Patient Instructions (Post-Spine Surgery)

Patient name:	[Patient name]
Date of birth:	[Date of birth]
Discharge date:	[Discharge date]
Surgeon:	[Surgeon name and credentials]
Facility:	[Facility name]

Procedure: [Procedure name in plain terms] at [spinal level(s)]

What was done: [One-sentence explanation of procedure]

Hardware: [Implants or hardware relevant to restrictions / none] (Include only if relevant to activity restrictions.)

Quick Reference

• Walk every day. Increase a little at a time.
• Protect your incision. Keep it clean and dry. [Dressing instructions]
• Avoid bending, lifting more than [weight limit] pounds, and twisting for [duration]. (Include only values explicitly provided; do not infer.)
• Wear your [brace/collar type] [when to wear]. (Include only if ordered.)
• Shower [when permitted and how to protect incision].
• Do not drive while taking sedating pain medicines. Wait for surgeon's clearance.
• Call now if you have chest pain, trouble breathing, new loss of bowel or bladder control, numbness in the saddle area, rapid leg weakness, or uncontrolled bleeding.

When to Get Help

Spine clinic:	[Clinic phone]	[Clinic hours]
After-hours/on-call:	[After-hours phone]
Home health:	[Agency name and phone]	(Include only if applicable.)
Pharmacy:	[Pharmacy name and phone]	(Include only if applicable.)

Incision Care

Location: [Incision location]

Closure: [staples / sutures / steri-strips / skin glue]

Dressing: [Dressing type and change schedule]

Showering: [When permitted and how to protect incision]

No soaking or submersion until: [Date or timeframe] (Include only if ordered.)

Drain: [none / drain type and care instructions]

Call if you notice: increasing redness, warmth, swelling, cloudy or new drainage, wound edges separating, or fever.

Activity and Restrictions

Walking: Walking is your main exercise. Start now and increase as tolerated.

Restrictions: (Include only values explicitly provided; do not infer.)

• Bending: [Bending restriction] for [duration]
• Lifting: Nothing over [weight limit] pounds for [duration]
• Twisting: [Twisting restriction] for [duration]

Sitting: [Sitting limits or guidance] (Include only if specified.)

Driving: Do not drive while taking sedating medicines. Drive only when you can move safely and your surgeon clears you.

Brace/collar: [not required / type and size]

• When to wear: [all times / when upright / as needed]
• Sleep: [Sleep instructions]
• Skin care: Check skin daily for redness. [Additional skin care guidance]
• Discontinue when: Cleared by surgeon

(Include brace section only if brace/collar is ordered.)

Equipment: [Equipment list with brief use guidance] (Include only if prescribed.)

Fall prevention: Use caution on stairs and uneven surfaces. Move slowly if taking sedating medicines.

Medications

This list matches your discharge plan. Do not add over-the-counter medicines or supplements without checking with your care team first—especially medicines containing acetaminophen (Tylenol) or NSAIDs (ibuprofen, naproxen).

Scheduled medicines:

Medication	Dose	How often	Purpose	Start	Stop
[Medication name]	[Dose]	[Frequency]	[Purpose]	[Start date]	[Stop date]

(Add rows as needed. Do not infer any medication values.)

As-needed medicines:

Medication	Dose	How often (max)	Purpose	Start	Stop
[Medication name]	[Dose]	[Frequency and maximum per day]	[Purpose]	[Start date]	[Stop date]

(Add rows as needed. Do not infer any medication values.)

Pain management: Some soreness is expected and will improve over time. Use non-opioid options first when appropriate. If you take opioid pain medicines, follow the taper plan and do not drive or drink alcohol.

Constipation prevention: Drink plenty of fluids, eat fiber, and use stool softeners as ordered. Call if no bowel movement by [timeframe]. (Include only if opioids prescribed.)

Avoid NSAIDs ([ibuprofen, naproxen, aspirin]) for [duration]. (Include only for fusion cases if ordered.)

Nicotine: Avoid all nicotine products (cigarettes, vaping, patches, gum). Nicotine slows bone healing. (Include for fusion cases.)

Blood thinners: Restart [medication name] on [date] at [time]. (Include only if applicable; do not infer.)

Refills: [Refill policy and contact information] (Include only if provided.)

Follow-Up

• [Appointment: date, time, location, phone]

(Add appointments as needed. If not yet scheduled: Call [clinic phone] to schedule within [timeframe].)

Suture/staple removal: [Who will remove] on [date]

Imaging: [Planned imaging and timing] (Include only if ordered.)

My Questions

Care partner name: ____________________

Care partner phone: ____________________

Prepared by: [Preparer name and role]

Date/time: [Date and time generated]

Reviewed with patient: [yes / no]

Interpreter: [not needed / yes, language: ___]