Operative Report (Anterior Cervical Discectomy and Fusion)

Document Title: Operative Report – Anterior Cervical Discectomy and Fusion

Date of Operation: [Date]

Start Time / End Time: [Start time] / [End time or "[pending]"]

Facility / OR: [Facility and OR number]

Patient Name: [Patient full name]

MRN: [Medical record number]

Urgency: [elective / urgent / emergent]

Preoperative Diagnosis

[Preoperative diagnosis with specific cervical level(s), laterality when applicable, and clinical syndrome such as radiculopathy, myelopathy, or axial neck pain]

Postoperative Diagnosis

[Postoperative diagnosis, or "Same as preoperative diagnosis" if unchanged]

Procedures Performed

(Numbered list of procedures actually performed. Specify precise level(s) and vertebral span. Omit components not performed.)

1. Anterior cervical discectomy at [level(s)]
2. Decompression of [spinal cord / nerve root / foramen] at [level(s)]
3. Interbody fusion/arthrodesis at [level(s)] with [graft type]
4. Interbody device/cage placement at [level(s)]
5. Anterior cervical plate fixation [vertebra to vertebra]
6. Intraoperative fluoroscopy for level confirmation and hardware positioning
7. Intraoperative neuromonitoring [SSEP / MEP / EMG] (Include only if used)

Surgical Team

Primary Surgeon: [Name and credentials]

Assistant(s): [Name(s) and credentials, or "None"]

Anesthesia Provider: [Name and credentials]

(If assistants performed significant portions such as exposure, discectomy, graft placement, instrumentation, or closure, specify who performed what.)

Anesthesia

[Type of anesthesia]. [Antibiotic prophylaxis]. [Perioperative steroids if administered]. (Keep concise if details are recorded in the anesthesia record.)

Indications

[Brief clinical summary including key symptoms/signs, neurologic deficits if present, imaging findings correlated to operative level(s), and response to conservative treatment if applicable] (1–2 short paragraphs; avoid copy-forward from other notes.)

Intraoperative Findings

(Document level-by-level findings. Include disc herniation location, osteophytes, foraminal stenosis with laterality, canal stenosis, cord compression, PLL status, and any variants or unexpected findings.)

[Level]: [Central / paracentral / foraminal] disc herniation; [osteophyte formation]; [foraminal stenosis with laterality]; [canal stenosis]; [cord compression present/absent]; PLL [intact / attenuated / ossified]. [Any anatomic variants or unexpected findings].

[Additional level if applicable]: [Findings as above].

Description of Procedure

Positioning and Preparation

[Patient positioning] with [neck positioning]. The neck and anterior cervical region were prepped and draped in sterile fashion.

Exposure and Level Localization

[Left / right]-sided anterior cervical approach (provide rationale if non-standard). [Skin incision type and location]. Standard dissection to the prevertebral fascia and anterior cervical spine. Level confirmation performed with [fluoroscopy / radiograph] using [marker / needle]. Confirmed operative level(s): [level(s)] before discectomy.

Discectomy and Decompression

(Document for each level.)

[Level]: Annulotomy performed. Disc material removed. Endplates prepared to bleeding bone while preserving cortical integrity. [Osteophyte removal if performed]. PLL [left intact / opened / partially resected / fully resected]. Foraminal decompression [left / right / bilateral] performed. Adequacy of decompression confirmed by [visualization of dura/nerve root / probe patency / other method].

[Additional level if applicable]: [As above].

Fusion and Instrumentation

Interbody device at [level]: [Cage / structural graft type] packed with [local autograft / allograft / DBM / biologic]. Size: [dimensions].

Plate fixation: Anterior plate spanning [cranial vertebra] to [caudal vertebra] with [number] screws. Fluoroscopy confirmed appropriate device and hardware position. (If no anterior plating, document stand-alone device or alternative fixation.)

Neuromonitoring Summary

(Include only if neuromonitoring was used. Do not infer stability unless confirmed by monitoring team.)

Modalities: [SSEP / MEP / EMG]. Baseline: [adequate / limited with reason].

Intraoperative changes: [None / event description with timing, suspected cause, and corrective actions].

End-of-case status: [Returned to baseline / improved / worsened / unchanged] as reported by monitoring team.

Hemostasis and Closure

Hemostasis achieved with [techniques/agents]. Wound irrigated with [solution]. Drain: [None / drain type and location]. Layered closure with [suture types by layer]. Dressing: [type applied].

Implants and Devices

[Brief narrative summary of implants and levels] (e.g., "PEEK cage at C5-6, anterior plate C5-C6 with 4 screws.")

• [Level]: [Device type], Size: [size], Manufacturer: [manufacturer], Lot/Serial: [identifier or "[pending]"], UDI: [UDI or "[pending]"]
• [Additional implant if applicable]: [Details as above]

(If no implants used, document "None.")

Specimens

[Specimen type] from [level] sent to [pathology / microbiology / discarded]. (If no specimens sent, document "None.")

Estimated Blood Loss

EBL: [mL or "[pending]"]

Blood Products: [Type and units transfused, or "None"]

Complications

[None / Description of complication including timing/operative step, clinical impact, corrective action taken, and status at end of case] (Never leave blank; explicitly document "None" if no complications.)

Disposition

Patient [stable / guarded] at case completion. [Extubated in OR / remained intubated with reason]. Transferred to [PACU / ICU / step-down]. Immediate postoperative neurologic status: [assessment if performed].

Postoperative Plan

• Activity and collar: [Activity restrictions]; [cervical collar type] for [duration]
• Diet/swallow: [Diet plan]; [swallowing evaluation if indicated]
• Antibiotics: [Postoperative antibiotic plan]
• Imaging: [Timing and modality for postoperative imaging]
• Drain: [Management instructions and removal criteria, or "None"]
• DVT prophylaxis: [Mechanical / pharmacologic plan]
• Pain management: [Key medications or pathway reference]
• Follow-up: [Clinic visit timing]

(If using an institutional pathway, reference it and document only patient-specific deviations.)