Operative Report (Lumbar Discectomy/Microdiscectomy)

Patient: [Patient name], MRN [Medical record number]

Date of Procedure: [Date]

Surgeon: [Primary surgeon name and credentials]

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

Anesthesia: [general endotracheal / spinal / monitored anesthesia care / other]

Preoperative Diagnosis

[Diagnosis with specific lumbar level(s), laterality, and associated radiculopathy if applicable] (Include revision status if reoperation.)

Postoperative Diagnosis

[Confirmed diagnosis at verified level(s) and side] (Update to reflect intraoperative findings including herniation characteristics: contained vs extruded vs sequestered, and migration if identified.)

Procedure(s) Performed

• [Lumbar discectomy / Lumbar microdiscectomy], [Level], [left / right]
• [Laminotomy / Hemilaminotomy / Medial facetectomy / Foraminotomy], [Level], [left / right] (Include each additional decompression procedure if performed.)
• [Approach: standard midline / paramedian / tubular MIS / far-lateral] (Include if non-standard.)
• [Visualization: operating microscope / endoscope] (Include if relevant to documentation.)

Indications

[Brief narrative summarizing symptom pattern and duration, failure of conservative management, imaging correlation at specific level and side, and any escalation factors such as progressive neurologic deficit or recurrent herniation] (2–5 sentences.)

Consent and Verification

Informed consent obtained. Pre-procedure time-out completed with spine level and laterality verification using [verification method].

Operative Findings

• Disc herniation: [Characteristics at specified level and side including contained/extruded/sequestered, location, and migration if present]
• Traversing nerve root: [Compression status, appearance, mobility after decompression]
• Dura: [intact / durotomy with location, size, and CSF leak status]
• Additional findings: [Epidural scarring, osteophytes, facet hypertrophy, adhesions / None] (Document only what was directly observed.)

Procedure Details

[Positioning and preparation narrative: patient position, frame/table type, padding, sterile prep and drape]

[Level localization narrative: specific method used to confirm operative level and timing of confirmation] (State the confirmation method explicitly—never assume correctness without documenting how level was verified.)

[Approach and exposure narrative: side of approach, incision type and location, fascial opening, muscle dissection method, identification of lamina and interlaminar space, introduction of microscope or endoscope if used]

[Decompression narrative: extent of bone removal performed, ligamentum flavum management, identification of dura and traversing nerve root, retraction and protection of neural elements, annulotomy status, removal of disc fragments from epidural space and/or disc space, characterization of fragments removed]

[Decompression endpoint: confirmation that traversing nerve root is freely mobile, lateral recess and foramen probed as indicated, absence of residual compression or residual pathology if present]

[Hemostasis and closure narrative: hemostasis method, irrigation, drain placement if applicable, layered closure technique, dressing applied]

Complications

[None / Description of complication with clinical significance and management] (For durotomy: document location, size, repair method, watertight status, and any resulting postoperative restrictions.)

Case Details

Estimated Blood Loss: [Volume in mL]

Specimens: [Disc material to pathology / None]

Drains: [Type and location / None]

Implants: [List if applicable] (Omit line if none.)

Counts: [correct per policy / discrepancy noted with details and actions taken]

Postoperative Status

Condition: [stable / extubated in OR / intubated to ICU / other]

Disposition: [PACU / ICU / other]

Neurologic Exam: [Motor strength by relevant myotomes on operative and contralateral sides; sensory exam if performed; comparison to preoperative baseline: unchanged / improved / new deficit with specification] (If exam cannot be performed, state reason and reassessment plan. Do not use vague statements such as "neuro intact" without specifying what was assessed.)

Postoperative Plan

• Activity: [Mobilization plan and precautions including BLT restrictions or bracing if applicable]
• Wound care: [Dressing management and showering guidance]
• DVT prophylaxis: [Mechanical and/or chemical prophylaxis as directed]
• Neurologic monitoring: [Neuro check frequency and escalation indications]
• CSF leak precautions: [Flat time, drain management, positioning restrictions] (Include only if durotomy occurred.)
• Follow-up: [Timing for clinic visit and imaging if planned]

(Do not auto-populate or infer level, laterality, operative findings, decompression endpoint, complications, or neurologic status from scheduling, consent, or preoperative documentation. These must reflect actual intraoperative events and immediate postoperative examination. If a critical element is unknown or unassessable, state the reason and follow-up plan rather than omitting.)