Operative Report (Posterior Lumbar Fusion/Instrumentation)

Patient: [Full name]; MRN [Medical record number]

Date of Surgery: [Date]

Start Time: [Start time / Not documented] / End Time: [End time / Not documented]

Facility/OR: [Facility name / OR number]

Surgeon: [Primary surgeon name and credentials]

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

Anesthesia: [General endotracheal / General LMA / Regional / MAC] (If details unknown, state "See anesthesia record.")

Preoperative Diagnosis: [Diagnosis with levels and laterality]

Postoperative Diagnosis: [Diagnosis with levels and laterality] (If unchanged, state "Same as preoperative diagnosis." If differs, note why.)

Procedure(s):

• [Billable procedure with explicit levels and laterality]
• [Additional procedures as applicable] (Levels and laterality must never be inferred—use [Not documented] if not dictated.)

Operative Team, Positioning, and Safety

• Positioning: [Prone on Jackson frame / Prone on Wilson frame / Other] with abdomen free; pressure points padded; eyes protected; arms [positioned].
• Level Localization: [Fluoroscopy / Navigation / Anatomic landmarks]; correct levels confirmed and marked prior to incision.
• Neuromonitoring: [SSEPs / MEPs / EMG / Neuromonitoring not used]; baseline [stable / not applicable].
• Antibiotic Prophylaxis: [Agent and dose / See anesthesia record].

Indications

[Clinical rationale for surgery including relevant history and pathology, key symptoms and neurologic findings, failure of conservative treatment, and rationale for fusion with instrumentation] (If details unavailable, reference preoperative evaluation note.)

[Intraoperative changes from planned levels with explanation] (Include only if levels changed intraoperatively.)

Findings

• [Level]: [Pathology encountered—stenosis severity, foraminal narrowing, instability, listhesis grade]
• [Level]: [Additional findings, anatomic variants, bone quality, technical constraints]
• [Revision findings if applicable: scar tissue, hardware status]

(If no unexpected findings: "Findings as expected per preoperative imaging.")

Procedure

Approach and Exposure

[Midline / Wiltse (paramedian) / MIS] incision over [levels]. [Open / Mini-open / MIS] [unilateral / bilateral] exposure to [bony landmarks] at [levels].

Decompression

(Include only if decompression performed. If explicitly not performed, state "No decompression performed." Omit section entirely if not addressed.)

• [Level]: [Laminectomy / Laminotomy / Medial facetectomy / Foraminotomy / Discectomy] [right / left / bilateral]; structures decompressed: [central canal / lateral recess / foramen / nerve root(s)].
• [Additional levels as applicable]
• [Incidental durotomy if occurred]: [Size, location]; repair [technique]; sealant [type]; Valsalva [no leak / leak repaired]; drain [placed / not placed].

Instrumentation

Instrumented levels: [List all levels with laterality]

Pedicle screws:

• [Level] Right: [Diameter] × [Length] mm; [cannulated / solid / reduction / cortical trajectory]; [freehand / fluoroscopic / navigated / robotic]
• [Level] Left: [Diameter] × [Length] mm; [cannulated / solid / reduction / cortical trajectory]; [freehand / fluoroscopic / navigated / robotic]
• [Additional levels as above]

Rods: [Ti / CoCr] [diameter] mm [right / left / bilateral]; [contouring/lordosis intent].

Additional hardware: [Crosslinks / Connectors / Offset devices with sizes and location / None]

Pelvic fixation: [S2-alar-iliac / Iliac screw] [right / left / bilateral]; [diameter] × [length] mm; [placement technique]. (Include only if performed.)

Interbody device: [PLIF / TLIF] at [level]; [approach corridor and laterality]; [cage type, footprint, height, lordosis]; graft inside cage: [material(s)]. (Include only if interbody performed.)

Confirmation: [Final fluoroscopy / Intraoperative CT] confirmed satisfactory hardware position and alignment.

Reduction and Deformity Correction

(Include only if reduction maneuvers performed. If explicitly not performed, state "No reduction maneuvers performed.")

• Pre-reduction: [Listhesis grade / Kyphosis angle / Coronal deformity]
• Maneuvers: [Reduction towers / Rod translation / Compression-distraction / Cantilever / Osteotomy]
• Outcome: [Objective result documented by imaging or assessment]
• Limitations: [Neuromonitoring changes / Bone quality constraints / None] (Include only if applicable.)

Fusion Bed and Bone Graft

Arthrodesis levels: [List fusion levels] (May differ from instrumented levels.)

Decortication: [Transverse processes / Facets / Pars / Lamina] [right / left / bilateral] at [levels].

Graft materials:

• Local autograft: [Approximate quantity]
• Iliac crest autograft: [Side, approach, quantity, closure] (Include only if harvested.)
• Allograft: [Type and quantity]
• DBM/cellular allograft: [Product name and quantity]
• BMP/biologics: [Product name, carrier, dose] (Do not infer dose; reference pharmacy/implant log if needed.)

Graft placement: [Posterolateral gutters left/right / Facet joints / Interbody] at [levels].

Closure

• Drains: [Type and number]; [subfascial / suprafascial]; [to bulb / to wall suction / none]
• Layered closure: [Fascia, subcutaneous, skin closure technique and materials]
• Skin: [Staples / Subcuticular / Sutures / Adhesive]
• Dressing: [Type]; [wound VAC if applied]

Implants and Devices

• Pedicle screws: [Manufacturer/system]; [sizes and quantities] at [level/side assignments]
• Rods: [Manufacturer/system]; [material and diameter] [bilateral / right / left]
• Crosslinks/connectors: [Manufacturer/system]; [size]; [location]
• Interbody cages: [Manufacturer/system]; [footprint × height, lordosis] at [level, side]
• Biologics: [Product names and quantities]

UDI/lot/serial: See implant log.

Specimens

[Specimen description] from [anatomic site/level] to [pathology / microbiology] for [studies requested]. (If no specimens, state "None" or omit section.)

Estimated Blood Loss

EBL: [Numeric value in mL] (Avoid "minimal"; if unknown, state "See anesthesia record.")

Transfusion: [Products and volumes / None]

Complications

[None apparent / Complication description: dural tear, neurologic change, malpositioned hardware, fracture, significant bleeding, hardware failure] (Document factually. If not stated, use [Not documented].)

Postoperative Condition

Condition: [Stable / Guarded / Critical]; Destination: [PACU / ICU]

Neurologic status: [Awake, moving all extremities symmetrically / Neurologic exam deferred; see PACU assessment / Not documented]

Postoperative Plan

• Bracing: [TLSO / LSO / None]; [continuous / out of bed only]; duration [timeframe]
• Activity: Mobilize [POD# / timing]; [bending/lifting/twisting restrictions]; weight-bearing [as tolerated / restrictions]
• Drains: [Management plan and removal criteria]
• Imaging: [Timing and views for postoperative radiographs]
• DVT prophylaxis: [Mechanical devices]; [chemical prophylaxis agent] starting [timeframe]
• Wound care: [Dressing changes; showering restrictions]
• Antibiotics: [Perioperative only / Extended course with duration and indication]
• Follow-up: [Clinic timeframe]; [suture/staple removal plan]

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Surgeon Signature / Date-Time