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(Affix patient identification label here) Extreme Lateral Interbody
Fusion (XLIF)
A. Interpreter / cultural needs
surgical approach. This may be temporary or permanent.
• Injury to the covering of the spinal cord. This may If yes, is a qualified Interpreter present? • Ongoing persistent back and leg pain, with possible leg numbness due to nerve damage If yes, is a Cultural Support Person present? Yes No from compressed nerve roots. This may require B. Condition and treatment
• Deterioration of other discs. This may require The doctor has explained that you have the following condition: (Doctor to document in patient’s own • Leakage of cerebrospinal fluid. This may require • The cage may injure the nerve root causing pain and/or weakness. This may be permanent.
. This condition requires the following procedure. • Inadequate placement of the Cage.
(Doctor to document - include site and/or side where healing or fusing. This may require further surgery. • The bone may not heal or fuse. This may cause This procedure is performed to relieve pressure on • Visual disturbance. This may be temporary or the fibrous sheath which contains the spinal nerves and stabilises the spine from slipping forward. • Small areas of the lung may collapse, increasing ced
C. Risks of this procedure
the risk of chest infection. This may need There are risks and complications with this procedure. • Increase risk in obese people of wound infection, ral
They include but are not limited to the following. chest infection, heart and lung complications, and Common risks and complications include:
• Infection, requiring antibiotics and further treatment. • Blood clot in the leg (DVT) causing pain and • Minor pain, bruising and/or infection from IV swelling. In rare cases part of the clot may break cannula site. This may require treatment with Rare risks and complications include:
• Hip pain and stiffness for a week or so. Physio • Paraplegia. This may require further surgery. Uncommon risks and complications include:
• Injury to major blood vessels. This will require • Bleeding can occur and may require a return to the operating room. Bleeding is more common if • Death as a result of this procedure is very rare. you have been taking blood thinning drugs such as Warfarin, Asprin, Clopidogrel (Plavix or D. Significant risks and procedure
• Heart attack due to the strain on the heart. (Doctor to document in space provided. Continue in • Stroke or stroke like complications may occur causing neurological deficits such as weakness in the face, arms and legs. This could be • Nerve root injury causing a weakness in foot movement which may affect mobility. This may • Damage to the bowel contents or blood vessels • Damage to the leg nerves that may cause (Affix patient identification label here) Extreme Lateral Interbody
Fusion (XLIF)
E. Risks of not having this procedure
procedure and its risks, and my treatment options. My questions and concerns have been (Doctor to document in space provided. Continue in discussed and answered to my satisfaction. • I understand I have the right to change my mind at any time before the procedure, including after I have signed this form but, preferably following a F. Anaesthetic
I request to have the procedure
This procedure may require an anaesthetic. (Doctor Name of Patient/
to document type of anaesthetic discussed) Substitute decision
maker and relationship:.
Signature:.
.…………………………………………………… …….
G. Patient consent
Substitute Decision-Maker: Under the Powers of Attorney Act
1998 and/or the Guardianship and Administration Act 2000. If the I acknowledge that the doctor has explained; patient is an adult and unable to give consent, an authorised decision-maker must give consent on the patient’s behalf. • my medical condition and the proposed procedure, including additional treatment if the doctor finds something unexpected. I understand H. Doctor’s statement
the risks, including the risks that are specific to I have explained to the patient all the above points under the Patient Consent section (G) and I am of • the anaesthetic required for this procedure. I the opinion that the patient/substitute decision- understand the risks, including the risks that are • other relevant procedure options and their Doctor:.
Designation:.
• my prognosis and the risks of not having the Signature:.
• that no guarantee has been made that the procedure will improve my condition even though .…………………………………………………………….
it has been carried out with due professional Anaesthetist:.
Designation:
• the procedure may include a blood transfusion. • tissues and blood may be removed and could be Signature:.
condition, stored and disposed of sensitively by Date:.…………………………………………………………….
I. Interpreter’s statement
• if immediate life-threatening events happen during the procedure, they will be treated (state the patient’s language here) of the consent form and assisted in the provision of any verbal and written information given to the patient/parent or I have been given the following Patient
guardian/substitute decision-maker by the doctor. Information Sheet/s;
About your Anaesthetic
Interpreter:.
Signature: .
Date:.…………………………………………………………….
• I was able to ask questions and raise concerns with the doctor about my condition, the proposed Consent Information - Patient Copy
Extreme Lateral Interbody Fusion (XLIF)
1. What is an Extreme Lateral Interbody
• Stroke or stroke like complications may occur causing neurological deficits such as weakness in the face, arms and legs. This could be temporary This keyhole procedure is performed to relieve lower back pain and/or leg pain associated with compression of the nerves or • Nerve root injury causing a weakness in foot the spinal canal (stenosis) usually due to instability of the spinal movement which may affect mobility. This may be column or arthritis causing the joints to not work properly in • Bladder or bowel problems due to nerve root injury X-rays will be taken throughout the case to ensure accurate or the surgical approach. This may be temporary A cut is made on your side and another near your back and the • Injury to the covering of the spinal cord. This may dilating tubes are inserted and negotiated past your abdominal • Ongoing persistent back and leg pain, with A special device called Neurovision that will guide the retractor possible leg numbness due to nerve damage from through the muscle and avoid the nerves. The disc is then compressed nerve roots. This may require further removed and replaced with a cage filled with synthetic bone graft to promote a fusion between the bones over time.This will • Deterioration of other discs. This may require open up the disc space and decompress the nerves and the spinal canal and help relieve the back pain and/or leg pain.
• Leakage of cerebrospinal fluid. This may require Sometimes a third incision will need to be made in the middle of the back to insert a plate and screws into the bones of the back to secure a solid fusion, or occasionally insert pedicle screws that ensure the strongest construct.
pain and/or weakness. This may be permanent. No drains need to be used as the blood loss is small and the • Inadequate placement of the cage. This would incisions are closed with sutures that dissolve over time A 1-3 night hospital stay is usually required My anaesthetic
or fusing. This may require further surgery This procedure will require a General Anaesthetic. • The bone may not heal or fuse. This may cause See About your Anaesthetic information sheet for
information about the anaesthetic and the risks • Visual disturbance. This may be temporary or involved. If you have any concerns, talk these over • Small areas of the lung may collapse, increasing If you have not been given an information sheet, the risk of chest infection. This may need 3. What are the risks of this specific
• Increase risk in obese people of wound infection, procedure?
chest infection, heart and lung complications, and There are risks and complications with this procedure. They include but are not limited to the following. • Blood clot in the leg (DVT) causing pain and swelling. In rare cases part of the clot may break Common risks and complications include:
• Infection, requiring antibiotics and further Rare risks and complications include:
• Minor pain, bruising and/or infection from IV Paraplegia. This may require further surgery. This cannula site. This may require treatment with • Injury to major blood vessels. This will require • Hip pain and stiffness for a week or so. The • Death as a result of this procedure is very rare. Uncommon risks and complications include:

Notes to talk to my doctor about
• Bleeding can occur and may require a return to the operating room. Bleeding is more common if you have been taking blood thinning drugs such as Warfarin, Asprin, Clopidogrel (Plavix or Iscover) or Dipyridamole (Persantin or Asasantin). • Heart attack due to the strain on the heart. • Damage to the bowel contents or blood vessels that • Damage to the leg nerves that may cause permanent weakness or numbness. This usually improves if it occurs. .

Source: http://discbulge.com.au/Patient%20Handouts/Consent_Forms/XLIF_Extreme-Lateral-Interbody-Fusion.pdf