Spinal Fusion Operative Report

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

DOB: [Date of birth]

Date of Surgery: [Surgery date]

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

Surgeon: [Primary surgeon name, credentials]

Co-Surgeon: [Co-surgeon name, credentials] (Include only if co-surgeon present; omit line if none)

Assistant(s): [Assistant name(s) and role(s)]

Access Surgeon: [Access surgeon name, credentials] (Include only for anterior/lateral exposure; omit line if not applicable)

Anesthesia: [Anesthesia type and airway]

(Do not infer levels, laterality, implant specifications, biologics, neuromonitoring findings, or complications. If specific device identifiers are not available from dictation, use "see implant log" for UDI/lot/serial. Omit conditional sections entirely when not applicable, except for Complications which must always be explicitly addressed.)

Preoperative Diagnosis

• [Primary diagnosis driving fusion]
• [Secondary diagnosis or contributing condition] (Add additional bullets as needed; list most clinically important first)

Postoperative Diagnosis

• [Definitive diagnosis based on intraoperative findings]
• [Additional confirmed findings] (Add bullets as needed; may match preoperative diagnoses)

Procedure(s) Performed

• [Standardized procedure name: approach (anterior/posterior/lateral; open/MIS/percutaneous), exact levels, fusion type (ALIF/TLIF/PLIF/LLIF/OLIF/posterolateral), decompression components, instrumentation description, osteotomies if applicable]
• [Additional procedure] (Add bullets as needed)

Indications

[Presenting symptoms, neurologic findings if present, key imaging findings, failure of nonoperative treatment if relevant, and surgical goals (decompression, stabilization, alignment correction, fusion). For revisions, include prior operations and reason for revision. Note discussion of risks/benefits/alternatives if high-risk elements involved.]

Operative Levels and Technique

Positioning: [Patient position (prone/supine/lateral), frame or table, head fixation if used]

Approach: [Corridor (posterior midline/Wiltse/percutaneous/anterior cervical/retroperitoneal/lateral transpsoas) with laterality when relevant]

Levels Decompressed: [Each level with laterality and structures decompressed (laminectomy/laminotomy/foraminotomy/facetectomy/discectomy); include nerve roots decompressed if clinically relevant] (Omit this field entirely if no decompression performed)

Levels Fused: [Each level with fusion technique (posterolateral/ALIF/TLIF/PLIF/LLIF/OLIF/facet fusion); specify interbody cage use and type]

Levels Instrumented: [Vertebral segments spanned and anchor types (pedicle screws/pelvic fixation/plates) with laterality]

Implants: [Construct description including manufacturer/system name (or "see implant log"), critical sizes (screw diameter/length, rod diameter, cage dimensions/lordosis), placement method (freehand/fluoroscopy/navigation/robot), confirmation imaging performed]

Bone Graft and Biologics: [Sources (local autograft, iliac crest autograft with side, allograft type, DBM, synthetics, BMP with product and dose) and placement locations (posterolateral gutters, interbody); fusion bed preparation (decortication sites, endplate preparation)]

Alignment and Reduction: [Goal (restore segmental lordosis/reduce spondylolisthesis/improve sagittal balance), maneuvers used (rod contouring, compression/distraction, cantilever, osteotomy type), achieved correction with imaging confirmation] (Include only if alignment correction was a surgical goal; omit if not applicable)

Neuromonitoring: [Modalities (SSEP/MEP/EMG), baseline and final status; if alerts occurred, describe timing, corrective actions, and outcome] (Include only if monitoring was used; omit if not applicable)

Intraoperative Imaging: [Type used (fluoroscopy/O-arm/navigation/robot) and what was confirmed (levels, cage position, screw position, alignment)]

Key Findings

[Intraoperative pathology encountered (stenosis severity, scar tissue, bone quality), relevant anatomy and prior hardware status, unexpected findings and any resulting changes to surgical plan]

Procedure in Detail

[Chronologic narrative from positioning through closure: positioning and preparation; exposure and level confirmation; instrumentation placement technique; decompression steps if performed; interbody work if performed (discectomy, endplate prep, trialing, cage and graft placement); posterolateral fusion bed preparation; reduction maneuvers if performed; final imaging and neuromonitoring confirmation; hemostasis; closure with drain placement if applicable. Write as flowing paragraphs to allow reconstruction of the operative course.]

EBL and Transfusions

EBL [volume] mL. [Transfusions: type and units given / No transfusions]

Specimens

• [Tissue type, source level/location, destination (pathology/microbiology)]

(Include this section only if specimens were sent; omit entirely if none)

Drains

[Drain type, number, and anatomic location (e.g., subfascial drain exiting right paraspinal). Brace applied in OR if applicable.]

Complications

[None / Specific complication with description, management, and status at case end] (This section is required; if complications occurred, describe each with specifics—e.g., for dural tear: location, repair method, presence of CSF leak at closure)

Disposition

Patient [stable / guarded / critical], transferred to [PACU / ICU / floor]. [Extubation status if relevant]

Postoperative Plan

Bracing: [Type (TLSO/LSO/cervical collar), wear schedule, duration or discontinuation criteria]

Activity: [Mobilization timing, restrictions (bending/lifting/twisting limits, weight limits), physical therapy plan]

VTE Prophylaxis: [Mechanical and pharmacologic measures with timing] (Adjust timing if dural tear occurred)

Antibiotics: [Duration: perioperative only / extended / until drain removal]

Wound Care: [Drain removal criteria, dressing changes, showering instructions]

Imaging: [Postoperative X-ray or CT timing] (Include if indicated)

Follow-up: [Appointment timing and suture/staple removal plan]