Informed Consent for Spinal Surgery

Procedure Name

Form Sections

Section 1info grid

Surgical Facility Name

Attending Spine Surgeon

Patient Full Legal Name

Date of Birth

Medical Record Number (MRN)

Spinal Level and Surgical Approach

Planned Anesthesia Type

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Section 3list block

Section 4text block

Section 5list block

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Section 12signature block

Patient / Authorized Representative Signature

Witness Signature (If Required)

Attending Surgeon Signature

Informed Consent for Spinal Surgery

Patient and Facility Information

Surgical Facility Name

Attending Spine Surgeon

Patient Full Legal Name

Date of Birth

Medical Record Number (MRN)

Spinal Level and Surgical Approach

Planned Anesthesia Type

Nature and Purpose of the Procedure

This document records authorization for spine surgery. The clinical intention is to relieve spinal cord or nerve root compression, address spinal instability, or repair structural defects. The procedure may involve decompression (removing bone or tissue to relieve pressure), discectomy (removing damaged disc material), or fusion (stabilizing the vertebrae using bone graft and surgical hardware such as screws, rods, or cages). The surgical approach (anterior, posterior, or lateral) will be determined based on the clinical diagnosis.

Material Risks and Potential Complications

Injury to spinal nerves or the spinal cord, potentially causing permanent numbness, weakness, foot drop, bowel/bladder dysfunction, or paralysis.

Cerebrospinal fluid (CSF) leak due to tearing of the dural membrane, which may require surgical repair or bed rest.

Infection at the surgical wound or within the spinal column (discitis), which may require surgical drainage and long-term antibiotics.

Failure of fusion or bone healing (pseudarthrosis), or hardware breakage/loosening, which may require repeat revision surgery.

Persistent or worsening pain in the back, neck, or lower extremities.

[Insert additional surgical risks related to the patient's specific comorbidities or spine level here]

Expected Benefits

Expected benefits of spine surgery include reduction in radiating arm or leg pain, improvement in neurological symptoms (such as numbness or weakness), restoration of spinal stability, and improvement in physical mobility.

Reasonable Alternatives

Non-operative care: physical therapy, exercise, and activity modification.

Interventional pain management: epidural steroid injections or nerve blocks.

Declining surgical intervention and continuing conservative management.

Consent for Anesthesia Services

I understand that anesthesia services are needed for this procedure. The anesthesia provider will separately explain the risks, benefits, and alternatives of the specific anesthesia plan (e.g., general, regional, or local sedation) and obtain separate consent.

Consent for Blood Transfusion

I understand that during this procedure, significant blood loss may occur. If my physician determines it is medically necessary to preserve my life or health, I consent to the administration of blood or blood products.

Tissue Disposal and Pathology

I authorize the medical facility to retain, preserve, use for educational purposes, or dispose of any tissue, fluid, or body parts removed during the procedure in accordance with standard medical practices and legal requirements.

Photography and Observer Consent

I consent to the photographing or video recording of the procedure for medical, scientific, or educational purposes, provided my identity is not revealed. I also consent to the presence of medical students, residents, or device manufacturer representatives as approved by my surgeon.

No Guarantees

I acknowledge that the practice of medicine and surgery is not an exact science. I understand that no guarantees or assurances have been made to me regarding the outcomes or results of this procedure.

Patient Acknowledgment and Consent

I certify that I have read and fully understand this consent form. My physician has explained the procedure, its risks, benefits, and alternatives. I have had all my questions answered to my satisfaction, and I voluntarily consent to the proposed treatment.

Signatures and Verification

Patient / Authorized Representative Signature

Witness Signature (If Required)

Attending Surgeon Signature

Document ID: CC-PENDING

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