CONSENT INFORMATION PATIENT COPY LUMBAR MICRODISCECTOMY PLEASE READ THIS SHEET BEFORE YOU CONSENT FOR YOUR

R SURGERY
This information sheet provides general information to a person having a Lumbar Microdiscectomy. It does not provide advice to the individual. It is important that the content is discussed between the patient and the concerned doctors who understand the level of fitness and medical condition. What is Lumbar Microdiscectomy? Lumbar microdiscectomy is an operation that involves using a surgical microscope and When Lumbar Microdiscectomy is NOT an Option The severity of your symptoms (pain, weakness, lack of mobility) and your general health and physical condition will play an important part in determining when surgery is not an option for you. In general, surgery is not an option when: o o o o your back and leg pain is not caused by a ruptured disc; or Pressure placed on one or more nerve roots by a herniated disc may irritate these neural structures and cause: o o o Debilitating leg pain Weakness and/or numbness in the legs and/or feet, and Bowel/bladder incontinence. o you do not have leg symptoms; there is a medical reason which prevents you from having surgery; medication which reduces swelling or relieves pain would provide you with adequate relief; Physical measures would improve your condition. When Lumbar Microdiscectomy IS an Option
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Patients who suffer from these symptoms as a result of a pinched nerve are potential candidates for this operation.

microsurgical techniques to access and treat the lumbar disc disease By providing magnification and illumination, the microscope allows for a limited dissection. Only that portion of the herniated disc, which is pinching one or more nerve roots, is removed. The term discectomy is derived from the Latin words discus (flat, circular object or plate) and -ectomy (removal). Why is it done?

Lumbar microdiscectomy is usually recommended only when specific conditions are met. In general, surgery is recommended when a ruptured disc is pinching a spinal nerve root(s) and you have: o o o o leg pain which limits your normal daily activities; or weakness in your leg(s) or feet; or numbness in your extremities; or Impaired bowel and/or bladder function.

herniated portion of the disc as well as any disc fragments that have broken off from the disc. The amount of effort required to complete the microdiscectomy depends, in part, on the size of the disc herniation, the number of fragments present, and the difficulty presented in finding and removing these fragments. Closure The operation is completed when your surgeon closes and dresses the incision.

What happens during the procedure? An understanding of what will a help lumbar you to Recovery: Your surgeon will have a specific post-operative recovery/exercise plan to help you return to normal life as soon as possible. The amount of time that you have to stay in the hospital will depend on this treatment plan. You will normally be up and walking in the hospital on the same day after your surgery. Post-operatively, patients may return to a normal level of daily activity quickly. What are my chances for success of the pinched surgery? Your level of healing will be determined by your age, your general health and the severity of the damage to your spinal nerve, as well as your attitude and your willingness to work at recovery. your What are the benefits of having this surgery? microdiscectomy confidence. Incision The operation is performed with you lying on your stomach. Because the operation is viewed through a microscope, this approach only requires a small incision. Your surgeon makes an incision in your lower back. Through this incision, microsurgical instruments are then inserted. Removal once your nerve is located, the extent of the pressure on the nerve can be determined. microsurgical techniques, surgeon removes the Using involves

approach your operation and recovery with

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A microdiscectomy requires only a very small incision and will remove only that portion of your ruptured disc which is "pinching" one or more spinal nerve roots. The recovery time for this particular surgery is usually much less than is required for traditional lumbar surgery. Expectations: Recognize that healing and recovery will not happen overnight. It is a process. It is normal to have some pain after any operation. After a lumbar microdiscectomy, there may be some leg "aching" which occurs as the nerve(s) attempts to heal. You also may feel some muscle spasms across your back and down your leg(s). And if there was inflammation in the nerve root, some pain may persist until this inflammation diminishes. You will be given appropriate

Most people with jobs that are not physically challenging can return to work in two to four weeks or less. Those with jobs that require heavy lifting or operating heavy machinery that can cause intense vibration may need to wait at least six to eight weeks after surgery to return to work. Again, physical therapy may have a role in your recovery. What are the preventive measures to avoid recurrence of the herniated disc? The best way to avoid the recurrence of a ruptured disc is to maintain a healthy lifestyle. It is important that you: o eat a well-balanced diet in order to aid proper healing (avoid foods high in calories and fat content); o continue to eat a healthy diet in the future to reach and maintain your proper body weight; o o get the proper amount of sleep; participate in some form of regular aerobic exercise (such as walking, swimming or riding a bike); o o o take extra care when lifting, bending or twisting; and Take care of other health problems (such as heart disease or diabetes). Watch your weight: If you are overweight, you must gradually return to your proper weight. Crash diets rarely work. Commit

medication to control your pain, relieve back spasms and reduce inflammation. What activities can I do after surgery? Walking is the first physical activity you can attemptin fact it is widely encouraged. Walking will allow you to maintain mobility in your spine as well as decrease the risk of scar tissue forming at the operative site. In a few weeks, you may be allowed to ride a bike or swim. Formal physical therapy may maximize your recovery.

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yourself to better eating habits and stay with them for the rest of your life. o Become more active: Your physician will tell you when you can resume normal physical activities after surgery. Make up your mind now that you will develop a regular aerobic exercise routine, such as walking, (However, program) General Risks of having an Operation: These have been mentioned in the Anesthesia Consent Form. Please discuss this with your Anesthetist before signing the Anesthesia Consent Form. What are the risks of the procedure? While majority of patients have an uneventful surgery and recovery, few cases may be associated with complications. These are seen infrequently and not all the ones listed below are applicable to one individual. However it is important that you are aware of the complications/risks that may arise out of this procedure which are as below: There are some risks/ complications, which include: (a) Nerve root injury that causes a weak ankle, this
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may be temporary or permanent. (b) Injury to the nerve covering (dura) with leakage of cerebro-spinal fluid that can cause meningitis and poor wound healing. This may need treatment with antibiotics and further surgery. (c) Further disc prolapse at the same level or other levels in the spine, this will cause pain and may need further surgery (d) Paraplegia (paralysis of the lower half of the body) which may be temporary or permanent and may require further surgery. (e) Infection in the wound causing redness, pain and possible discharge or abscess. This may need antibiotics. (f) Possible bleeding into the wound with swelling and bruising and possible blood stained discharge. (g) The wound may not heal normally. The wound can thicken and turn red (keloid scar) and the scar may be painful. (h) Ongoing persistent back and leg pain, with possible leg numbness due to nerve damage from the disc prolapse. (i) Increased risk in obese people of wound infection, chest infection, heart and lung complications, thrombosis. (j) Increased risk in smokers of wound and chest infections, heart and lung complications and thrombosis. After the surgery contact your doctor if: o o Fever - even one degree. Increased pain at the incision site.

swimming always

or

riding

bike. your

check

with

physician before starting any exercise

MSSH/Physician/Consent Lumbar Microdiscectomy/Ver.1/Oct.2007

o o o o

Drainage that is pus-like in nature. Redness and swelling at the incision. Heat at the incision. Unpleasant odor at the incision.

I understand that if organs or tissues are removed during the surgery, that these may be retained for tests for a period of time and then disposed of sensitively by the hospital. The doctor has explained to me that if immediate life-threatening events happen during the procedure, they will be treated as appropriate. It has been explained to me, that during the course of or subsequent to the Operation/Procedure, unforeseen conditions may be revealed or encountered which may necessitate urgent surgical or other procedures in addition to or different from

10. Consent Acknowledgement: The doctor has explained my medical condition and the proposed surgical procedure. I understand the risks of the procedure, including the risks that are specific to me, and the likely outcomes. The doctor has explained other relevant treatment options and their associated risks, the prognosis and the risks of not having the procedure. I have been given an Anesthesia Informed Consent Form. I have been given a Patient Information Sheet about the Condition, the Procedure, and associated risks.

those contemplated. In such exigency, I further request and authorize the above named Physician / Surgeon or his designee to perform such additional surgical or other procedures as he or they consider necessary or desirable. On the basis of the above statements,

I was able to ask questions and raise concerns with the doctor about my condition, the procedure and its risks, and my treatment options. My questions and concerns have been

I REQUEST TO HAVE THE PROCEDURE. Name of Patient/Substitute Decision

Maker. Relationship . Signature Date

discussed and answered to my satisfaction. I understand that the procedure may include a blood / blood product transfusion.

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Name of the Witness Relationship/Designation

Signature.. Date

INFORMED CONSENT: LUMBAR MICRODISCECTOMY

Patient Identification Label to be affixed here

A. INTERPRETER An interpreter service is required.Yes______________No_______________ If Yes, is a qualified interpreter present.Yes_____________No___________ B. CONDITION AND PROCEDURE The doctor has explained that I have the following condition: (Doctor to document in patients own words) _______________________________________________and I have been advised to undergo the following treatment/procedure______________________________________________________________________ ______________________________________________________________________________________ See patient information sheet- "Lumbar Microdiscectomy for more C.ANAESTHETIC Please see your Anesthesia Consent Form. This gives you information of the General Risks of Surgery. If you have any concern, talk these over with your anesthetist. OPERATION: Your surgeon inflates and deflates the angioplasty balloon to flatten the plaque and widen the space where the blood flows through. After the artery is open, your physician then removes the catheter with the balloon attached.

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D.RISKS OF THIS PROCEDURE While majority of patients have an uneventful surgery and recovery, few cases may be associated with complications. These are seen infrequently and not all the ones listed below are applicable to one individual. However it is important that you are aware of the complications/risks that may arise out of this procedure which are as below: (a) Nerve root injury that causes a weak ankle, this may be temporary or permanent. (b) Injury to the nerve covering (dura) with leakage of cerebro-spinal fluid that can cause meningitis and poor wound healing. This may need treatment with antibiotics and further surgery. (c) Further disc prolapse at the same level or other levels in the spine, this will cause pain and may need further surgery (d) Paraplegia (paralysis of the lower half of the body) which may be temporary or permanent and may require further surgery. (e) Infection in the wound causing redness, pain and possible discharge or abscess. This may need antibiotics. (f) Possible bleeding into the wound with swelling and bruising and possible blood stained discharge. (g) The wound may not heal normally. The wound can thicken and turn red (keloid scar) and the scar may be painful. (h) Ongoing persistent back and leg pain, with possible leg numbness due to nerve damage from the disc prolapse. (i) Increased risk in obese people of wound infection, chest infection, heart and lung complications, thrombosis. (j) Increased risk in smokers of wound and chest infections, heart and lung complications and thrombosis. SIGNIFICANT RISKS AND RELEVANT TREATMENT OPTIONS:F. SIGNIFICANT RISKS AND The doctor has explained any significant risks and problems specific to me, and the likely outcomes if complications occur. The doctor has also explained relevant treatment options as well as the risks of not having the procedure. (Doctor to document in Medical Record if necessary. Cross out if not applicable. )

PATIENT CONSENT: CONSENT

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I acknowledge that: The doctor has explained my medical condition and the proposed procedure. I understand the risks of the procedure, including the risks that are specific to me, and the likely outcomes. The doctor has explained other relevant treatment options and their associated risks. The doctor has explained my prognosis and the risks of not having the procedure. I have been given a Patient Information Sheet on Anesthesia. I have been given the patient information sheet regarding the condition, procedure, risks and other associated information. I was able to ask questions and raise concerns with the doctor about my condition, the procedure and its risks, and my treatment options. My questions and concerns have been discussed and answered to my satisfaction. I understand that the procedure may include a blood transfusion. I understand that if organs or tissues are removed during the surgery, that these may be retained for tests for a period of time and then disposed of sensitively by the hospital. The doctor has explained to me that if immediate life-threatening events happen during the procedure, they will be treated accordingly. I understand that photographs or video footage maybe taken during my operation. These may then be used for teaching health professionals. (You will not be identified in any photo or video). I understand that no guarantee has been made that the procedure will improve the condition, and that the procedure may make my condition worse.

On the basis of the above statements, I hereby authorize Drand those he may designate as associates or assistants to perform upon me the following medical treatment, surgical operation and / or diagnostic / therapeutic procedure.. I REQUEST TO HAVE THE PROCEDURE

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Name of Patient/Substitute Decision Maker. Relationship . SignatureDate. Name of the Witness Relationship/Designation SignatureDate FERENCES INTERPRETERS STATEMENT: I have given a translation in Name of interpreter. SignatureDate DOCTORS STATEMENTS I have explained The patient s condition Need for treatment The procedure and the risks Relevant treatment options and their risks Likely consequences if those risks occur The significant risks and problems specific to this patient I have given the Patient/ Guardian an opportunity to: Ask questions about any of the above matters Raise any other concerns, which I have answered as fully as possible. I am of the opinion that the Patient/ Substitute Decision Maker understood the above information. Name of doctor.. Designation SignatureDate

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