Operative Report (Posterior Cervical Decompression/Fusion)

Date of Procedure: [Date]

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

Facility/OR: [Facility name and OR number]

Primary Surgeon: [Name, credentials]

Assistant(s): [Name(s) and role(s)] (Only include if applicable)

Anesthesia Provider: [Name, credentials]

Anesthesia Type: [general endotracheal / other]

Urgency: [elective / urgent / emergent]

Preoperative Diagnosis: [Diagnosis with specific levels and laterality]

Postoperative Diagnosis: [Diagnosis with specific levels and laterality]

Procedure(s) Performed:

• [Decompression type: laminectomy / laminoplasty / partial laminectomy] at [exact levels] [laterality if applicable]
• [Foraminotomy/foraminotomies] at [each level] – [right / left / bilateral]
• [Instrumentation/fixation] at [each level] – [screw type by level and side]
• [Fusion/arthrodesis type] at [each level]

(Include only procedures actually performed. List each with precise levels and laterality; do not use "multilevel" without explicit level listing.)

Indications

[Chief indication: myelopathy / radiculopathy / stenosis / instability / trauma / tumor / infection / deformity / revision] [Pertinent imaging findings guiding level selection with exact levels] [Response to conservative management if elective degenerative case] [Surgical goals including decompression extent, stabilization rationale, and alignment intent] [Confirmation that informed consent was obtained including discussion of procedure-specific risks]

Operative Findings

[Key intraoperative pathology correlated to levels and symptoms, such as ligamentum flavum hypertrophy, facet arthrosis, disc-osteophyte complex, cord/root compression, instability] [Status of prior hardware/fusion if revision] (Only include if applicable) [Unexpected findings if present]

Operative Description

Preparation and Positioning

[Anesthesia induction and airway] [Antibiotic prophylaxis agent and timing relative to incision] [DVT prophylaxis measures initiated] [Time-out confirming patient identity, procedure, and operative levels] [Positioning: prone, head fixation method, neck position and alignment intent, pressure point padding, eye protection] [Neuromonitoring: used with modalities and baseline status / Not used] [Skin prep and drape]

Approach and Level Localization

[Incision: midline posterior cervical, approximate length and levels spanned] [Exposure: dissection through fascia to spinous processes, lamina, lateral masses/facets; extent of exposure] [Level confirmation method: fluoroscopy / radiograph / navigation], [reference point for counting], [marker placement if used] [Separate localization time-out if performed]

Decompression

[Decompression type and each level decompressed explicitly] [Foraminotomies: each level and side] [Extent of bony resection: central canal, lateral recess, medial facetectomy] [Ligamentum flavum resection and extent] [Confirmation dura visualized and decompression adequate] [Durotomy if occurred: location, repair technique, sealant used] (Only include if applicable)

(For laminoplasty: state technique [open-door / French-door], hinge and opening sides, levels, fixation method [plates / sutures / bone graft], and whether prophylactic foraminotomies were performed.)

Instrumentation and Fixation

(Include this section only if instrumentation was placed; omit entirely for decompression-only cases.)

• [Instrumented levels from cranial to caudal]
• [Fixation by level and side: lateral mass screws / pedicle screws / pars screws / laminar screws with sizes]
• [Guidance method: navigation / fluoroscopy for placement confirmation]
• [Rod construct: material, contouring, crosslinks if used]
• [Reduction/alignment maneuvers: compression, distraction, deformity correction; alignment assessment method]
• [Final hardware verification with intraoperative imaging]

Fusion/Arthrodesis

(Include this section only if fusion was performed; omit entirely otherwise.)

• [Fusion type: posterolateral / facet / other at each level]
• [Decortication sites and levels]
• [Bone graft materials: local autograft / iliac crest autograft / allograft type / biologics with name and amount]
• [Iliac crest harvest if performed: side, approach, technique, closure]
• [Off-label biologic use: indication, containment method, consent confirmation] (Only include if applicable)

Closure

[Hemostasis methods] [Irrigation] [Drains: type, number, location, suction] (Only include if placed) [Layered closure: fascia, subcutaneous, skin technique] [Dressing applied] [Immobilization placed in OR: collar type / brace / halo] (Only include if applicable)

End of Case

[Counts: sponge, needle, and instrument counts correct] [Neuromonitoring end status: stable / describe changes and responses / Not used] [Disposition: extubated in OR / planned postoperative ventilation; transfer to PACU / ICU; condition] [Immediate postoperative neurologic exam if assessable; if not assessable due to sedation, state this]

Implants

(Include this section only if implants were placed; omit entirely otherwise.)

• [Level]: [Side] [implant type] [size]
• Rods: [bilateral / right / left] [length] [material]
• Crosslink: [size/type] (Only include if used)
• Manufacturer/System: [Name]
• Serial/Lot/UDI: [Numbers as available]

Specimens

(Include only if specimens were collected; omit entirely otherwise.)

• [Specimen description] – [site/level], [sent to pathology / microbiology], [tests requested]

Estimated Blood Loss and Fluids

EBL: [mL]

Blood Products: [type and units / None]

Fluids: [volume and type, or reference anesthesia record per local policy]

Complications

[None / List each complication with intraoperative management]

(This field must always be explicitly documented; never omit.)

Postoperative Plan

• Immobilization: [Collar / brace / halo type and expected duration]
• Activity: [Spine precautions, lifting limits, ambulation restrictions]
• Neurologic checks: [Frequency and location]
• DVT prophylaxis: [Mechanical and chemoprophylaxis plan with timing, or reason deferred]
• Antibiotics: [Agent and duration]
• Postoperative imaging: [Modality and timing]
• Drain management: [Removal criteria] (Only include if drains placed)
• Follow-up: [Clinic appointment timeframe; wound care plan]

(If information is not provided in dictation, state "not specified" rather than inferring procedural details.)