Consent – Surgery – Center for Advanced Spine Care of Southern Arizona

Consent - Surgeries

Procedure
Patient Name
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I authorize the following procedure: ANTERIOR CERVICAL DISCECOMTY AND FUSION (ACDF) C.
THIS PROCEDURE INVOLVES THE REMOVAL OF AN INTERVERTEBRAL DISC AND FUSION IN YOUR NECK BETWEEN THE (State Nature and Extent of Procedure) VERTEBRAL BODIES OF and USING A PLASTIC CAGE AND/OR BONE GRAFT, A PLATE AND SCREWS by Dr. Kai-Uwe Lewandrowski and associates and assistants of his/her choice.
I authorize the following procedure: ANTERIOR LUMBAR INTERBODY FUSION
THIS PROCEDURE INVOLVES THE REMOVAL OF INTERVERTEBRAL DISC(S) AND FUSION IN YOUR LUMBAR SPINE BETWEEN VERTEBRAL SEGMENTS AND THROUGH INCISIONS IN YOUR LOWER ABDOMEN WITH BONE GRAFT (CADAVERIC BONE FROM A BONE BANK), ARTIFICIAL BONE SUBSTITUTES, CAGE(S), AND GROWTH FACTORS to be performed by Dr._Kai-Uwe Lewandrowski and associates and assistants of his/her choice
I authorize the following procedure: LAMINOFORAMINOTOMY MICRODISCECTOMY WITH RHIZOTOMIES
THIS PROCEDURE INVOLVES PERCUTANEOUS REMOVAL OF HERNIATED DISC OR DECOMPRESSION OF PINCHED NERVES DUE TO SPINAL STENOSIS BETWEEN VERTEBRAL SEGMENTS AND UNDER LOCAL ANESTHESIA AND SEDATION to be performed by Dr._Kai-Uwe Lewandrowski and associates and assistants of his/her choice
I authorize the following procedure: CERVICAL LAMINOFORAMINOTOMY WITH RHIZOTOMIES
THIS PROCEDURE INVOLVES PERCUTANEOUS DENERVATION OF CERIVCAL FACET JOINTS OR DECOMPRESSION OF PINCHED NERVES DUE TO SPINAL STENOSIS BETWEEN VERTEBRAL SEGMENTS AND UNDER LOCAL ANESTHESIA AND SEDATION to be performed by Dr. Kai-Uwe Lewandrowski and associates and assistants of his/her choice
I authorize the following procedure: LAMINOFORAMINOTOMY MICRODISCECTOMY
THIS PROCEDURE INVOLVES PERCUTANEOUS REMOVAL OF HERNIATED DISC OR DECOMPRESSION OF PINCHED NERVES DUE TO SPINAL STENOSIS BETWEEN VERTEBRAL SEGMENTS AND UNDER LOCAL ANESTHESIA AND SEDATION to be performed by Dr. Kai-Uwe Lewandrowski and associates and assistants of his/her choice
I authorize the following procedure: Laminoforaminotomy with Rhizotomies and Hardware Removal
THIS PROCEDURE INVOLVES PERCUTANEOUS REMOVAL OF HERNIATED DISC OR DECOMPRESSION OF PINCHED NERVES DUE TO SPINAL STENOSIS BETWEEN VERTEBRAL SEGMENTS AND UNDER LOCAL ANESTHESIA AND SEDATION to be performed by Dr. Kai-Uwe Lewandrowski and associates and assistants of his/her choice
I authorize the following procedure: Laminoforaminotomy with Rhizotomies
THIS PROCEDURE INVOLVES PERCUTANEOUS REMOVAL OF HERNIATED DISC OR DECOMPRESSION OF PINCHED NERVES DUE TO SPINAL STENOSIS BETWEEN VERTEBRAL SEGMENTS AND UNDER LOCAL ANESTHESIA AND SEDATION to be performed by Dr. Kai-Uwe Lewandrowski and associates and assistants of his/her choice
I authorize the following procedure: LUMBAR HEMILAMINECTOMY, FORAMINOTOMY, MICRODISCECTOMY
THIS PROCEDURE INVOLVES THE REMOVAL OF BONE IN THE POSTERIOR ELEMENTS YOUR OF LUMBAR SPINE TO DECOMPRESS PINCHED NERVES BETWEEN VERTEBRAL SEGMENTS AND THROUGH INCISIONS IN YOUR LOWER BACK to be performed by Dr. Kai-Uwe Lewandrowski and associates and assistants of his/her choice
I authorize the following procedure: LUMBAR LAMINECTOMY
THIS PROCEDURE INVOLVES THE REMOVAL OF BONE IN THE POSTERIOR ELEMENTS OF YOUR LUMBAR SPINE TO DECOMPRESS PINCHED NERVES BETWEEN VERTEBRAL SEGMENTS AND THROUGH INCISIONS IN YOUR LOWER BACK to be performed by Dr. Kai-Uwe Lewandrowski and associates and assistants of his/her choice
I authorize the following procedure: LUMBAR LAMINECTOMY AND IN SITU FUSION
THIS PROCEDURE INVOLVES THE REMOVAL OF BONE IN THE POSTERIOR ELEMENTS OF YOUR LUMBAR SPINE TO DECOMPRESS PINCHED NERVES BETWEEN VERTEBRAL SEGMENTS AND THROUGH INCISIONS IN YOUR LOWER BACK WITH BONE GRAFT (SOMETIMES FROM YOUR HIP OR CADAVERIC BONE FROM A BONE BANK), ARTIFICIAL BONE SUBSTITUTES, AND GROWTH FACTORS_TO ACHIEVE IN SITU (WITHOUT SCREWS OR RODS) FUSION to be performed by Dr._Kai-Uwe Lewandrowski and associates and assistants of his/her choice
I authorize the following procedure: POSTERIOR LUMBAR INTERBODY FUSION
THIS PROCEDURE INVOLVES THE REMOVAL OF INTERVERTEBRAL DISC(S) AND FUSION IN YOUR LUMBAR SPINE BETWEEN VERTEBRAL SEGMENTS AND THROUGH INCISIONS IN YOUR LOWER BACK WITH BONE GRAFT (SOMETIMES FROM YOUR HIP OR CADAVERIC BONE FROM A BONE BANK), ARTIFICIAL BONE SUBSTITUTES, CAGE(S), AND GROWTH FACTORS to be performed by Dr. Kai-Uwe Lewandrowski and associates and assistants of his/her choice
I authorize the following procedure: Posterior Spinal Fusion to be performed by Dr. Kai-Uwe Lewandrowski and associates and assistants of his/her choice
I authorize the following procedure: Kyphoplasty to be performed by Dr. Kai-Uwe Lewandrowski and associates and assistants of his/her choice
I authorize the following procedure: Posterior Cervical Laminectomy to be performed by Dr. Kai-Uwe Lewandrowski and associates and assistants of his/her choice
I authorize the following procedure: Posterior Cervical Fusion to be performed by Dr. Kai-Uwe Lewandrowski and associates and assistants of his/her choice
I authorize the following procedure: Posterior Cervical Copectomy to be performed by Dr. Kai-Uwe Lewandrowski and associates and assistants of his/her choice
I authorize the following procedure: Posterior Cervical Foraminotomy to be performed by Dr. Kai-Uwe Lewandrowski and associates and assistants of his/her choice
I authorize the following procedure: Anterior Cervical Hardware Removal with Exploration Spinal Fusion to be performed by Dr. Kai-Uwe Lewandrowski and associates and assistants of his/her choice
I authorize the following procedure: TRANSFORAMINAL LUMBAR INTERBODY FUSION (TLIF)
THIS PROCEDURE INVOLVES THE REMOVAL OF INTERVERTEBRAL DISC(S), FACET JOINT(S) AND FUSION IN YOUR LUMBAR SPINE BETWEEN VERTEBRAL SEGMENTS AND THROUGH INCISIONS IN YOUR LOWER BACK WITH USE OF PEDICLE SCREWS, RODS, BONE GRAFT (SOMETIMES FROM YOUR HIP OR CADAVERIC BONE FROM A BONE BANK), ARTIFICIAL BONE SUBSTITUTES, CAGE(S), AND GROWTH FACTORS to be performed by Dr. Kai-Uwe Lewandrowski and associates and assistants of his/her choice
I authorize the following procedure: Vari Lift to be performed by Dr. Kai-Uwe Lewandrowski and associates and assistants of his/her choice
Levels
- Cervical
- Lumbar
- Thoracic
Side
- Left
- Right
- Bi-lateral
Cervical
- C1
- C2
- C3
- C4
- C5
- C6
- C7
Lumbar
- L1
- L2
- L3
- L4
- L5
- S1
- S2
Thoracic
- T1
- T2
- T3
- T4
- T5
- T6
- T7
- T8
- T9
- T10
- T11
- T12

The benefits, risks, and alternatives to this procedure are list in the following table:

Benefits	Risks	Alternatives
ACDF may relieve neck pain, arm pain, and numbness or weakness caused by a pinched nerve root.	• Blood loss. Blood loss from ACDF is usually very small. But as with any surgery, there is always the potential for major or even lifethreatening blood loss. • Hoarse voice or swallowing difficulties. • Failure of fusion (fewer than 1 in 50 cases). If the bone fusion fails to heal, you may need to have more surgery. • Infection (fewer than 1 in 100 cases). Even with antibiotics and careful sterile techniques, there is still a very small risk of developing a wound infection. • Damage to spinal nerves or the spinal cord (fewer than 1 in 10,000 cases). If nerves or spinal cord are damaged, you could be left with permanent pain, numbness or weakness in your arms or legs. • Failure to relieve symptoms. Your surgeon will do everything possible to give you the best results. Even so, surgery may not relieve all your symptoms.	ACDF is usually done after nonsurgical treatment options have failed. These can include: • Medications • Physical therapy • Traction • Spinal injections • Watching and waiting If you feel your symptoms are not severe enough to have surgery, tell your doctor. He or she will respect your decision. Some patients with a diseased disc in their neck may be a candidate for an artificial disc.

The benefits, risks, and alternatives to this procedure are list in the following table:

BENEFITS	RISKS	ALTERNATIVES
ALIF may relieve back pain, leg pain, and numbness or weakness caused by a pinched nerve root.	• Blood loss. Blood loss from ALIF is usually small. But as with any surgery, there is always the potential for major or even life threatening blood loss. • Dysthetic (stabbing, burning) leg pain fewer than 5 in 100 cases). • Failure of fusion (fewer than 30 in 100 cases), particularly with smoking. If the bone fusion fails to heal, you may need to have more surgery. • Infection (fewer than 1 in 100 cases). Even with antibiotics and careful sterile techniques, there is still a very small risk of developing a wound infection. • Damage to spinal nerves (fewer than 1 in 10,000 cases). If nerves are damaged, you could be left with permanent pain, numbness or weakness in your arms (as a result of prolonged position) or your legs, such as foot drop. • Failure to relieve symptoms. Your surgeon will do everything possible to give you the best results. Even so, surgery may not relieve all your symptoms.	ALIF is usually done after nonsurgical treatment options have failed. These can include: • Medications • Physical therapy • Traction • Spinal injections • Watching and waiting If you feel your symptoms are not severe enough to have surgery, tell your doctor. He or she will respect your decision. Some patients with a diseased disc in their lower back may be a candidate for an artificial disc, or other non-fusion technologies.

The benefits, risks, and alternatives to this procedure are list in the following table:

BENEFITS

RISKS

ALTERNATIVES

ENDOSCOPIC TRANS- FORAMINAL MICRODISCECTOMY may relieve back pain, leg pain, and numbness or weakness caused by a pinched nerve root.

• Blood loss. Blood loss from ENDOSCOPIC TRANSFORAMINAL MICRODISCECTOMY is usually very small. But as with any surgery, there is always the potential for major or even life-threatening blood loss.
• Dysthetic (stabbing, burning) leg pain (fewer than 5 in 100 cases).
• Infection (fewer than 1 in 100 cases). Even with antibiotics and careful sterile techniques, there is still a very small risk of developing a wound infection.
• Damage to spinal nerves (fewer than 1 in 10,000 cases). If nerves are damaged, you could be left with permanent pain, numbness or weakness in your arms (as a result of prolonged position) or your legs, such as foot drop.
• Scar tissue formation (postlaminectomy syndrome; fewer than 5 in 100 cases), and development of spinal instability (postlaminectomy instability; fewer than 20 in 100 cases) requiring more surgery including spinal fusion
• Failure to relieve symptoms. Your surgeon will do everything possible to give you the best results. Even so, surgery may not relieve all your symptoms.

ENDOSCOPIC TRANSFORAMINAL MICRODISCECTOMY is usually done after nonsurgical treatment options have failed. These can include:

• Medications
• Physical therapy
• Traction
• Spinal injections
• Watching and waiting

If you feel your symptoms are not severe enough to have surgery, tell your doctor. He or she will respect your decision.

The benefits, risks, and alternatives to this procedure are list in the following table:

BENEFITS	RISKS	ALTERNATIVES
LAMINOFORAMINOTOMY MICRODISCECTOMY THROUGH DIRECT POSTERIOR AND TRANSFORAMINAL APPROACH may relieve back pain, leg pain, and numbness or weakness caused by a pinched nerve root.	• Blood loss. Blood loss from LAMINOFORAMINOTOMY MICRODISCECTOMY THROUGH DIRECT POSTERIOR AND TRANSFORAMINAL APPROACH is usually very small. But as with any surgery, there is always the potential for major or even life-threatening blood loss. • Dysthetic (stabbing, burning) leg pain (fewer than 5 in 100 cases). • Infection (fewer than 1 in 100 cases). Even with antibiotics and careful sterile techniques, there is still a very small risk of developing a wound infection. • Damage to spinal nerves (fewer than 1 in 10,000 cases). If nerves are damaged, you could be left with permanent pain, numbness or weakness in your arms (as a result of prolonged position) or your legs, such as foot drop. • Scar tissue formation (postlaminectomy syndrome; fewer than 5 in 100 cases), and development of spinal instability (postlaminectomy instability; fewer than 20 in 100 cases) requiring more surgery including spinal fusion • Failure to relieve symptoms. Your surgeon will do everything possible to give you the best results. Even so, surgery may not relieve all your symptoms.	LAMINOFORAMINOTOMY MICRODISCECTOMY THROUGH DIRECT POSTERIOR AND TRANSFORAMINAL APPROACH is usually done after nonsurgical treatment options have failed. These can include: • Medications • Physical therapy • Traction • Spinal injections • Watching and waiting If you feel your symptoms are not severe enough to have surgery, tell your doctor. He or she will respect your decision.

The benefits, risks, and alternatives to this procedure are list in the following table:

BENEFITS	RISKS	ALTERNATIVES
HEMILAMINECTOMY / MICRODISCECTOMY may relieve back pain, leg pain, and numbness or weakness caused by a pinched nerve root.	• Blood loss. Blood loss from HEMILAMINECTOMY / MICRODISCECTOMY is usually small. But as with any surgery, there is always the potential for major or even life-threatening blood loss. • Dysthetic (stabbing, burning) leg pain (fewer than 5 in 100 cases). • Infection (fewer than 1 in 100 cases). Even with antibiotics and careful sterile techniques, there is still a very small risk of developing a wound infection. • Damage to spinal nerves (fewer than 1 in 10,000 cases). If nerves are damaged, you could be left with permanent pain, numbness or weakness in your arms (as a result of prolonged position) or your legs, such as foot drop. • Scar tissue formation (postlaminectomy syndrome; fewer than 5 in 100 cases), and development of spinal instability (postlaminectomy instability; fewer than 20 in 100 cases) requiring more surgery including spinal fusion • Failure to relieve symptoms. Your surgeon will do everything possible to give you the best results. Even so, surgery may not relieve all your symptoms..	HEMILAMINECTOMY / MICRODISCECTOMY is usually done after nonsurgical treatment options have failed. These can include: • Medications • Physical therapy • Traction • Spinal injections • Watching and waiting If you feel your symptoms are not severe enough to have surgery, tell your doctor. He or she will respect your decision.

The benefits, risks, and alternatives to this procedure are list in the following table:

BENEFITS	RISKS	ALTERNATIVES
LAMINECTOMY may relieve back pain, leg pain, and numbness or weakness caused by a pinched nerve root. It may heal the bones in your back together.	• Blood loss. Blood loss from LAMINECTOMY is usually small. But as with any surgery, there is always the potential for major or even life-threatening blood loss. • Dysthetic (stabbing, burning) leg pain (fewer than 5 in 100 cases). • Failure of fusion (fewer than 30 in 100 cases), particularly with smoking. If the bone fusion fails to heal, you may need to have more surgery. • Infection (fewer than 1 in 100 cases). Even with antibiotics and careful sterile techniques, there is still a very small risk of developing a wound infection. • Damage to spinal nerves (fewer than 1 in 10,000 cases). If nerves are damaged, you could be left with permanent pain, numbness or weakness in your arms (as a result of prolonged position) or your legs, such as foot drop. • Scar tissue formation (postlaminectomy syndrome; fewer than 5 in 100 cases), and development of spinal instability (postlaminectomy instability; fewer than 20 in 100 cases) requiring more surgery including spinal fusion • Failure to relieve symptoms. Your surgeon will do everything possible to give you the best results. Even so, surgery may not relieve all your symptoms.	LAMINECTOMY is usually done after nonsurgical treatment options have failed. These can include: • Medications • Physical therapy • Traction • Spinal injections • Watching and waiting If you feel your symptoms are not severe enough to have surgery, tell your doctor. He or she will respect your decision.

The benefits, risks, and alternatives to this procedure are list in the following table:

BENEFITS	RISKS	ALTERNATIVES
LAMINECTOMY WITH IN SITU FUSION may relieve back pain, leg pain, and numbness or weakness caused by a pinched nerve root. It may heal the bones in your back together.	• Blood loss. Blood loss from LAMINECTOMY WITH IN SITU FUSION is usually small. But as with any surgery, there is always the potential for major or even life-threatening blood loss. • Dysthetic (stabbing, burning) leg pain (fewer than 5 in 100 cases). • Failure of fusion (fewer than 30 in 100 cases), particularly with smoking. If the bone fusion fails to heal, you may need to have more surgery. • Infection (fewer than 1 in 100 cases). Even with antibiotics and careful sterile techniques, there is still a very small risk of developing a wound infection. • Damage to spinal nerves (fewer than 1 in 10,000 cases). If nerves are damaged, you could be left with permanent pain, numbness or weakness in your arms (as a result of prolonged position) or your legs, such as foot drop. • Scar tissue formation (postlaminectomy syndrome; fewer than 5 in 100 cases), and development of spinal instability (postlaminectomy instability; fewer than 20 in 100 cases) requiring more surgery including spinal fusion • Failure to relieve symptoms. Your surgeon will do everything possible to give you the best results. Even so, surgery may not relieve all your symptoms.	LAMINECTOMY WITH IN SITU FUSION is usually done after nonsurgical treatment options have failed. These can include: • Medications • Physical therapy • Traction • Spinal injections • Watching and waiting If you feel your symptoms are not severe enough to have surgery, tell your doctor. He or she will respect your decision.

The benefits, risks, and alternatives to this procedure are list in the following table:

BENEFITS	RISKS	ALTERNATIVES
PLIF may relieve back pain, leg pain, and numbness or weakness caused by a pinched nerve root.	• Blood loss. Blood loss from PLIF is usually small. But as with any surgery, there is always the potential for major or even life threatening blood loss. • Dysthetic (stabbing, burning) leg pain (fewer than 5 in 100 cases). • Failure of fusion (fewer than 30 in 100 cases), particularly with smoking. If the bone fusion fails to heal, you may need to have more surgery. • Infection (fewer than 1 in 100 cases). Even with antibiotics and careful sterile techniques, there is still a very small risk of developing a wound infection. • Damage to spinal nerves (fewer than 1 in 10,000 cases). If nerves are damaged, you could be left with permanent pain, numbness or weakness in your arms (as a result of prolonged position) or your legs, such as foot drop. • Failure to relieve symptoms. Your surgeon will do everything possible to give you the best results. Even so, surgery may not relieve all your symptoms.	PLIF is usually done after nonsurgical treatment options have failed. These can include: • Medications • Physical therapy • Traction • Spinal injections • Watching and waiting If you feel your symptoms are not severe enough to have surgery, tell your doctor. He or she will respect your decision. Some patients with a diseased disc in their lower back may be a candidate for an artificial disc, or other non-fusion technologies.

The benefits, risks, and alternatives to this procedure are list in the following table:

BENEFITS	RISKS	ALTERNATIVES
TLIF may relieve back pain, leg pain, and numbness or weakness caused by a pinched nerve root.	• Blood loss. Blood loss from TLIF is usually small. But as with any surgery, there is always the potential for major or even life threatening blood loss. • Dysthetic (stabbing, burning) leg pain (fewer than 5 in 100 cases). • Failure of fusion (fewer than 30 in 100 cases), particularly with smoking. If the bone fusion fails to heal, you may need to have more surgery. • Infection (fewer than 1 in 100 cases). Even with antibiotics and careful sterile techniques, there is still a very small risk of developing a wound infection. • Damage to spinal nerves (fewer than 1 in 10,000 cases). If nerves are damaged, you could be left with permanent pain, numbness or weakness in your arms (as a result of prolonged position) or your legs, such as foot drop. • Failure to relieve symptoms. Your surgeon will do everything possible to give you the best results. Even so, surgery may not relieve all your symptoms.	TLIF is usually done after nonsurgical treatment options have failed. These can include: • Medications • Physical therapy • Traction • Spinal injections • Watching and waiting If you feel your symptoms are not severe enough to have surgery, tell your doctor. He or she will respect your decision. Some patients with a diseased disc in their lower back may be a candidate for an artificial disc, or other non-fusion technologies.

The most significant risks to this surgery are of hoarseness of the voice, swallowing problems, neck pain, perforation of the breathing (trachea) and feeding (eosophagus) tube, spinal nerve and spinal cord damage, need for more surgery due to infection, failure of healing, failure of hardware, or breakdown of adjacent levels.
In addition to the risks outlined below this surgery carries the specific risks of dysethetic leg pain (more leg pain than you had before), inflammatory reaction possibly resulting in scarring of nerves and dissolution of your bone (osteolysis), heterotopic (unwanted) bone formation causing more pain, destabilization of adjacent levels during surgery requiring additional levels to be fused during your surgery, need for more surgery due to infection, failure of healing, failure of hardware, or breakdown of adjacent levels, or painful spinal instrumentation (myofascial low back pain), retrograde ejaculation (ejection of semen into the bladder).
Please read and acknowledge every paragraph with a check.
Agree to all?
- Yes
Additional Procedures: I consent to the performance of operation(s) or procedure(s) in addition to or different from those now contemplated, arising from presently unforeseen conditions, which the above named doctor or his/her associates or assistants may consider necessary or advisable in the course of the operation.
Accept Additional Procedures*
- I accept
Anesthesia: The administration of anesthesia also involves serious risks, most importantly, a rare risk of reaction to the medications causing death. I understand that in the event that anesthesia is administered by an anesthesiologist, then I should discuss the specific risk with the anesthesiologist providing the service. I consent to the use of such anesthetics as may be considered necessary by the person responsible for these services
Accept Anesthesia*
- I accept
Results Not Guaranteed: I understand that in some cases the operation may not be successful, and that I could be no better or even worse than I am now. Furthermore, I understand that no guarantee or assurance has been made as to the results of the surgery/procedure(s) and that it may not cure the condition.
Accept Results Not Guaranteed*
- I accept
Major Surgery: Reconstructive orthopaedic surgery, such as total joint replacement or spinal fusion and instrumentation surgery is considered MAJOR SURGERY. The procedure may require blood transfusion during or after the operation. Blood replacement may be autologous (self-given), or homologous (from someone else), and the risks of that have been explained to me.
Accept Major Surgery*
- I accept
Patient Compliance: I understand that my continuing of smoking after surgery or non-compliance with my physician’s advice as to weight-bearing status, restrictions & limitations, or specific instructions for recovery and rehabilitation may have deleterious effects on clinical results.
Accept Patient Compliance*
- I accept
Disposal of Tissues/Body Parts: I consent to the examination and retention for anatomical purposes and destruction by the hospital of any tissue or body parts, which may be removed during the operation or procedure.
Accept Disposal*
- I accept
Risks and Complications: I understand that complications are infrequent, but have been described to me so that I can make an informed decision. Furthermore, I understand that the proposed surgery/procedure(s) has inherent risks and complications that can be serious and possibly fatal. These risk and complications include but are not limited to: Infection, bleeding and blood loss (anemia), nerve and vessel damage, blot clots migrating to vital organs, including the lungs, brain, kidneys, or the extremities resulting in loss of function, heart attack, stroke, allergic reaction, injury to the spinal cord or nerve roots which may result in paralysis, paraplegia, motor and sensory loss (lack of feeling or strength), scarring of the nerve roots (arachonoditis), upper and lower extremity weakness (for example foot drop), hoarseness and/or loss of the voice, loss of bladder, bowel, and sexual function, retrograde ejaculation, bowel perforation and need for colostomy (external diversion of bowel to the outside of your stomach), dural leaks (leakage of spinal fluid secondary to a tear of the dura mater), non-union of the bone, failure of internal fixation device(s), continuing or additional pain (for example from bone graft sites), respiratory problems like pneumonia, and in some instances, death. Additional risks include accelerated breakdown and degeneration of other adjacent or distant body parts and the need for further surgery. Furthermore, I understand that my surgeon may use medical devices, or implants that may not be regulated or approved by the Food and Drug Administration (FDA) for my type of surgery.
Accept Risks and Complications*
- I accept
Additional Surgery Due To Complications Or Failure Of Internal Fixation Device(s)/Implants: The use of metallic surgical implants provides the surgeon a means of accurate bone fixation and helps generally in the management of reconstructive surgery. However, these implants are not intended to replace normal body structures or bear the weight of the body in the presence of incomplete bone healing. No partial weight bearing or non-weight bearing device can be expected to withstand the unsupported stresses of full weight bearing and as such, these instruments are used to temporarily stabilize your body parts, such as the bones in the foot or the vertebrae in the spine, until bony union between them occurs. The patient may have to employ external support and should restrict physical activities which would place stresses upon the implant or allow movement and delay healing. Otherwise, breakage of devices or implants may occur.
Accept Additional Surgery*
- I accept
Medical Education & Research: I consent to the photographing or televising of the operations or procedures to be performed, including appropriate portions of my body, for medical, scientific or educational purposes, providing my identity is not revealed by the pictures or by descriptive text accompanying them.
Accept Medical Education & Research*
- I accept
Healthcare Personnel In Training: I consent to the admittance of observers to the operating room/procedure room for the purpose of advancing medical education. I further understand that some services relating to the operation/procedure may be provided by the healthcare personnel in training, residents and medical students under the supervision of the surgeon, anesthesiologist or hospital employees.
Accept Healthcare Personnel In Training*
- I accept
Equipment/Supply/Implants/Bone Grafts: I understand a hospital equipment/supply/implant company representative may be present in the operating/procedure room to provide my physician technical information related to a specific product relating to my case. Furthermore, I understand that my surgeon may use implants from companies or vendors in which he may have financial interests. In addition, I recognize that my surgery may entail the use of internal fixation devices, including screws, rods, plates, hook or wires (for the fixation) and stabilization of bones, such as in the foot, spine, or any other body part. Various bone grafts may be selected: Autograft (patients own bone) or allograft (banked bone).
Accept Equipment/Supply/Implants/Bone Grafts*
- I accept
Radiation & Contrast: I consent to the use of x-rays, fluoroscopy, and contrast media, if necessary for radiological purposes and understand that this may have some undesirable side effects.
Accept Radiation & Contrast*
- I accept
Additional Services: I understand that the above name surgeon/physician and his/her associate or assistant will be occupied solely with performing such operation/procedure and the persons in attendance at such services involving pathology, radiology or other services, are not the agents, servants or employees of your surgeon’s organization, but may be hospital employees or independent contractors.
Accept Additional Services*
- I accept
Disclosures: Your surgeon/physician may recommend the use of equipment and/or implants in which he/she may have a financial interest due to ownership of shares, membership, and/or stock options in companies that may manufacture said equipment or implants. In addition your surgeon/physician may benefit from the use of recommended equipment and/or implants from royalties, educational grants and consulting agreements.
Accept Disclosures*
- I accept
Patient’s Consent: I confirm, that my physician has explained to me the nature, purpose and possible consequences of the operation/procedure stated on this form, as well as the risk involved, the possibility of complications and the possible alternative methods of treatment; that I understand that the explanation I have received is not exhaustive and that other, more remote risks and consequences may arise; that I have been advised that a more detailed and complete explanation of any of the foregoing matters will be given to me if I so desire; that I do not desire such further explanation; and that I acknowledge that I have received no guarantees or assurances from anyone as to the results that may be obtained.
Accept Patient’s Consent*
- I accept
Dispute Resolution: I agree and consent to resolve any dispute(s) that may arise out of my medical treatment(s) by physicians at the Center for Advanced Spinal Surgery of Southern Arizona via mediation by filing the case with the American Arbitration Association. I understand that this does not apply to any billing or collection related disputes for services provided to me.
Accept Dispute Resolution*
- I accept
I agreed to all of these conditions by selecting Yes to the "Agree to All?" check mark above.
I agreed to all of these conditions by selecting "I accept" to each condition listed.
Disclosure On The Impact Of Health Care Reform On Your Care

I hereby ACKNOWLEDGE that my doctor will make every attempt to deliver the best care possible in the context of the dynamically changing health care environment. where there is an increasing amount of regulation and rules as to appropriateness and medical necessity of procedures and surgeries. In fact, your doctor is subject to such Medical Necessity and Appropriateness of Procedure Rules imposed by insurance companies, hospitals and surgery centers, where providers at the Center For Advanced Spine Care are currently performing procedures and surgeries at. As a result, the treatment recommendation that your doctor/surgeon may make could be affected by these rules and may not be necessarily the most appropriate or preferred treatment in his or her clinical judgement. In addition, procedures and surgeries may not be authorized and your doctor may simply not be able to perform certain procedures on you. With the transition of our local health care system from a Clinical Guidelines based system to a Rules based system, your doctor may not be able to provide the preferred recommended care given those newly imposed constraints.
IF YOU HAVE ANY QUESTIONS AS TO THE RISK OR HAZARDS OF THE PROPOSED SURGERY/PROCEDURE(S) OR ANY QUESTIONS CONCERNING THEM ASK YOUR PHYSICIAN BEFORE SIGNING THIS FORM.
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I HAVE EXPLAINED THE RISK/BENEFITS/ALTERNATIVES OF THIS OPERATION/PROCEDURE TO THE PATIENT/REPRESENTATIVE WHO HAS INDICATED UNDERSTANDING THEREOF AND HAS CONSENTED TO ITS PERFORMANCE.
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Consent - Surgeries

I HAVE EXPLAINED THE RISK/BENEFITS/ALTERNATIVES OF THIS OPERATION/PROCEDURE TO THE PATIENT/REPRESENTATIVE WHO HAS INDICATED UNDERSTANDING THEREOF AND HAS CONSENTED TO ITS PERFORMANCE.