Consent For Spinal Surgery (Page 2 of 4) in pdf

6. ___

I understand that I am free to seek other opinions about the proposed surgery and that

my doctors encourage me to do this if I wish.

7. ___

My doctors have discussed and fully informed me about the nature of my problem, the

proposed operation, all known alternative treatments and the possible complications of

both operative and non-operative care of my problem.

8. ___

Reasonable alternative treatments and their risks, consequences and probable

effectiveness have been discussed with me including doing nothing, conservative

therapy with drugs and/or exercise and/or nerve blocks or injections. At this time, I do

not wish to engage in these alternative treatments.

9. ___

I understand that, in general, the surgery is to help relieve pain and to improve function,

but I also am aware that after surgery there may be unresolved symptoms or worsening

of symptoms as well as other sensations which may not have been present before

surgery. I understand less common problems may occur as a result of surgery such as

paralysis, airway difficulties, hematoma, prolonged intubation, numbness, hoarseness

(i.e., recurrent laryngeal nerve palsy), muscle weakness, nonimprovement or worsening

myelopathy or neurogenic claudication, esophageal, great vessel or nerve injury or

difficulty swallowing with anterior cervical procedures, spinal fluid leakage, loss of bowel

or bladder control, arachnoiditis (i.e., scarring of the nerves in the dural sac) and, in

men, impotence, loss of sexual function and retrograde ejaculation. I also understand

that other problems might develop within my spine which may require additional

treatment or even another operation. I am aware that it is not possible to cure or totally

correct my spinal problem and depending on the type of pathology, i.e. tumor or

infection, there may be recurrence or spread.

10. ___

In procedures requiring bone grafting, I understand that healing of my bone graft into a

bone fusion is largely a biological function of my body. Failure of the bone graft to heal

may result in persistent symptoms necessitating additional surgery.

11. ___

I understand that other general problems may occur with any surgery such as death,

deep venous thrombosis (blood clots), stroke, phlebitis, embolism, infection (wound,

discitic, osteomyelitis, epidural abscess), pneumonia, stroke, blindness, cardiac arrest,

anesthesia problems, blood loss, allergic reaction to medications or materials and

diseases transmitted by blood transfusions or other means.

12.___

I have had ample opportunity to discuss my condition, treatment and surgery with my

doctor(s), his/their associates, and with my family. All of my questions have been

answered to my satisfaction. I believe that I have adequate knowledge upon which to

base my decision regarding the proposed operation and to sign this permit.

13. ___

It has been determined that to best treat my spinal problem a fusion may be necessary.

A fusion is an operation designed to eliminate movement between two or more adjacent

vertebrae. My doctor will take bone from my body or use bone from a cadaver and

place this around vertebrae that are meant to be fused. Thereafter, my body must

complete the healing process. Unfortunately, not all fusions heal. Excessive motion,

smoking, steroid use and the use of non-steroidal anti-inflammatory medications within

six to ten weeks of surgery and certain medical conditions such as diabetes and renal

disease may act to cause the fusion to not heal. In an effort to provide the highest

probability that my fusion will heal, my doctor has determined that the use of a spinal

Consent For Spinal Surgery Page 2

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