Hospital Logo Patient Identification Label

Informed Consent for Lumbar Laminectomy

Name: Age (in years): Gender:  M  F  Other

UHID No./Registration No.:

Interpreter Service:  Yes  No Consultant’s Name:

Medical Condition
The doctor has explained that I/my child/my ………………………………………………………………...........have the following medical condition:
.……………………………………………………………………………………………………………………………………………………...............................................................
and I/my child/my………………………………………………………have been explained and advised to undergo the following treatment/procedure:
………………………………………………………………………………………………………………………………………………………………………………………………………………....
I authorise Dr. ………………………………………………………………………………………………………………………………………….…………………………………… and
his/her associates to perform the above treatment/ procedure.
The doctor should document the site and/or side where relevant to the procedure:………………………………………………………………………………...
……………………………………………………………………………………………………………………………………………………………………………………………………………………

Introduction

Lumbar laminectomy is performed to relieve pressure on the nerve roots in the lower back.
The doctor will administer general anaesthesia. The doctor will take an X-ray during surgery
and use it to confirm the correct level of surgery. The doctor will make a midline cut (incision)
in your lower back over the site where the nerves are compressed. And strip the muscles from
the bones at the back of the spine.
The doctor will remove the bones and ligaments from the back of your spine (spinous process
and laminae) until the pressure on the nerve roots is relieved. If needed, the doctor may insert
a small plastic tube to drain any residual fluid. The doctor will close the cut with stitches or
staples.

Consent for Blood Transfusion

Please see Blood Transfusion Consent Form. This will give you information about the type of the blood products, benefits
and risks of blood transfusion. If you have any concern(s), please discuss with your doctor.
Consent for Anaesthesia
Please see Anaesthesia Consent Form. This will give you information about the type of the anaesthesia, its benefits and general risks. If
you have any concern(s), please discuss with your anaesthetist(s).
Intended Benefits Risks and Complications Patient Specific Risks
(To be documented by doctor) (To be documented by doctor) (To be documented by doctor)
▪ To relieve the pressure on ▪ Bleeding
the nerve roots in your back ▪ Cardiac malfunction including cardiac arrest 1)
▪ To cure or to provide ▪ Nerve root injury causing a weakness in foot movement which
significant improvement in may affect mobility 2)
the symptoms ▪ Injury to the covering of the spinal cord/nerve
▪ Others, if any specify: ▪ Instability of the spine or abnormal alignment of spine 3)
▪ Bladder or bowel problems due to nerve root injury
▪ Persistent back and leg pain, with possible leg numbness due to 4)
nerve damage from compressed nerve roots
▪ Leakage of cerebrospinal fluid
▪ Visual disturbance which may be temporary or permanent
▪ Minor pain, bruising and/or infection from intravenous (IV)
cannula site
▪ Paraplegia which may be temporary or permanent
▪ Death
▪ Others, if any specify:

Likelihood of the Success Rate of Procedure Alternatives (To be documented by doctor)

The success rate of a laminectomy surgery is favourable. Following
surgery, approximately 70% to 80% of patients will have significant ▪ Not to have the surgery
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 Hospital Logo Patient Identification Label

Informed Consent for Lumbar Laminectomy

improvement in their function (ability to perform normal daily ▪ Others, if any specify:
activities) and markedly reduced level of pain and discomfort.

Specific Notes Related to Procedure (Strike out if not required) Precise Action Points Understood by the Patient/Substitute
Decision Maker (To be documented by patient/substitute decision maker in
his/her language)

Patient’s Authorisation
• The doctor has explained my/patient’s medical condition and proposed treatment/procedure. I have been explained and have
understood the intended benefits/risks known to be attached with the planned treatment/procedure including the risks that are
specific to me/patient and their likely outcomes.
• The doctor has explained other relevant/alternate treatment options and their associated benefits/risks. The doctor has also
explained the risks of not having the procedure. I have been given the choice to take a second opinion.
• I was able to ask questions and raise concerns with the doctor about the procedure and its benefits/risks and my/patient’s treatment
options. My queries and concerns have been discussed and answered to my full satisfaction.
• I understand that the treatment/procedure may include blood/blood product transfusion (for which a separate consent shall be
obtained).
• The doctor has explained the requirement for anaesthesia for this procedure and I understand the risks associated with anaesthesia,
including the risks specific to me (for which a separate consent shall be taken).
• The doctor has explained to me, that during the course of or subsequent to the operation/procedure, unforeseen conditions may be
revealed or encountered which may necessitate urgent surgical or other procedures in addition to or different from those
contemplated. In such exigency, I further request and authorise the above-named physician/surgeon or his designee to perform such
additional surgical or other procedures as he or they consider necessary or desirable in my interest. I understand and agree that in
such condition there will be no requirement of any additional consent from me or my family members/attendants.
• I declare that no guarantee of whatsoever nature has been given by anyone as to the results that may be obtained.
• I understand that I have the right to refuse treatment before the procedure. I agree that any such refusal shall be in writing and
acknowledged by the hospital and I shall be solely responsible for the outcome of such refusal.
• I consent to if any photographing or television of operation(s) or procedure(s) to be performed, including appropriate portions of my
body, for medical, scientific or educational purposes. However, suitable precautions shall be taken by the hospital that my identity is
not revealed anywhere. □ Yes □ No
• For purposes of advancing medical education, I consent to the admittance of observers to the operating room. □ Yes □ No

Patient Name: Signature: Date and Time:

Substitute Decision Maker Name: Relationship: Reason (patient is Signature: Date and Time:
unable to give
consent because):

Witness Name: Relationship: Signature: Date and Time:

Interpreter Name: Translation given in: Signature: Date and Time:

Declaration by the Doctor

I have explained to the patient / authorised representatives the medical condition, need for the procedure, its alternatives and
benefits/risks, likely consequences if those risks occur and the significant risks and problems specific to this patient including the risks of not
undergoing the procedure. I have given the patient/ authorised representatives an opportunity to ask questions about any of the above
matters and raise any other concerns. I have answered all their queries to the best of my knowledge.

Name and Signature of the Doctor with Reg No: Date and Time:

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