0844 589 2020/3030
0203 973 8810
19 Harley St, London, W1G 9QJ, UK
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Spinal Assessments
Back Pain
Diagnostics
Slipped Disc
Sciatica
Lumbago
Spinal Disc Problems
Sacroiliac Joint Disorders
Spine Cancer
Laser Disc Surgery
Percutaneous Laser Discectomy
Minimally invasive or Keyhole discectomy
Keyhole Spinal Surgery
Spinal Endoscopic Surgery
Open Spinal Surgery
Lumbar Decompression
Anterior Cervical Discectomy + Fusion
Disc Replacement Surgery
Lumbar Fusion Surgery
Balloon Kyphoplasty
Spinal Epiduroscopy Surgery
Spinal Ozone Therapy
Spinal Stem Cells
Platelet Rich Plasma (PRP) ?
Spinal Injections
Facet Joint Injections Blocks
Lumbar Caudal Epidural
Physical Therapy
Non-Invasive Pain Management
Spinal Tumours Treatment
Advanced Spine Scanning Technology
About Us
About Us
Clinic Prices
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Book an Appointment
Clinical Details Form
Book a Second Opinion
Our Clinics
Harley Street London Clinic
Islamabad Spinal Clinic
The Harley Street Hospital
Our Team
Mr Mo Akmal MBBS BSc (Hons) MD FRCS (Orth)
Mr Mo Akmal Profile
Mr Masood Shafafy MBBS FRCS(Orth)
Mr Masood Shafafy CV
Mr Ahmed Hussein FRCS (Neur.Surg)
Mr Reza Mobasheri FRCS(Orth)
Mr Mohammed Ahmed FRCS
Therapists
APPI – Wimbledon
Boost Physio
Carla Pozner M.Ost, ND, DO
Central Health – Chelsea
Central Health – Farringdon
Central Health – Chancery Lane
Central Health – Highgate
Central Health – St Johns Wood
Injury Rehab
Onebody Clinic
North West London Physio & Treatment Centre
Physio Ed
Testimonials
Spinal Injection Testimonials
Spinal Surgery Testimonials
Resources
Published Research Articles
Information Leaflets
Consent Forms
Consent Form Cervical Spine Surgery
Lumbar Spine Surgery Consent Form
Menu
Home
Appointment
Treatments
What we do
Spinal Assessments
Back Pain
Diagnostics
Slipped Disc
Sciatica
Lumbago
Spinal Disc Problems
Sacroiliac Joint Disorders
Spine Cancer
Laser Disc Surgery
Percutaneous Laser Discectomy
Minimally invasive or Keyhole discectomy
Keyhole Spinal Surgery
Spinal Endoscopic Surgery
Open Spinal Surgery
Lumbar Decompression
Anterior Cervical Discectomy + Fusion
Disc Replacement Surgery
Lumbar Fusion Surgery
Balloon Kyphoplasty
Spinal Epiduroscopy Surgery
Spinal Ozone Therapy
Spinal Stem Cells
Platelet Rich Plasma (PRP) ?
Spinal Injections
Facet Joint Injections Blocks
Lumbar Caudal Epidural
Physical Therapy
Non-Invasive Pain Management
Spinal Tumours Treatment
Advanced Spine Scanning Technology
About Us
About Us
Clinic Prices
Contact Us
Book an Appointment
Clinical Details Form
Book a Second Opinion
Our Clinics
Harley Street London Clinic
Islamabad Spinal Clinic
The Harley Street Hospital
Our Team
Mr Mo Akmal MBBS BSc (Hons) MD FRCS (Orth)
Mr Mo Akmal Profile
Mr Masood Shafafy MBBS FRCS(Orth)
Mr Masood Shafafy CV
Mr Ahmed Hussein FRCS (Neur.Surg)
Mr Reza Mobasheri FRCS(Orth)
Mr Mohammed Ahmed FRCS
Therapists
APPI – Wimbledon
Boost Physio
Carla Pozner M.Ost, ND, DO
Central Health – Chelsea
Central Health – Farringdon
Central Health – Chancery Lane
Central Health – Highgate
Central Health – St Johns Wood
Injury Rehab
Onebody Clinic
North West London Physio & Treatment Centre
Physio Ed
Testimonials
Spinal Injection Testimonials
Spinal Surgery Testimonials
Resources
Published Research Articles
Information Leaflets
Consent Forms
Consent Form Cervical Spine Surgery
Lumbar Spine Surgery Consent Form
Appointment
Home
Appointment
Treatments
What we do
Spinal Assessments
Back Pain
Diagnostics
Slipped Disc
Sciatica
Lumbago
Spinal Disc Problems
Sacroiliac Joint Disorders
Spine Cancer
Laser Disc Surgery
Percutaneous Laser Discectomy
Minimally invasive or Keyhole discectomy
Keyhole Spinal Surgery
Spinal Endoscopic Surgery
Open Spinal Surgery
Lumbar Decompression
Anterior Cervical Discectomy + Fusion
Disc Replacement Surgery
Lumbar Fusion Surgery
Balloon Kyphoplasty
Spinal Epiduroscopy Surgery
Spinal Ozone Therapy
Spinal Stem Cells
Platelet Rich Plasma (PRP) ?
Spinal Injections
Facet Joint Injections Blocks
Lumbar Caudal Epidural
Physical Therapy
Non-Invasive Pain Management
Spinal Tumours Treatment
Advanced Spine Scanning Technology
About Us
About Us
Clinic Prices
Contact Us
Book an Appointment
Clinical Details Form
Book a Second Opinion
Our Clinics
Harley Street London Clinic
Islamabad Spinal Clinic
The Harley Street Hospital
Our Team
Mr Mo Akmal MBBS BSc (Hons) MD FRCS (Orth)
Mr Mo Akmal Profile
Mr Masood Shafafy MBBS FRCS(Orth)
Mr Masood Shafafy CV
Mr Ahmed Hussein FRCS (Neur.Surg)
Mr Reza Mobasheri FRCS(Orth)
Mr Mohammed Ahmed FRCS
Therapists
APPI – Wimbledon
Boost Physio
Carla Pozner M.Ost, ND, DO
Central Health – Chelsea
Central Health – Farringdon
Central Health – Chancery Lane
Central Health – Highgate
Central Health – St Johns Wood
Injury Rehab
Onebody Clinic
North West London Physio & Treatment Centre
Physio Ed
Testimonials
Spinal Injection Testimonials
Spinal Surgery Testimonials
Resources
Published Research Articles
Information Leaflets
Consent Forms
Consent Form Cervical Spine Surgery
Lumbar Spine Surgery Consent Form
Menu
Home
Appointment
Treatments
What we do
Spinal Assessments
Back Pain
Diagnostics
Slipped Disc
Sciatica
Lumbago
Spinal Disc Problems
Sacroiliac Joint Disorders
Spine Cancer
Laser Disc Surgery
Percutaneous Laser Discectomy
Minimally invasive or Keyhole discectomy
Keyhole Spinal Surgery
Spinal Endoscopic Surgery
Open Spinal Surgery
Lumbar Decompression
Anterior Cervical Discectomy + Fusion
Disc Replacement Surgery
Lumbar Fusion Surgery
Balloon Kyphoplasty
Spinal Epiduroscopy Surgery
Spinal Ozone Therapy
Spinal Stem Cells
Platelet Rich Plasma (PRP) ?
Spinal Injections
Facet Joint Injections Blocks
Lumbar Caudal Epidural
Physical Therapy
Non-Invasive Pain Management
Spinal Tumours Treatment
Advanced Spine Scanning Technology
About Us
About Us
Clinic Prices
Contact Us
Book an Appointment
Clinical Details Form
Book a Second Opinion
Our Clinics
Harley Street London Clinic
Islamabad Spinal Clinic
The Harley Street Hospital
Our Team
Mr Mo Akmal MBBS BSc (Hons) MD FRCS (Orth)
Mr Mo Akmal Profile
Mr Masood Shafafy MBBS FRCS(Orth)
Mr Masood Shafafy CV
Mr Ahmed Hussein FRCS (Neur.Surg)
Mr Reza Mobasheri FRCS(Orth)
Mr Mohammed Ahmed FRCS
Therapists
APPI – Wimbledon
Boost Physio
Carla Pozner M.Ost, ND, DO
Central Health – Chelsea
Central Health – Farringdon
Central Health – Chancery Lane
Central Health – Highgate
Central Health – St Johns Wood
Injury Rehab
Onebody Clinic
North West London Physio & Treatment Centre
Physio Ed
Testimonials
Spinal Injection Testimonials
Spinal Surgery Testimonials
Resources
Published Research Articles
Information Leaflets
Consent Forms
Consent Form Cervical Spine Surgery
Lumbar Spine Surgery Consent Form
19 Harley St, London, W1G 9QJ, UK
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Consent Form - Lumbar Spine Surgery
Thank you for completing this form.
Please note that this form is
not designed to frighten you or put you off surgery
. It is very important that you are fully informed about the risks of any surgical procedure. Mr Akmal and the spinal unit have a very low complication rate and it is probably one of the reasons that you have been referred to our Spine Unit. All surgical procedures carry risks in the same way that driving a car for example carries risks regardless of how skilled the operator is.
Although Mr Akmal and his colleagues have a lot of experience in spinal surgery, it is very important that surgeons give their patients a fully informed consent.
It is also a requirement of
Insurance companies and Regulators
that surgeons inform patients of as many risks as possible before undertaking any surgery in order to provide insurance cover for them.
Please do not hesitate to speak to your GP or any of the spinal team doctors or nurses if you are unsure about any aspects of your treatment or wish to discuss other treatment options.
Personal Details
Full Name
*
Date of Birth
*
Date Format: DD slash MM slash YYYY
Address
Your Email
*
Today's Date
Date Format: DD slash MM slash YYYY
Consent for Treatment
It is important for you to understand the nature of your operative procedure,
You should be aware what to expect from your surgery and the risks which may occur with this operation and also rare but significant other complications which have been known to occur. The main complications will be explained below, however,
this is not an exhaustive
and exclusive list and other unforeseen complications such as death and paralysis may occur.
Mr Akmal and the spinal surgeons at The Spine Unit are all highly experienced surgeons in the UK who regularly perform these procedures. Complications are rare but you need to be aware of the risks reported to occur.
Please tick to confirm
*
I agree to this consent process
Cancelling Surgery
Are you aware that you can cancel the surgery at any time and there is no obligation for you to proceed.
You may also contact your doctor or the spine team for a further consultation if you are unsure about any aspect of the surgery.
We always recommend that you do not proceed to surgery
without careful consideration
and adequate time to think about other options.
Please confirm that you understand that you can cancel surgery at anytime without any obligations.
*
Select one
Yes I understand that I can cancel or postpone surgery at any time.
I prefer to cancel surgery at this time
Residual Symptoms
Pain often masks numbness and weakness
. These symptoms may persist after surgery. It can take a long time for symptoms of numbness, weakness or back pain to improve.
In some cases
there may be no improvemen
t at all. Some patients will continue to experience nerve pain if the nerve compression has been going on for a prolonged period.
You need to be aware that symptoms of Numbness, Weakness and Pain may not get better with surgery and may even worsen?
Please confirm that you understand the above statement about residual symptoms.
*
Select one
No- I cannot accept any risk of residual symptoms so do not wish to proceed to Surgery
Yes- I understand that symptoms may persist or even worsen with surgery.
Other Treatments
Back pain and sciatica can improve without surgery
.
Pain relief may be achieved with physical therapy, tablets or injections. We would always recommend trying simpler methods before surgery.
Your doctor should explain that you should try simpler methods to help control the pain such as physical therapy, painkillers and injections.
Please confirm that you understand the above statement about conservative treatment options.
*
Select one
No - I was not aware that there are other methods of controlling pain and I prefer to try these prior to surgery.
Yes - I am aware that there are other methods that can help to control pain. I wish to proceed to surgery.
Infection
Infection affects around 2 out of every 100 patients treated (ie 1 to 2%)
: this can be serious if the infection gets into your spine or settles in your disc space. If it occurs, you will need an intense course of antibiotics in hospital and may require further surgery.
You should understand that there a risk of infection is despite the use of routine antibiotics during surgery.
What is the % risk of Infection in spinal surgery ?
*
Select one
20%
10%
1-2%
Spinal Fluid (CSF) Leak
Spinal fluid (CSF) leak affects about 1 out of every 50 patients treated ( 2% )
Occasionally the outer covering of your spinal cord (dura) may come apart causing leakage of spinal fluid (CSF). This is usually not serious but it can cause a dull headache for some time after surgery and you may need to lie flat for some days after the procedure.
Spinal fluid leak may delay your discharge from Hospital and your recovery or may require further surgery if it does not heal naturally.
What is the risk of Spinal Fluid (CSF) Leak?
*
2%
20%
Never Happens
Bleeding
Bleeding affects less than one out of every 100 patients treated (less than 1%).
Very rarely this may include damage to the main blood vessel lying at the front of the spine (the aorta or Inferior Vena Cava) requiring emergency vascular surgery.
If you take medicines to thin your blood, there is an increase risk of an epidural haematoma (a localised collection of blood around your spinal nerves). This can cause complications, such as spinal cord and nerve compression which may require a further surgical procedure to evacuate the blood clot.
You may need to stop taking blood-thinning medicines before your operation. Please check with your GP to make sure it is safe to stop the blood thinning tablets.
There is a risk of major bleeding during surgery or bleeding after surgery.
What is the risk or Bleeding ?
*
Select one
10%
1% or less
5%
Nerve Injury
Spinal nerve injury affects around 1 out of every 100 patients treated ( 1% ).
Your nerve roots (nerves in the lower part of your spine) may be stretched, bruised or damaged as part of the procedure. This can lead to a loss of feeling or muscle weakness. In the worst case scenario a permanent weakness (paralysis) can occur. This is more common in
revision surgery
(ie patients who had previous surgery).
Please note that nerve damage can also occur without treatment or delayed surgery.
There is a risk of nerve injury during surgery.
What is the risk of Nerve Injury during Surgery?
*
Select one
10%
5%
1%
Cauda Equina Syndrome
Cauda Equina injury affects around one out of every 1000 patients treated ( 0.1% ).
Your cauda equina (nerves in the lower part of your spine travelling to bowel and bladder) may be stretched, bruised or damaged as part of the procedure. This can lead to a loss of feeling or muscle weakness resulting in bladder/bowel dysfunction. Rarely these symptoms can be permanent and cause incontinence.
Please note that
Cauda Equina Syndrome
(bowel and bladder nerve dysfunction) can also occur in upto 2% of untreated disc prolapses without surgery.
There is a risk of cauda equina injury during surgery.
What is the risk of Cauda Equina Syndrome during surgery?
*
Select one
20%
5%
0.1%
Recurrent Problems
Recurrent back pain or leg pain occurs in approximately 5% of patients after surgery.
This may occur immediately after surgery or in the future and maybe related to adjacent disc problems or implant related issues.
You should be aware that your condition may recur after surgery ?
Are you aware that your symptoms may recur after surgery?
*
Select one
Yes - I understand that the symptoms may recur and wish to proceed to surgery.
No - I cannot accept that symptoms may recur after surgery
Obesity
There is an increased risk of complications in overweight people.
Complications such as Wound infection, chest infection, heart and lung complications, and thrombosis are more common.
You should be aware that the risks are higher in obesity and you should make every effort to lose weight prior to surgery.
Please confirm that you understand that there are higher risks to surgery if you are overweight.
*
Select one
No -I would rather avoid surgery at this stage
Yes - I understand that there are increased risks
Rare Complications
Are you aware that there are other rare unexpected complications
that may occur with spinal or other forms of surgery requiring General Anaesthetic.
Please note that Mr Akmal and the other spinal surgeons all take the highest level of precautions to prevent these complications from occurring.
Below is a list of rare complications.
-
Wrong level surgery
due to limitations of imaging during surgery
-
Heart attack
due the strain on the heart
- Visual disturbance or
Blindness
from being positioned on your front during the operation
-
Stroke
may occur causing neurological deficits such as weakness in the face, arms and legs. This could be temporary or permanent.
- Blood clot in the leg
(DVT)
causing pain and swelling. In rare cases part of the clot may break off and go to the lungs
Please confirm that you understand the risk of Rare Complications
*
Select one
Yes - I understand the risk of Rare Complications
No - I was not aware of rare complications and do not wish to proceed
Implants
Implants can sometimes cause problems during or after surgery
.
Although implants are sometimes used during surgery. They can become loose, infected or press on vital structures such as nerves or other organs and may need to be removed or revised during or after surgery.
I understand the potential problems that can occur with Implants
*
Select one
I understand the statement about Implants
I do not wish to proceed to surgery
Medical Indemnity
Our Surgeons and the Hospital have a standard insurance policy to cover legal and financial liabilities against malpractice (limited to £500k cover). If you require a higher rate of cover due to the nature of your profession (or any other reason) ie professional sportsman, celebrity or businessman, high net worth individual, special needs etc then it is your responsibility to ensure that extra cover is arranged prior to surgery. You must let us know before proceeding to surgery so that we can get a quote for you.
Please confirm that you understand our Medical Insurance Disclaimer
*
Select one
Yes - I understand. The £500k cover is adequate and I wish to proceed
No - I prefer to cancel surgery at this stage.
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Confirmation of Consent
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