Lumbar Decompression (With or Without Discectomy) Operative Report

Patient Name: [Patient full name]

MRN: [Medical record number]

Date of Procedure: [Procedure date]

Facility/OR: [Facility name and OR number]

Primary Surgeon: [Surgeon name and credentials]

Assistant(s): [Assistant name(s) and role(s) / None]

Anesthesia Type: [general / spinal / epidural / MAC]

Preoperative Diagnosis and Indication

Preoperative Diagnosis: [Clinical diagnosis with specific level(s) and laterality]

[Brief indication statement summarizing symptoms, neurologic findings, failed conservative therapies, and imaging findings correlating with operative level(s)] (2–4 sentences)

Planned Procedure: [Planned decompression type(s) and any discectomy with explicit level(s) and laterality]

Postoperative Diagnosis

[Same as preoperative diagnosis / Postoperative diagnosis reflecting intraoperative findings with explicit level(s) and laterality]

Procedure(s) Performed

• [Level]: [laminectomy / laminotomy / hemilaminotomy], [right / left / bilateral]; [medial facetectomy extent if performed]; [foraminotomy if performed]; [discectomy / microdiscectomy / no discectomy]

(List each level separately on its own line; do not combine levels. Avoid vague terms like "multilevel decompression.")

• Microsurgical technique with operating microscope: [Yes / No]
• Intraoperative fluoroscopy for level localization: [Yes / No]

Intraoperative Findings

• [Level]:
  • Stenosis: [central canal / lateral recess / foraminal]—[mild / moderate / severe]
  • Hypertrophy: [ligamentum flavum / facet / osteophytes]
  • Synovial cyst: [present with location / absent]
  • Disc pathology: [contained / extruded / sequestered]; [central / paracentral / foraminal / far-lateral]; [right / left / bilateral]
  • Nerve root(s) affected: [root level(s)]—[compression characteristics]; post-decompression status: [freely mobile / decompressed without tension]

(Duplicate the above block for each level addressed.)

Operative Technique

Positioning and Level Localization: Patient positioned prone on [frame type]. Pressure points padded and eyes protected. Level confirmed with [fluoroscopy / X-ray] using [AP / lateral / oblique] imaging prior to incision.

Approach and Exposure: [Midline / paramedian] incision over [level(s)]. [Open / tubular MIS] approach. Dissection carried through subcutaneous tissue and fascia to [spinous processes / lamina] at [level(s)], maintaining [subperiosteal / intramuscular] plane. [Retractors / tubular dilators] placed to expose target anatomy.

[Level] Decompression—[Right / Left / Bilateral]

Bony work: [Laminectomy / laminotomy / hemilaminotomy] performed at [specific lamina/level] using [Kerrison rongeurs / high-speed drill]. [Medial facetectomy extent]. [Foraminotomy extent if performed].

Ligamentum flavum: [Partial / complete] resection to expose the [thecal sac / traversing root].

Neural decompression: The [thecal sac / traversing root / exiting root] was decompressed and all compressive elements removed.

Adequacy of decompression: [Nerve root freely mobile / probe passes into foramen without resistance / pulsatile thecal sac without residual compression].

(Duplicate this subsection for each decompressed level; do not combine multiple levels.)

[Level] Discectomy—[Right / Left / Bilateral]

(Include only if discectomy/microdiscectomy was performed at this level. Omit entirely if no discectomy was done.)

Disc work: [Annulotomy performed / fragmentectomy only]. [Fragment type and location]. [Disc space entered and explored / disc space not entered].

Technique: [Standard / microsurgical] technique using [operative microscope / loupes].

Post-disc decompression status: [Traversing / exiting] nerve root [freely mobile / decompressed without tension]; foramen and lateral recess [patent / without residual compression].

Dural Integrity: [Dural integrity confirmed; no CSF leak encountered. / Intraoperative durotomy at [location] measuring [size]; repaired with [primary suture / patch / sealant]. Valsalva test [negative / positive]. Postoperative plan adjusted to include [flat positioning / drain management / other].] (Always document dural status explicitly.)

Hemostasis and Closure: Hemostasis achieved with [bipolar cautery / hemostatic agents]. Wound irrigated. Closure in layers: fascia with [suture type], subcutaneous with [suture type], skin with [subcuticular suture / staples / adhesive]. [Local anesthetic infiltrated / no local used]. [Dressing type] applied.

Specimens and Implants

• Specimens to pathology: [disc material / cyst / tissue for culture / None]
• Implants/materials: [dural patch / sealant / hemostatic matrix / None]

Drains

[None / [Drain type] placed in [location]; plan: [management and removal criteria]]

(May omit section entirely if no drain placed.)

Estimated Blood Loss

[EBL in mL]

Transfusions: [None / units and product type]

(Required field; if not provided in dictation, flag for completion.)

Complications

[None / List each complication with description, intraoperative management, and residual concerns]

(Durotomy, neurologic changes, level localization issues, and significant bleeding must be addressed here if they occurred.)

Disposition

Patient [hemodynamically stable / specify condition], [extubated / intubated], transferred to [PACU / recovery / ICU]. Immediate neurologic status: [moving all extremities / at baseline / changes noted].

Postoperative Plan

• Activity: [Mobilization plan]; restrictions: [bending/lifting/twisting limits and duration]
• Wound care: [Dressing care and timeline]; [showering guidance]; [suture/staple removal timing]
• Pain management: [Multimodal regimen details]
• VTE prophylaxis: [Mechanical / chemical] with [agent and timing]
• Follow-up: [Clinic visit timing]; [imaging if planned]
• Warning signs reviewed: new/worsening weakness, numbness, bowel/bladder dysfunction, saddle anesthesia, fever, escalating pain, wound drainage/erythema

(Do not infer operative levels, laterality, or decompression extent—document exactly what was performed. Always document dural integrity. If EBL is not provided, flag as incomplete.)