Operative Report (Lumbar Interbody Fusion)

Date: [Procedure date]

Start/End Time: [Start time] – [End time]

Location: [Facility name, OR number]

Primary Surgeon: [Name, credentials]

Co-Surgeon/Assistants: [Name(s) and role(s)] (Only include if applicable)

Anesthesia: [Anesthesia type and provider]

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

Postoperative Diagnosis: [Diagnosis reflecting intraoperative findings with level(s) and laterality]

Procedure(s) Performed:

• [Procedure component with level and laterality specificity]
• (List each distinct component performed; specify exact level and side for each)

Indications

[Clinical rationale for surgery including presenting symptoms/functional impact, relevant imaging findings and pathology, failed conservative management, and surgical strategy rationale] (Include why TLIF vs PLIF, level selection, and alignment goals if relevant. Include patient-specific risk factors only if they materially influenced the surgical approach.)

Operative Summary

Levels (Decompression): [Level(s)]

Levels (Interbody): [Level(s)]

Levels (Instrumented): [Level(s)]

Levels (Posterolateral Fusion): [Level(s)]

Approach: [TLIF / PLIF]; [open / minimally invasive]; [unilateral / bilateral]

Interbody Device(s): [Cage type, material, dimensions, lordosis angle; TLIF approach side]

Instrumentation: [Pedicle screw/rod system]; [placement method: freehand / fluoroscopy / navigation / robot]

Graft/Biologics: [Materials used and placement locations]

Alignment: [Reduction/correction performed with pre/post measurements] (Only include if reduction or correction performed)

EBL: [Estimated blood loss in mL]

Drains: [Type and location / None]

Complications: [None / Description] (State explicitly; never leave blank)

Neuromonitoring: [Modalities used and end-of-case status] (Omit if not used)

Operative Findings

[Key anatomic and pathologic findings] (Include degree/location of stenosis with laterality, facet hypertrophy, disc collapse, endplate quality, instability, scar tissue if revision, and any findings that altered the surgical plan.)

Description of Procedure

Positioning and Preparation: [Positioning with padding/pressure point protection; localization method; skin prep and draping]

Approach and Exposure: [Approach type with laterality for TLIF corridor; levels exposed; handling of posterior elements]

Decompression: [Techniques performed with explicit laterality; confirmation of adequate decompression with nerve roots and levels identified]

Discectomy and Endplate Preparation: [Annulotomy location; discectomy technique; endplate preparation; disc space distraction method]

Interbody Cage Placement: [For TLIF: approach side and facetectomy extent; nerve root protection; trialing and sizing; graft material placement; final cage position and confirmation method] (For expandable cages, include pre-expansion and final expanded dimensions.)

Posterior Instrumentation: [Pedicle screw placement method and levels; triggered EMG results if relevant; rod placement; compression/distraction maneuvers; reduction technique if performed; final construct confirmation]

Posterolateral Arthrodesis: [Decortication targets; graft composition and placement; bilateral vs unilateral] (Only include if performed)

Hemostasis and Closure: [Hemostasis; irrigation volume/type; topical antibiotics if used; drain placement; layered closure technique; dressing]

Final Status: [Counts correct; neuromonitoring status at case end; patient condition; immediate neurologic exam if assessed]

(If dural tear occurred: document location, repair technique, adjuncts used, Valsalva test result, and resulting postoperative restrictions at point of occurrence in narrative.)

Implants

Pedicle Screws:

• [Level–Side: diameter × length] (List each screw; note cement augmentation if used)

Rods: [Diameter, material, connectors/crosslinks if used]

Interbody Cage(s): [Level; approach side; dimensions; lordosis angle; material; static/expandable; final expanded height if applicable]

Implant Identifiers: [See implant log] (Reconcile in final report if not available at dictation)

Specimens

[None / Tissue type(s) and destination] (Note pending results and where final result will appear.)

Complications

[None / Description including timing, recognition, management, and residual concerns] (Explicit documentation required; never leave blank or imply absence through omission.)

Disposition and Postoperative Plan

Disposition: [PACU / ICU]; [Airway/hemodynamic status]; [Immediate neurologic status]

Antibiotics: [Standard perioperative protocol / Extended duration with rationale]

DVT Prophylaxis: [Timing and agent] (Note adjustments for bleeding risk or durotomy)

Mobilization: [Restrictions, brace requirements, weight-bearing precautions]

Imaging: [Postoperative imaging plan and timing]

Drains: [Management plan and removal criteria]

Durotomy Precautions: [Flat bedrest parameters; activity limitations] (Only include if durotomy occurred)

(Do not infer levels, laterality, implant specifications, or complications—these must be explicitly stated. If implant identifiers are pending, document "see implant log" and reconcile in final report. Omit any section explicitly stated as not applicable.)