term
Procedure Reporting Field
Procedure Reporting Field Values
Type
 Frame based
 Frameless
Thalamotomy
STEREOSTATIC PAEDIATRIC
Board Reporting Term
Deep brain stimulation
Needle biopsy
Pallidotomy
Stereotactic radiosurgery
 Chemopallidectomy
 Pallidoamygdalotomy
 Stereotactic ablation of globus pallidus
tissue
 Stereotactic focused gamma
radiosurgery of cerebrum
 Stereotactic focused proton beam on
cerebrum
 Stereotactic radiosurgery of brain tissue
Thalamotomy
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Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
TRAUMA ADULT
Board Reporting Term
Cerebral duraplasty
Correction of complex craniofacial
deformity
Craniectomy
Cranioplasty
Craniotomy
Elevation of skull fracture fragments
Evacuation of intracerebral
haematoma
Terms that roll up to the Board
Reporting Term
Procedure Reporting Field
Procedure Reporting Field Values
Type
 Acute subdural haematoma
 Chronic subdural haematoma
 Correction of oblique facial cleft
 Elevation of depressed fracture of skull
and debridement of brain
 Elevation of orbital bone fragments of
frontal sinus
 Osteoplasty of cranium with bone graft
 Craniotomy and decompression of
brain
 Craniotomy and transection of
tentorium cerebelli
 Craniotomy by retromastoid approach
 Exploratory craniotomy, infratentorial
 Exploratory open craniotomy
 Reduction and reconstruction of
craniomegalic skull with craniotomy
 Reopening of craniotomy site
 Strip craniectomy with opening of
cranial suture
 Evacuation of haematoma from
cerebellum
 Evacuation of haematoma from
temporal lobe of brain
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Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
TRAUMA ADULT
Board Reporting Term
Evacuation of intracranial extradural
haematoma
Evacuation of spinal extradural
haematoma
Evacuation of subdural haematoma
Operation on cystic hygroma
Trephination of cranium
Terms that roll up to the Board
Reporting Term
Procedure Reporting Field
Procedure Reporting Field Values
 Trephination of cranium and drainage
of haematoma from subdural space
 Excision of cystic hygroma
Type
 Acute
 Chronic
Type
 Acute subdural haematoma
 Chronic subdural haematoma
Procedure Reporting Field
Procedure Reporting Field Values
Type
 Acute subdural haematoma
 Chronic subdural haematoma
TRAUMA PAEDIATRIC
Board Reporting Term
Cerebral duraplasty
Correction of complex craniofacial
deformity
Craniectomy
Cranioplasty
Craniotomy
Terms that roll up to the Board
Reporting Term
 Correction of oblique facial cleft
 Elevation of depressed fracture of skull
and debridement of brain
 Elevation of orbital bone fragments of
frontal sinus
 Osteoplasty of cranium with bone graft
 Craniotomy and decompression of
brain
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Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
TRAUMA PAEDIATRIC
Board Reporting Term
Elevation of skull fracture fragments
Evacuation of intracerebral
haematoma
Evacuation of intracranial extradural
haematoma
Evacuation of spinal extradural
haematoma
Evacuation of subdural haematoma
Operation on cystic hygroma
Trephination of cranium
Terms that roll up to the Board
Reporting Term
 Craniotomy and transection of
tentorium cerebelli
 Craniotomy by retromastoid approach
 Exploratory craniotomy, infratentorial
 Exploratory open craniotomy
 Reduction and reconstruction of
craniomegalic skull with craniotomy
 Reopening of craniotomy site
 Strip craniectomy with opening of
cranial suture
Procedure Reporting Field
Procedure Reporting Field Values
Type
 Acute
 Chronic
Type
 Acute subdural haematoma
 Chronic subdural haematoma
 Evacuation of haematoma from
cerebellum
 Evacuation of haematoma from
temporal lobe of brain
 Trephination of cranium and drainage
of haematoma from subdural space
 Excision of cystic hygroma
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Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
TUMOUR ADULT
Board Reporting Term
Terms that roll up to the Board
Reporting Term
Craniotomy and excision of pituitary
tumour using intracranial approach
Debulking of tumour
Endoscopic biopsy
Excision of brain metastasis
Excision of colloid cyst
Excision of cranial tumour
Excision of diencephalic glioma
Excision of lesion of cranium
Excision of lesion of peripheral nerve
Excision of lesion of pineal gland
Procedure Reporting Field Values
Glioma
 High grade
 Low grade
Indication
 High Grade Glioma (WHO III/IV)
 Low Grade Glioma (WHO I/II)
 Other
 Pilocytic Astrocytoma
 PNET
 Excision of chemodectoma of pineal
gland
Excision of lesion of ventricle of
brain
Excision of optic nerve glioma
Excision of pituitary tumour by transsphenoidal approach
Exploratory craniotomy,
supratentorial
Needle biopsy of brain
Procedure Reporting Field
 Excisional biopsy of brain,
percutaneous, needle
 Fine needle aspiration biopsy of
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Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
TUMOUR ADULT
Board Reporting Term
Terms that roll up to the Board
Reporting Term
hypophysis
 Fine needle aspiration biopsy of
Rathke's pouch
Partial excision of meningioma
Posterior fossa craniotomy
Procedure Reporting Field
Procedure Reporting Field Values
Indication
 Ependymoma
 Medulloblastoma
 Other
 Pilocytic Astrocytoma
Procedure Reporting Field
Procedure Reporting Field Values
Glioma
 High grade
 Low grade
Puncture and drainage of
craniopharyngioma
Removal of acoustic neuroma
Stereotactic radiosurgery
Total excision of meningioma
TUMOUR PAEDIATRIC
Board Reporting Term
Craniotomy and excision of pituitary
tumour using intracranial approach
Debulking of tumour
Terms that roll up to the Board
Reporting Term
Endoscopic biopsy
Excision of brain metastasis
Excision of colloid cyst
Excision of cranial tumour
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Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
TUMOUR PAEDIATRIC
Board Reporting Term
Excision of diencephalic glioma
Excision of lesion of cranium
Excision of lesion of peripheral nerve
Excision of lesion of pineal gland
Terms that roll up to the Board
Reporting Term
Partial excision of meningioma
Posterior fossa craniotomy
Procedure Reporting Field Values
Indication
 High Grade Glioma (WHO III/IV)
 Low Grade Glioma (WHO I/II)
 Other
 Pilocytic Astrocytoma
 PNET
Indication
 Ependymoma
 Medulloblastoma
 Other
 Pilocytic Astrocytoma
 Excision of chemodectoma of pineal
gland
Excision of lesion of ventricle of
brain
Excision of optic nerve glioma
Excision of pituitary tumour by transsphenoidal approach
Exploratory craniotomy,
supratentorial
Needle biopsy of brain
Procedure Reporting Field
 Excisional biopsy of brain,
percutaneous, needle
 Fine needle aspiration biopsy of
hypophysis
 Fine needle aspiration biopsy of
Rathke's pouch
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Morbidity Audit and Logbook Tool
SNOMED Board Reporting Terms for SET and IMG Neurosurgery
TUMOUR PAEDIATRIC
Board Reporting Term
Terms that roll up to the Board
Reporting Term
Procedure Reporting Field
Procedure Reporting Field Values
Puncture and drainage of
craniopharyngioma
Removal of acoustic neuroma
Stereotactic radiosurgery
Total excision of meningioma
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