Address: 19 Harley Street, London, LONDON, W1G 9QJ, GB
Telephone: +448445892020

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*
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Address
Your Email*
Today's Date
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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.*
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 improvement 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.*
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.*
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 ?*
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 ?*
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?*
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?*
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?*
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.*
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*
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*
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*
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Confirmation of Consent
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19 Harley St, London, W1G 9QJ, UK

Consent Form - Lumbar Spine Surgery

Personal Details

Consent for Treatment

Cancelling Surgery

Residual Symptoms

Other Treatments

Infection

Spinal Fluid (CSF) Leak

Bleeding

Nerve Injury

Cauda Equina Syndrome

Recurrent Problems

Obesity

Rare Complications

Implants

Medical Indemnity

Confirmation of Consent

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