Brainsurgeon.com.au

(Affix patient identification label here) Beneficence and Nonmaleficence
Neurosurgeon and Spine Surgeon
Lumbar Decompression and
Pedicle Screw Fusion
A. Interpreter / cultural needs
• Bladder or bowel problems due to nerve root injury. This may be temporary or permanent. • Injury to the covering of the spinal cord. This may If yes, is a qualified Interpreter present? • Ongoing persistent back and leg pain, with possible leg numbness due to nerve damage If yes, is a Cultural Support Person present? Yes No from compressed nerve roots. This may require B. Condition and treatment
• Deterioration of other discs. This may require The doctor has explained that you have the following condition: (Doctor to document in patient’s own • Leakage of cerebrospinal fluid. This may require • The pedicle screw may injure the nerve root causing pain and/or weakness. This may be This condition requires the following procedure. • Inadequate placement of the pedicle screw. This (Doctor to document - include site and/or side where • The metal rods or screws may break whilst the bone is healing or fusing. This may require • The bone may not heal or fuse. This may cause This procedure is performed to relieve pressure on the fibrous sheath which contains the spinal nerves • Visual disturbance. This may be temporary or and stabilises the spine from slipping forward. C. Risks of this procedure
• Small areas of the lung may collapse, increasing ced
the risk of chest infection. This may need There are risks and complications with this procedure. They include but are not limited to the following. • Increase risk in obese people of wound infection, ral
Common risks and complications include:
chest infection, heart and lung complications, and co
• Infection, requiring antibiotics and further • Blood clot in the leg (DVT) causing pain and • Minor pain, bruising and/or infection from IV swelling. In rare cases part of the clot may break cannula site. This may require treatment with Rare risks and complications include:
• Pain from the bone graft site of the hip. This • Paraplegia. This may require further surgery. Uncommon risks and complications include:
• Injury to major blood vessels. This will require • Bleeding can occur and may require a return to the operating room. Bleeding is more common if • Death as a result of this procedure is very rare. you have been taking blood thinning drugs such as Warfarin, Asprin, Clopidogrel (Plavix or D. Significant risks and procedure
• Heart attack due to the strain on the heart. (Doctor to document in space provided. Continue in • Stroke or stroke like complications may occur causing neurological deficits such as weakness in the face, arms and legs. This could be • Nerve root injury causing a weakness in foot movement which may affect mobility. This may (Affix patient identification label here) Beneficence and Nonmaleficence
Neurosurgeon and Spine Surgeon
Lumbar Decompression and
Pedicle Screw Fusion
E. Risks of not having this procedure
procedure and its risks, and my treatment options. My questions and concerns have been (Doctor to document in space provided. Continue in discussed and answered to my satisfaction. • I understand I have the right to change my mind at any time before the procedure, including after I have signed this form but, preferably following a F. Anaesthetic
I request to have the procedure
This procedure may require an anaesthetic. (Doctor Name of Patient/
to document type of anaesthetic discussed) Substitute decision
maker and relationship:.
Signature:.
.…………………………………………………… …….
G. Patient consent
Substitute Decision-Maker: Under the Powers of Attorney Act
1998 and/or the Guardianship and Administration Act 2000. If the I acknowledge that the doctor has explained; patient is an adult and unable to give consent, an authorised decision-maker must give consent on the patient’s behalf. • my medical condition and the proposed procedure, including additional treatment if the doctor finds something unexpected. I understand H. Doctor’s statement
the risks, including the risks that are specific to I have explained to the patient all the above points under the Patient Consent section (G) and I am of • the anaesthetic required for this procedure. I the opinion that the patient/substitute decision- understand the risks, including the risks that are • other relevant procedure options and their Doctor:.
Designation:.
• my prognosis and the risks of not having the Signature:.
• that no guarantee has been made that the procedure will improve my condition even though .…………………………………………………………….
it has been carried out with due professional Anaesthetist:.
Designation:
• the procedure may include a blood transfusion. • tissues and blood may be removed and could be Signature:.
condition, stored and disposed of sensitively by Date:.…………………………………………………………….
I. Interpreter’s statement
• if immediate life-threatening events happen during the procedure, they will be treated • a doctor other than the Specialist Neurosurgeon (state the patient’s language here) of the consent may conduct the procedure. I understand this form and assisted in the provision of any verbal and could be a doctor undergoing further training. written information given to the patient/parent or I have been given the following Patient
guardian/substitute decision-maker by the doctor. Information Sheet/s;
About your Anaesthetic
Interpreter:.
Lumbar Decompression & Pedicle Screw
Signature: .
Date:.…………………………………………………………….
• I was able to ask questions and raise concerns with the doctor about my condition, the proposed Consent Information - Patient Copy
Beneficence and Nonmaleficence
Lumbar Decompression and Pedicle Screw Fusion
1. What is a Lumbar Decompression and
• Stroke or stroke like complications may occur Pedicle Screw Fusion?
causing neurological deficits such as weakness in the face, arms and legs. This could be temporary This procedure is performed to relieve pressure on the fibrous sheath which contains the spinal nerves and stabilises the spine from slipping forward. • Nerve root injury causing a weakness in foot movement which may affect mobility. This may be X-rays will be taken during surgery to determine the • Bladder or bowel problems due to nerve root A cut is made down the middle of the back, over the injury. This may be temporary or permanent. decompression site. To decompress the spine, the muscles are stripped from the bones at the back of the • Injury to the covering of the spinal cord. This may spine. The bones on the back of the spine (spinous process and laminae) maybe removed from the spine • Ongoing persistent back and leg pain, with possible leg numbness due to nerve damage from Following the decompression, supporting screws are compressed nerve roots. This may require further inserted into the pedicles of the vertebrae which require support. Sometimes, a computer navigation • Deterioration of other discs. This may require X-rays are taken to ensure the screws are in the • Leakage of cerebrospinal fluid. This may require correct place. The screws are then joined together • The pedicle screw may injure the nerve root A separate cut may be made over the hip to harvest causing pain and/or weakness. This may be some hip bone. Harvested bone is sometimes mixed with a bone substitute. It is then packed along the • Inadequate placement of the pedicle screw. This A small plastic tube (drain) may be inserted to allow • The metal rods or screws may break whilst the any residual fluid to be drained away. This will be bone is healing or fusing. This may require further The cut is closed with stitches or staples. • The bone may not heal or fuse. This may cause 2. My anaesthetic
This procedure will require a General Anaesthetic. • Visual disturbance. This may be temporary or See About your Anaesthetic information sheet for
information about the anaesthetic and the risks • Small areas of the lung may collapse, increasing involved. If you have any concerns, talk these over the risk of chest infection. This may need If you have not been given an information sheet, • Increase risk in obese people of wound infection, chest infection, heart and lung complications, and 3. What are the risks of this specific
procedure?
• Blood clot in the leg (DVT) causing pain and swelling. In rare cases part of the clot may break There are risks and complications with this procedure. They include but are not limited to the following. Rare risks and complications include:
Common risks and complications include:
• Paraplegia. This may require further surgery. This • Infection, requiring antibiotics and further • Injury to major blood vessels. This will require • Minor pain, bruising and/or infection from IV cannula site. This may require treatment with • Death as a result of this procedure is very rare. • Pain from the bone graft site of the hip. This Notes to talk to my doctor about
Uncommon risks and complications include:
• Bleeding can occur and may require a return to the operating room. Bleeding is more common if you have been taking blood thinning drugs such as Warfarin, Asprin, Clopidogrel (Plavix or Iscover) or Dipyridamole (Persantin or Asasantin). • Heart attack due to the strain on the heart.

Source: http://www.brainsurgeon.com.au/Patient%20Handouts/Consent_Forms/Consent_Lumbar_Fusion.pdf