Before we walk into the waves we make an assessment: Weather. Swell. Rip. Swimming ability. Other people around. Sharks. Jellyfish. Watercraft.
Then we dive in. No paperwork. This is informed consent.
You have informed yourself and you have given yourself permission to act. You cannot know everything. You cannot avoid all risk. If you want to avoid all risk, then you don't swim. There is a risk in not learning to swim in the ocean. Life contains risk. We cannot know or control everything.
You have informed consent when YOU have decided YOU have enough information to ACT.
Below are copies of the consent forms I use for surgery. These are NOT specific to you. This is information of a general nature. If you choose to read or act on information provided here you do so without Mr Knight's endorsement or recommendation.
These are copyrighted to Mr Michael Knight, but maybe freely copied and distributed under fair use, but not used for profit.
CONSENT FOR CARPAL TUNNEL RELEASE
Dear ,
You have a problem of carpal tunnel syndrome. This is a ****** problem, but much worse on the *** than the ***. This has been demonstrated clinically and by Nerve conduction studies.
Carpal Tunnel Syndrome means that the nerve that supplies the thumb, index and middle fingers is being squashed as it passes from the forearm to the hand. This nerve, called the median nerve, travels in a tunnel made up by bones on 3 sides, and a soft tissue called retinaculum, as a roof. The nerve travels with tendons through the tunnel. As we age, this tunnel can change in size and shape causing an increased pressure on the nerve. The nerve then sends pain signals that make the fingers hurt. If the pressure is too great the nerve may stop working and you may develop weakness in your fingers and thumb.
You have failed to respond to non-operative therapy. That is all the treatment options, apart from surgery, that you have used, have not given you any long-term benefit.
You have told me that you life is often very miserable because of the pain in your fingers. You told me that if you did not have pain your life would be much improved.
I am able to offer you 2 choices of treatment.
First option.
Continue to manage the problem non-surgically. Given that carpal tunnel symptoms fluctuate in most people you would have to intermittently decrease your activity, both social and physical to fit your physical disability. You would need to use pain killers and night splintage to control your pain during these exacerbations. A small number of patients undergo a relentless deterioration, but it is impossible to determine who these patients are.
The use of physical therapy, chiropractic, and alternative health interventions have not been shown to be useful in the resolution of chronic pain based on controlled trials in the scientific literature. Such therapies may make you feel better in the very short term. However they cannot provide you with a permanent cure.
Non-operative management is not always the safest alternative. While there can be no surgical complications if there is no surgery, other problems may arise such as permanent muscle weakness, and permanent pain.
Second option.
Undergo carpal tunnel release.
The Operation.
The anaesthetist will give you a sedation anaesthetic. You will be awake, but probably not remember much about the surgery. You will lie on your back on the operating table, and I shall inject local anaesthetic into the skin over your wrist. This will hurt a bit, but it will rapidly become numb.
A tourniquet will be placed loosely over your upper arm. If needed this can be inflated briefly to control bleeding. It is not inflated routinely.
The arm will be washed with antiseptic, and you will be given antibiotics to help prevent infection.
An incision (cut) will then be made. This will NOT be a cosmetic incision. I do not do “keyhole” surgery. Key hole surgery is available for this operation but it has a higher risk of complications and so I do not perform it.
The incision will be about 2.5 cm (an inch) from the wrist toward the fingers. Under the skin there is fat, and fascia (gristle) and then the flexor retinaculum (roof of the carpal tunnel). With a special headlight and special magnifying glasses I shall be able to see this clearly. I shall cut the flexor retinaculum along its entire length. This will release the carpal tunnel. I shall be able to see the median nerve below, and I shall use a metal shield to protect it as the flexor retinaculum is cut completely.
Once the entire carpal tunnel is released I shall close the wound with a combination of dissolving and non-dissolving suture(stitch) material. I have found this combination to cause the least problems with scarring and infection. This will need to be removed at 2 weeks.
The wound will be dressed with a bandage. Inside the bandage will be a small piece of plaster-of-Paris. This keeps the wrist stiff for 2 weeks while the wound heals.
Your hand will be numb for up to 8 hrs after the operation. In this time you should go home and keep the hand above the level of your heart. This keeps the swelling down. As you start to feel some pain you should IMMEDIATELY take some medication to help with the pain. This is useful for the next 48hrs, and can be taken every four hours as required. You should aim to keep the hand elevated as much as possible over the next 2 weeks. Keep in mind that a sling will actually allow the hand to fall below the level of the heart, so is NOT a good idea for prolonged periods. The fingers should be kept moving at all times, even if this is painful. If the fingers are kept still for even a few days they can become permanently stiff.
DO NOT PICK UP ANYTHING HEAVIER THAN A PENCIL.
YOU CANNOT CARRY ANYTHING FOR 2 WEEKS.
IF THERE IS INCREASING PAIN NOT CONTROLLED ON SIMPLE MEDICATION YOU MUST CALL 0400828506.
DO NOT GET THE BANDAGE WET. IF IT GETS WET YOU MUST HAVE IT CHANGED THE NEXT DAY.
You will return to see me after two weeks and I shall remove the bandage, and the sutures. After this you will not need any further dressing or covering. You will need to keep the wrist, hand and fingers moving. I may send you to physiotherapy if you are too stiff. You may now pick up objects as heavy as a tea cup, but no more. This limitation remains until 6 weeks post surgery when I shall review you again for the last time. Hopefully all you finger pain will have resolved by then, and you will be well on your way to full function.
However SOME PATIENTS ARE NOT BETTER WITH SURGERY, SOME PATIENTS CAN BE WORSE.
About 5% of carpal tunnel operations are complicated by an adverse outcome. That is something happens that was not expected, and requires extra treatment. This does not mean that in the end a good result will not occur. It does mean that extra work may be required to achieve a good outcome.
COMPLICATIONS
I will try to cover the most serious. However you must note that I will not cover everything. An absolutely comprehensive list is NOT possible. The unexpected can always occur, I cannot warn you about everything.
Adverse risk rate I would estimate to be around 5%. This means that one in every twenty operations incurs an unexpected outcome.
This can be something simple such as a superficial wound infection that resolves with oral antibiotics, or it may be something extremely dangerous such as a blood clot, or heart attack.
People have died having this surgery, however the risk of this is about 1 in 100,000 (American Society of Anaesthesiologists Grade 1). The risk of a fatal car accident is about 1 in 15,000 per year.
Anaesthetics carry risk. This risk should be discussed with your anaesthetist.
Risks of all Orthopaedic Surgery
Death
Heart Attack
Stroke
Blood Clots
Bleeding requiring blood transfusion (this has never happened in this surgery)
Blood transfusion causing infection with hepatitis or AIDS
Lung failure : breathing difficulties
Kidney failure : unable to make urine, requiring dialysis
Liver failure: usually caused by an unexpected reaction to a medication
Bowel paralysis (ileus): a temporary condition caused by fasting
Nerve injury - this occurs in the skin when an incision is made causing permanent numbness.
Failure to improve.
Despite a technically perfect operation it can be possible that your symptoms may not improve. I give no guarantee that the surgery will improve any or all of your symptoms. However I believe strongly that you will get better. I would not do the surgery otherwise.
Infection: some infections are simple to treat. Other infections are a disaster, requiring repeat surgery. The very worst outcome means that your entire hand and forearm could be infected. This is a very rare outcome, only seen in patients will other major diseases.
Specific Risks of Carpal Tunnel Surgery
Damage to the median nerve (Permanent pain or weakness in the thumb, index and middle fingers)
Damage to a single branch of the median nerve. (Permanent pain or weakness of a single finger or the thumb)
Wound pain. This usually resolves, but can last forever.
Recurrence. The scar that forms after the surgery can retighten the carpal tunnel
Tendon problems. The tendons that pass through the carpal tunnel can be affected, causing a change in the way they move through the carpal tunnel, with loss of hand strength or even tendon rupture.
Complex Region Pain Syndrome: This is a very difficult thing to explain, but is very debilitating when it occurs. The surgery sets off a chain reaction of responses within the body causing the hand and possibly the entire upper limb to become overly sensitive. That is, normal sensation is felt as pain. It also causes finger and hand stiffness, swelling and skin colour changes. This requires months of occupational therapy to over come and will make you very unhappy. Fortunately it is rare in this surgery.
Your risk to the operating team.
During surgery it is possible for one of the operating team to cut themselves on a needle or other sharp object that has your blood on it. Blood can transmit infection from you to the staff member. There are drugs that can be given to the staff member to stop infection but they can only be given if your blood is tested for possible infection. I require you to give permission for taking and testing of your blood in the unlikely event that such an injury occurs. The blood will be tested for Hepatitis, and the Aids Virus (HIV). If you don't feel that you can give this permission then please discuss this with me. Your signature on this document serves as permission for this testing.
As I said earlier in this letter. There are always complications that I cannot think about or cannot warn you about. I have covered what I think is the most common, the most dangerous, and the most concerning. If you have anything else you would like to discuss you can do so by contacting me.
SUMMARY
This document is a consent form.
You must read it thoroughly. I have given you an extra copy to give to your GP. I would strongly suggest that you have a friend, or relative read this with you. You may even wish to get a lawyer to read it. If you have any concerns you should not proceed with the surgery. I would advise you to get another opinion from another surgeon if you have any concerns. Public hospitals with fully trained orthopaedic surgeons include the AUSTIN HOSPITAL, THE ROYAL MELBOURNE HOSPITAL, MONASH MEDICAL CENTRE, and THE ALFRED HOSPITAL. All of these hospitals have public clinics you could visit. There are many other surgeons in Melbourne who do carpal tunnel surgery who you could see privately.
As I have told you, I am an orthopaedic surgeon who has done many of these operations with an excellent outcome. We have also discussed the most significant complications I have personally encountered. Clearly I am not the oldest or busiest surgeon in Melbourne. You must consider this in deciding who does your surgery.
Your signature on this letter, with initials on every page must be returned to my office prior to the day of surgery. You should keep a copy for yourself. Your signature is acknowledgement of that you have read and understood the document; that you request the proposed surgery, and that you give me permission to perform the surgery and the Hospital to look after you during and after the surgery.
Yours sincerely,
Mr. Michael KNIGHT
MBBS FAOA
Signature:......................................................
Date: .............../................./...................
CONSENT FOR AN OPERATION
Multilevel Cervical Foraminotomy/Laminectomy ***
Dear
You have a problem of cervical (neck) intervertebral disc and facet joint degenerative change resulting in spondylosis with radiculopathy.
In Plain English that is: Ageing has caused deterioration of the disc joint (intervertebral disc) between the neck spinal bones, and the small shingle joints behind the spine. This combination causes a narrowing of the small windows that allow spinal nerves to leave the main spinal trunk. These windows are so narrowed that the nerves are being squashed as they leave the neck. This causes pain, numbness and altered feeling, and weakness in your upper arms.
The diagnosis is based on my examination of you, the story you have told me, and the imaging available.
You have failed to respond to maximal conservative therapy. That is all the treatment options apart from surgery that you have used have not given you any long-term benefit.
My concern is that the pressure on the spinal nerves may result in permanent loss of function if you are not treated. This is not a certainty, but your clinical presentation suggests you are at risk of such a deterioration.
I am able to offer you 2 choices of treatment.
First option: Continue to manage the problem non-surgically.
It is unlikely that given time your symptoms will gradually improve. Most patients who develop spinal nerve root compression do improve with time. However given the period you have already waited this is increasingly unlikely for you.
The use of physiotherapy, chiropractic, and alternative health interventions have not been shown to be useful in the improvement of cervical radiculopathy. They may give you short term pain relief, and this is not a bad thing, but they cannot provide you with a permanent cure.
Non-surgical treatment is the safest alternative. There can be no surgical complications if there is no surgery, your condition may deteriorate to the point you can no longer care for yourself, but this is very uncommon. Unfortunately there is no way of telling which patients will deteriorate. Deterioration in this condition is usually arrestable if it is caught early, but it is not usually reversible.
Second option.
Decompression of the spinal nerves by posterior foraminotomy.
The Operation
In this operation you are given an anaesthetic. You will be completely asleep. While you are asleep, at least two “drips” (intravenous and intra-arterial catheters) will be placed in your upper limbs.
You will be placed onto your stomach on a special table. A cut (incision) will be made in the back of your neck over the location of your problem.
A portable x-ray machine will be used to make sure I know which level of the spine I am operating upon.
I will carefully find the passage from the skin to the spine through all the structures in the back of your neck. I will again use x-ray to make sure I am at the correct spinal level.
I shall cut the lamina (bone) on the back of the neck, just next to the shingle joints. This will expose the nerves as they leave the spinal cord and head out through the windows. I shall then remove half of the shingle joint that compresses the nerve. The rest of the joint will be left intact. I shall do all of the joints that are involved.
The wound is then washed out to remove any bacteria that has fallen in from your skin, and closed with sutures (stitches).
The suture is dissolvable and below the skin.
You will be put back onto your bed and woken up. Once you are awake enough to breathe for yourself you will be transferred to recovery. Once you are awake enough to move your arms and legs I shall ring your nominated next of kin and tell them that you are OK.
The Outcome:
Immediately after the surgery you will not be too sore because you will have lots of medication in your system. As this wears off the pain will increase. This is a very painful operation.
Over the next few days the pain will increase and you will need pain killers. These drugs are often used for weeks or even months after this surgery. This is because the muscles that hold the neck up have been cut, and they take quite sometime to reattach to the underlying bone.
Most patients get some immediate relief of pain/numbness/tingling. However lack of an immediate response does not mean that you will not get better. Most of the improvement in symptoms does not occur until days or weeks after the surgery. If recovery requires the nerves to regrow (in very severe cases), then it can be up to 18 months before the symptoms go away. It is very common to feel much better for a few days and then the symptoms come back again. This does not mean that the operation has failed. It means that the ongoing inflammation from the surgery is causing nerve irritation. As the wound heals this secondary stimulation goes away and the pain settles again. In my experience more than 95% of patients with cervical radiculopathy have significant improvement. If they didn’t, I wouldn’t do the surgery.
Scarring: This is not cosmetic surgery, the wounds are large and however long term they are not usually too obvious. However I do not guarantee a “nice” looking scar.
SOME PATIENTS ARE NOT BETTER WITH SURGERY, SOME PATIENTS CAN BE WORSE.
About 2% of spinal fusion operations are complicated by an adverse outcome. That is something happens that was not expected, and requires extra treatment.
Adverse Outcomes (Complications)
I will try to cover the most serious. However you must note that I will not cover everything. An absolutely comprehensive list is NOT possible. The unexpected can always occur, I cannot warn you about everything.
Adverse risk rate I would estimate to be around 2%. This means that one in every fifty operations incurs an unexpected outcome.
This can be something simple such as a skin infection that resolves with tablet antibiotics, or it may be something extremely dangerous such as a blood clot, or heart attack.
People have died having this surgery, however the risk of this is about 1 in 100,000 (American Society of Anaesthesiologists Grade 1). To put this in perspective the risk of a fatal car accident in a year is about 1 in 10,000. Or ten times more likely.
It is possible to make you quadriplegic by damaging the spinal cord. However this would be extremely rare, and I cannot put a percentage on this risk. This is irreversible and would leave you in bed for the rest of your life, unable to care for yourself. It would significantly shorten your life.
Risks of all Orthopaedic Surgery
Death
Heart Attack
Stroke
Blood Clots
Bleeding requiring blood transfusion
Blood transfusion causing infection with hepatitis or AIDS
Lung failure : breathing difficulties
Kidney failure : unable to make urine, requiring dialysis
Liver failure : usually caused by an unexpected reaction to a medication
Bowel paralysis (ileus): a temporary condition caused by fasting
Superficial Nerve injury - this occurs in the skin when an incision is made causing permanent numbness of the skin.
Major Nerve Injury - In spinal surgery damage to a single nerve in the spinal canal can have permanent paralysing effects on a group of muscles. This is rare, but usually irreversible.
Failure to improve.
Despite a technically perfect operation it can be possible that your symptoms may not improve. I give no guarantee that the surgery will improve any or all of your symptoms. However I believe strongly that you will get better. I would not do the surgery otherwise.
Infection
Some infections are simple to treat. Other infections are a disaster, requiring repeat surgery and removal the implants. Long term antibiotics may also be required.
Your risk to the operating team.
During surgery it is possible for one of the operating team to cut themselves on a needle or other sharp object that has your blood on it. Blood can transmit infection from you to the staff member. There are drugs that can be given to the staff member to stop infection but they can only be given if your blood is tested for possible infection. I require you to give permission for taking and testing of your blood in the unlikely event that such an injury occurs. The blood will be tested for Hepatitis, and the Aids Virus (HIV). If you don't feel that you can give this permission then please discuss this with me. Your signature on this document serves as permission for this testing.
I have covered what I think are the most concerning adverse outcomes. If you have anything else you would like to discuss you can do so by contacting me.
SUMMARY
This document is a consent form.
You must read it thoroughly. I have sent you extra copies to give to your GP. I would strongly suggest that you have a friend, or relative read this with you. You may even wish to get a lawyer to read it. If you have any concerns you should not proceed with the surgery. If you are uncertain I would advise you to get another opinion from another spinal surgeon. Public hospitals with fully trained spinal surgeons include the AUSTIN HOSPITAL, THE ROYAL MELBOURNE HOSPITAL, MONASH MEDICAL CENTRE, and THE ALFRED HOSPITAL. All of these hospitals have public clinics you could visit. There are both neurosurgeons and other orthopaedic surgeons in Melbourne who do spinal surgery you could see privately.
As I have told you I am an orthopaedic surgeon who has done extra training in spinal surgery. I am neither the oldest nor most experienced spine surgeon in Melbourne, however I have extensive experience in treating spinal conditions and I am fully qualified to perform your surgery.
Your signature on this letter, with initials on every page must be returned to the hospital on the day of surgery. You should keep a copy for yourself. Your signature is acknowledgement of that you have read and understood the document; that you request the proposed surgery, and that you give me permission to perform the surgery and the Hospital to look after you during and after the surgery.
Yours sincerely,
Dr. Michael KNIGHT
MBBS FAOA
Your Signature.........................................
Date:......./........../...........
CONSENT FOR AN OPERATION
Dear ,
You have a problem of cervical (neck) intervertebral disc herniation, with myelopathy.
That is: Injury and ageing have caused deterioration of the disc joint (intervertebral disc) between the neck spinal bones && and &&. This has caused the disc to rupture and the contents of the disc to spill out (herniation) and push on the spinal cord. This compression causes increased tone in your limbs.
The diagnosis is based on my examination of you, the story you have told me, and the imaging available.
My concern is that the spinal cord changes may result in permanent loss of function if you are not treated. This is not a certainty, but your clinical presentation suggests you are at risk of such a deterioration.
I am able to offer you 2 choices of treatment.
First option.
Continue to manage the problem non-surgically.
The use of physiotherapy, chiropractic, and alternative health interventions have not been shown to be useful in the improvement of a radiculopathy or myelopathy based on controlled trials in the scientific literature. They may give you short term pain relief, and this is not a bad thing, but they cannot provide you with a permanent cure.
It is likely that given enough time your symptoms will gradually improve, but it is unlikely you will return to "normal". Most patients have spontaneous fluctuation in their symptoms, with some reaching a plateau. That is, they are not quite normal, but the don't deteriorate catastrophically. It is impossible to be sure if you will improve to a level that you are happy but it is possible. It is possible you may never be worse than you currently are.
Non-surgical treatment is NOT necessarily the safest alternative. While there can be no surgical complications if there is no surgery, your condition may well deteriorate to the point you can no longer care for yourself.
This would be the case for about 33% of patients with spinal cord damage (myelopathy), so it is possible. Unfortunately there is no way of telling which patients will deteriorate. Deterioration in this condition is not usually reversible, even if it is caught early, but usually it is arrestable. That is I cannot make you better, but I can stop you from getting worse.
Second option.
Undergo removal of the disc fragment and spinal fusion.
The Operation
In this operation you are given an anaesthetic. You will be completely asleep. While you are asleep at least two “drips” (intravenous and intra-arterial catheters) will be placed in your upper limbs. You will be placed onto your back on a special table. A cut (incision) will be made in the front of your neck over the location of your problem. A portable x-ray machine will be used to make sure I know which level of the spine I am operating upon. I will carefully find the passage from the skin to the spine through all the structures in the front of your neck. I will again use x-ray to make sure I am at the correct spinal level. I shall remove the entire disc at this level including the piece of disc pushing on the nerve. The spine will be more wobbly (unstable) once all this disc is removed. Therefore I shall put a small PEEK (a type of biological plastic) spacer between the bone above and below. This spacer is designed to make the spine stable, and to allow the two bones to join into each other, i.e. fuse together. The wound is then washed out to remove any bacteria that has fallen in from your skin, and closed with sutures (stitches). Most of the suture is dissolvable and below the skin. Only the skin suture needs to be removed. This is because removable suture has a better cosmetic result, and less infection than dissolvable skin suture or staples.
You will be put back onto your bed and woken up. Once you are awake enough to breathe for yourself you will be transferred to recovery. Once you are awake enough to move your legs I shall ring your nominated next of kin and tell them that you are OK.
The Outcome:
Immediately after the surgery you will not be too sore because you will have lots of medication in your system. As this wears off the pain will increase. This is not a very painful operation. Most patients go home the next day.
Most patients get some immediate relief of pain/numbness/tingling. However lack of an immediate response does not mean that you will not get better. Most of the improvement in symptoms does not occur until days or weeks after the surgery. If recovery requires the nerves to regrow (in very severe cases), then it can be up to 18 months before the symptoms go away. It is very common to feel much better for a few days and then the symptoms come back again. This does not mean that the operation has failed. It means that the ongoing inflammation from the surgery is causing nerve irritation. As the wound heals this secondary stimulation goes away and the pain settles again. In my experience more than 95% of patients with cervical radiculopathy have significant improvement. If they didn’t I wouldn’t do the surgery.
Scarring: This is not cosmetic surgery, yet the wounds are not large and long term they are not usually obvious. However I do not guarantee a “nice” looking scar.
SOME PATIENTS ARE NOT BETTER WITH SURGERY, SOME PATIENTS CAN BE WORSE. About 2% of spinal fusion operations are complicated by an adverse outcome. That is something happens that was not expected, and requires extra treatment.
Adverse Outcomes (Complications)
I will try to cover the most serious. However you must note that I will not cover everything. An absolutely comprehensive list is NOT possible. The unexpected can always occur, I cannot warn you about everything.
Adverse risk rate I would estimate to be around 2%. This means that one in every fifty operations incurs an unexpected outcome.
This can be something simple such as a skin infection that resolves with tablet antibiotics, or it may be something extremely dangerous such as a blood clot, or heart attack.
People have died having this surgery, however the risk of this is about 1 in 100,000 (American Society of Anaesthesiologists Grade 1). To put this in perspective the risk of a fatal car accident in a year is about 1 in 10,000. Or ten times more likely.
QUADRIPLEGIA
It is possible to make you quadriplegic by damaging the spinal cord.
THIS MEANS NOTHING WORKS BELOW THE LEVEL OF THE SURGERY. AT C6-C7 THIS MEANS YOU WOULD NOT BE ABLE TO WALK, OR SIT UP, AND YOU WOULD HAVE ONLY VERY LIMITED HAND FUNCTION. YOU COULD BREATH AND TALK ON YOUR OWN, BUT WOULD STRUGGLE TO FEED YOURSELF. THIS WOULD BE A PERMANENT LIFE ALTERING DISASTER.
This is so unlikely that I cannot put a percentage risk on this. You are more likely to be struck by lightening than go quadriplegic.
Injury to structures in the neck
Your neck carries structures that allow: Breathing, Eating, Swallowing, that Carry Blood to and from the Brain, and Nerves that allow you to talk.
There are no spare parts. If any of these structures is damaged, the consequences are always a disaster. Fortunately this is very rare.
Everyone has a few weeks of a hoarse voice and difficulty swallowing, this is temporary swelling and will resolve.
Damage to breathing tube (Trachea) - need a breathing hole in the neck ( tracheostomy) until it heals
Damage to swallowing/ eating - need a feeding tube directly into the stomach until it heals
Damage to Blood vessels to the brain - stroke - with variable consequences
Damage to Nerves of the Larynx and Pharynx - Permanent voice change, and permanent swallowing problems.
Damage to the thyroid or para thyroid glands - Permanent use of replacement medication.
All of these things have happened to someone somewhere, but they are uncommon.
Risks of all Orthopaedic Surgery
Death
Heart Attack
Stroke
Blood Clots
Bleeding requiring blood transfusion
Blood transfusion causing infection with hepatitis or AIDS
Lung failure : breathing difficulties
Kidney failure : unable to make urine, requiring dialysis
Liver failure : usually caused by an unexpected reaction to a medication
Bowel paralysis (ileus): a temporary condition caused by fasting
Superficial Nerve injury - this occurs in the skin when an incision is made causing permanent numbness of the skin.
Major Nerve Injury - In spinal surgery damage to a single nerve in the spinal canal can have permanent paralysing effects on a group of muscles. This is rare, but usually irreversible.
Failure to improve.
Despite a technically perfect operation it can be possible that your symptoms may not improve. I give no guarantee that the surgery will improve any or all of your symptoms. However I believe strongly that you will get better. I would not do the surgery otherwise.
Infection
Some infections are simple to treat. Other infections are a disaster, requiring repeat surgery and removal the implants. Long term antibiotics may also be required.
Your risk to the operating team.
During surgery it is possible for one of the operating team to cut themselves on a needle or other sharp object that has your blood on it. Blood can transmit infection from you to the staff member. There are drugs that can be given to the staff member to stop infection but they can only be given if your blood is tested for possible infection. I require you to give permission for taking and testing of your blood in the unlikely event that such an injury occurs. The blood will be tested for Hepatitis, and the Aids Virus (HIV). If you don't feel that you can give this permission then please discuss this with me. Your signature on this document serves as permission for this testing.
I have covered what I think are the most concerning adverse outcomes. If you have anything else you would like to discuss you can do so by contacting me.
SUMMARY
This document is a consent form.
You must read it thoroughly. I have sent you extra copies to give to your GP. I would strongly suggest that you have a friend, or relative read this with you. You may even wish to get a lawyer to read it. If you have any concerns you should not proceed with the surgery. If you are uncertain I would advise you to get another opinion from another spinal surgeon. Public hospitals with fully trained spinal surgeons include the AUSTIN HOSPITAL, THE ROYAL MELBOURNE HOSPITAL, MONASH MEDICAL CENTRE, and THE ALFRED HOSPITAL. All of these hospitals have public clinics you could visit. There are both neurosurgeons and other orthopaedic surgeons in Melbourne who do spinal surgery you could see privately.
As I have told you I am an orthopaedic surgeon who has done extra training in spinal surgery. I am neither the oldest nor most experienced spine surgeon in Melbourne, however I have extensive experience in treating spinal conditions and I am fully qualified to perform your surgery.
Your signature on this letter, with initials on every page must be returned to the hospital on the day of surgery. You should keep a copy for yourself. Your signature is acknowledgement of that you have read and understood the document; that you request the proposed surgery, and that you give me permission to perform the surgery and the Hospital to look after you during and after the surgery.
Yours sincerely,
Mr Michael Knight
MBBS FAOA
Date:........./............./...........
Signature: ...................................................................
October 4, 2022
CONSENT FOR AN OPERATION
Dear ,
You have a problem of cervical (neck) intervertebral disc herniation, with radiculopathy.
That is: Injury and ageing have caused deterioration of the disc joint (intervertebral disc) between the neck spinal bones && and &&. This has caused the disc to rupture and the contents of the disc to spill out (herniation) and push on the spinal nerve . This compression causes pain in your && arm. You also have weakness of &&&.
The diagnosis is based on my examination of you, the story you have told me, and the imaging available.
I am able to offer you 2 choices of treatment.
First option.
Continue to manage the problem non-surgically.
It is likely that given enough time your symptoms will gradually improve. Most patients (up to 90%)have spontaneous gradual improvement from this condition. It is impossible to be sure if you will improve to a level that you are happy with, but it is likely.
The use of physiotherapy, chiropractic, and alternative health interventions have not been shown to be useful in the improvement of a radiculopathy or myelopathy based on controlled trials in the scientific literature. They may give you short term pain relief, and this is not a bad thing, but they cannot provide you with a permanent cure.
Non-surgical treatment is NOT necessarily the safest alternative. While there can be no surgical complications if there is no surgery, your condition can deteriorate. This is rare, but it is possible. Unfortunately there is no way of telling which patients will deteriorate. Deterioration in this condition is usually reversible if it is caught early, but sometimes it is not reversible.
Your condition may not improve over time, and while it may not worsen, lack of improvement may be a sign that the compression of the nerve is causing a permanent injury to the nerve. We have no way of measuring this.
Second option.
Undergo removal of the disc fragment and spinal fusion:
Anterior Cervical Decompression and Fusion.
The Operation
In this operation you are given an anaesthetic. You will be completely asleep. While you are asleep at least two “drips” (intravenous and intra-arterial catheters) will be placed in your upper limbs. You will be placed onto your back on a special table.
A cut (incision) will be made in the front of your neck over the location of your problem. A portable x-ray machine will be used to make sure I know which level of the spine I am operating upon.
I will carefully find the passage from the skin to the spine through all the structures in the front of your neck. I will again use x-ray to make sure I am at the correct spinal level. I shall remove the entire disc at this level including the piece of disc pushing on the nerve.
The spine will be more wobbly (unstable) once all this disc is removed. Therefore I shall put a small PEEK (a type of biological plastic) spacer between the bone above and below. This spacer is designed to make the spine stable, and to allow the two bones to join into each other, i.e. fuse together.
The wound is then washed out to remove any bacteria that has fallen in from your skin, and closed with sutures (stitches). The suture is dissolvable and below the skin.
You will be put back onto your bed and woken up. Once you are awake enough to breathe for yourself you will be transferred to recovery. Once you are awake enough to move your legs I shall ring your nominated next of kin and tell them that you are OK.
The Outcome:
Immediately after the surgery you will not be too sore because you will have lots of medication in your system. As this wears off the pain will increase. This is not a very painful operation. Many patients go home the next day.
Most patients get some immediate relief of pain/numbness/tingling. However lack of an immediate response does not mean that you will not get better. Most of the improvement in symptoms does not occur until days or weeks after the surgery. If recovery requires the nerves to regrow (in very severe cases), then it can be up to 18 months before the symptoms go away. It is very common to feel much better for a few days and then the symptoms come back again. This does not mean that the operation has failed. It means that the ongoing inflammation from the surgery is causing nerve irritation.
As the wound heals this secondary stimulation goes away and the pain settles again. In my experience more than 95% of patients with cervical radiculopathy have significant improvement. If they didn’t I wouldn’t do the surgery.
Scarring: This is not cosmetic surgery, yet the wounds are not large and long term they are not usually obvious. However I do not guarantee a “nice” looking scar.
SOME PATIENTS ARE NOT BETTER WITH SURGERY, SOME PATIENTS CAN BE WORSE. About 2% of spinal fusion operations are complicated by an adverse outcome. That is something happens that was not expected, and requires extra treatment.
Adverse Outcomes (Complications)
I will try to cover the most serious. However you must note that I will not cover everything. An absolutely comprehensive list is NOT possible. The unexpected can always occur, I cannot warn you about everything.
Adverse risk rate I would estimate to be around 5%. This means that one in every 20 operations incurs an unexpected outcome.
This can be something simple such as a skin infection that resolves with tablet antibiotics, or it may be something extremely dangerous such as a blood clot, or heart attack.
People have died having this surgery, however the risk of this is about 1 in 100,000 (American Society of Anaesthesiologists Grade 1). To put this in perspective the risk of a fatal car accident in a year is about 1 in 20,000. Or five times more likely.
QUADRIPLEGIA
It is possible to make you quadriplegic by damaging the spinal cord.
THIS MEANS NOTHING WORKS BELOW THE LEVEL OF THE SURGERY.
AT C5-C6 THIS MEANS YOU WOULD NOT BE ABLE TO WALK, OR SIT UP, AND YOU WOULD HAVE ONLY VERY LIMITED HAND FUNCTION. YOU COULD BREATH AND TALK ON YOUR OWN, BUT WOULD STRUGGLE TO FEED YOURSELF. THIS WOULD BE A PERMANENT LIFE ALTERING DISASTER.
This is so unlikely that I cannot put a percentage risk on this. You are more likely to be struck by lightning than go quadriplegic from this surgery.
Injury to structures in the neck
Your neck carries structures that allow: Breathing, Eating, Swallowing, that Carry Blood to and from the Brain, and Nerves that allow you to talk.
There are no spare parts. If any of these structures is damaged, the consequences are always a disaster. Fortunately this is very rare.
Everyone has a few weeks of a hoarse voice and difficulty swallowing, this is temporary swelling and will resolve, this is not a complications.
Damage to breathing tube (Trachea) - need a breathing hole in the neck (tracheostomy) until it heals
Damage to swallowing/ eating - need a feeding tube directly into the stomach until it heals
Damage to Blood vessels to the brain - stroke - with variable consequences - from unnoticeable, to a disaster, to death.
Damage to Nerves of the Larynx and Pharynx - Permanent voice change, and permanent swallowing problems.
Damage to the thyroid or para thyroid glands - Permanent use of replacement medication.
All of these things have happened to someone somewhere having this surgery, but they are uncommon.
Risks of all Orthopaedic Surgery
Death
Heart Attack
Stroke
Blood Clots
Bleeding requiring blood transfusion
Blood transfusion causing infection with hepatitis or AIDS
Lung failure : breathing difficulties
Kidney failure : unable to make urine, requiring dialysis
Liver failure : usually caused by an unexpected reaction to a medication
Bowel paralysis (ileus): a temporary condition caused by fasting
Superficial Nerve injury - this occurs in the skin when an incision is made causing permanent numbness of the skin.
Major Nerve Injury - In spinal surgery damage to a single nerve in the spinal canal can have permanent paralysing effects on a group of muscles. This is rare, but usually irreversible.
Failure to improve.
Despite a technically perfect operation it can be possible that your symptoms may not improve. I give no guarantee that the surgery will improve any or all of your symptoms. However I believe strongly that you will get better. I would not do the surgery otherwise.
Infection
Some infections are simple to treat. Other infections are a disaster, requiring repeat surgery and removal the implants. Long term antibiotics may also be required.
Your risk to the operating team.
During surgery it is possible for one of the operating team to cut themselves on a needle or other sharp object that has your blood on it. Blood can transmit infection from you to the staff member. There are drugs that can be given to the staff member to stop infection but they can only be given if your blood is tested for possible infection. I require you to give permission for taking and testing of your blood in the unlikely event that such an injury occurs. The blood will be tested for Hepatitis, and the Aids Virus (HIV). If you don't feel that you can give this permission then please discuss this with me. Your signature on this document serves as permission for this testing.
I have covered what I think are the most concerning adverse outcomes. If you have anything else you would like to discuss you can do so by contacting me.
SUMMARY
This document is a consent form.
You must read it thoroughly. I have sent you extra copies to give to your GP. I would strongly suggest that you have a friend, or relative read this with you. You may even wish to get a lawyer to read it. If you have any concerns you should not proceed with the surgery. If you are uncertain I would advise you to get another opinion from another spinal surgeon. Public hospitals with fully trained spinal surgeons include the AUSTIN HOSPITAL, THE ROYAL MELBOURNE HOSPITAL, MONASH MEDICAL CENTRE, and THE ALFRED HOSPITAL. All of these hospitals have public clinics you could visit. There are both neurosurgeons and other orthopaedic surgeons in Melbourne who do spinal surgery you could see privately.
As I have told you I am an orthopaedic surgeon who has done extra training in spinal surgery. I am neither the oldest nor most experienced spine surgeon in Melbourne, however I have extensive experience in treating spinal conditions and I am fully qualified to perform your surgery.
Your signature on this letter, with initials on every page must be returned to the hospital on the day of surgery. You should keep a copy for yourself. Your signature is acknowledgement of that you have read and understood the document; that you request the proposed surgery, and that you give me permission to perform the surgery and the Hospital to look after you during and after the surgery.
Yours sincerely,
Mr Michael Knight
MBBS FAOA
Date:........./............./...........
Signature: ...................................................................
October 4, 2022
CONSENT FOR AN OPERATION
Dear ,
You have a problem of cervical (neck) spinal canal stenosis, with myelopathy.
That is:
You have deterioration of the disc joints (intervertebral disc) between the neck spinal bones C3-4, C4-5 and C5-6. This has caused the discs to rupture and the bones to change shape and push on the spinal cord. This pushing (compression) causes damage to the spinal cord. The damaged spinal cord causes weakness of your left upper limb, and increased tone in your limbs (spasticity).
The diagnosis is based on my examination of you, the story you have told me, and the imaging available.
My concern is that the spinal cord changes may result in progressive loss of function and even death if you are not treated. This is not a certainty, but your clinical presentation suggests you are at risk of such a deterioration.
I am able to offer you 2 choices of treatment.
First option.
Continue to manage the problem non-surgically.
It is very unlikely that over time your symptoms will gradually improve. You may stay the same for a long time, but you will not get better. It is impossible to be sure if you will stabilise to a level that you are happy with, but it is unlikely.
The use of physiotherapy, chiropractic, and alternative health interventions have not been shown to be useful in the improvement of a radiculopathy or myelopathy based on controlled trials in the scientific literature. They may give you short term pain relief, and this is not a bad thing, but they cannot provide you with a permanent cure.
Non-surgical treatment is NOT the safest alternative. While there can be no surgical complications if there is no surgery, your condition is likely to deteriorate to the point you can no longer care for yourself. This is slow, but it is the most likely thing without treatment. Unfortunately there is no way of telling which patients will deteriorate. Deterioration in this condition is usually arrestable, if it is caught early, but mostly it is not reversible.
Second option.
Undergo removal of the compression and spinal fusion.
The Operation
In this operation you are given an anaesthetic. You will be completely asleep. While you are asleep at least two “drips” (intravenous and intra-arterial catheters) will be placed in your upper limbs. You will be placed onto your back on a special table. A cut (incision) will be made in the front of your neck over the location of your problem. A portable x-ray machine will be used to make sure I know which level of the spine I am operating upon. I will carefully find the passage from the skin to the spine through all the structures in the front of your neck. I will again use x-ray to make sure I am at the correct spinal level. I shall remove the entire bone at C4 and C5, and the discs of C3-4, C4-5 and C5-6. The spine will be more wobbly (unstable) once all this disc is removed. Therefore I shall put a small titanium spacer between the bone above C3 and below, C6. This spacer is designed to make the spine stable, and to allow the two bones C3 and C6 to join into each other, i.e. fuse together. To achieve fusion the bone that I have taken out of your neck will be ground up in a food processor type machine to make bone paste. This is called bone graft. This is packed around the spacer to help with fusion. The wound is then washed out to remove any bacteria that has fallen in from your skin, and closed with sutures (stitches). The suture is dissolvable and below the skin.
You will be put back onto your bed and woken up. Once you are awake enough to breathe for yourself you will be transferred to recovery. Once you are awake enough to move your legs I shall ring your nominated next of kin and tell them that you are OK. Sometimes the swelling in your neck is too great to allow you to breath immediately. Therefore you will be transferred to Intensive Care until it is safe to remove the breathing tube.
The Outcome:
Immediately after the surgery you will not be too sore because you will have lots of medication in your system. As this wears off the pain will increase. This is not a very painful operation. Most patients go home in the next few days.
Most patients get some immediate relief of pain/numbness/tingling. However lack of an immediate response does not mean that you will not get better. Most of the improvement in symptoms does not occur until days or weeks after the surgery. If recovery requires the nerves to regrow (in very severe cases), then it can be up to 18 months before the symptoms go away. It is very common to feel much better for a few days and then the symptoms come back again. This does not mean that the operation has failed. It means that the ongoing inflammation from the surgery is causing nerve irritation. As the wound heals this secondary stimulation goes away and the pain settles again. In my experience more than 95% of patients with cervical myelopathy have significant improvement in pain. If they didn’t I wouldn’t do the surgery. The weakness in your arm may well stay forever. This operation is good a preventing further weakness, but no guarantee is given about the return of what is lost.
Scarring: This is not cosmetic surgery, yet the wounds are not large and long term they are not usually obvious. However I do not guarantee a “nice” looking scar.
SOME PATIENTS ARE NOT BETTER WITH SURGERY, SOME PATIENTS CAN BE WORSE. About 2% of spinal fusion operations are complicated by a permanent adverse outcome. That is something happens that was not expected, and requires extra treatment and never fully recovers.
Adverse Outcomes (Complications)
I will try to cover the most serious. However you must note that I will not cover everything. An absolutely comprehensive list is NOT possible. The unexpected can always occur, I cannot warn you about everything.
Permanent adverse risk rate I would estimate to be around 2%. This means that one in every fifty operations incurs an unexpected outcome that never improves.
Up to 50% of patients have this type of neck surgery have short term problems that get better eventually
This can be something simple such as a skin infection that resolves with tablet antibiotics, or it may be something extremely dangerous such as a blood clot, or heart attack.
People have died having this surgery, however the risk of this is about 1 in 100,000 (American Society of Anaesthesiologists Grade 1). To put this in perspective the risk of a fatal car accident in a year is about 1 in 10,000. Or ten times more likely.
QUADRIPLEGIA
It is possible to make you quadriplegic by damaging the spinal cord.
THIS MEANS NOTHING WORKS BELOW THE LEVEL OF THE SURGERY. AT C3-4 THIS MEANS YOU WOULD NOT BE ABLE TO BREATH, WALK, OR SIT UP, AND YOU WOULD HAVE NO HAND FUNCTION. . THIS WOULD BE A PERMANENT LIFE ALTERING DISASTER AND COULD RESULT IN DEATH.
It is very uncommon. It is more likely that you will go Quadriplegic from not having the surgery
Injury to structures in the neck
Your neck carries structures that allow: Breathing, Eating, Swallowing, that Carry Blood to and from the Brain, and Nerves that allow you to talk.
There are no spare parts. If any of these structures is damaged, the consequences are always a disaster. Fortunately this is very rare.
Everyone has a few weeks of a hoarse voice and difficulty swallowing, this is temporary swelling and will resolve.
Damage to breathing tube (Trachea) - need a breathing hole in the neck ( tracheostomy) until it heals
Damage to swallowing/ eating - need a feeding tube directly into the stomach until it heals
Damage to Blood vessels to the brain - stroke - with variable consequences
Damage to Nerves of the Larynx and Pharynx - Permanent voice change, and permanent swallowing problems.
Damage to the thyroid or para thyroid glands - Permanent use of replacement medication.
All of these things have happened to someone somewhere, but they are uncommon.
Risks of all Orthopaedic Surgery
Death
Heart Attack
Stroke
Blood Clots
Bleeding requiring blood transfusion
Blood transfusion causing infection with hepatitis or AIDS
Lung failure : breathing difficulties
Kidney failure : unable to make urine, requiring dialysis
Liver failure : usually caused by an unexpected reaction to a medication
Bowel paralysis (ileus): a temporary condition caused by fasting
Superficial Nerve injury - this occurs in the skin when an incision is made causing permanent numbness of the skin.
Major Nerve Injury - In spinal surgery damage to a single nerve in the spinal canal can have permanent paralysing effects on a group of muscles. This is rare, but usually irreversible.
Failure to improve.
Despite a technically perfect operation it can be possible that your symptoms may not improve. I give no guarantee that the surgery will improve any or all of your symptoms. However I believe strongly that you will get better. I would not do the surgery otherwise.
Infection
Some infections are simple to treat. Other infections are a disaster, requiring repeat surgery and removal the implants. Long term antibiotics may also be required.
Your risk to the operating team.
During surgery it is possible for one of the operating team to cut themselves on a needle or other sharp object that has your blood on it. Blood can transmit infection from you to the staff member. There are drugs that can be given to the staff member to stop infection but they can only be given if your blood is tested for possible infection. I require you to give permission for taking and testing of your blood in the unlikely event that such an injury occurs. The blood will be tested for Hepatitis, and the Aids Virus (HIV). If you don't feel that you can give this permission then please discuss this with me. Your signature on this document serves as permission for this testing.
I have covered what I think are the most concerning adverse outcomes. If you have anything else you would like to discuss you can do so by contacting me.
SUMMARY
This document is a consent form.
You must read it thoroughly. I have sent you extra copies to give to your GP. I would strongly suggest that you have a friend, or relative read this with you. You may even wish to get a lawyer to read it. If you have any concerns you should not proceed with the surgery. If you are uncertain I would advise you to get another opinion from another spinal surgeon. Public hospitals with fully trained spinal surgeons include the AUSTIN HOSPITAL, THE ROYAL MELBOURNE HOSPITAL, MONASH MEDICAL CENTRE, and THE ALFRED HOSPITAL. All of these hospitals have public clinics you could visit. There are both neurosurgeons and other orthopaedic surgeons in Melbourne who do spinal surgery you could see privately.
As I have told you I am an orthopaedic surgeon who has done extra training in spinal surgery. I am neither the oldest nor most experienced spine surgeon in Melbourne, however I have extensive experience in treating spinal conditions and I am fully qualified to perform your surgery.
Your signature on this letter, with initials on every page must be returned to the hospital on the day of surgery. You should keep a copy for yourself. Your signature is acknowledgement of that you have read and understood the document; that you request the proposed surgery, and that you give me permission to perform the surgery and the Hospital to look after you during and after the surgery.
Yours sincerely,
Mr Michael Knight
MBBS FAOA
Date:........./............./...........
Signature: ...................................................................
CONSENT FOR AN OPERATION
Dear
You have a problem of cervical (neck) intervertebral disc degeneration and facet joint degenerative change resulting in spondylosis with myelopathy.
That is: Injury and ageing have caused deterioration of the neck spinal bones. This has caused the discs to rupture and the contents of the discs to spill out (herniation) and push on the spinal cord. This can cause pain, numbness and altered feeling, and weakness in your upper arms. There is also increased tone in your limbs.
The diagnosis is based on my examination of you, the story you have told me, and the imaging available.
You have failed to respond to maximal conservative therapy. That is all the treatment options apart from surgery that you have used have not given you any long-term benefit.
My concern is that the spinal cord changes may result in permanent loss of function if you are not treated. This is not a certainty, but your clinical presentation suggests you are at risk of such a deterioration.
I am able to offer you 2 choices of treatment.
First option.
Continue to manage the problem non-surgically.
It is unlikely that given time your symptoms will gradually improve. Most patients who develop spinal cord compression do not improve with time. They may not deteriorate, but often they do.
The use of physiotherapy, chiropractic, and alternative health interventions have not been shown to be useful in the improvement of myelopathy. They may give you short term pain relief, and this is not a bad thing, but they cannot provide you with a permanent cure.
Non-surgical treatment is NOT the safest alternative. While there can be no surgical complications if there is no surgery, your condition may well deteriorate to the point you can no longer care for yourself. Unfortunately there is no way of telling which patients will deteriorate. Deterioration in this condition is usually arrestable if it is caught early, but it is not usually reversible. This deterioration is called Quadriplegia.
Second option.
Decompression of the spinal canal and individual bone fusion.
The Operation
In this operation you are given an anaesthetic. You will be completely asleep. While you are asleep, at least two “drips” (intravenous and intra-arterial catheters) will be placed in your upper limbs.
You will be placed onto your stomach on a special table. A cut (incision) will be made in the back of your neck over the location of your problem.
A portable x-ray machine will be used to make sure I know which level of the spine I am operating upon.
I will carefully find the passage from the skin to the spine through all the structures in the back of your neck. I will again use x-ray to make sure I am at the correct spinal level.
I shall cut the lamina (bone) on the back of the neck, on both sides of the spine. On one side this will be a hinge cut, on the other side it will be a cut all the way through the bone.
The bone will be lifted up like a trapdoor and secured into its new position with metal plates. The spine will be fused into its new position. However each level of the spine will still move independently.
The wound is then washed out to remove any bacteria that has fallen in from your skin, and closed with sutures (stitches).
Most of the suture is dissolvable and below the skin. Only the skin suture needs to be removed. This is because removable suture has a better cosmetic result, and less infection than dissolvable skin suture or staples.
You will be put back onto your bed and woken up. Once you are awake enough to breathe for yourself you will be transferred to recovery. Once you are awake enough to move your arms and legs I shall ring your nominated next of kin and tell them that you are OK.
The Outcome:
Immediately after the surgery you will not be too sore because you will have lots of medication in your system. As this wears off the pain will increase. This is not a very painful operation. Most patients go home the next day.
Most patients get some immediate relief of pain/numbness/tingling. However lack of an immediate response does not mean that you will not get better. Most of the improvement in symptoms does not occur until days or weeks after the surgery. If recovery requires the nerves to regrow (in very severe cases), then it can be up to 18 months before the symptoms go away. It is very common to feel much better for a few days and then the symptoms come back again. This does not mean that the operation has failed. It means that the ongoing inflammation from the surgery is causing nerve irritation. As the wound heals this secondary stimulation goes away and the pain settles again. In my experience more than 95% of patients with cervical myelopathy have significant improvement. If they didn’t I wouldn’t do the surgery.
Scarring: This is not cosmetic surgery, the wounds are large and however long term they are not usually too obvious. However I do not guarantee a “nice” looking scar.
SOME PATIENTS ARE NOT BETTER WITH SURGERY, SOME PATIENTS CAN BE WORSE.
About 2% of spinal fusion operations are complicated by an adverse outcome. That is something happens that was not expected, and requires extra treatment.
Adverse Outcomes (Complications)
I will try to cover the most serious. However you must note that I will not cover everything. An absolutely comprehensive list is NOT possible. The unexpected can always occur, I cannot warn you about everything.
Adverse risk rate I would estimate to be around 2%. This means that one in every fifty operations incurs an unexpected outcome.
This can be something simple such as a skin infection that resolves with tablet antibiotics, or it may be something extremely dangerous such as a blood clot, or heart attack.
People have died having this surgery, however the risk of this is about 1 in 100,000 (American Society of Anaesthesiologists Grade 1). To put this in perspective the risk of a fatal car accident in a year is about 1 in 10,000. Or ten times more likely.
It is possible to make you quadriplegic by damaging the spinal cord. However this would be extremely rare, and I cannot put a percentage on this risk. This is irreversible and would leave you in bed for the rest of your life, unable to care for yourself. It would significantly shorten your life.
Risks of all Orthopaedic Surgery
Death
Heart Attack
Stroke
Blood Clots
Bleeding requiring blood transfusion
Blood transfusion causing infection with hepatitis or AIDS
Lung failure : breathing difficulties
Kidney failure : unable to make urine, requiring dialysis
Liver failure : usually caused by an unexpected reaction to a medication
Bowel paralysis (ileus): a temporary condition caused by fasting
Superficial Nerve injury - this occurs in the skin when an incision is made causing permanent numbness of the skin.
Major Nerve Injury - In spinal surgery damage to a single nerve in the spinal canal can have permanent paralysing effects on a group of muscles. This is rare, but usually irreversible.
Failure to improve.
Despite a technically perfect operation it can be possible that your symptoms may not improve. I give no guarantee that the surgery will improve any or all of your symptoms. However I believe strongly that you will get better. I would not do the surgery otherwise.
Infection
Some infections are simple to treat. Other infections are a disaster, requiring repeat surgery and removal the implants. Long term antibiotics may also be required.
Your risk to the operating team.
During surgery it is possible for one of the operating team to cut themselves on a needle or other sharp object that has your blood on it. Blood can transmit infection from you to the staff member. There are drugs that can be given to the staff member to stop infection but they can only be given if your blood is tested for possible infection. I require you to give permission for taking and testing of your blood in the unlikely event that such an injury occurs. The blood will be tested for Hepatitis, and the Aids Virus (HIV). If you don't feel that you can give this permission then please discuss this with me. Your signature on this document serves as permission for this testing.
I have covered what I think are the most concerning adverse outcomes. If you have anything else you would like to discuss you can do so by contacting me.
SUMMARY
This document is a consent form.
You must read it thoroughly. I have sent you extra copies to give to your GP. I would strongly suggest that you have a friend, or relative read this with you. You may even wish to get a lawyer to read it. If you have any concerns you should not proceed with the surgery. If you are uncertain I would advise you to get another opinion from another spinal surgeon. Public hospitals with fully trained spinal surgeons include the AUSTIN HOSPITAL, THE ROYAL MELBOURNE HOSPITAL, MONASH MEDICAL CENTRE, and THE ALFRED HOSPITAL. All of these hospitals have public clinics you could visit. There are both neurosurgeons and other orthopaedic surgeons in Melbourne who do spinal surgery you could see privately.
As I have told you I am an orthopaedic surgeon who has done extra training in spinal surgery. I am neither the oldest nor most experienced spine surgeon in Melbourne, however I have extensive experience in treating spinal conditions and I am fully qualified to perform your surgery.
Your signature on this letter, with initials on every page must be returned to the hospital on the day of surgery. You should keep a copy for yourself. Your signature is acknowledgement of that you have read and understood the document; that you request the proposed surgery, and that you give me permission to perform the surgery and the Hospital to look after you during and after the surgery.
Yours sincerely, Signature;.........................................
Dr. Michael KNIGHT Date:......./........../...........
MBBS FAOA
Coccygectomy - Removal of the Coccyx Bone
Dear ,
You have a problem of severe coccygeal pain.
That is you have a pain syndrome that has not responded to all conservative therapies. You have a limited quality of your life and you are not happy.
There is good "randomised controlled trial" evidence that up to 80% of patients are improved with removal of the coccyx. Surgery can decrease their reliance on medication, and can improve the quality of their lives.
This also means that 20% of patients have no significant improvement in their pain.
5% of cases suffer an adverse reaction, that is an unwanted side-effect. Often this is minor and reversible, sometimes however the complication can be permanent and debilitating.
It is possible to be worse off after this surgery. I shall go into the risks in more detail below.
Patients who always have a poor outcome are those with psychiatric illness, those who smoke, and those with diabetes or renal impairment.
Patient's who have a compensation claim also have a worse outcome, although the precise reason for this is not well understood.
This surgery is hard work. It hurts and it takes 6 weeks for the surgical pain to resolve. It then takes about 12 months to gain maximum benefit from the surgery.
You are a candidate for surgery as you have reached the end of the road in terms of conservative management. You need to understand all of the things I have written in this letter.
I have made this diagnosis based on my examination of you, the story you have told me, and the imaging available.
First option.
Continue to manage the problem non-surgically. That would mean gradually decreasing your activity; both social and physical, to meet you level of disability. You will need to rely on medication, and psychological interventions.
The use of physical therapy, chiropractic, and alternative health interventions have not been shown to be useful in the management of chronic pain, based on controlled trials in the scientific literature. They may give you short term pain relief, and this is not a bad thing, but they cannot provide you with a permanent cure.
Multimodal integrated pain management has been shown in some trials to be just as useful as surgery. You have been offered this.
With this condition non-surgical treatment is always the safest alternative. There can be no surgical complications if there is no surgery. Your condition cannot deteriorate to the point you can no longer care for yourself.
Second option.
Undergo Coccygectomy surgery.
The Operation
In this operation you are given an anaesthetic. You will be completely asleep. At least one “drips” (intravenous) will be placed in your arm. You will be rolled onto your stomach on a special table. A cut (incision) will be made in the mid-line just above your anus. Care will have been taken to isolate the area of incision from this potential infective area.
I will carefully remove all of the surrounding structures from the coccyx, including the ligaments and muscles that attach to it. I will take great care not to enter the bowel with the dissection. I shall remove the entire coccyx.
The wound is then washed out to remove any bacteria that has fallen in from your skin, and closed with sutures (stitches). The suture is dissolvable and below the skin.
You will be rolled onto your back and woken up. Once you are awake enough to breathe for yourself you will be transferred to the recovery room. Once you are awake enough to move your legs I shall ring your nominated next of kin and tell them that you are OK.
The Outcome:
Immediately after the surgery you will not be too sore because you will have lots of medication in your system. As this wears off the pain will increase. Many people describe the third 24 hrs as very painful. This settles quickly, and you will be provided with lots more pain relieving medication. You are allowed to get up and move immediately. You are allowed to walk, or sit; however you probably will not feel like it.
You will be supplied with medication to prevent constipation, and allow relaxed bowel movement. It is VERY IMPORTANT that you use this medication. Constipation after this surgery will cause you increasing pain and wound problems.
Most patients get some immediate relief of pain/numbness/tingling. However lack of an immediate response does not mean that you will not get better. Most of the improvement in symptoms does not occur until days or weeks after the surgery. It is very common to feel much better for a few days and then some of the symptoms come back again. This does not mean that the operation has failed. It means that the ongoing inflammation from the surgery is causing local irritation. As the wound heals the pain settles again.
Scarring: This is not cosmetic surgery. The wound is obvious, but only if you expose the area. It is not likely to cause you any embarrassment. If you are concerned about this, then you should seek another opinion as I do not do keyhole spine surgery for this condition.
COMPLICATIONS
The commonest outcome from surgery is for you to get better with NO complication.
SOME PATIENTS ARE NOT BETTER WITH SURGERY, SOME PATIENTS CAN BE WORSE. About 5% of spinal operations are complicated by an adverse outcome. That is something happens that was not expected, and requires extra treatment.
I will try to cover the most serious complications. However you must note that I will not cover everything. An absolutely comprehensive list is NOT possible. The unexpected can always occur; I cannot warn you about everything.
Adverse risk rate I would estimate to be around 5%. This means that one in every twenty operations incurs an unexpected outcome.
This can be something simple such as a skin infection that resolves with tablet antibiotics, or it may be something extremely dangerous such as a blood clot, or heart attack.
Risks of this Surgery:
The 3 biggest risks of this surgery are:
Infection: Due to the location of the incision the risk of infection is much higher here than in other locations. You will need special care to clean and dress the wound. The nursing team will help you with this. You will need to attend the office regularly to check the status of the wound. Any infection will need to be treated aggressively.
Bowel Injury - Incontinence: The muscles of the anus are in part attached to this bone. There is a remote possibility that removing this bone will cause problems with the control of your anal sphincter. This may cause leakage from the anus. Even if this occurs initially it will usually settle as the wound heals. There is a very remote possibility that this would be a permanent problem. It is this very unlikely possibility that puts most patients off this operation. I do not know of any surgeon who has a patient with this complication, but it is reported in the orthopaedic literature.
Ongoing pain: This surgery is to remove the most likely cause of your pain. The previous injections and treatment have identified this as the most likely cause. However pain cannot be seen, or imaged by another person. It is something you feel. It is possible, although unlikely that the surgery will not improve your situation.
Risks of all Orthopaedic Surgery
Death
People have died having surgery, however the risk of this is about 1 in 100,000 (American Society of Anaesthesiologists Grade 1). To put this in perspective the risk of a fatal car accident in a year is about 1 in 10,000. Or ten times more likely. Causes of death are listed below:
Heart Attack
Stroke
Blood Clots
Other complications of surgery can be:
Bleeding requiring blood transfusion
Blood transfusion causing infection with hepatitis or AIDS
Lung failure: breathing difficulties
Kidney failure: unable to make urine, requiring dialysis
Liver failure: usually caused by an unexpected reaction to a medication
Bowel paralysis (ileus): a temporary condition caused by fasting and operating through the abdomen
Superficial Nerve injury - this occurs in the skin when an incision is made causing permanent numbness.
Failure to improve.
Despite a technically perfect operation it can be possible that your symptoms may not improve. I give no guarantee that the surgery will improve any or all of your symptoms. However I believe strongly that you will get better. I would not do the surgery otherwise.
Infection
Some infections are simple to treat. Other infections are a disaster, requiring repeat surgery and removal the implants. Long term antibiotics may also be required.
Your risk to the operating team.
During surgery it is possible for one of the operating team to cut themselves on a needle or other sharp object that has your blood on it. Blood can transmit infection from you to the staff member. There are drugs that can be given to the staff member to stop infection but they can only be given if your blood is tested for possible infection. I require you to give permission for taking and testing of your blood in the unlikely event that such an injury occurs. The blood will be tested for Hepatitis, and the Aids Virus (HIV). If you don't feel that you can give this permission then please discuss this with me. Your signature on this document serves as permission for this testing.
I have covered what I think is the most dangerous and the most concerning. If you have anything else you would like to discuss you can do so by contacting me.
SUMMARY
This document is a consent form.
You must read it thoroughly. I have sent you extra copies to give to your GP. I would strongly suggest that you have a friend, or relative read this with you. You may even wish to get a lawyer to read it.
If you have any concerns you should not proceed with the surgery and I would advise you to get another opinion from another spinal surgeon. Public hospitals with fully trained spinal surgeons include the AUSTIN HOSPITAL, THE ROYAL MELBOURNE HOSPITAL, MONASH MEDICAL CENTRE, and THE ALFRED HOSPITAL. All of these hospitals have public clinics you could visit. There are both neurosurgeons and other orthopaedic surgeons in Melbourne who do spinal surgery you could see privately.
As I have told you I am an orthopaedic surgeon who has done extra training in spinal surgery. I am not the oldest, or the most experienced surgeon in Melbourne. However I am very well qualified and experienced in this surgery.
Your signature on this letter, with initials on every page must be returned to the hospital on the day of surgery. You should keep a copy for yourself. Your signature is acknowledgement of that you have read and understood the document; that you request the proposed surgery, and that you give me permission to perform the surgery and the Hospital to look after you during and after the surgery.
Yours Sincerely,
Mr Michael KNIGHT .
MBBS FAOA
Signature.........................................
Date:.........../............../................
Dear
You have spinal canal stenosis. This is an age related narrowing of the spinal canal that is compressing the nerves in the spinal canal. These nerves supply sensation and function to your legs.
When you walk or stand up for a period of time this narrowing worsens, and the pressure on the nerves increases.
You feel symptoms in your legs, even though the problem is actually in your back. This is because the nerves supply the legs, not the back.
This narrowness can only be improved with surgery.
However the pain/numbness/cramping/pins & needles that you feel in your legs can be improved by using medication.
One of these medications is steroid injected directly into the space around the nerves. This space is called the epidural space. So the injection is called an epidural injection.
The risks of this injection are:
Bleeding into the epidural space
Infection of the epidural space
Puncture of the dura (insulating sac around the nerves)
Permanent nerve damage
Paraplegia due to any of the above. (Paraplegia is the complete loss of all function below your legs, with permanent weakness, inability to walk, loss of bladder and bowel control.)
Allergy to the steroid compound.
This all sounds quite terrifying. However the rate of complications of very low. Most complications can be treated before they cause any permanent problems.
The only complication that any of my patients have had is the dural puncture, and no one has had any long term problems from this.
The radiologists who do this procedure do hundreds of these every year, and are highly competent. The are able to recognise problems very early and will refer you back to me if problems occur.
Epidural injections are frequently performed while patients are on Aspirin. This has not been shown to be dangerous for most patients. Other medications need to be stopped to prevent bleeding.
If bleeding or infection occurred within the spinal canal you would need urgent surgery to drain this collection. I would do this surgery as an emergency if necessary. I have NEVER had to do this.
Most patients have some improvement within a few hours or days, other patients have improvement in the period up to 10 days afterward.
The improvement in symptoms does not last. For some patients there are only days of benefit, some weeks, some months. Everyone will eventually have a return of the pain. If you get weeks or months of benefit, then you can consider have a repeat injection. There does not seem to be any major side-effect to repeat injections, and many patients have had 2 or 3 in 12 months.
Sometimes the epidural steroid injection does not help at all.
If you have severe narrowing, and severe symptoms, and the epidural does not help, then the only thing that will improve the situation is an operation.
The epidural steroid injection does not make surgery more difficult, nor easier afterward.
Please consider your options, and if you need to discuss this further, please make another appointment to discuss this with me.
If you wish to proceed, please sign this document below, and my PA will be happy to organise this for you.
Signed:............................... Date:............................
CONSENT FOR AN OPERATION
Dear ,
You have a problem of XXXXXX
There are always two ways of treating a fracture.
First option.
Continue to manage the problem non-surgically. This is not an acceptable option in Australia. Leaving this fracture without treatment would mean that you have a permanent disability.
No one would recommend leaving this fracture untreated, but it would heal and eventually you would have some function, although it is likely to be permanently painful.
Second option.
Undergo reduction of the fracture. This will require an anaesthetic, and an operation.
The Operation
In this operation you are given an anaesthetic. You will be completely asleep. At least one “drips” (intravenous catheter) will be placed in your arm.
You will be placed on an operating table and position so that I have access to your fracture. Using an intra-operative X-ray machine I will observe the position of the fracture and try to reposition the bones by pushing directly on the bones. This is a closed reduction. If the bones go back into an acceptable position, and if they can be held there with a plaster then your operation is over.
If they cannot be reduced into an acceptable position, or if the position cannot be held with plaster, then you will need an operation to open up the skin.
The bones will be exposed. The fracture reduced in to the original position, and held with a combination of pins, screws and plates.
This process will cause bleeding. We will give you fluid to replace the blood, but very occasionally may need to give you some blood from the blood bank.
The nerves, muscles and joints will be protected during the surgery, but there is always some injury when making a cut through to the bone. These injuries usually fully recover.
At the completion of the operation the wound is then washed out to remove any bacteria that has fallen in from your skin, and closed with sutures (stitches). Most of the suture is dissolvable and below the skin. Sometimes I use skin suture that needs to be removed. This is because in some cases removable suture has a better cosmetic result, and less infection than dissolvable skin suture or staples.
You will be put back on your hospital bed and woken up. Once you are awake enough to breathe for yourself you will be transferred to the recovery room.
Once you are fully awake I shall ring your nominated next of kin and tell them that you are OK.
The Outcome:
Immediately after the surgery you will not be too sore because you will have lots of medication in your system. As this wears off the pain will increase. Many people describe the first 24 hrs as very painful.
This settles quickly, and you will be provided with lots more pain relieving medication.
Either on the day of surgery or the very next day you will be expected to get up and stand. You are allowed to walk, or sit; however you probably will not feel like it. Any restrictions on your mobility will be explained in detail before you go home.
Each day you will feel better and you will have less pain.
Fractures heal at different rates depending on your age, and the fracture location. A general rule of thumb is that most fractures take between 6-12 weeks to achieve 80% stability and 12 months to achieve full strength.
Scarring: This is not cosmetic surgery. The wounds are large and obvious. If you are concerned about this, then you should seek another opinion as I do not do keyhole surgery for fractures.
COMPLICATIONS
MOST PATIENTS GET BETTER, MOST PROBLEMS ARE SOLVED AND MOST PEOPLE ARE HAPPY WITH THEIR OUTCOME.
SOME PATIENTS ARE NOT BETTER WITH SURGERY, SOME PATIENTS CAN BE WORSE.
About 5% of fracture operations are complicated by an adverse outcome. That is something happens that was not expected, and requires extra treatment.
I will try to cover the most serious complications. However you must note that I will not cover everything. An absolutely comprehensive list is NOT possible. The unexpected can always occur; I cannot warn you about everything.
Adverse risk rate I would estimate to be around 5%. This means that one in every twenty operations incurs an unexpected outcome.
This can be something simple such as a skin infection that resolves with tablet antibiotics, or it may be something extremely dangerous such as a blood clot, or heart attack.
Death
People have died having this surgery, however the risk of this is about 1 in 100,000 (American Society of Anaesthesiologists Grade 1). To put this in perspective the risk of a fatal car accident in a year is about 1 in 10,000. Or ten times more likely.
Risks of all Orthopaedic Surgery
Death
Heart Attack
Stroke
Blood Clots
Bleeding requiring blood transfusion
Blood transfusion causing infection with hepatitis or AIDS
Lung failure: breathing difficulties
Kidney failure: unable to make urine, requiring dialysis
Liver failure: usually caused by an unexpected reaction to a medication
Bowel paralysis (ileus): a temporary condition caused by fasting and operating through the abdomen
Superficial Nerve injury - this occurs in the skin when an incision is made causing permanent numbness.
Major Nerve Injury - Damage to a single nerve can have permanent paralysing effects on a group of muscles. This is rare, but usually irreversible.
Failure to improve.
Despite a technically perfect operation it can be possible that your symptoms may not improve. I give no guarantee that the surgery will improve any or all of your symptoms. However I believe strongly that you will get better. I would not do the surgery otherwise.
Most fracture result in joint stiffness. This can be quite debilitating. Diligent physiotherapy is required to prevent this from occurring, once the fracture is stable enough to move.
Loss of Position
While the bones are in a good position at the time of surgery, they don't always stay there. The constant pressure on the bones applied by muscle tension and gravity can pull the fracture apart. Even with screws and wires in place this can happen, although it is more likely if only plaster is used. Review X-rays demonstrate the fracture position, and if it moves a second procedure will be required.
Non-union or Delayed Union
Fractures should heal up. Most of the time the do. Sometimes they don't, and then they require further treatment.
Advanced age, major illnesses, multiple fractures, diabetes, smoking, liver disease, kidney disease, and infection all slow fracture healing.
Some drugs prevent fracture healing.
Should your fracture fail to heal there is usually something else that can be done, but it is usually more complicated and more invasive.
Infection
Some infections are simple to treat. Other infections are a disaster, requiring repeat surgery and removal the implants. Long term antibiotics may also be required.
Your risk to the operating team.
During surgery it is possible for one of the operating team to cut themselves on a needle or other sharp object that has your blood on it. Blood can transmit infection from you to the staff member. There are drugs that can be given to the staff member to stop infection but they can only be given if your blood is tested for possible infection. I require you to give permission for taking and testing of your blood in the unlikely event that such an injury occurs. The blood will be tested for Hepatitis, and the Aids Virus (HIV). If you don't feel that you can give this permission then please discuss this with me. Your signature on this document serves as permission for this testing.
I have covered what I think is the most dangerous and the most concerning. If you have anything else you would like to discuss you can do so by contacting me.
SUMMARY
This document is a consent form.
You must read it thoroughly. I have sent you extra copies to give to your GP. I would strongly suggest that you have a friend, or relative read this with you. You may even wish to get a lawyer to read it.
If you have any concerns you should not proceed with the surgery and I would advise you to get another opinion from another orthopaedic surgeon. Public hospitals with fully trained orthopaedic trauma surgeons include the AUSTIN HOSPITAL, THE ROYAL MELBOURNE HOSPITAL, MONASH MEDICAL CENTRE, and THE ALFRED HOSPITAL. All of these hospitals have public clinics you could visit.
As I have told you, I am an orthopaedic surgeon who has done extra training in spinal surgery. I am not the oldest, or the most experienced surgeon in Melbourne. However I am very well qualified and experienced in this surgery.
Your signature on this letter, with initials on every page must be in my office before the day of surgery. You should keep a copy for yourself. Your signature is acknowledgement of that you have read and understood the document; that you request the proposed surgery, and that you give me permission to perform the surgery and the Hospital to look after you during and after the surgery.
Yours Sincerely,
Dr. Michael KNIGHT
MBBS FAOA
Signature: ...................................................
Date:.............../.................../......................
CONSENT FOR SURGERY
** HIP REPLACEMENT
Dear ,
You have a problem of (osteoarthritis) wear and tear arthritis of the *** hips.
Sometimes osteoarthritis is called osteoarthrosis. This is not really a disease, more an accelerated ageing process of the hip joints. It also causes joint stiffness, as well as pain.
You have failed to respond to maximal conservative therapy. That is all the treatment options, apart from surgery, that you have used, have not given you any long-term benefit.
You have told me that you life is a constant physical misery. You told me that this pain is a single constant destructive force in your life and that this makes every day terrible. You told me that if you did not have leg pain your life would be much improved.
I am able to offer you 2 choices of treatment.
First option.
Continue to manage the problem non-surgically. That would mean gradually decreasing your activity, both social and physical to fit your increasing physical disability. It would also mean relying on medication, and psychological interventions. The use of physical therapy, chiropractic, and alternative health interventions have not been shown to be useful in the resolution of chronic pain based on controlled trials in the scientific literature. Such therapies may make you feel better in the very short term. However they cannot provide you with a permanent cure. Non-operative management is always the safest alternative. There can be no surgical complications if there is no surgery.
Second option.
Undergo total hip replacement. (Arthroplasty).
The Operation.
You will undergo pre-operative wash with an aqueous chlorhexidine detergent preparation. Clean hospital clothing will be given to you to wear to the operating theatre.
The anaesthetist will give you an anaesthetic. This usually requires 2 " drips" ( arterial cannula and a venous cannula), and monitoring for: oxygen ( Pulse Oximetry), carbon dioxide (Capnograph) , heart function (ECG), awareness (BISS), blood pressure cuff, and urinary output (catheter in the bladder). Whether this is a spinal anaesthetic, or a general anaesthetic is up to the anaesthetist and you to decide. If possible a spinal anaesthetic is best for your brain functioning afterward, you wake up more alert and aware.
You will be placed bad side up on the operating table and a metal clamp will hold you tightly to the table. This allows accurate referencing of your bones. It means I can put the cup and ball in the correct position.
Your && leg will have been previously marked by me, and we will keep checking this until you go to sleep.
All your bony prominences will be padded to prevent injury. You will be washed down with an anaesthetic solution, and plastic drapes will keep the area as sterile as possible.
An incision (cut) will then made. This will NOT be a cosmetic incision. I do not do “keyhole” surgery. Keyhole hip replacement surgery is experimental, and has resulted in WORSE outcomes when compared with routine incisions.
The muscles behind the hip will be stripped off the thigh bone. This is the biggest cause of pain after the surgery. They take up to 12 months to fully strengthen again.
The sciatic nerve is right next to the hip, and it will be protected as the muscles are folded back over it.
The ball of the thigh bone will be pushed up and out of the socket (dislocated). Then the ball is cut off the main thigh bone, about 8 cm from the top, through the narrow part of the neck. This is discarded, or sometimes used as bone graft for the operation if needed.
The cup (acetabulum) of the pelvis is enlarged to accommodate the metal cup implant. This is usually about 52 mm. The hip replacement cup will then be cemented into the pelvis This is held in place with liquid plastic that sets hard in 12 minutes. This is called bone cement, but is nothing like building cement. Super strong plastic now lasts longer than metal or ceramic lining. It is be preferred option.
Once the cup is fixed. I will prepare to put the new the ball on the upper end of the thigh bone. The hollow in the middle of the thigh bone is enlarged. A metal stem (stick) will be placed inside the middle of the thigh bone, with the top part sitting out. This is held in place with liquid plastic that sets hard in 12 minutes. This is called bone cement, but is nothing like building cement.
Once the stick is firmly set, a ball is placed onto this stick, and this makes up the hip replacement. The length of the leg is set by the position of the stick and the ball. Sometimes I have to intentionally lengthen the leg to keep the hip joint in place, but usually the length is within 5 mm of the original. (Shoe raises are not required if the legs are within 1.5 cm of each other, your brain gets used to the new length over about 12 weeks)
The ball and cup will then be engaged, and hopefully will be very stable. The muscles will be re-attached.
The skin will be closed with dissolving suture material. I have found this to cause the least problems with scarring and infection.
The reason this operation works is that man made materials act as the joint, and therefore prevent the painful bone rubbing on bone.
A new hip moves better and improves your hip range of movement. Hip arthroplasty is the best operation there is. It causes more improvement in the quality of life than any other operation in any surgical speciality. 95% of patients are improved.
However SOME PATIENTS ARE NOT BETTER WITH SURGERY, SOME PATIENTS CAN BE WORSE.
About 5% of hip operations are complicated by an adverse outcome. That is something happens that was not expected, and requires extra treatment. This does not mean that in the end a good result will not occur. It does mean that extra work may be required to achieve a good outcome.
COMPLICATIONS
I will try to cover the most serious complications. However you must note that I will not cover everything. An absolutely comprehensive list is NOT possible. The unexpected can always occur, I cannot warn you about everything.
Adverse risk rate I would estimate to be around 5%. This means that one in every twenty operations incurs an unexpected outcome.
This can be something simple such as a superficial wound infection that resolves with oral antibiotics, or it may be something extremely dangerous such as a blood clot, or heart attack.
People have died having this surgery, however the risk of this is about 1 in 100,000 (American Society of Anaesthesiologists Grade 1). The risk of a fatal car accident is about 1 in 15,000 per year.
Anaesthetics carry risk. This risk should be discussed with your anaesthetist.
Risks of all Orthopaedic Surgery
Death
Heart Attack
Stroke
Blood Clots
Bleeding requiring blood transfusion
Blood transfusion causing infection with hepatitis or AIDS
Lung failure : breathing difficulties
Kidney failure : unable to make urine, requiring dialysis
Liver failure: usually caused by an unexpected reaction to a medication
Bowel paralysis (ileus): a temporary condition caused by fasting
Nerve injury - this occurs in the skin when an incision is made causing permanent numbness.
Failure to improve.
Despite a technically perfect operation it can be possible that your symptoms may not improve. I give no guarantee that the surgery will improve any or all of your symptoms. However I believe strongly that you will get better. I would not do the surgery otherwise.
Infection: some infections are simple to treat. Other infections are a disaster, requiring repeat surgery and removal of the artificial hip, and subsequent operations. The very worst outcome means that your hip could be fused, or you may have no hip joint if the infection is not treatable. This is a very rare outcome.
Specific Risks of Hip Replacement.
Damage to the sciatic nerve (Permanent pain or weakness in the foot)
Fracture of the pelvis or femur ( A delay before you can walk unaided)
Dislocation: where the ball and socket joint separate and require surgery to put them back together.
Leg length inequality: To avoid dislocation, tension is required in the muscles of the hip. Sometimes a longer hip is required to maintain this tension. This results in one leg being longer than the other. A shoe raise maybe required.
Wear: Artificial joints do not last for ever. They sometimes require re-doing, and this is a much bigger undertaking than the first operation. I cannot guarantee how long your hip will last, however more than 90% of hips last more than 15 years. Even the very old designs can last 30 yrs. Hopefully your newer design will last the rest of your life.
Remember: Most patients do NOT have complications. Most patients have good outcomes and return home able to function almost as well as before their fracture.
You are the most likely to return to normal eventually. This is a long road to travel, and it takes most patients 12 months to achieve their best outcome.
Immediately afterward you will be in bed, struggling to move, in pain, nauseated, constipated, and in pain. You will think that the operation has made you worse. This will last for a few days.
The physiotherapist, and the nursing staff will try to get you out of bed as much as possible. There will be some restrictions on what you can do, but essentially we want you up and moving as much as possible, as soon as possible.
Slowly we will remove things from your body. Drips, cables, catheters will all be removed when we think you can manage without them.
Eventually you will be disconnected from all these.
Pain can be a problem for weeks. It gets better every day, but you often need strong pain killers for up to a month, and moderate to mild pain killers for 3 months.
Most painkillers cause constipation. Therefore you will need medication for this for several weeks. One good bowel action does not mean you can stop these medications. You need to drink water, eat fruit and vegetables, take stool softening drugs and keep moving to fight constipation. It is an ongoing battle.
You will need to use a frame to walk at first, and slowly you will progress to crutches. It may be months before you finally walk without some gait aid.
You will no longer need a dressing after 14 to 20 days, as long as you wound heals properly.
By about 5 days after surgery we will be discussing rehabilitation with you. Almost everyone goes there for a couple of weeks. It acts as a transition between home and hospital. When you leave rehab you will be able to care for yourself around the house.
10 days after your discharge from rehab you should see me again. If you do not have an appointment ring Angelica on 0448844244 to get one. Your GP is not trained to help you with complications of hip surgery. RING MY OFFICE FIRST.
You will not be able to care for someone else for at least 3 months.
Driving depends on many things, but it is usually at least 6 weeks, sometimes 12 weeks before you can drive.
You cannot do any fixed pelvis rotation sport until I say so. This includes Golf, Tennis, Squash, etc
Your risk to the operating team.
During surgery it is possible for one of the operating team to cut themselves on a needle or other sharp object that has your blood on it. Blood can transmit infection from you to the staff member. There are drugs that can be given to the staff member to stop infection but they can only be given if your blood is tested for possible infection. I require you to give permission for taking and testing of your blood in the unlikely event that such an injury occurs. The blood will be tested for Hepatitis, and the Aids Virus (HIV). If you don't feel that you can give this permission then please discuss this with me. Your signature on this document serves as permission for this testing.
As I said earlier in this letter. There are always complications that I cannot think about or cannot warn you about. I have covered what I think is the most common, the most dangerous, and the most concerning. If you have anything else you would like to discuss you can do so by contacting me.
SUMMARY
This document is a consent form.
You must read it thoroughly. I would strongly suggest that you have a friend, or relative read this with you. You may even wish to get a lawyer to read it. If you have any concerns you should not proceed with the surgery. I would advise you to get another opinion from another surgeon if you have any concerns. Public hospitals with fully trained orthopaedic surgeons include the AUSTIN HOSPITAL, THE ROYAL MELBOURNE HOSPITAL, MONASH MEDICAL CENTRE, and THE ALFRED HOSPITAL. All of these hospitals have public clinics you could visit. There are other orthopaedic surgeons in Melbourne who do joint resurfacing you could see privately.
As I have told you, I am an orthopaedic surgeon who has does at least 30 hip replacements a year. However clearly I am not the oldest or busiest surgeon in Melbourne. You must consider this in deciding who does your surgery.
Your signature on this letter, with initials on every page must be returned to my office before the day of surgery. You should keep a copy for yourself. Your signature is acknowledgement of that you have read and understood the document; that you request the proposed surgery, and that you give me permission to perform the surgery and the Hospital to look after you during and after the surgery.
Yours sincerely,
Dr. Michael KNIGHT
MBBS FAOA
Signature: ......... ........................................
Date: ................/................../..............
October 4, 2022
CONSENT FOR SURGERY
FRACTURE: HALF HIP REPLACEMENT
Dear ,
You have a problem of a fracture of the neck of the &&&& femur.
Sometimes called a broken hip, or fractured hip.
You have failed to respond to maximal conservative therapy. That is all the treatment options, apart from surgery, that you have used, have not given you any long-term benefit.
This fracture has occurred in a way that breaks the blood vessels that supply the ball of the hip. In most cases if I try to fix the bones together they will not heal, and the hip will fall apart over time.
Therefore the best option for you is to have a half hip replacement. This involves replacing the ball of the hip joint, but not replacing the socket. As the socket is not worn out, it will work well for many years to come. Replacing both the ball and socket after a fracture is more risky than just replacing the ball.
Not having this operation would result losing your ability to walk, and a prolonged stay in hospital, with increased risk of death from pneumonia, blood clot and pressure sores. Not having this operation will guarantee permanent severe pain.
The best option for you is to have this operation.
The Operation: Cemented Bipolar Hemi-Arthroplasty
You will undergo pre-operative wash with an aqueous chlorhexidine detergent preparation. Clean hospital clothing will be given to you to wear to the operating theatre.
The anaesthetist will give you an anaesthetic. This usually requires two "drips" ( an arterial line, and a venous cannula), and oxygen, carbon dioxide, blood pressure and heart function monitors.
A catheter will be placed in your bladder. This will stay for a couple of days.
You will be placed bad side up on the operating table and a metal clamp will hold you tightly to the table. This allows accurate referencing of your bones. It means I can put the ball in the correct position.
Your broken leg will have been previously marked by me, and we will keep checking this until you go to sleep.
All your bony prominences will be padded to prevent injury. You will be washed down with an anaesthetic solution, and plastic drapes will keep the area as sterile as possible.
An incision (cut) will then made. This will NOT be a cosmetic incision. I do not do “keyhole” surgery. Keyhole hip replacement has WORSE outcomes than regular hip replacement surgery.
The muscles behind the hip will be stripped off the thigh bone. This is the biggest cause of pain after the surgery. They take up to 12 months to fully strengthen again. The sciatic nerve is right next to the hip, and it will be protected as the muscles are folded back over it.
The broken head of the femur ( the ball piece) will be removed from the cup.
A metal stem (stick) will be placed inside the middle of the thigh bone, with the top part sitting out. This is held in place with liquid plastic that hardens in 12 minutes. This is called bone cement, but it is nothing like the cement you see in houses.
A small ball is placed onto this stick, and this is placed inside a larger ball that is the same size as your original cup. This double ball arrangement is called a bipolar head, and this makes the hip very stable, while minimising the stress on the native cup.
The skin will be closed with dissolving suture material (Stitches) . I have found this combination to cause the least problems with scarring and infection.
The reason this operation works is that man made materials act as the joint. They are instantly stable and you can walk on them the next day.
However SOME PATIENTS ARE NOT BETTER WITH SURGERY, SOME PATIENTS CAN BE WORSE.
About 10% of hip operations for fractures are complicated by an adverse outcome. That is something happens that was not expected, and requires extra treatment. This does not mean that in the end a good result will not occur. It does mean that extra work may be required to achieve a good outcome.
COMPLICATIONS
I will try to cover the most serious complications. However you must note that I will not cover everything. An absolutely comprehensive list is NOT possible. The unexpected can always occur, I cannot warn you about everything.
Adverse risk rate I would estimate to be around 10%. This means that one in every ten operations incurs an unexpected outcome.
This can be something simple such as a superficial wound infection that resolves with oral antibiotics, or it may be something extremely dangerous such as a blood clot, or heart attack.
People have died having this surgery, the risk of this is between, 1 in 1000 and 1 in 10,000 (American Society of Anaesthesiologists Grade 2-3).
The risk of a fatal car accident is about 1 in 15,000 per year.
Anaesthetics carry risk. This risk should be discussed with your anaesthetist.
Risks of all Orthopaedic Surgery
Death
Heart Attack
Stroke
Blood Clots
Bleeding requiring blood transfusion
Blood transfusion causing infection with hepatitis or AIDS
Lung failure : breathing difficulties
Kidney failure : unable to make urine, requiring dialysis
Liver failure: usually caused by an unexpected reaction to a medication
Bowel paralysis (ileus): a temporary condition caused by fasting
Nerve injury - this occurs in the skin when an incision is made causing permanent numbness.
Failure to improve.
Despite a technically perfect operation it can be possible that your symptoms may not improve. I give no guarantee that the surgery will improve any or all of your symptoms. However I believe strongly that you will get better. I would not do the surgery otherwise.
Infection: some infections are simple to treat. Other infections are a disaster, requiring repeat surgery and removal of the artificial hip, and subsequent operations. The very worst outcome means that your hip could be fused, or you may have no hip joint if the infection is not treatable. This is a very rare outcome.
Specific Risks of Hip Replacement.
Damage to the sciatic nerve (Permanent pain or weakness in the foot)
Fracture of the pelvis or femur ( A delay before you can walk unaided)
Dislocation: where the ball and socket joint separate and require surgery to put them back together.
Leg length inequality: To avoid dislocation, tension is required in the muscles of the hip. Sometimes a longer hip is required to maintain this tension. This results in one leg being longer than the other. A shoe raise maybe required.
Wear: Artificial joints do not last for ever. They sometimes require redoing, and this is a much bigger undertaking than the first operation. I cannot guarantee how long your hip will last, however more than 90% of hip last more than 15 years. Even the very old designs can last 30 yrs. Hopefully your newer design will last the rest of your life. With a bipolar hip, the original cup was not replaced. The cartilage in this cup may wear out, and this might become painful, and you might need an artificial cup. This occurs in less than 10% of bipolar hips, and usually takes years to occur.
Pain: Before your broke your hip, it was probably pain free. It will never be the same after the fracture. Even the best outcomes result is slightly uncomfortable movement. Most patients get used to their new hip, almost none forgets that they broke the original one.
Remember: Most patients do NOT have complications. Most patients have good outcomes and return home able to function almost as well as before their fracture.
What happens afterward?
Hip fractures change lives, not for the better. Fortunately your fracture combined with this treatment is reserved for patients with normal function before the fracture. You are the most likely to return to normal eventually. This is a long road to travel, and it takes most patients 12 months to achieve their best outcome.
Immediately afterward you will be in bed, struggling to move, in pain, nauseated, constipated, and in pain. You will think that the operation has made you worse. This will last for a few days.
The physiotherapist, and the nursing staff will try to get you out of bed as much as possible. There will be some restrictions on what you can do, but essentially we want you up and moving as much as possible, as soon as possible.
Slowly we will remove things from your body. Drips, cables, catheters will all be removed when we think you can manage without them.
Eventually you will be disconnected from all these.
Pain is a problem for weeks. It gets better every day, but you often need strong pain killers for up to a month, and moderate to mild pain killers for 3 months.
Most painkillers cause constipation. Therefore you will need medication for this for several weeks. One good bowel action does not mean you can stop these medications. You need to drink water, eat fruit and vegetables, take stool softening drugs and keep moving to fight constipation. It is an ongoing battle.
You will need to use a frame to walk at first, and slowly you will progress to crutches. It may be months before you finally walk without some gait aid.
You will no longer need a dressing after 14 to 20 days, as long as you wound heals properly.
By about 5 days after surgery we will be discussing rehabilitation with you. Almost everyone goes there for a couple of weeks. It acts as a transition between home and hospital. When you leave rehab you will be able to care for yourself around the house.
10 days after your discharge from rehab you should see me again. If you do not have an appointment ring Ursula on 0448844244 to get one. Your GP is not trained to help you with complications of hip surgery. RING MY OFFICE FIRST.
You will not be able to care for someone else for at least 3 months.
Driving depends on many things, but it is usually at least 6 weeks, sometimes 12 weeks before you can drive.
You may need to reassess you living situation. This can be the time many people are forced to think about what housing and living arrangements are right for the future.
Your risk to the operating team.
During surgery it is possible for one of the operating team to cut themselves on a needle or other sharp object that has your blood on it. Blood can transmit infection from you to the staff member. There are drugs that can be given to the staff member to stop infection but they can only be given if your blood is tested for possible infection. I require you to give permission for taking and testing of your blood in the unlikely event that such an injury occurs. The blood will be tested for Hepatitis, and the Aids Virus (HIV). If you don't feel that you can give this permission then please discuss this with me. Your signature on this document serves as permission for this testing.
As I said earlier in this letter. There are always complications that I cannot think about or cannot warn you about. I have covered what I think is the most common, the most dangerous, and the most concerning. If you have anything else you would like to discuss you can do so by contacting me.
SUMMARY
This document is a consent form.
You must read it thoroughly. I would strongly suggest that you have a friend, or relative read this with you. You may even wish to get a lawyer to read it. If you have any concerns you should not proceed with the surgery.
I could advise you to get another opinion from another surgeon if you have any concerns. However this is usually impractical with a broken hip.
If you are concerned you could be transferred to a public hospital.
Public hospitals with fully trained orthopaedic surgeons include the AUSTIN HOSPITAL, THE ROYAL MELBOURNE HOSPITAL, MONASH MEDICAL CENTRE, and THE ALFRED HOSPITAL.
As I have told you, I am an orthopaedic surgeon who has does at least 30 hip replacements a year. However clearly I am not the oldest or busiest surgeon in Melbourne. You must consider this in deciding who does your surgery.
Your signature on this letter, with initials on every page, indicate you have read this document. Often you do not get to read this until after your operation, as it is an emergency. However I still provide this information for you to understand what you are going through. You should keep a copy for yourself. Your signature is acknowledgement of that you have read and understood the document; that you request the proposed surgery, and that you give me permission to perform the surgery and the Hospital to look after you during and after the surgery.
Yours sincerely,
Dr. Michael KNIGHT
MBBS FAOA
Patient Signature: .................................................
Date: ................/................../..............
CONSENT FOR SURGERY
XXXX HYBRID HIP REPLACEMENT
Dear ,
You have a problem of (osteoarthritis) wear and tear arthritis of the XXX hip.
Sometimes osteoarthritis is called osteoarthrosis. This is not really a disease, more an accelerated ageing process of the hip joints. It also causes joint stiffness, as well as pain.
You have failed to respond to maximal conservative therapy. That is all the treatment options, apart from surgery, that you have used, have not given you any long-term benefit.
You have told me that you life is a constant physical misery. You told me that this pain is a single constant destructive force in your life and that this makes every day terrible. You told me that if you did not have leg pain your life would be much improved.
I am able to offer you 2 choices of treatment.
First option.
Continue to manage the problem non-surgically. That would mean gradually decreasing your activity, both social and physical to fit your increasing physical disability. It would also mean relying on medication, and psychological interventions. The use of physical therapy, chiropractic, and alternative health interventions have not been shown to be useful in the resolution of chronic pain based on controlled trials in the scientific literature. Such therapies may make you feel better in the very short term. However they cannot provide you with a permanent cure. Non-operative management is always the safest alternative. There can be no surgical complications if there is no surgery.
Second option.
Undergo XXX total hip replacement. (Arthroplasty).
The Operation.
You will undergo pre-operative wash with an aqueous chlorhexidine detergent preparation. Clean hospital clothing will be given to you to wear to the operating theatre.
The anaesthetist will give you an anaesthetic. This usually requires 2 " drips" ( arterial cannula and a venous cannula), and monitoring for: oxygen ( Pulse Oximetry), carbon dioxide (Capnograph) , heart function (ECG), awareness (BISS), blood pressure cuff, and urinary output (catheter in the bladder). Whether this is a spinal anaesthetic, or a general anaesthetic is up to the anaesthetist and you to decide. If possible a spinal anaesthetic is best for your brain functioning afterward, you wake up more alert and aware.
You will be placed bad side up on the operating table and a metal clamp will hold you tightly to the table. This allows accurate referencing of your bones. It means I can put the cup and ball in the correct position.
Your XXX leg will have been previously marked by me, and we will keep checking this until you go to sleep.
All your bony prominences will be padded to prevent injury. You will be washed down with an anaesthetic solution, and plastic drapes will keep the area as sterile as possible.
An incision (cut) will then made. This will NOT be a cosmetic incision. I do not do “keyhole” surgery. Keyhole hip replacement surgery is experimental, and has resulted in WORSE outcomes when compared with routine incisions.
The muscles behind the hip will be stripped off the thigh bone. This is the biggest cause of pain after the surgery. They take up to 12 months to fully strengthen again.
The sciatic nerve is right next to the hip, and it will be protected as the muscles are folded back over it.
The ball of the thigh bone will be pushed up and out of the socket (dislocated). Then the ball is cut off the main thigh bone, about 8 cm from the top, through the narrow part of the neck. This is discarded, or sometimes used as bone graft for the operation if needed.
The cup (acetabulum) of the pelvis is enlarged to accommodate the metal cup implant. This is usually about 52 mm. The hip replacement cup will then be impacted into the pelvis. (Hit with a hammer). It should lock in tight. Sometimes screws are also used to hold the cup. The cup is made to allow bone to grow into it. After the metal cup is stable, then a plastic liner will be placed into the metal cup. Super strong plastic now lasts longer than metal or ceramic lining. It is be preferred option.
Once the cup is fixed. I will prepare to put the new the ball on the upper end of the thigh bone. The hollow in the middle of the thigh bone is enlarged. Liquid plastic will be poured into the enlarged hole in the thigh bone.
A metal stem (stick) will be placed inside the middle of the thigh bone, with the top part sitting out. Over the next 12 minutes the liquid plastic hardens like cement (it is called bone cement). Once this is hard, then the stem is firmly fixed
Then a ball is placed onto the stem, and this makes up the hip replacement. The length of the leg is set by the position of the stem and the ball. Sometimes I have to intentionally lengthen the leg to keep the hip joint in place, but usually the length is within 5 mm of the original. (Shoe raises are not required if the legs are within 1.5 cm of each other, your brain gets used to the new length over about 12 weeks)
The ball and cup will then be engaged, and hopefully will be very stable. The muscles will be re-attached.
The skin will be closed with dissolving suture material. I have found this to cause the least problems with scarring and infection.
The reason this operation works is that man made materials act as the joint, and therefore prevent the painful bone rubbing on bone.
A new hip moves better and improves your hip range of movement. Hip arthroplasty is the best operation there is. It causes more improvement in the quality of life than any other operation in any surgical speciality. 95% of patients are improved.
However SOME PATIENTS ARE NOT BETTER WITH SURGERY, SOME PATIENTS CAN BE WORSE.
About 5% of hip operations are complicated by an adverse outcome. That is something happens that was not expected, and requires extra treatment. This does not mean that in the end a good result will not occur. It does mean that extra work may be required to achieve a good outcome.
COMPLICATIONS
I will try to cover the most serious complications. However you must note that I will not cover everything. An absolutely comprehensive list is NOT possible. The unexpected can always occur, I cannot warn you about everything.
Adverse risk rate I would estimate to be around 5%. This means that one in every twenty operations incurs an unexpected outcome.
This can be something simple such as a superficial wound infection that resolves with oral antibiotics, or it may be something extremely dangerous such as a blood clot, or heart attack.
People have died having this surgery, however the risk of this is about 1 in 100,000 (American Society of Anaesthesiologists Grade 1). The risk of a fatal car accident is about 1 in 15,000 per year.
Anaesthetics carry risk. This risk should be discussed with your anaesthetist.
Risks of all Orthopaedic Surgery
Death
Heart Attack
Stroke
Blood Clots
Bleeding requiring blood transfusion
Blood transfusion causing infection with hepatitis or AIDS
Lung failure : breathing difficulties
Kidney failure : unable to make urine, requiring dialysis
Liver failure: usually caused by an unexpected reaction to a medication
Bowel paralysis (ileus): a temporary condition caused by fasting
Nerve injury - this occurs in the skin when an incision is made causing permanent numbness.
Failure to improve.
Despite a technically perfect operation it can be possible that your symptoms may not improve. I give no guarantee that the surgery will improve any or all of your symptoms. However I believe strongly that you will get better. I would not do the surgery otherwise.
Infection: some infections are simple to treat. Other infections are a disaster, requiring repeat surgery and removal of the artificial hip, and subsequent operations. The very worst outcome means that your hip could be fused, or you may have no hip joint if the infection is not treatable. This is a very rare outcome.
Specific Risks of Hip Replacement.
Damage to the sciatic nerve (Permanent pain or weakness in the foot)
Fracture of the pelvis or femur ( A delay before you can walk unaided)
Dislocation: where the ball and socket joint separate and require surgery to put them back together.
Leg length inequality: To avoid dislocation, tension is required in the muscles of the hip. Sometimes a longer hip is required to maintain this tension. This results in one leg being longer than the other. A shoe raise maybe required.
Wear: Artificial joints do not last for ever. They sometimes require re-doing, and this is a much bigger undertaking than the first operation. I cannot guarantee how long your hip will last, however more than 90% of hips last more than 15 years. Even the very old designs can last 30 yrs. Hopefully your newer design will last the rest of your life.
Remember: Most patients do NOT have complications. Most patients have good outcomes and return home able to function almost as well as before their hip replacement.
What happens afterward?
Immediately afterward you will be in bed, struggling to move, in pain, nauseated, constipated, and in pain. You will think that the operation has made you worse. This will last for a few days.
The physiotherapist, and the nursing staff will try to get you out of bed as much as possible. There will be some restrictions on what you can do, but essentially we want you up and moving as much as possible, as soon as possible.
Slowly we will remove things from your body. Drips, cables, catheters will all be removed when we think you can manage without them.
Eventually you will be disconnected from all these.
Pain is a problem for weeks. It gets better every day, but you often need strong pain killers for up to a month, and moderate to mild pain killers for 3 months.
Most painkillers cause constipation. Therefore you will need medication for this for several weeks. One good bowel action does not mean you can stop these medications. You need to drink water, eat fruit and vegetables, take stool softening drugs and keep moving to fight constipation. It is an ongoing battle.
You will need to use a frame to walk at first, and slowly you will progress to crutches. It may be months before you finally walk without some gait aid.
You will no longer need a dressing after 14 to 20 days, as long as you wound heals properly.
By about 5 days after surgery we will be discussing rehabilitation with you. About half of patients go there for about a week. It acts as a transition between home and hospital. When you leave rehab you will be able to care for yourself around the house.
10 days after your discharge from rehab you should see me again. If you do not have an appointment ring on 0448844244 to get one. Your GP is not trained to help you with complications of hip surgery. RING MY OFFICE FIRST.
You will not be able to care for someone else for at least 3 months.
Driving depends on many things, but it is usually at least 6 weeks, sometimes 12 weeks before you can drive.
You cannot do any fixed pelvis rotation sport until I say so. This includes Golf, Tennis, Squash, etc
Your risk to the operating team.
During surgery it is possible for one of the operating team to cut themselves on a needle or other sharp object that has your blood on it. Blood can transmit infection from you to the staff member. There are drugs that can be given to the staff member to stop infection but they can only be given if your blood is tested for possible infection. I require you to give permission for taking and testing of your blood in the unlikely event that such an injury occurs. The blood will be tested for Hepatitis, and the Aids Virus (HIV). If you don't feel that you can give this permission then please discuss this with me. Your signature on this document serves as permission for this testing.
As I said earlier in this letter. There are always complications that I cannot think about or cannot warn you about. I have covered what I think is the most common, the most dangerous, and the most concerning. If you have anything else you would like to discuss you can do so by contacting me.
SUMMARY
This document is a consent form.
You must read it thoroughly. I would strongly suggest that you have a friend, or relative read this with you. You may even wish to get a lawyer to read it. If you have any concerns you should not proceed with the surgery. I would advise you to get another opinion from another surgeon if you have any concerns. Public hospitals with fully trained orthopaedic surgeons include the AUSTIN HOSPITAL, THE ROYAL MELBOURNE HOSPITAL, MONASH MEDICAL CENTRE, and THE ALFRED HOSPITAL. All of these hospitals have public clinics you could visit. There are other orthopaedic surgeons in Melbourne who do joint resurfacing you could see privately.
As I have told you, I am an orthopaedic surgeon who has does at least 30 hip replacements a year. However clearly I am not the oldest or busiest surgeon in Melbourne. You must consider this in deciding who does your surgery.
Your signature on this letter, with initials on every page must be returned to my office before the day of surgery. You should keep a copy for yourself. Your signature is acknowledgement of that you have read and understood the document; that you request the proposed surgery, and that you give me permission to perform the surgery and the Hospital to look after you during and after the surgery.
Yours sincerely,
Mr Michael Knight
MBBS FAOA
Signature: ......... ........................................
Date: ................/................../..............
October 4, 2022
CONSENT FOR SURGERY
UNCEMENTED HIP REPLACEMENT
Dear ,
You have a problem of (osteoarthritis) wear and tear arthritis of the hip.
Sometimes osteoarthritis is called osteoarthrosis. This is not really a disease, more an accelerated ageing process of the hip joints. It also causes joint stiffness, as well as pain.
You have failed to respond to maximal conservative therapy. That is all the treatment options, apart from surgery, that you have used, have not given you any long-term benefit.
You have told me that you life is a constant physical misery. You told me that this pain is a single constant destructive force in your life and that this makes every day terrible. You told me that if you did not have leg pain your life would be much improved.
I am able to offer you 2 choices of treatment.
First option.
Continue to manage the problem non-surgically. That would mean gradually decreasing your activity, both social and physical to fit your increasing physical disability. It would also mean relying on medication, and psychological interventions. The use of physical therapy, chiropractic, and alternative health interventions have not been shown to be useful in the resolution of chronic pain based on controlled trials in the scientific literature. Such therapies may make you feel better in the very short term. However they cannot provide you with a permanent cure. Non-operative management is always the safest alternative. There can be no surgical complications if there is no surgery.
Second option.
Undergo total hip replacement. (Arthroplasty).
The Operation.
You will undergo pre-operative wash with an aqueous chlorhexidine detergent preparation. Clean hospital clothing will be given to you to wear to the operating theatre.
The anaesthetist will give you an anaesthetic. This usually requires 2 " drips" ( arterial cannula and a venous cannula), and monitoring for: oxygen ( Pulse Oximetry), carbon dioxide (Capnograph) , heart function (ECG), awareness (BISS), blood pressure cuff, and urinary output (catheter in the bladder). Whether this is a spinal anaesthetic, or a general anaesthetic is up to the anaesthetist and you to decide. If possible a spinal anaesthetic is best for your brain functioning afterward, you wake up more alert and aware.
You will be placed bad side up on the operating table and a metal clamp will hold you tightly to the table. This allows accurate referencing of your bones. It means I can put the cup and ball in the correct position.
Your **** leg will have been previously marked by me, and we will keep checking this until you go to sleep.
All your bony prominences will be padded to prevent injury. You will be washed down with an anaesthetic solution, and plastic drapes will keep the area as sterile as possible.
An incision (cut) will then made. This will NOT be a cosmetic incision. I do not do “keyhole” surgery. Keyhole hip replacement surgery is experimental, and has resulted in WORSE outcomes when compared with routine incisions.
The muscles behind the hip will be stripped off the thigh bone. This is the biggest cause of pain after the surgery. They take up to 12 months to fully strengthen again.
The sciatic nerve is right next to the hip, and it will be protected as the muscles are folded back over it.
The ball of the thigh bone will be pushed up and out of the socket (dislocated). Then the ball is cut off the main thigh bone, about 8 cm from the top, through the narrow part of the neck. This is discarded, or sometimes used as bone graft for the operation if needed.
The cup (acetabulum) of the pelvis is enlarged to accommodate the metal cup implant. This is usually about 52 mm. The hip replacement cup will then be impacted into the pelvis. (Hit with a hammer). It should lock in tight. Sometimes screws are also used to hold the cup. The cup is made to allow bone to grow into it. After the metal cup is stable, then a plastic liner will be placed into the metal cup. Super strong plastic now lasts longer than metal or ceramic lining. It is be preferred option.
Once the cup is fixed. I will prepare to put the new the ball on the upper end of the thigh bone. The hollow in the middle of the thigh bone is enlarged. A metal stem (stick) will be placed inside the middle of the thigh bone, with the top part sitting out. This is impacted into the femur (hit with a hammer) until it locks in place. Then eventually the bone will grow into the titanium making it part of your body.
Once the stick is firmly fixed, a ball is placed onto this stick, and this makes up the hip replacement. The length of the leg is set by the position of the stick and the ball. Sometimes I have to intentionally lengthen the leg to keep the hip joint in place, but usually the length is within 5 mm of the original. (Shoe raises are not required if the legs are within 1.5 cm of each other, your brain gets used to the new length over about 12 weeks)
The ball and cup will then be engaged, and hopefully will be very stable. The muscles will be re-attached.
The skin will be closed with dissolving suture material. I have found this to cause the least problems with scarring and infection.
The reason this operation works is that man made materials act as the joint, and therefore prevent the painful bone rubbing on bone.
A new hip moves better and improves your hip range of movement. Hip arthroplasty is the best operation there is. It causes more improvement in the quality of life than any other operation in any surgical speciality. 95% of patients are improved.
However SOME PATIENTS ARE NOT BETTER WITH SURGERY, SOME PATIENTS CAN BE WORSE.
About 5% of hip operations are complicated by an adverse outcome. That is something happens that was not expected, and requires extra treatment. This does not mean that in the end a good result will not occur. It does mean that extra work may be required to achieve a good outcome.
COMPLICATIONS
I will try to cover the most serious complications. However you must note that I will not cover everything. An absolutely comprehensive list is NOT possible. The unexpected can always occur, I cannot warn you about everything.
Adverse risk rate I would estimate to be around 5%. This means that one in every twenty operations incurs an unexpected outcome.
This can be something simple such as a superficial wound infection that resolves with oral antibiotics, or it may be something extremely dangerous such as a blood clot, or heart attack.
People have died having this surgery, however the risk of this is about 1 in 100,000 (American Society of Anaesthesiologists Grade 1). The risk of a fatal car accident is about 1 in 15,000 per year.
Anaesthetics carry risk. This risk should be discussed with your anaesthetist.
Risks of all Orthopaedic Surgery
Death
Heart Attack
Stroke
Blood Clots
Bleeding requiring blood transfusion
Blood transfusion causing infection with hepatitis or AIDS
Lung failure : breathing difficulties
Kidney failure : unable to make urine, requiring dialysis
Liver failure: usually caused by an unexpected reaction to a medication
Bowel paralysis (ileus): a temporary condition caused by fasting
Nerve injury - this occurs in the skin when an incision is made causing permanent numbness.
Failure to improve.
Despite a technically perfect operation it can be possible that your symptoms may not improve. I give no guarantee that the surgery will improve any or all of your symptoms. However I believe strongly that you will get better. I would not do the surgery otherwise.
Infection: some infections are simple to treat. Other infections are a disaster, requiring repeat surgery and removal of the artificial hip, and subsequent operations. The very worst outcome means that your hip could be fused, or you may have no hip joint if the infection is not treatable. This is a very rare outcome.
Specific Risks of Hip Replacement.
Damage to the sciatic nerve (Permanent pain or weakness in the foot)
Fracture of the pelvis or femur ( A delay before you can walk unaided)
Dislocation: where the ball and socket joint separate and require surgery to put them back together.
Leg length inequality: To avoid dislocation, tension is required in the muscles of the hip. Sometimes a longer hip is required to maintain this tension. This results in one leg being longer than the other. A shoe raise maybe required.
Wear: Artificial joints do not last for ever. They sometimes require re-doing, and this is a much bigger undertaking than the first operation. I cannot guarantee how long your hip will last, however more than 90% of hips last more than 15 years. Even the very old designs can last 30 yrs. Hopefully your newer design will last the rest of your life.
Remember: Most patients do NOT have complications. Most patients have good outcomes and return home able to function almost as well as before their fracture.
What happens afterward?
Hip fractures change lives, not for the better. Fortunately your fracture combined with this treatment is reserved for patients with normal function before the fracture. You are the most likely to return to normal eventually. This is a long road to travel, and it takes most patients 12 months to achieve their best outcome.
Immediately afterward you will be in bed, struggling to move, in pain, nauseated, constipated, and in pain. You will think that the operation has made you worse. This will last for a few days.
The physiotherapist, and the nursing staff will try to get you out of bed as much as possible. There will be some restrictions on what you can do, but essentially we want you up and moving as much as possible, as soon as possible.
Slowly we will remove things from your body. Drips, cables, catheters will all be removed when we think you can manage without them.
Eventually you will be disconnected from all these.
Pain is a problem for weeks. It gets better every day, but you often need strong pain killers for up to a month, and moderate to mild pain killers for 3 months.
Most painkillers cause constipation. Therefore you will need medication for this for several weeks. One good bowel action does not mean you can stop these medications. You need to drink water, eat fruit and vegetables, take stool softening drugs and keep moving to fight constipation. It is an ongoing battle.
You will need to use a frame to walk at first, and slowly you will progress to crutches. It may be months before you finally walk without some gait aid.
You will no longer need a dressing after 14 to 20 days, as long as you wound heals properly.
By about 5 days after surgery we will be discussing rehabilitation with you. Almost everyone goes there for a couple of weeks. It acts as a transition between home and hospital. When you leave rehab you will be able to care for yourself around the house.
10 days after your discharge from rehab you should see me again. If you do not have an appointment ring Ursula on 0448844244 to get one. Your GP is not trained to help you with complications of hip surgery. RING MY OFFICE FIRST.
You will not be able to care for someone else for at least 3 months.
Driving depends on many things, but it is usually at least 6 weeks, sometimes 12 weeks before you can drive.
You cannot do any fixed pelvis rotation sport until I say so. This includes Golf, Tennis, Squash, etc
Your risk to the operating team.
During surgery it is possible for one of the operating team to cut themselves on a needle or other sharp object that has your blood on it. Blood can transmit infection from you to the staff member. There are drugs that can be given to the staff member to stop infection but they can only be given if your blood is tested for possible infection. I require you to give permission for taking and testing of your blood in the unlikely event that such an injury occurs. The blood will be tested for Hepatitis, and the Aids Virus (HIV). If you don't feel that you can give this permission then please discuss this with me. Your signature on this document serves as permission for this testing.
As I said earlier in this letter. There are always complications that I cannot think about or cannot warn you about. I have covered what I think is the most common, the most dangerous, and the most concerning. If you have anything else you would like to discuss you can do so by contacting me.
SUMMARY
This document is a consent form.
You must read it thoroughly. I would strongly suggest that you have a friend, or relative read this with you. You may even wish to get a lawyer to read it. If you have any concerns you should not proceed with the surgery. I would advise you to get another opinion from another surgeon if you have any concerns. Public hospitals with fully trained orthopaedic surgeons include the AUSTIN HOSPITAL, THE ROYAL MELBOURNE HOSPITAL, MONASH MEDICAL CENTRE, and THE ALFRED HOSPITAL. All of these hospitals have public clinics you could visit. There are other orthopaedic surgeons in Melbourne who do joint resurfacing you could see privately.
As I have told you, I am an orthopaedic surgeon who has does at least 30 hip replacements a year. However clearly I am not the oldest or busiest surgeon in Melbourne. You must consider this in deciding who does your surgery.
Your signature on this letter, with initials on every page must be returned to my office before the day of surgery. You should keep a copy for yourself. Your signature is acknowledgement of that you have read and understood the document; that you request the proposed surgery, and that you give me permission to perform the surgery and the Hospital to look after you during and after the surgery.
Yours sincerely,
Mr Michael Knight
MBBS FAOA
Signature: ......... ........................................
Date: ................/................../..............
CONSENT FOR SURGERY
HIP REVISION OF REPLACEMENT
Dear ,
You have a problem of wear and tear of the hip.
This hip replacement has served you well for many years, but it has reached the end of its life.
There is no alternative to this than to revise (change) the replacement over.
The Operation.
You will undergo pre-operative wash with an aqueous chlorhexidine detergent preparation. Clean hospital clothing will be given to you to wear to the operating theatre.
The anaesthetist will give you an anaesthetic. You will be placed bad side up on the operating table and a metal clamp will hold you tightly to the table. This allows accurate referencing of your bones. It means I can put the cup and ball in the correct position.
Your leg will have been previously marked by me, and we will keep checking this until you go to sleep.
All your bony prominences will be padded to prevent injury. You will be washed down with an anaesthetic solution, and plastic drapes will keep the area as sterile as possible.
An incision (cut) will then be made. This will NOT be a cosmetic incision. I do not do “keyhole” surgery. This cut will be through the original scar. The muscles behind the hip will be stripped off the thigh bone. This is the biggest cause of pain after the surgery. They take up to 12 months to fully strengthen again. The sciatic nerve is right next to the hip, and it will be protected as the muscles are folded back over it.
The hip will be disengaged, and then the ball will be removed from the thigh bone stem.
The stem in the thigh bone will probably almost fall out. However sometimes it needs to be cut out of the bone. The associated cement will also need to be removed. This will create an empty thigh bone to allow a new implant to be inserted. Any unwanted spaces will be filled with donor bone bank bone. Sometimes a cable is used to hold the donor bone onto your thigh bone to reinforce it.
With the thigh bone stem removed I shall have good access to the pelvis. The old cup will be removed. Again this should almost fall out. However it may not. In which case it will be removed by hammering it out, along with any cement. New bone will be put into the pelvis to reinforce the area where bone has been lost. Metal cages, screws and plates may also be required to further strengthen the pelvis. Then a new cup will be placed into the pelvis.
Then the new thigh bone stem will be inserted, and a new ball put on the thigh bone.
The ball and cup will then be engaged, and hopefully will be very stable.
The muscles will be re-attached.
The skin will be closed with a combination of dissolving and non-dissolving suture material. I have found this combination to cause the least problems with scarring and infection.
While this is a big operation, hip replacement improves quality of life more than any other operation in any surgical speciality. 95% of patients are improved.
However SOME PATIENTS ARE NOT BETTER WITH SURGERY, SOME PATIENTS CAN BE WORSE.
About 5% of hip operations are complicated by an adverse outcome. That is something happens that was not expected, and requires extra treatment. This does not mean that in the end a good result will not occur. It does mean that extra work may be required to achieve a good outcome. I have provided you with an information sheet on hip replacement and resurfacing.
COMPLICATIONS
I will try to cover the most serious. However you must note that I will not cover everything. An absolutely comprehensive list is NOT possible. The unexpected can always occur, I cannot warn you about everything.
Adverse risk rate I would estimate to be around 5%. This means that one in every twenty operations incurs an unexpected outcome.
This can be something simple such as a superficial wound infection that resolves with oral antibiotics, or it may be something extremely dangerous such as a blood clot, or heart attack.
People have died having this surgery, however the risk of this is about 1 in 100,000 (American Society of Anaesthesiologists Grade 1). The risk of a fatal car accident is about 1 in 15,000 per year.
Anaesthetics carry risk. This risk should be discussed with your anaesthetist.
Risks of all Orthopaedic Surgery
Death
Heart Attack
Stroke
Blood Clots
Bleeding requiring blood transfusion
Blood transfusion causing infection with hepatitis or AIDS
Lung failure : breathing difficulties
Kidney failure : unable to make urine, requiring dialysis
Liver failure: usually caused by an unexpected reaction to a medication
Bowel paralysis (ileus): a temporary condition caused by fasting
Nerve injury - this occurs in the skin when an incision is made causing permanent numbness.
Failure to improve.
Despite a technically perfect operation it can be possible that your symptoms may not improve. I give no guarantee that the surgery will improve any or all of your symptoms. However I believe strongly that you will get better. I would not do the surgery otherwise.
Infection: some infections are simple to treat. Other infections are a disaster, requiring repeat surgery and removal of the artificial hip, and subsequent operations. The very worst outcome means that your hip could be fused, or you may have no hip joint if the infection is not treatable. This is a very rare outcome.
Specific Risks of Hip Replacement.
Damage to the sciatic nerve (Permanent pain or weakness in the foot)
Fracture of the pelvis or femur ( A delay before you can walk unaided)
Dislocation: where the ball and socket joint separate and require surgery to put them back together.
Leg length inequality: To avoid dislocation, tension is required in the muscles of the hip. Sometimes a longer hip is required to maintain this tension. This results in one leg being longer than the other. A shoe raise maybe required.
Wear: Artificial joints do not last for ever. They sometimes require re-doing a third or fourth time, and this is a much bigger undertaking than the first operation. I cannot guarantee how long your hip will last, however more than 80% of revision hips last more than 10 years. Even the very old designs can last 30 yrs. Hopefully your newer design will last the rest of your life.
Your risk to the operating team.
During surgery it is possible for one of the operating team to cut themselves on a needle or other sharp object that has your blood on it. Blood can transmit infection from you to the staff member. There are drugs that can be given to the staff member to stop infection but they can only be given if your blood is tested for possible infection. I require you to give permission for taking and testing of your blood in the unlikely event that such an injury occurs. The blood will be tested for Hepatitis, and the Aids Virus (HIV). If you don't feel that you can give this permission then please discuss this with me. Your signature on this document serves as permission for this testing.
As I said earlier in this letter. There are always complications that I cannot think about or cannot warn you about. I have covered what I think is the most common, the most dangerous, and the most concerning. If you have anything else you would like to discuss you can do so by contacting me.
SUMMARY
This document is a consent form.
You must read it thoroughly. I have sent a copy to your GP. I would strongly suggest that you have a friend, or relative read this with you. You may even wish to get a lawyer to read it. If you have any concerns you should not proceed with the surgery. I would advise you to get another opinion from another surgeon if you have any concerns. Public hospitals with fully trained orthopaedic surgeons include the AUSTIN HOSPITAL, THE ROYAL MELBOURNE HOSPITAL, MONASH MEDICAL CENTRE, and THE ALFRED HOSPITAL. All of these hospitals have public clinics you could visit. There are other orthopaedic surgeons in Melbourne who do joint resurfacing you could see privately.
As I have told you I am an orthopaedic surgeon who has does at least 30 hip replacements a year. However clearly I am not the oldest or busiest surgeon in Melbourne. You must consider this in deciding who does your surgery.
Your signature on this letter, with initials on every page must be returned to my office prior to the day of surgery. You should keep a copy for yourself. Your signature is acknowledgement of that you have read and understood the document; that you request the proposed surgery, and that you give me permission to perform the surgery and the Hospital to look after you during and after the surgery.
Yours sincerely,
Mr Michael Knight Signature:..................................................
MBBS FAOA
Date.........../................./.........................
CONSENT FOR SURGERY
Fixation of Hip Fracture
Dear ,
You have a problem of a fracture of the neck of the left femur.
Sometimes called a broken hip, or fractured hip.
This fracture has occurred in a way that maintains the blood vessels that supply the ball of the hip. In most cases if I fix the bones together they will heal, and the hip will return to a solid functioning joint.
Therefore the best option for you is to have the hip bone fixed with a metal device that will enable you to get up and walk immediately.
Not having this operation would result losing your ability to walk, and a prolonged stay in hospital, with increased risk of death from pneumonia, blood clot and pressure sores. Not having this operation will guarantee permanent severe pain.
The best option for you is to have this operation.
The Operation: Internal Fixation of Hip Fracture
You will undergo pre-operative wash with an aqueous chlorhexidine detergent preparation. Clean hospital clothing will be given to you to wear to the operating theatre.
The anaesthetist will give you an anaesthetic. This usually requires two "drips" ( an arterial line, and a venous cannula), and oxygen, carbon dioxide, blood pressure and heart function monitors.
A catheter will be placed in your bladder. This will stay for a couple of days.
You will be placed on the operating table and a metal clamp will hold you tightly to the table. This allows accurate referencing of your bones. It means I can X-ray your hip, and at the same time hold the bones and fix them together.
Your broken leg will have been previously marked by me, and we will keep checking this until you go to sleep.
All your bony prominences will be padded to prevent injury. You will be washed down with an anaesthetic solution, and plastic drapes will keep the area as sterile as possible.
An incision (cut) will then made. This will NOT be a cosmetic incision. I do not do “keyhole” surgery. Keyhole hip surgery has WORSE outcomes than regular hip surgery.
The muscles around the hip will be split. This is the biggest cause of pain after the surgery. They take up to 12 months to fully strengthen again, but they normally recover with time. The sciatic and femoral nerves are right next to the hip, and they will be protected.
The broken femur is held together with either a metal rod inside the bone, or a metal plate on the outside of the bone. The type of fracture determines the correct device. These are permanent implants. I never plan to remove them. Regardless of what type of implant I use these are too deep inside the body to feel.
The X-ray machine in the operating theatre tells me that I have put the bone back together in a suitable way.
The skin will be closed with dissolving suture material (Stitches) . I have found this combination to cause the least problems with scarring and infection.
The reason this operation works is that man-made materials are strong enough to hold the bone together while it heals. They are instantly stable and you can walk on them the next day in almost every instance.
However SOME PATIENTS ARE NOT BETTER WITH SURGERY, SOME PATIENTS CAN BE WORSE.
About 10% of hip operations for fractures are complicated by an adverse outcome. That is something happens that was not expected, and requires extra treatment. This does not mean that in the end a good result will not occur. It does mean that extra work may be required to achieve a good outcome.
COMPLICATIONS
I will try to cover the most serious complications. However you must note that I will not cover everything. An absolutely comprehensive list is NOT possible. The unexpected can always occur, I cannot warn you about everything.
Adverse risk rate I would estimate to be around 10%. This means that one in every ten operations incurs an unexpected outcome.
This can be something simple such as a superficial wound infection that resolves with oral antibiotics, or it may be something extremely dangerous such as a blood clot, or heart attack.
People have died having this surgery, the risk of this is between, 1 in 1000 and 1 in 10,000 (American Society of Anaesthesiologists Grade 2-3).
The risk of a fatal car accident is about 1 in 15,000 per year.
Anaesthetics carry risk. This risk should be discussed with your anaesthetist.
Risks of all Orthopaedic Surgery
Death
Heart Attack
Stroke
Blood Clots
Bleeding requiring blood transfusion
Blood transfusion causing infection with hepatitis or AIDS
Lung failure : breathing difficulties
Kidney failure : unable to make urine, requiring dialysis
Liver failure: usually caused by an unexpected reaction to a medication
Bowel paralysis (ileus): a temporary condition caused by fasting
Nerve injury - this occurs in the skin when an incision is made causing permanent numbness.
Failure to improve.
Despite a technically perfect operation it can be possible that your symptoms may not improve. I give no guarantee that the surgery will improve any or all of your symptoms. However I believe strongly that you will get better. I would not do the surgery otherwise.
Infection: some infections are simple to treat. Other infections are a disaster, requiring repeat surgery and removal of the artificial hip, and subsequent operations. The very worst outcome means that your hip could be fused, or you may have no hip joint if the infection is not treatable. This is a very rare outcome.
Specific Risks of Hip Fracture Fixation.
Damage to the sciatic nerve (Permanent pain or weakness in the foot)
Fracture of the pelvis or femur ( A delay before you can walk unaided)
Dislocation: where the ball and socket joint separate and require surgery to put them back together.
Leg length inequality: Sometimes the bone is so badly broken that it cannot be put back together as it was, and sometimes as it heals it shortens. This results in one leg being longer than the other. A shoe raise maybe required.
Bone Death: (Avascular Necrosis) Sometimes the bone of the hip dies because the fracture has destroyed the blood supply. If I expect this is going to happen I will do a hip replacement as the first operation. However sometimes this happens despite our best intentions. This cannot always be predicted at the time of surgery. If the bone dies, you will need a hip replacement as a second operation. It usually takes 3 -12 months to know whether this has happened or not.
Pain: Before your broke your hip, it was probably pain free. It will never be the same after the fracture. Even the best outcomes result in slightly uncomfortable movement. Most patients get used to their healed hip, almost none forget they broke the it.
Remember: Most patients do NOT have complications. Most patients have good outcomes and return home able to function almost as well as before their fracture.
What happens afterward?
Hip fractures change lives, not for the better. You are the most likely to return to near your pre-fracture functioning - eventually. This is a long road to travel, and it takes most patients 12 months to achieve their best outcome.
Immediately afterward you will be in bed, struggling to move, in pain, nauseated, constipated, and in pain. You will think that the operation has made you worse. This will last for a few days.
The physiotherapist, and the nursing staff will try to get you out of bed as much as possible. There will be some restrictions on what you can do, but essentially we want you up and moving as much as possible, as soon as possible.
Slowly we will remove things from your body. Drips, cables, catheters will all be removed when we think you can manage without them.
Eventually you will be disconnected from all these.
Pain is a problem for weeks. It gets better every day, but you often need strong pain killers for up to a month, and moderate to mild pain killers for 3 months.
Most painkillers cause constipation. Therefore you will need medication for this for several weeks. One good bowel action does not mean you can stop these medications. You need to drink water, eat fruit and vegetables, take stool softening drugs and keep moving to fight constipation. It is an ongoing battle.
You will need to use a frame to walk at first, and slowly you will progress to crutches. It may be months before you finally walk without some gait aid.
You will no longer need a dressing after 14 to 20 days, as long as you wound heals properly.
By about 5 days after surgery we will be discussing rehabilitation with you. Almost everyone goes there for a couple of weeks. It acts as a transition between home and hospital. When you leave rehab you will be able to care for yourself around the house.
10 days after your discharge from rehab you should see me again. If you do not have an appointment ring Ursula on 0448844244 to get one. Your GP is not trained to help you with complications of hip fracture surgery. RING MY OFFICE FIRST.
You will not be able to care for someone else for at least 3 months.
Driving depends on many things, but it is usually at least 6 weeks, sometimes 12 weeks before you can drive.
You may need to reassess you living situation. This can be the time many people are forced to think about what housing and living arrangements are right for the future.
Your risk to the operating team.
During surgery it is possible for one of the operating team to cut themselves on a needle or other sharp object that has your blood on it. Blood can transmit infection from you to the staff member. There are drugs that can be given to the staff member to stop infection but they can only be given if your blood is tested for possible infection. I require you to give permission for taking and testing of your blood in the unlikely event that such an injury occurs. The blood will be tested for Hepatitis, and the Aids Virus (HIV). If you don't feel that you can give this permission then please discuss this with me. Your signature on this document serves as permission for this testing.
As I said earlier in this letter. There are always complications that I cannot think about or cannot warn you about. I have covered what I think is the most common, the most dangerous, and the most concerning. If you have anything else you would like to discuss you can do so by contacting me.
SUMMARY
This document is a consent form.
You must read it thoroughly. I would strongly suggest that you have a friend, or relative read this with you. You may even wish to get a lawyer to read it. If you have any concerns you should not proceed with the surgery.
I could advise you to get another opinion from another surgeon if you have any concerns. However this is usually impractical with a broken hip.
If you are concerned you could be transferred to a public hospital.
Public hospitals with fully trained orthopaedic surgeons include the AUSTIN HOSPITAL, THE ROYAL MELBOURNE HOSPITAL, MONASH MEDICAL CENTRE, and THE ALFRED HOSPITAL.
As I have told you, I am an orthopaedic surgeon who has does at least 30 hip replacements a year. However clearly I am not the oldest or busiest surgeon in Melbourne. You must consider this in deciding who does your surgery.
Your signature on this letter, with initials on every page, indicate you have read this document. Often you do not get to read this until after your operation, as it is an emergency. However I still provide this information for you to understand what you are going through. You should keep a copy for yourself. Your signature is acknowledgement of that you have read and understood the document; that you request the proposed surgery, and that you give me permission to perform the surgery and the Hospital to look after you during and after the surgery.
Yours sincerely,
Dr. Michael KNIGHT
MBBS FAOA
Patient Signature: .................................................
Date: ................/................../..............
CONSENT FOR KNEE ARTHROSCOPY - RIGHT
Dear ,
You have a problem of (osteoarthritis) wear and tear arthritis of the RIGHT knee.
Sometimes osteoarthritis is called osteoarthrosis. This is not really a disease, more an accelerated ageing process of the knee joints. It also causes joint stiffness, as well as pain.
It causes tears in the cartilage of the knee, and these tears can be painful. Removal of these tears and washing out of the debris, from the wear of the knee, can improve pain.
I am able to offer you 2 choices of treatment.
First option.
Continue to manage the problem non-surgically. That would mean gradually decreasing your activity, both social and physical to fit your increasing physical disability. It could also mean relying on medication, and psychological interventions. However most knee pain does settle over time and many people are completely pain free even though they still have underlying degeneration.
The use of physical therapy, chiropractic, and alternative health interventions have not been shown to be useful in the resolution of chronic pain based on controlled trials in the scientific literature. Such therapies may make you feel better in the very short term. However they cannot provide you with a permanent cure.
Non-operative management is always the safest alternative. There can be no surgical complications if there is no surgery.
Second option.
Undergo knee arthroscopy and removal of debris.
The Operation.
You will undergo pre-operative wash with an aqueous chlorhexidine detergent preparation. Clean hospital clothing will be given to you to wear to the operating theatre.
The anaesthetist will give you an anaesthetic. You will be placed on your back on the operating table .
Your right leg will have been previously marked by me, and we will keep checking this is the correct limb, until you go to sleep.
All your bony prominences will be padded to prevent injury. You will be washed down with an anaesthetic solution, and plastic drapes will keep the area as sterile as possible.
Three 1 cm incisions (cut) will then be made. This is “keyhole” surgery.
A telescope will be placed through one of these cuts. The other two incisions allow instruments to operate on the cartilage of the knee.
Where the cartilage is torn and loose it is removed. This is particularly the case when the meniscus is torn. Cartilage cannot be repaired in your age group. It does not grow back. Meniscal tears are repaired in the very young, but even then the repair has a low chance of working.
Where the bone is exposed and the cartilage is missing entirely, the bone will be drilled with a tiny drill to cause localised bleeding. This allows the bone to be covered with a "scar cartilage" (fibrocartilage) that can significantly decrease your pain.
Once the surgery is over, the knee is washed out to remove all debris.
The skin is closed with a non-dissolving suture material.
The knee will remain swollen and tender for at least 2 weeks after this surgery, but you can walk on this immediately. The sooner you return to normal activity the faster you will get better.
Most patients are improved with this surgery.
However SOME PATIENTS ARE NOT BETTER WITH SURGERY, SOME PATIENTS CAN BE WORSE.
About 2% of arthroscopic knee operations are complicated by an adverse outcome. That is something happens that was not expected, and requires extra treatment. This does not mean that in the end a good result will not occur. It does mean that extra work may be required to achieve a good outcome.
COMPLICATIONS
I will try to cover the most serious. However you must note that I will not cover everything. An absolutely comprehensive list is NOT possible. The unexpected can always occur, I cannot warn you about everything.
Adverse risk rate, I would estimate, to be around 2%. This means that one in every 50 operations incurs an unexpected outcome.
This can be something simple such as a superficial wound infection that resolves with oral antibiotics, or it may be something extremely dangerous such as a blood clot, or heart attack.
People have died having this surgery, however the risk of this is about 1 in 100,000 (American Society of Anaesthesiologists Grade 1). The risk of a fatal car accident is about 1 in 15,000 per year.
Anaesthetics carry risk. This risk should be discussed with your anaesthetist.
Risks of all Orthopaedic Surgery
Death
Heart Attack
Stroke
Blood Clots
Bleeding requiring blood transfusion
Blood transfusion causing infection with hepatitis or AIDS
Lung failure : breathing difficulties
Kidney failure : unable to make urine, requiring dialysis
Liver failure: usually caused by an unexpected reaction to a medication
Bowel paralysis (ileus): a temporary condition caused by fasting
Nerve injury - this occurs in the skin when an incision is made causing permanent numbness.
Failure to improve.
Despite a technically perfect operation it can be possible that your symptoms may not improve. I give no guarantee that the surgery will improve any or all of your symptoms. However I believe strongly that you will get better. I would not do the surgery otherwise.
Infection: some infections are simple to treat. Other infections are a disaster, requiring repeat surgery. The very worst outcome means that your knee could be fused, or you may have no knee joint if the infection is not treatable. This is a very rare outcome.
Specific Risks of Knee Arthroscopy.
Damage to the sciatic nerve (Permanent pain or weakness in the foot)
Pain over the incisions. This usually improves but not always.
Numbness over the incisions.
Haemarthrosis (Bleeding into the knee that causes the knee to swell)
Knee Stiffness. The range of movement of the knee should be improved with surgery, however sometimes it becomes less than before. This occurs because of scar tissue that occurs within the knee over time. This can often be overcome with physiotherapy, but sometimes it is a major problem that leaves the knee very stiff.
PAIN: Mostly pain decreases with surgery. However if you have severe pain before surgery it may not be immediately improved and take up to 3 months for this to settle down. Indeed pain is one of the problems that prevents the knee from bending and results in permanent stiffness. If you don't think you pain is being adequately treated you MUST let me know.
Your risk to the operating team.
During surgery it is possible for one of the operating team to cut themselves on a needle or other sharp object that has your blood on it. Blood can transmit infection from you to the staff member. There are drugs that can be given to the staff member to stop infection but they can only be given if your blood is tested for possible infection. I require you to give permission for taking and testing of your blood in the unlikely event that such an injury occurs. The blood will be tested for Hepatitis, and the Aids Virus (HIV). If you don't feel that you can give this permission then please discuss this with me. Your signature on this document serves as permission for this testing.
As I said earlier in this letter. There are always complications that I cannot think about or cannot warn you about. I have covered what I think is the most common, the most dangerous, and the most concerning. If you have anything else you would like to discuss you can do so by contacting me.
SUMMARY
This document is a consent form.
You must read it thoroughly. I have sent a copy to your GP. I would strongly suggest that you have a friend, or relative read this with you. You may even wish to get a lawyer to read it. If you have any concerns you should not proceed with the surgery. I would advise you to get another opinion from another surgeon if you have any concerns. Public hospitals with fully trained orthopaedic surgeons include the AUSTIN HOSPITAL, THE ROYAL MELBOURNE HOSPITAL, MONASH MEDICAL CENTRE, and THE ALFRED HOSPITAL. All of these hospitals have public clinics you could visit.
As I have told you I am an orthopaedic surgeon who has does at least 30 knee arthroscopies a year. However clearly I am not the oldest or busiest surgeon in Melbourne. You must consider this in deciding who does your surgery.
Your signature on this letter, with initials on every page must be returned to my office before the day of surgery. You should keep a copy for yourself. Your signature is acknowledgement of that you have read and understood the document; that you request the proposed surgery, and that you give me permission to perform the surgery and the Hospital to look after you during and after the surgery.
Yours sincerely,
Dr. Michael KNIGHT
MBBS FAOA
.........................................
DATE:.........../.............../...............
CONSENT FOR TOTAL KNEE REPLACEMENT - LEFT
Dear ,
You have a problem of (osteoarthritis) wear and tear arthritis of the left knee.
Sometimes osteoarthritis is called osteoarthrosis. This is not really a disease, more an accelerated ageing process of the knee joints. It also causes joint stiffness, as well as pain.
You have failed to respond to maximal conservative therapy. That is, all the treatment options, apart from surgery, that you have used, have not given you any long-term benefit.
You have told me that you life is a constant physical misery. You told me that this pain is a single constant destructive force in your life and that this makes every day terrible. You told me that if you did not have leg pain your life would be much improved.
I am able to offer you 2 choices of treatment.
First option.
Continue to manage the problem non-surgically. That would mean gradually decreasing your activity, both social and physical to fit your increasing physical disability. It would also mean relying on medication, and psychological interventions. The use of physical therapy, chiropractic, and alternative health interventions have not been shown to be useful in the resolution of chronic pain based on controlled trials in the scientific literature. Such therapies may make you feel better in the very short term. However they cannot provide you with a permanent cure. Non-operative management is always the safest alternative. There can be no surgical complications if there is no surgery.
Second option.
Undergo left total knee replacement. (Arthroplasty).
The Operation.
You will undergo pre-operative wash with an aqueous chlorhexidine detergent preparation. Clean hospital clothing will be given to you to wear to the operating theatre.
The anaesthetist will give you an anaesthetic. You will be placed on your back on the operating table and a metal clamp will keep your left knee in the correct position .
Your left leg will have been previously marked by me, and we will keep checking this until you go to sleep.
All your bony prominences will be padded to prevent injury. You will be washed down with an anaesthetic solution, and plastic drapes will keep the area as sterile as possible.
An incision (cut) will then be made. This will NOT be a cosmetic incision. I do not do “keyhole” surgery. The muscles over the front of the knee will be cut through down to the bone. This is the biggest cause of pain after the surgery. It can take up to 12 months to fully strengthen again. The bottom end of the thigh bone, and the top end of the shin bone will be cut to allow the knee replacement to fit. The under surface of the knee cap is also trimmed to allow a plastic button to be cemented on. The sciatic nerve and major leg blood vessels are right behind the knee, and these will be protected by placing a metal protector behind the shin bone while I am cutting the shin bone. The metal components of the knee replacement will then be cemented onto the bones. After the metal parts are stable, then a plastic liner will be placed onto the metal shin bone component.
The muscles will be sutured up to close the knee.
The skin will be closed with a combination of dissolving and non-dissolving suture material. I have found this combination to cause the least problems with scarring and infection.
The reason this operation works is that man-made materials act as the joint, and therefore prevent the painful bone rubbing on bone. A new knee moves better and improves your knee range of movement. Knee replacement surgery is a good operation. Up to 95% of patients are improved.
However SOME PATIENTS ARE NOT BETTER WITH SURGERY, SOME PATIENTS CAN BE WORSE.
About 5% of knee operations are complicated by an adverse outcome. That is something happens that was not expected, and requires extra treatment. This does not mean that in the end a good result will not occur. It does mean that extra work may be required to achieve a good outcome. I have provided you with an information sheet on knee replacement.
COMPLICATIONS
I will try to cover the most serious. However you must note that I will not cover everything. An absolutely comprehensive list is NOT possible. The unexpected can always occur, I cannot warn you about everything.
Adverse risk rate I would estimate to be around 5%. This means that one in every twenty operations incurs an unexpected outcome.
This can be something simple such as a superficial wound infection that resolves with oral antibiotics, or it may be something extremely dangerous such as a blood clot, or heart attack.
People have died having this surgery, however the risk of this is about 1 in 100,000 (American Society of Anaesthesiologists Grade 1). The risk of a fatal car accident is about 1 in 15,000 per year.
Anaesthetics carry risk. This risk should be discussed with your anaesthetist.
Risks of all Orthopaedic Surgery
Death
Heart Attack
Stroke
Blood Clots
Bleeding requiring blood transfusion
Blood transfusion causing infection with hepatitis or AIDS
Lung failure : breathing difficulties
Kidney failure : unable to make urine, requiring dialysis
Liver failure: usually caused by an unexpected reaction to a medication
Bowel paralysis (ileus): a temporary condition caused by fasting
Nerve injury - this occurs in the skin when an incision is made causing permanent numbness.
Failure to improve.
Despite a technically perfect operation it can be possible that your symptoms may not improve. I give no guarantee that the surgery will improve any or all of your symptoms. However I believe strongly that you will get better. I would not do the surgery otherwise.
Infection: some infections are simple to treat. Other infections are a disaster, requiring repeat surgery and removal of the artificial knee, and subsequent operations. The very worst outcome means that your knee could be fused, or you could have your leg amputated if the infection is not treatable. This is very rare.
Specific Risks of Knee Replacement or Resurfacing.
Damage to the sciatic nerve (Permanent pain or weakness in the foot)
Fracture of the tibia or femur ( A delay before you can walk unaided)
Dislocation: where the joint separates and requires surgery to put it back together.
Wear: Artificial joints do not last for ever. They sometimes require re-doing, and this is a much bigger undertaking than the first operation. I cannot guarantee how long your knee will last, however more than 90% of knees last more than 15 years. Even the very old designs can last 30 yrs. Hopefully your newer design will last the rest of your life.
Knee Stiffness. The range of movement of the knee should be improved with surgery, however sometimes it becomes less than before. This occurs because of scar tissue that occurs within the knee over time. This can often be overcome with physiotherapy, but sometimes it is a major problem that leaves the knee very stiff.
PAIN: post operating pain after a knee replacement is very common. It can take 3 months for this to settle down. Indeed pain is one of the problems that prevents the knee from bending and results in permanent stiffness. If you don't think you pain is being adequately treated you MUST let me know.
This is not a NEW knee, it is a replacement for a worn out knee. Knee replacements often clunk, and click, and make funny noises, and feel odd. There is often permanent numbness over the front of the knee, and sometimes the pain relief is not complete even though the operation has been technically uncomplicated. This is the nature of the operation. While improvement can be expected up to 12 months after surgery, beyond this time the changes are usually fixed.
Your risk to the operating team.
During surgery it is possible for one of the operating team to cut themselves on a needle or other sharp object that has your blood on it. Blood can transmit infection from you to the staff member. There are drugs that can be given to the staff member to stop infection but they can only be given if your blood is tested for possible infection. I require you to give permission for taking and testing of your blood in the unlikely event that such an injury occurs. The blood will be tested for Hepatitis, and the Aids Virus (HIV). If you don't feel that you can give this permission then please discuss this with me. Your signature on this document serves as permission for this testing.
As I said earlier in this letter. There are always complications that I cannot think about or cannot warn you about. I have covered what I think is the most common, the most dangerous, and the most concerning. If you have anything else you would like to discuss you can do so by contacting me.
SUMMARY
This document is a consent form.
You must read it thoroughly. I have sent a copy to your GP. I would strongly suggest that you have a friend, or relative read this with you. You may even wish to get a lawyer to read it. If you have any concerns you should not proceed with the surgery. I would advise you to get another opinion from another surgeon if you have any concerns. Public hospitals with fully trained orthopaedic surgeons include the AUSTIN HOSPITAL, THE ROYAL MELBOURNE HOSPITAL, MONASH MEDICAL CENTRE, and THE ALFRED HOSPITAL. All of these hospitals have public clinics you could visit.
As I have told you I am an orthopaedic surgeon who has does at least 30 knee replacement a year. However clearly I am not the oldest or busiest surgeon in Melbourne. You must consider this in deciding who does your surgery.
Your signature on this letter, with initials on every page must be returned to my office before the day of surgery. You should keep a copy for yourself. Your signature is acknowledgement of that you have read and understood the document; that you request the proposed surgery, and that you give me permission to perform the surgery and the Hospital to look after you during and after the surgery.
Yours sincerely,
Mr Michael KNIGHT Signature:..............................................................
MBBS FAOA
Date:............/............../......................
CONSENT FOR AN OPERATION
Bilateral L5 spinal nerve root decompression (rhizolysis) and L5-S1 interbody and posterolateral fusion with pedicle screw fixation.
Dear ,
You have a problem of lytic spondylolisthesis at L5-S1. This is causing both neurogenic and mechanical low back pain.
That is: At some point in your youth or childhood you sustained a stress fracture of the L5 vertebra. This occurred between the joint that attaches to S1 and the joint that attaches to L4. Therefore the L5 vertebra and all of the spine above it has moved forward on the S1 vertebra. This is called a spondylolisthesis, or slipped vertebral body. This is VERY different to a slipped disc.
This spondylolisthesis can be very common. In some Eskimo populations up to 60% of the population has the problem. Therefore the presence of a slip does not warrant intervention.
However over time ageing has caused deterioration of the disc joints (intervertebral discs) between L5 and S1 to the point that there is no functioning disc at this level. This wear and tear can be a cause of back pain, however the real problem is that the foramen (window) where the L5 spinal nerve leaves the spinal canal and travels out to the body, has collapsed. The nerve is being trapped in this space. This causes pain, numbness and altered feeling in the buttocks, and also in the legs.
This is a structural change and cannot spontaneously improve, however the pain can fluctuate and the pain can even spontaneously improve, although the mechanism for this is poorly understood.
I have made this diagnosis based on my examination of you, the story you have told me, and the imaging available.
I am able to offer you 2 choices of treatment.
First option.
Continue to manage the problem non-surgically. That would mean gradually decreasing your activity; both social and physical, to meet you level of disability. You may need to rely on medication, and psychological interventions.
The use of physical therapy, chiropractic, and alternative health interventions have not been shown to be useful in the management of spondylolisthesis, based on controlled trials in the scientific literature. They may give you short term pain relief, and this is not a bad thing, but they cannot provide you with a permanent cure.
With this condition non-surgical treatment is the safest alternative. There can be no surgical complications if there is no surgery. There is no underlying cancer, tumour or infection. This condition cannot cause paraplegia in you. There is a risk of deterioration in the L5 nerve root functioning, with the development of a limp, and foot weakness. There is no way of telling which patients will deteriorate. Deterioration in this condition is usually reversible if it is caught early, but I cannot guarantee this will be the case.
Second option.
Undergo bilateral L5 spinal nerve root decompression and L5-S1 interbody fusion.
The Operation
In this operation you are given an anaesthetic. You will be completely asleep. While you are asleep a drainage tube (urinary catheter will be placed in your bladder. At least two “drips” (intravenous and intra-arterial catheters) will be placed in your upper limbs.
You will be rolled onto your stomach on a special table. Two cuts (incisions) will be made either side of the midline of your back over the location of your problem. A portable x-ray machine will be used to make sure I know which level of the spine I am operating upon.
I will push the muscles off the spinal bones (vertebrae) and I will remove some of the bone knobs/spurs, ligaments and joints to allow the L5 nerves to recover their normal volume. This process will cause bleeding. We will give you fluid to replace the blood, but may need to give you some blood from the blood bank.
The nerves will be protected during the surgery.
The spine will be more wobbly (unstable) once all this bone is removed. Therefore I shall put small metal screws into the bones to hold them in place, and a small titanium spacer in the disc space to keep the exit foramen open while the spinal fusion heals. Once this is done I shall take the bone I have removed and some extra bone, and mix them together. This is called bone graft. I place this in the disc space and also in a different location at the edge of the spine, away from the nerves. This bone graft forms a solid bridge between the vertebrae. Sometimes this is as solid as bone; sometimes it is more like a strong ligament (gristle) between the bones. It adds further stability to the spine in the long term.
The wound is then washed out to remove any bacteria that has fallen in from your skin, and closed with sutures (stitches). Most of the suture is dissolvable and below the skin. Only the skin suture needs to be removed. This is because removable suture has a better cosmetic result, and less infection than dissolvable skin suture or staples.
You will be rolled onto your back and woken up. Once you are awake enough to breathe for yourself you will be transferred to the recovery room. Once you are awake enough to move your legs I shall ring your nominated next of kin and tell them that you are OK.
The Outcome:
Immediately after the surgery you will not be too sore because you will have lots of medication in your system. As this wears off the pain will increase. Many people describe the first 24 hrs as quite painful. Usually after 48 hrs the pain settles quickly, and you will be provided with lots more pain relieving medication as you need it. The day after surgery you will be expected to get up and stand. You are allowed to walk, or sit; however you probably will not feel like it. Each day you will be asked to do more moving, and you will have less pain. Once you can safely and comfortably get to the toilet the urinary catheter will be removed. Once you can safely move around the ward you will be assessed for rehabilitation.
Most patients get some immediate relief of pain/numbness/tingling. However lack of an immediate response does not mean that you will not get better. Most of the improvement in symptoms does not occur until days or weeks after the surgery. If recovery requires the nerves to regrow (in very severe cases), then it can be up to 18 months before the symptoms go away. It is very common to feel much better for a few days and then some of the symptoms come back again. This does not mean that the operation has failed. It means that the ongoing inflammation from the surgery is causing nerve irritation. As the wound heals the pain settles again. In my experience more than 90% of patients with this condition have significant improvement. If they didn’t I wouldn’t do the surgery.
Scarring: This is not cosmetic surgery. The wounds are obvious initially, but usually fade to invisible over 12 months. If you are concerned about this, then talk to me about it.
"Keyhole spine surgery" is marketing hype. Unlike the abdomen, or the knee, where there is a cavity that can be expanded to allow true keyhole surgery, the spine is encased in muscle. There is no cavity that can be expanded. "Keyhole" surgery implies that the surgeon makes the smallest possible hole to get to the spine. All spine surgeons do this. No surgeon uses a bigger wound than absolutely necessary. All spine surgery is minimally invasive. No surgeon would do unnecessarily invasive surgery. Try to Google "maximally invasive spinal surgery" it doesn't exist! Some surgeons combine lots of small cuts in the skin to do a complex operation, but under the skin the injury to the patient is exactly the same. It has to be, because the operation is exactly the same. Unfortunately making the incision too small can increase complications. This has been show in several studies of disc surgery, spinal stenosis surgery and fusion surgery. In order to do safe and reliable spine surgery the surgeon has to see what she/he is doing, therefore I call this "appropriate incision surgery".
COMPLICATIONS
SOME PATIENTS ARE NOT BETTER WITH SURGERY, SOME PATIENTS CAN BE WORSE. About 5% of spinal fusion operations are complicated by an adverse outcome. That is something happens that was not expected, and requires extra treatment.
I will try to cover the most serious complications. However you must note that I will not cover everything. An absolutely comprehensive list is NOT possible. The unexpected can always occur; I cannot warn you about everything.
Adverse risk rate I would estimate to be around 5%. This means that one in every twenty operations incurs an unexpected outcome.
This can be something simple such as a skin infection that resolves with tablet antibiotics, or it may be something extremely dangerous such as a blood clot, or heart attack.
Death
People have died having this surgery, however the risk of this is about 1 in 100,000 (American Society of Anaesthesiologists Grade 1). To put this in perspective the risk of a fatal car accident in a year is about 1 in 10,000. Or ten times more likely.
Paraplegia
It is possible to make you paraplegic by damaging all the nerves below the level of the surgery. This means you would be unable to walk, and would have no feeling below your waist. You would also not be able to control your bladder or bowel, and would lose normal sexual function. Paraplegia is irreversible. However this would be extremely rare, so rare I cannot put a percentage on this risk.
Dural Tear
The nerves of the spinal canal are enclosed in a fine skin. This is called the dura. This dura keeps the nerves and spinal cord, and brain floating in a bath of fluid called Cerebrospinal Fluid (CSF). It is possible to tear or cut this dura (durotomy) , without damaging the nerves directly. This occurs in about 1 in 200 first time operations and 1 in 10 revision operations. This causes a loss of CSF. These incidental durotomies can be repaired, or sealed. The body makes up the lost fluid in 48 hrs. However during this 48 hours you may have a very severe headache, and you will be required to remain flat in bed. Very rarely the dura doesn't seal up, and further surgery is required to prevent the CSF from leaking continuously.
Implant complications.
Despite using X-ray in the operating theatre to assist placement of the screws and rods and bone grafts it is not possible to gain the same level of information as a high quality CT scanner. Therefore sometimes these implants can be mal-positioned. This very occasionally requires returning to the operating theatre to reposition the devices. Sometimes your body reacts in an unwanted way to the implants, that is you are allergic to the implants. This requires implant removal. Very rarely sometime into the future there is a recall of implanted medical devices by the manufacturer. This almost never requires further surgery in the case of spinal fusion, but I cannot exclude the possibility. The only implants that I use are those approved by the Australian Therapeutic Goods Administration at the time of implantation
Risks of all Orthopaedic Surgery
Death
Heart Attack
Stroke
Blood Clots
Bleeding requiring blood transfusion
Blood transfusion causing infection with hepatitis or AIDS
Lung failure: breathing difficulties
Kidney failure: unable to make urine, requiring dialysis
Liver failure: usually caused by an unexpected reaction to a medication
Bowel paralysis (ileus): a temporary condition caused by fasting and operating through the abdomen
Superficial Nerve injury - this occurs in the skin when an incision is made causing permanent numbness.
Major Nerve Injury - In spinal surgery damage to a single nerve in the spinal canal can have permanent paralysing effects on a group of muscles. This is rare, but usually irreversible.
Failure to improve.
Despite a technically perfect operation it can be possible that your symptoms may not improve. I give no guarantee that the surgery will improve any or all of your symptoms. However I believe strongly that you will get better. I would not do the surgery otherwise.
Infection
Some infections are simple to treat. Other infections are a disaster, requiring repeat surgery and removal the implants. Long term antibiotics may also be required.
Your risk to the operating team.
During surgery it is possible for one of the operating team to cut themselves on a needle or other sharp object that has your blood on it. Blood can transmit infection from you to the staff member. There are drugs that can be given to the staff member to stop infection but they can only be given if your blood is tested for possible infection. I require you to give permission for taking and testing of your blood in the unlikely event that such an injury occurs. The blood will be tested for Hepatitis, and the Aids Virus (HIV). If you don't feel that you can give this permission then please discuss this with me. Your signature on this document serves as permission for this testing.
I have covered what I think is the most dangerous and the most concerning. If you have anything else you would like to discuss you can do so by contacting me.
SUMMARY
This document is a consent form.
You must read it thoroughly. I have sent you extra copies to give to your GP. I would strongly suggest that you have a friend, or relative read this with you. You may even wish to get a lawyer to read it.
If you have any concerns you should not proceed with the surgery and I would advise you to get another opinion from another spinal surgeon. Public hospitals with fully trained spinal surgeons include the AUSTIN HOSPITAL, THE ROYAL MELBOURNE HOSPITAL, MONASH MEDICAL CENTRE, and THE ALFRED HOSPITAL. All of these hospitals have public clinics you could visit. There are both neurosurgeons and other orthopaedic surgeons in Melbourne who do spinal surgery you could see privately.
As I have told you I am an orthopaedic surgeon who has done extra training in spinal surgery. I am not the oldest, or the most experienced surgeon in Melbourne. However I am very well qualified and experienced in this surgery.
Your signature on this letter, with initials on every page must be returned to the hospital on the day of surgery. You should keep a copy for yourself. Your signature is acknowledgement of that you have read and understood the document; that you request the proposed surgery, and that you give me permission to perform the surgery and the Hospital to look after you during and after the surgery.
Yours sincerely,
Mr Michael Knight
MBBS FAOA
Signature:...........................................................
Date: ............./................/................................
CONSENT FOR AN OPERATION -
Microdiscectomy and Nerve Root Decompression (Rhizolysis)
,
You have a problem of an acute @@@ disc prolapse with neurogenic pain in the @@@ leg and foot.
I have made this diagnosis based on my examination of you, the story you have told me, and the imaging available.
I am able to offer you 2 choices of treatment.
First option.
Continue to manage the problem non-surgically. That would mean decreasing your activity; both social and physical, to meet you level of disability and pain.
You would need to rely on medication, and psychological interventions.
Patients can get better by just waiting. It can take up to 2 years to fully recover.
For 80% of patients at 2 years there is very little difference between those who wait and those who have surgery. However the path they travel to get there is very different.
The use of physical therapy, chiropractic, and alternative health interventions have NOT been shown to be useful in the management of disc herniation and nerve root compression, based on controlled trials in the scientific literature. They may give you short term pain relief, and this is not a bad thing, but they cannot provide you with a permanent cure.
While there can be no surgical complications if there is no surgery, non-surgical treatment is not always the safest alternative.
It is uncommon for your condition to deteriorate to the point you can no longer care for yourself. Deterioration to this level is usually reversible if it is caught early, but I cannot guarantee this will be the case.
Uncommonly there can be progression of your disc problem resulting in permanent nerve damage, even as extreme as paraplegia and loss of bladder and bowel control. I do not expect this will be the case with you.
There are people who do not get better with time.
The risk of waiting is that the nerve develops a "memory" of the pain. In this situation even with eventual surgery the pain does not go away, and the muscles do not recover.
These patients should have had early surgery, but we have no way of knowing whether you are one of these patients or not.
Second option.
Undergo removal of disc fragment (microdiscectomy) and release nerve from it entrapped corner by making more space for it (nerve root decompression or rhizolysis).
This has been shown to give better results, faster for the majority of patients.
While this operation requires a high level of skill and training to perform, it is NOT a major insult to your body.
Most patients get better very quickly.
Very few patients have any complications, and even if the do have a complication it is usually minor and reversible.
The Operation
In this operation you are given an anaesthetic. You will be completely asleep. . At least one “drips” (intravenous and possibly intra-arterial catheters) will be placed in your upper limbs. You will be rolled onto your stomach on a special table.
A cut (incision) will be made in the middle of your back over the location of your problem. A portable x-ray machine will be used to make sure I know which level of the spine I am operating upon.
I will push the muscles off the spinal bones (vertebrae) and I will remove some of the bone knobs/spurs, ligaments and remove the disc herniation.
This process will cause very little bleeding. Only very rarely would we need to give you some blood from the blood bank.
The nerves will be protected during the surgery.
The wound is then washed out to remove any bacteria that has fallen in from your skin, and closed with sutures (stitches). Most of the suture is dissolvable and below the skin.
You will be rolled onto your back and woken up. Once you are awake enough to breathe for yourself you will be transferred to the recovery room.
The Outcome:
Immediately after the surgery you will not be too sore because you will have lots of medication in your system. The first 48 hrs will usually be blissful, as you will have no pain and think you are cured.
Unfortunately as the local anaesthetic wears off the pain will increase. Many people describe the third 24 hrs as very painful.
This settles quickly, and you will be provided with lots more pain relieving medication.
The day after surgery you will be expected to get up and stand. You are allowed to walk, or sit. Many patients go home later that next day.
Each day you stay in hospital you will be asked to do more moving, and you will have less pain.
Most patients get some immediate relief of pain/numbness/tingling. However lack of an immediate response does not mean that you will not get better. Most of the improvement in symptoms does not occur until days or weeks after the surgery. If recovery requires the nerves to regrow (in very severe cases), then it can be up to 18 months before the symptoms go away.
It is very common to feel much better for a few days and then for some of the symptoms to come back again. This does not mean that the operation has failed. It means that the ongoing inflammation from the surgery is causing nerve irritation. As the wound heals the pain settles again.
In my experience more than 95% of patients who have surgery for a recent disc herniation have significant improvement. If they didn’t I wouldn’t do the surgery.
Scarring: This is not cosmetic surgery. The wounds are not large, usually less than 3 cm. However the wounds can be obvious initially, but fade to invisible over 12 month.
If you are concerned about this, then you should seek another opinion as I do not do telescopic keyhole spine surgery for this condition.
I used to do telescopic keyhole surgery, however I found that the pain was not less, the radiation dose was greatly increased (if you cannot see with your eyes you have to see with X-rays), and the complication rate with keyhole surgery is greater.
"Keyhole spine surgery" is marketing hype. Unlike the abdomen, or the knee, where there is a cavity that can be expanded to allow true keyhole surgery, the spine is encased in muscle. There is no cavity that can be expanded. "Keyhole" surgery implies that the surgeon makes the smallest possible hole to get to the spine. All spine surgeons do this. No surgeon uses a bigger wound than absolutely necessary. All spine surgery is minimally invasive. No surgeon would do unnecessarily invasive surgery. Try to Google "maximally invasive spinal surgery" it doesn't exist! Some surgeons combine lots of small cuts in the skin to do a complex operation, but under the skin the injury to the patient is exactly the same. It has to be, because the operation is exactly the same. Unfortunately making the incision too small can increase complications. This has been show in several studies of disc surgery, spinal stenosis surgery and fusion surgery. In order to do safe and reliable spine surgery the surgeon has to see what she/he is doing, therefore I call this "appropriate incision surgery".
COMPLICATIONS
SOME PATIENTS ARE NOT BETTER WITH SURGERY, SOME PATIENTS CAN BE WORSE. About 2% of microdiscectomy operations are complicated by an adverse outcome. That is something happens that was not expected, and requires extra treatment.
I will try to cover the most serious complications. However you must note that I will not cover everything. An absolutely comprehensive list is NOT possible. The unexpected can always occur; I cannot warn you about everything.
Adverse risk rate I would estimate to be around 2%. This means that one in every fifty operations incurs an unexpected outcome.
This can be something simple such as a skin infection that resolves with tablet antibiotics, or it may be something extremely dangerous such as a blood clot, or heart attack.
MOST PATIENTS WHO HAVE A SHORT-TERM ADVERSE OUTCOME, STILL HAVE A GOOD LONG TERM OUTCOME.
Death
People have died having this surgery, however the risk of this is about 1 in 100,000 (American Society of Anaesthesiologists Grade 1). To put this in perspective the risk of a fatal car accident in a year is about 1 in 10,000. Or ten times more likely.
Paraplegia
It is possible to make you paraplegic by damaging all the nerves below the level of the surgery.This means you would be unable to walk, and would have no feeling below your waist. You would also not be able to control your bladder or bowel, and would lose normal sexual function. Paraplegia is irreversible. However this would be extremely rare, so rare I cannot put a percentage on this risk.
Dural Tear
The nerves of the spinal canal are enclosed in a fine skin. This is called the dura. This dura keeps the nerves and spinal cord, and brain floating in a bath of fluid called Cerebrospinal Fluid (CSF). It is possible to tear or cut this dura (durotomy) , without damaging the nerves directly. This occurs in about 1 in 200 first time operations and 1 in 10 revision operations. This causes a loss of CSF. These incidental durotomies can be repaired, or sealed. The body makes up the lost fluid in 48 hrs. However during this 48 hours you may have a very severe headache, and you will be required to remain flat in bed. Very rarely the dura doesn't seal up, and further surgery is required to prevent the CSF from leaking continuously.
Risks of all Orthopaedic Surgery
- Death
- Heart Attack
- Stroke
- Blood Clots
- Bleeding requiring blood transfusion
- Blood transfusion causing infection with hepatitis or AIDS
- Lung failure: breathing difficulties
- Kidney failure: unable to make urine, requiring dialysis
- Liver failure: usually caused by an unexpected reaction to a medication
- Bowel paralysis (ileus): a temporary condition caused by fasting and operating through the abdomen
- Superficial Nerve injury - this occurs in the skin when an incision is made causing permanent numbness.
- Major Nerve Injury - In spinal surgery damage to a single nerve in the spinal canal can have permanent paralysing effects on a group of muscles. This is rare, but usually irreversible.
Failure to improve.
Despite a technically perfect operation it can be possible that your symptoms may not improve. I give no guarantee that the surgery will improve any or all of your symptoms. However I believe strongly that you will get better. I would not do the surgery otherwise.
Infection
Some infections are simple to treat. Other infections are a disaster, requiring repeat surgery and removal the implants. Long term antibiotics may also be required.
Your risk to the operating team.
During surgery it is possible for one of the operating team to cut themselves on a needle or other sharp object that has your blood on it. Blood can transmit infection from you to the staff member. There are drugs that can be given to the staff member to stop infection but they can only be given if your blood is tested for possible infection. I require you to give permission for taking and testing of your blood in the unlikely event that such an injury occurs. The blood will be tested for Hepatitis, and the Aids Virus (HIV). If you don't feel that you can give this permission then please discuss this with me. Your signature on this document serves as permission for this testing.
I have covered what I think is the most dangerous and the most concerning. If you have anything else you would like to discuss you can do so by contacting me.
SUMMARY
This document is a consent form.
You must read it thoroughly. I have sent you extra copies to give to your GP. I would strongly suggest that you have a friend, or relative read this with you. You may even wish to get a lawyer to read it.
If you have any concerns you should not proceed with the surgery and I would advise you to get another opinion from another spinal surgeon. Public hospitals with fully trained spinal surgeons include the AUSTIN HOSPITAL, THE ROYAL MELBOURNE HOSPITAL, MONASH MEDICAL CENTRE, and THE ALFRED HOSPITAL. All of these hospitals have public clinics you could visit. There are both neurosurgeons and other orthopaedic surgeons in Melbourne who do spinal surgery you could see privately.
As I have told you, I am an orthopaedic surgeon who has done extra training in spinal surgery. I am not the oldest, or the most experienced surgeon in Melbourne. However I am very well qualified and experienced in this surgery.
Your signature on this letter, with initials on every page must be in my office before the day of surgery. You should keep a copy for yourself. Your signature is acknowledgement of that you have read and understood the document; that you request the proposed surgery, and that you give me permission to perform the surgery and the Hospital to look after you during and after the surgery.
Yours Sincerely,
Dr. Michael KNIGHT
MBBS FAOA
Signature:...................................................Date:....../......../........
Dear ,
You have a problem of spinal canal stenosis with neurogenic claudication.
That is: Ageing has caused deterioration of the disc joints (intervertebral discs) and the small joints (facet joints) of your spine. This wearing out causes knobs of bone (osteophytes or bone spurs) to form on the joints. These knobs point in toward the spinal cord putting pressure on it. This pressure is increased when you stand or walk. This causes pain, numbness and altered feeling in the back, the buttocks, and also in the legs. This is caused by temporary nerve damage that goes away when you sit down again.
If the pain/numbness/tingling does not improve with sitting or laying then this is indicates some ongoing nerve damage.
Any loss of bladder or bowel control is an EMERGENCY. This requires immediate surgery or the loss can be permanent.
The levels affected are.....
I have made this diagnosis based on my examination of you, the story you have told me, and the imaging available.
I am able to offer you 2 choices of treatment.
First option.
Continue to manage the problem non-surgically. That would mean gradually decreasing your activity; both social and physical, to meet you level of disability. You will need to rely on medication, and psychological interventions.
The use of physical therapy, chiropractic, and alternative health interventions have not been shown to be useful in the management of spinal canal stenosis, based on controlled trials in the scientific literature. They may give you short term pain relief, and this is not a bad thing, but they cannot provide you with a permanent cure.
With this condition non-surgical treatment is NOT necessarily the safest alternative.
There can be no surgical complications if there is no surgery.
However your condition may well deteriorate to the point you can no longer care for yourself.
This occurs in about 1/3 of cases, and there is no way of telling which patients will deteriorate. Deterioration in this condition is usually reversible if it is caught early, but I cannot guarantee this will be the case.
Second option.
Undergo spinal canal decompression.
This operation is sometimes called a "Laminectomy"
The Operation
In this operation you are given an anaesthetic. You will be completely asleep. While you are asleep a drainage tube (urinary catheter) will be placed in your bladder. At least two “drips” (intravenous and intra-arterial catheters) will be placed in your upper limbs. You will be rolled onto your stomach on a special table. A cut (incision) will be made in the middle of your back over the location of your problem. A portable x-ray machine will be used to make sure I know which level of the spine I am operating upon. I will push the muscles off the spinal bones (vertebrae) and I will remove some of the bone knobs/spurs, ligaments and joints to allow the spinal canal to recover its normal volume. This process will cause bleeding. We will give you fluid to replace the blood, but may need to give you some blood from the blood bank. The nerves will be protected during the surgery.
The wound is then washed out to remove any bacteria that has fallen in from your skin, and closed with stitches(suture ). Most of the stitches are dissolvable and below the skin. Only the skin stitches needs to be removed. This is because removable stitches have a better cosmetic result, and less infection than dissolvable skin stitches or staples.
You will be rolled onto your back and woken up. Once you are awake enough to breathe for yourself you will be transferred to the recovery room. Once you are awake enough to move your legs I shall ring your nominated next of kin and tell them that you are OK.
The Outcome:
Immediately after the surgery you will not be too sore because you will have lots of medication in your system. As this wears off the pain will increase. It can take up to 3 days for the pain to reach a maximum.
Fortunately with good treatment this pain settles quickly, and you will be provided with lots more pain relieving medication.
The day after surgery you will be expected to get up and stand. You are allowed to walk, or sit; however you probably will not feel like it. Each day you will be asked to do more moving, and you will have less pain. Once you can safely and comfortably get to the toilet the urinary catheter will be removed. Once you can safely move around the ward you will be assessed for rehabilitation. Most patients go to rehabilitation.
Most patients get some immediate relief of pain/numbness/tingling. However lack of an immediate response does not mean that you will not get better. Most of the improvement in symptoms does not occur until days or weeks after the surgery. If recovery requires the nerves to regrow (in very severe cases), then it can be up to 18 months before the symptoms go away. It is very common to feel much better for a few days and then some of the symptoms come back again. This does not mean that the operation has failed. It means that the ongoing inflammation from the surgery is causing nerve irritation. As the wound heals the pain settles again. In my experience more than 90% of patients with spinal canal stenosis have significant improvement. If they didn’t I wouldn’t do the surgery.
Reoperation
Unfortunately the removal of bone from the spine to make more room for the nerves does weaken the connection between the bones. In 10 to 20% of patients this may result in a slippage of one bone on the other, causing recurrent symptoms. This can be prevented by undertaking a spinal fusion. However if everyone having this surgery also had a spinal fusion then 80-90 % of patient would be having an operation they didn't need. Therefore in a small number of patients this slippage will cause recurrent symptoms and they will need another operation for fusing the bones together.
Scarring: This is not cosmetic surgery. The wounds are obvious initially, but usually fade to invisible over 12 months. If you are concerned about this, then talk to me about it.
"Keyhole spine surgery" is marketing hype. Unlike the abdomen, or the knee, where there is a cavity that can be expanded to allow true keyhole surgery, the spine is encased in muscle. There is no cavity that can be expanded. "Keyhole" surgery implies that the surgeon makes the smallest possible hole to get to the spine. All spine surgeons do this. No surgeon uses a bigger wound than absolutely necessary. All spine surgery is minimally invasive. No surgeon would do unnecessarily invasive surgery. Try to Google "maximally invasive spinal surgery" it doesn't exist! Some surgeons combine lots of small cuts in the skin to do a complex operation, but under the skin the injury to the patient is exactly the same. It has to be, because the operation is exactly the same. Unfortunately making the incision too small can increase complications. This has been show in several studies of disc surgery, spinal stenosis surgery and fusion surgery. In order to do safe and reliable spine surgery the surgeon has to see what she/he is doing, therefore I call this "appropriate incision surgery".
COMPLICATIONS
SOME PATIENTS ARE NOT BETTER WITH SURGERY, SOME PATIENTS CAN BE WORSE.
About 5% of spinal decompression operations are complicated by an adverse outcome. That is something happens that was not expected, and requires extra treatment.
I will try to cover the most serious complications. However you must note that I will not cover everything. An absolutely comprehensive list is NOT possible. The unexpected can always occur; I cannot warn you about everything.
Complication rate is around 5%. This means that one in every twenty operations incurs an unexpected problem.
This can be something simple such as a skin infection that resolves with tablet antibiotics, or it may be something extremely dangerous such as a blood clot, or heart attack.
MOST COMPLICATIONS ARE REVERSIBLE AND THE PATIENTS STILL HAVE A GOOD RESULT.
Death
People have died having this surgery, however the risk of this is about 1 in 10,000 (American Society of Anaesthesiologists Grade 2). To put this in perspective the risk of a fatal car accident in a year is about 1 in 10,000. Or about as likely.
Paraplegia
This is a very rare complication. It is possible to make you paraplegic by damaging all the nerves below the level of the surgery. This means you would be unable to walk, and would have no feeling below your waist. You would also not be able to control your bladder or bowel, and would lose normal sexual function. Paraplegia is irreversible. However this would be extremely rare, so uncommon that I cannot put a percentage on this risk.
Dural Tear
The nerves of the spinal canal are enclosed in a fine skin. This is called the dura. This dura keeps the nerves and spinal cord, and brain floating in a bath of fluid called Cerebrospinal Fluid (CSF). It is possible to tear or cut this dura (durotomy) , without damaging the nerves directly. This occurs in about 1 in 200 first time operations and 1 in 10 revision operations. This causes a loss of CSF. These incidental durotomies can be repaired, or sealed. The body makes up the lost fluid in 48 hrs. However during this 48 hours you may have a very severe headache, and you will be required to remain flat in bed. Very rarely the dura doesn't seal up, and further surgery is required to prevent the CSF from leaking continuously.
Risks of all Orthopaedic Surgery
Death
Heart Attack
Stroke
Blood Clots
Bleeding requiring blood transfusion
Blood transfusion causing infection with hepatitis or AIDS
Lung failure: breathing difficulties
Kidney failure: unable to make urine, requiring dialysis
Liver failure: usually caused by an unexpected reaction to a medication
Bowel paralysis (ileus): a temporary condition caused by fasting and operating through the abdomen
Superficial Nerve injury - this occurs in the skin when an incision is made causing permanent numbness.
Major Nerve Injury - In spinal surgery damage to a single nerve in the spinal canal can have permanent paralysing effects on a group of muscles. This is rare, but usually irreversible.
Failure to improve.
Despite a technically perfect operation it can be possible that your symptoms may not improve. I give no guarantee that the surgery will improve any or all of your symptoms. However I believe strongly that you will get better. I would not do the surgery otherwise.
Infection
Some infections are simple to treat. Other infections are a disaster, requiring repeat surgery and removal the implants. Long term antibiotics may also be required.
Your risk to the operating team.
During surgery it is possible for one of the operating team to cut themselves on a needle or other sharp object that has your blood on it. Blood can transmit infection from you to the staff member. There are drugs that can be given to the staff member to stop infection but they can only be given if your blood is tested for possible infection. I require you to give permission for taking and testing of your blood in the unlikely event that such an injury occurs. The blood will be tested for Hepatitis, and the Aids Virus (HIV). If you don't feel that you can give this permission then please discuss this with me. Your signature on this document serves as permission for this testing.
I have covered what I think is the most dangerous and the most concerning. If you have anything else you would like to discuss you can do so by contacting me.
SUMMARY
This document is a consent form.
You must read it thoroughly. I have sent you extra copies to give to your GP. I would strongly suggest that you have a friend, or relative read this with you. You may even wish to get a lawyer to read it.
If you have any concerns you should not proceed with the surgery and I would advise you to get another opinion from another spinal surgeon. Public hospitals with fully trained spinal surgeons include the AUSTIN HOSPITAL, THE ROYAL MELBOURNE HOSPITAL, MONASH MEDICAL CENTRE, and THE ALFRED HOSPITAL. All of these hospitals have public clinics you could visit. There are both neurosurgeons and other orthopaedic surgeons in Melbourne who do spinal surgery you could see privately.
As I have told you I am an orthopaedic surgeon who has done extra training in spinal surgery. I am not the oldest, or the most experienced surgeon in Melbourne. However I am very well qualified and experienced in this surgery.
Your signature on this letter, with initials on every page must be returned to the hospital on the day of surgery. You should keep a copy for yourself. Your signature is acknowledgement of that you have read and understood the document; that you request the proposed surgery, and that you give me permission to perform the surgery and the Hospital to look after you during and after the surgery.
Yours Sincerely,
Dr. Michael KNIGHT ..................................
MBBS FAOA
Date:......../........../..........
You have a problem of multilevel central and foraminal spinal canal stenosis with neurogenic claudication.
That is: Ageing has caused deterioration of the disc joints (intervertebral discs) and the small joints (facet joints) of your spine. This wearing out causes knobs of bone (osteophytes or bone spurs) to form on the joints. These knobs point in toward the spinal cord putting pressure on it. This pressure is increased when you stand or walk. This causes pain, numbness and altered feeling in the back, the buttocks, and also in the legs. This is caused by temporary nerve damage that goes away when you sit down again.
If the pain/numbness/tingling does not improve with sitting or laying then this indicates some ongoing nerve damage. Any loss of bladder or bowel control is an EMERGENCY. This requires immediate surgery or the loss can be permanent.
I have made this diagnosis based on my examination of you, the story you have told me, and the imaging available.
I am able to offer you 2 choices of treatment.
First option.
Continue to manage the problem non-surgically. That would mean gradually decreasing your activity; both social and physical, to meet you level of disability. You will need to rely on medication, and psychological interventions.
The use of physical therapy, chiropractic, and alternative health interventions have not been shown to be useful in the management of spinal canal stenosis, based on controlled trials in the scientific literature. They may give you short term pain relief, and this is not a bad thing, but they cannot provide you with a permanent cure.
With this condition non-surgical treatment is NOT necessarily the safest alternative. While there can be no surgical complications if there is no surgery, your condition may well deteriorate to the point you can no longer care for yourself. This occurs in about 1/3 of cases, and there is no way of telling which patients will deteriorate. Deterioration in this condition is usually reversible if it is caught early, but I cannot guarantee this will be the case.
Second option.
Undergo spinal canal decompression and stabilisation.
The Operation
In this operation you are given an anaesthetic. You will be completely asleep. While you are asleep a drainage tube (urinary catheter will be placed in your bladder. At least two “drips” (intravenous and intra-arterial catheters) will be placed in your upper limbs. You will be rolled onto your stomach on a special table. A cut (incision) will be made in the middle of your back over the location of your problem. A portable x-ray machine will be used to make sure I know which level of the spine I am operating upon. I will push the muscles off the spinal bones (vertebrae) and I will remove some of the bone knobs/spurs, ligaments and joints to allow the spinal canal to recover its normal volume. This process will cause bleeding. We will give you fluid to replace the blood, but may need to give you some blood from the blood bank. The nerves will be protected during the surgery.
The amount of bone that needs to be removed will result in unstable movement of the spine. Untreated, it will cause further problems. In this circumstance you will need the spine to be fused together to keep it stable. Fusion is when the bones grow together to be one living structure. Surgery creates an environment for fusion to occur, by making the bones think they were broken apart and need to joint back up together. I use screws, rods and titanium spacers to hold the spine in the correct position while fusion occurs. Fusion takes over 12 months in many adults, and does not occur in approximately 10 % of non-smokers (Smokers almost universally fail to fuse)
The wound is then washed out to remove any bacteria that has fallen in from your skin, and closed with sutures (stitches). The suture is dissolvable and below the skin.
You will be rolled onto your back and woken up. Once you are awake enough to breathe for yourself you will be transferred to the recovery room. Once you are awake enough to move your legs I shall ring your nominated next of kin and tell them that you are OK.
The Outcome:
Immediately after the surgery you will not be too sore because you will have lots of medication in your system. As this wears off the pain will increase. Many people describe the first 24 hrs as very painful.
This pain usually settles quickly, and you will be provided with lots more pain relieving medication. The day after surgery you will be expected to get up and stand. You are allowed to walk, or sit; however you probably will not feel like it. Each day you will be asked to do more moving, and you will have less pain. Once you can safely and comfortably get to the toilet the urinary catheter will be removed. Once you can safely move around the ward you will be assessed for rehabilitation. Most patients go to rehabilitation.
Most patients get some immediate relief of pain/numbness/tingling. However lack of an immediate response does not mean that you will not get better. Most of the improvement in symptoms does not occur until days or weeks after the surgery. If recovery requires the nerves to regrow (in very severe cases), then it can be up to 18 months before the symptoms go away. It is very common to feel much better for a few days and then some of the symptoms come back again. This does not mean that the operation has failed. It means that the ongoing inflammation from the surgery is causing nerve irritation. As the wound heals the pain settles again. In my experience more than 90% of patients with spinal canal stenosis have significant improvement. If they didn’t I wouldn’t do the surgery.
Scarring: This is not cosmetic surgery. The wounds are obvious initially, but usually fade to invisible over 12 months. If you are concerned about this, then talk to me about it.
"Keyhole spine surgery" is marketing hype. Unlike the abdomen, or the knee, where there is a cavity that can be expanded to allow true keyhole surgery, the spine is encased in muscle. There is no cavity that can be expanded. "Keyhole" surgery implies that the surgeon makes the smallest possible hole to get to the spine. All spine surgeons do this. No surgeon uses a bigger wound than absolutely necessary. All spine surgery is minimally invasive. No surgeon would do unnecessarily invasive surgery. Try to Google "maximally invasive spinal surgery" it doesn't exist! Some surgeons combine lots of small cuts in the skin to do a complex operation, but under the skin the injury to the patient is exactly the same. It has to be, because the operation is exactly the same. Unfortunately making the incision too small can increase complications. This has been show in several studies of disc surgery, spinal stenosis surgery and fusion surgery. In order to do safe and reliable spine surgery the surgeon has to see what she/he is doing, therefore I call this "appropriate incision surgery".
COMPLICATIONS
SOME PATIENTS ARE NOT BETTER WITH SURGERY, SOME PATIENTS CAN BE WORSE. About 5% of spinal operations are complicated by an adverse outcome. That is something happens that was not expected, and requires extra treatment.
I will try to cover the most serious complications. However you must note that I will not cover everything. An absolutely comprehensive list is NOT possible. The unexpected can always occur; I cannot warn you about everything.
Adverse risk rate I would estimate to be around 5%. This means that one in every twenty operations incurs an unexpected outcome.
This can be something simple such as a skin infection that resolves with tablet antibiotics, or it may be something extremely dangerous such as a blood clot, or heart attack.
Death
People have died having this surgery, however the risk of this is about 1 in 100,000 (American Society of Anaesthesiologists Grade 1). To put this in perspective the risk of a fatal car accident in a year is about 1 in 10,000. Or ten times more likely.
Paraplegia
It is possible to make you paraplegic by damaging all the nerves below the level of the surgery.This means you would be unable to walk, and would have no feeling below your waist. You would also not be able to control your bladder or bowel, and would lose normal sexual function. Paraplegia is irreversible. However this would be extremely rare, so rare I cannot put a percentage on this risk.
Dural Tear
The nerves of the spinal canal are enclosed in a fine skin. This is called the dura. This dura keeps the nerves and spinal cord, and brain floating in a bath of fluid called Cerebrospinal Fluid (CSF). It is possible to tear or cut this dura (durotomy) , without damaging the nerves directly. This occurs in about 1 in 200 first time operations and 1 in 10 revision operations. This causes a loss of CSF. These incidental durotomies can be repaired, or sealed. The body makes up the lost fluid in 48 hrs. However during this 48 hours you may have a very severe headache, and you will be required to remain flat in bed. Very rarely the dura doesn't seal up, and further surgery is required to prevent the CSF from leaking continuously.
Risks of all Orthopaedic Surgery
Death
Heart Attack
Stroke
Blood Clots
Bleeding requiring blood transfusion
Blood transfusion causing infection with hepatitis or AIDS
Lung failure: breathing difficulties
Kidney failure: unable to make urine, requiring dialysis
Liver failure: usually caused by an unexpected reaction to a medication
Bowel paralysis (ileus): a temporary condition caused by fasting and operating through the abdomen
Superficial Nerve injury - this occurs in the skin when an incision is made causing permanent numbness.
Major Nerve Injury - In spinal surgery damage to a single nerve in the spinal canal can have permanent paralysing effects on a group of muscles. This is rare, but usually irreversible.
Failure to improve.
Despite a technically perfect operation it can be possible that your symptoms may not improve. I give no guarantee that the surgery will improve any or all of your symptoms. However I believe strongly that you will get better. I would not do the surgery otherwise.
Infection
Some infections are simple to treat. Other infections are a disaster, requiring repeat surgery and removal the implants. Long term antibiotics may also be required.
Your risk to the operating team.
During surgery it is possible for one of the operating team to cut themselves on a needle or other sharp object that has your blood on it. Blood can transmit infection from you to the staff member. There are drugs that can be given to the staff member to stop infection but they can only be given if your blood is tested for possible infection. I require you to give permission for taking and testing of your blood in the unlikely event that such an injury occurs. The blood will be tested for Hepatitis, and the Aids Virus (HIV). If you don't feel that you can give this permission then please discuss this with me. Your signature on this document serves as permission for this testing.
I have covered what I think is the most dangerous and the most concerning. If you have anything else you would like to discuss you can do so by contacting me.
SUMMARY
This document is a consent form.
You must read it thoroughly. I have sent you extra copies to give to your GP. I would strongly suggest that you have a friend, or relative read this with you. You may even wish to get a lawyer to read it.
If you have any concerns you should not proceed with the surgery and I would advise you to get another opinion from another spinal surgeon. Public hospitals with fully trained spinal surgeons include the AUSTIN HOSPITAL, THE ROYAL MELBOURNE HOSPITAL, MONASH MEDICAL CENTRE, and THE ALFRED HOSPITAL. All of these hospitals have public clinics you could visit. There are both neurosurgeons and other orthopaedic surgeons in Melbourne who do spinal surgery you could see privately.
As I have told you, I am an orthopaedic surgeon who has done extra training in spinal surgery. I am not the oldest, or the most experienced surgeon in Melbourne. However I am very well qualified and experienced in this surgery.
Your signature on this letter, with initials on every page must be in my office before the day of surgery. You should keep a copy for yourself. Your signature is acknowledgement of that you have read and understood the document; that you request the proposed surgery, and that you give me permission to perform the surgery and the Hospital to look after you during and after the surgery.
Yours Sincerely,
MBBS FAOA
Signature: ...................................................
Date:.............../.................../......................
CONSENT FOR REMOVAL OF METAL IMPLANTS
Dear ,
You have a problem of pain in your ****. It is most likely that this pain is arising from the prominence of the metal fixation device in your ****.
You have failed to respond to maximal conservative therapy. That is all the treatment options, apart from surgery, that you have used, have not given you any long-term benefit.
You told me that this pain is constant and interferes with the quality of your life. This is a problem for you daily. You told me that if you did not have this pain your life would be much improved.
I am able to offer you 2 choices of treatment.
First option.
Continue to manage the problem non-surgically. That would mean gradually decreasing your activity, both social and physical to fit your pain. It may mean relying on medication, and psychological interventions.
Non-operative management is always the safest alternative. There can be no surgical complications if there is no surgery.
Second option.
Undergo removal of metal
The Operation.
You will undergo pre-operative wash with an aqueous chlorhexidine detergent preparation. Clean hospital clothing will be given to you to wear to the operating theatre.
The anaesthetist will give you an anaesthetic.
Your *** will be marked by me, and we will keep checking this is the correct site until you go to sleep.
All your bony prominences will be padded to prevent injury. You will be washed down with an anaesthetic solution, and plastic drapes will keep the area as sterile as possible.
An incision will be made through your previous scar. This will NOT be a cosmetic incisions. I do not do “keyhole” surgery. I should be able to utilise the previous scars, without creating new scars or longer scars, but I do not guarantee this.
I shall remove all the metal implants that I can without substantially damaging the bone, however it often requires some removal of bone to achieve metal removal.
The wounds will be closed with sutures.
The skin will be closed with a combination of dissolving and non-dissolving suture material. I have found this combination to cause the least problems with scarring and infection.
The reason this operation works is that removing prominent metal implants prevents pain caused by compression of the skin overlying the implants. However there is no guarantee that your pain will resolve. It maybe that the pain is coming from the joints or bones themselves, and that removing the metal may not help you.
SOME PATIENTS ARE NOT BETTER WITH SURGERY, SOME PATIENTS CAN BE WORSE.
About 14% of removal of metal operations are complicated by an adverse outcome. That is something happens that was not expected, and requires extra treatment. This does not mean that in the end a good result will not occur. Indeed most of these adverse outcomes are only minor problems such as wound pain or skin infection. It does mean that extra work may be required to achieve a good outcome.
ADVERSE OUTCOMES - COMPLICATIONS
I will try to cover the most serious. However you must note that I will not cover everything. An absolutely comprehensive list is NOT possible. The unexpected can always occur, I cannot warn you about everything.
Adverse risk rate I would estimate to be around 14%. This means that one in every six operations incurs an unexpected outcome.
This can be something simple such as a superficial wound infection that resolves with oral antibiotics, or it may be something extremely dangerous such as a blood clot, or heart attack.
People have died having this surgery, however the risk of this is about 1 in 100,000 (American Society of Anaesthesiologists Grade 1) for healthy patients. The risk of a fatal car accident is about 1 in 15,000 per year.
Anaesthetics carry risk. This risk should be discussed with your anaesthetist.
Risks of all Orthopaedic Surgery
Death
Heart Attack
Stroke
Blood Clots
Bleeding requiring blood transfusion
Blood transfusion causing infection with hepatitis or AIDS
Lung failure : breathing difficulties
Kidney failure : unable to make urine, requiring dialysis
Liver failure: usually caused by an unexpected reaction to a medication
Bowel paralysis (ileus): a temporary condition caused by fasting
Nerve injury - this occurs in the skin when an incision is made causing permanent numbness.
Failure to improve.
Despite a technically perfect operation it can be possible that your symptoms may not improve. I give no guarantee that the surgery will improve any or all of your symptoms. However I believe strongly that you will get better. I would not do the surgery otherwise.
Infection: most infections are simple to treat and do not affect long term outcome. A very severe infection could result in loss of life or limb. This is a very rare.
PAIN: post operative pain after surgery is very common. It can take 3 months for this to settle down. If you don't think you pain is being adequately treated you MUST let me know.
Your risk to the operating team.
During surgery it is possible for one of the operating team to cut themselves on a needle or other sharp object that has your blood on it. Blood can transmit infection from you to the staff member. There are drugs that can be given to the staff member to stop infection but they can only be given if your blood is tested for possible infection. I require you to give permission for taking and testing of your blood in the unlikely event that such an injury occurs. The blood will be tested for Hepatitis, and the Aids Virus (HIV). If you don't feel that you can give this permission then please discuss this with me. Your signature on this document serves as permission for this testing.
As I said earlier in this letter. There are always complications that I cannot think about or cannot warn you about. I have covered what I think is the most common, the most dangerous, and the most concerning. If you have anything else you would like to discuss you can do so by contacting me.
SUMMARY
This document is a consent form.
You must read it thoroughly. I have given you an extra copy to give to your GP. I would strongly suggest that you have a friend, or relative read this with you. You may even wish to get a lawyer to read it. If you have any concerns you should not proceed with the surgery. I would advise you to get another opinion from another surgeon if you have any concerns. Public hospitals with fully trained orthopaedic surgeons include the AUSTIN HOSPITAL, THE ROYAL MELBOURNE HOSPITAL, MONASH MEDICAL CENTRE, and THE ALFRED HOSPITAL. All of these hospitals have public clinics you could visit.
As I have told you, I am an orthopaedic surgeon. However clearly I am not the oldest or busiest surgeon in Melbourne. You must consider this in deciding who does your surgery.
Your signature on this letter, with initials on every page must be returned to my office before the day of surgery. You should keep a copy for yourself. Your signature is acknowledgement of that you have read and understood the document; that you request the proposed surgery, and that you give me permission to perform the surgery and the Hospital to look after you during and after the surgery.
Yours sincerely,
Dr. Michael KNIGHT
MBBS FAOA
Signature: .................................................
Date:............../................./..................
CONSENT FOR LUMBAR FACET JOINT RADIOFREQUENCY NEUROTOMY (RFN)
Dear ,
You have facet joint osteoarthrosis that causes mechanical low back pain.
In plain English this means:
Ageing has caused deterioration of the large disc joints (intervertebral discs) and the small joints (facet joints) of your spine. This wearing out causes knobs of bone (osteophytes or bone spurs) to form on these joints. It also causes the joints to change in shape. This is no different from a worn out knee, or hip, or shoulder. The pain you get is from the movement of these worn out joints. The pain is not from pressure on the nerves in the spine. Sometimes this is called osteoarthritis, but this is not accurate. (Arthritis is a disease that occurs when the joint lining becomes red and angry, not just worn down.)
I have made this diagnosis based on my examination of you, the story you have told me, and the imaging available.
Unfortunately there is no cure for this condition. That would require a cure for ageing. There is no joint replacement for the facet joints of the spine. Experimental work in this area is often reported in the media, but these reports are a long way ahead of reality.
The only option for facet joint wear and tear is pain management.
Pain management takes many forms.
Non-medical options include active and passive therapies. Active pursuits such as physical strength training, or exercise work by training muscles to hold your joints in such a way as to avoid pain. There are certain postural philosophies that help in a similar way. You can find these in books written by Robin McKenzie, and Hamilton Hall. Active therapy is the safest way to achieve long term pain relief.
Passive therapies are physiotherapy, chiropractic, osteopathy, massage etc. These all rely on someone doing something to you. These have only been shown to be useful for short period. They never provide long term relief. However there is nothing wrong with short term relief if you have the time and money to have continued treatments.
Medical pain management takes 3 forms. Psychological, Medication or
Procedural. Psychological treatment is not my area of expertise but involves getting your brain to accept that your pain is not going to kill you, and therefore it shouldn't hurt anymore. Medication is just that. It is the use of drugs to remove pain. Anti-inflammatories are the most commonly used, but probably don't provide any long term benefit. They are useful in short bursts of a few weeks. Panadol taken up to 4000mg per day can be useful if taken every 4 hours. Stronger medication is addictive and should only be used after surgery or by experts in medical pain management.
Procedural options are limited. Spinal fusion for back pain has been shown to be useful in only about 70% of cases were all other options have failed. It is a big operation that takes 12 months to get over, and only about 5-10% of patients get back to work, even if their pain is improved. So it is a last resort.
Radiofrequency neurotomy(RFN) (using electricity to damage a nerve's ability to conduct information), is a low risk, rapid recovery procedure that is performed as a day procedure. Most patients return to work within a week. Most have long term benefit. Properly performed it has an extremely low risk of side-effects.
You are given a sedating drug. You are rolled onto your stomach on a special table. Using an X-ray machine the facet joints are identified. Local anaesthetic is placed in the skin - this hurts a bit. A big needle is then used to put a fine wire against the facet joint. The nerve that supplies the joint with pain sensations lies here. The wire has a small current placed down it first. This does not cause any damage but makes muscles move. If the leg muscles move then the wire is relocated, until there are no leg movements. Then a stronger current is placed down the wire. This heats the nerve to 80 degrees. Remember that it takes 100 degrees to cook an egg, so the nerve is not destroyed. Like a long day in the sun makes you skin turn red, a 80 degree heating causes the nerve to stop conducting pain. Just like a sun burn, eventually you regrow new nerve fibres and the nerve starts working again. This takes 12 to 36 months.
So if this is so easy and so safe why doesn't every one get this procedure?
It doesn't always work. In the laboratory this should always work, but the human body is more complex than a lab. If this RFN doesn't work I won't be able to tell you specifically why.
The reasons are:
a. That there can be multiple nerves sending pain messages.
b. That sometimes the nerves are in different positions, (there is no way of seeing them on an X-ray),
c. That sometimes other structures are causing the pain.
d. Sometimes pain is caused by multiple worn out parts of the body, and dealing with only one, doesn't allow me to removal all of your pain.
The result of this procedure can be improved by putting you through a series of trial injections to assess your suitability. This requires two sets of injections over 2 weeks followed by the RFN. If either of the first two injections fails then you don't get the RFN. Effectively this means doing the whole procedure 3 times, which is expensive in both time and money. However it does mean a 96% effectiveness rate.
I take a more practical approach. I just do the RFN. It works 75% of the time in patients like you. This means that 25% of patients do not get a good response. I do this very carefully. If it doesn't work the first time, its not worth repeating. It means that I cannot help some people. They have to rely on other options of pain management.
SOME PATIENTS ARE NOT BETTER , SOME PATIENTS CAN BE WORSE.
COMPLICATIONS
I will try to cover the most serious. However you must note that I will not cover everything. An absolutely comprehensive list is NOT possible. The unexpected can always occur; I cannot warn you about everything.
Adverse risk rate I would estimate to be around 1 in 5000.
I have never had a complication of this procedure.
This does not mean that it won't happen.
An Adverse Event can be something simple such as a skin infection that resolves with tablet antibiotics, or it may be something extremely dangerous such as a blood clot, or heart attack.
People have died having this procedure, however the risk of this is about 1 in 100,000 (American Society of Anaesthesiologists Grade 1). To put this in perspective the risk of a fatal car accident in a year is about 1 in 10,000. Or ten times more likely. All deaths have been related to underlying medical problems that get worse under anaesthesia.
Risks of all Orthopaedic Surgery
Death
Heart Attack
Stroke
Blood Clots
Bleeding requiring blood transfusion
Blood transfusion causing infection with hepatitis or AIDS
Lung failure: breathing difficulties
Kidney failure: unable to make urine, requiring dialysis
Liver failure: usually caused by an unexpected reaction to a medication
Bowel paralysis (ileus): a temporary condition caused by fasting and operating through the abdomen
Superficial Nerve injury - this occurs in the skin when an incision is made causing permanent numbness.
Major Nerve Injury - In spinal surgery damage to a single nerve in the spinal canal can have permanent paralysing effects on a group of muscles. This is rare, but usually irreversible.
Failure to improve.
Despite a technically perfect operation it can be possible that your symptoms may not improve. I give no guarantee that the surgery will improve any or all of your symptoms. However I believe strongly that you will get better. I would not do the surgery otherwise.
Infection
Some infections are simple to treat. Other infections are a disaster, requiring repeat surgery. Long term antibiotics may also be required.
Your risk to the operating team.
During surgery it is possible for one of the operating team to cut themselves on a needle or other sharp object that has your blood on it. Blood can transmit infection from you to the staff member. There are drugs that can be given to the staff member to stop infection but they can only be given if your blood is tested for possible infection. I require you to give permission for taking and testing of your blood in the unlikely event that such an injury occurs. The blood will be tested for Hepatitis, and the Aids Virus (HIV). If you don't feel that you can give this permission then please discuss this with me. Your signature on this document serves as permission for this testing.
I have covered what I think is the most dangerous and the most concerning. If you have anything else you would like to discuss you can do so by contacting me.
SUMMARY
This document is a consent form.
You must read it thoroughly. I have sent a copy to your GP. I would strongly suggest that you have a friend, or relative read this with you. You may even wish to get a lawyer to read it.
If you have any concerns you should not proceed with the procedure and I would advise you to get another opinion from another spinal surgeon. Public hospitals with fully trained spinal surgeons include the AUSTIN HOSPITAL, THE ROYAL MELBOURNE HOSPITAL, MONASH MEDICAL CENTRE, and THE ALFRED HOSPITAL. All of these hospitals have public clinics you could visit. There are both neurosurgeons and other orthopaedic surgeons in Melbourne who do spinal surgery you could see privately.
As I have told you I am an orthopaedic surgeon who has done extra training in spinal surgery. I am not the oldest, or the most experienced surgeon in Melbourne. However I am very well qualified and experienced in this procedure.
Your signature on this letter, with initials on every page must be returned to my office before the day of surgery. You should keep a copy for yourself. Your signature is acknowledgement of that you have read and understood the document; that you request the proposed surgery, and that you give me permission to perform the surgery and the Hospital to look after you during and after the surgery.
Kind regards
Mr Michael Knight
MBBS FAOA
Signature: ........ ........................................
Date: ............/.............../......................
CONSENT FOR CERVICAL FACET JOINT RADIOFREQUENCY NEUROTOMY (RFN)
Dear
You have cervical facet joint osteoarthrosis that causes mechanical neck pain.
In plain English this means:
Ageing has caused deterioration of the disc joints (intervertebral discs) and the small joints (facet joints) of your spine. This wearing out causes knobs of bone (osteophytes or bone spurs) to form on these joints. It also causes the joints to change in shape.
This is no different from a worn out knee, or hip, or shoulder. The pain you get is from the movement of these worn out joints.
The pain is not from pressure on the nerves in the spine.
Sometimes this is called osteoarthritis, but this is not accurate. (Arthritis is a disease that occurs when the joint lining becomes red and angry, not just worn down.)
I have made this diagnosis based on my examination of you, the story you have told me, and the imaging available.
Unfortunately there is no cure for this condition. That would require a cure for ageing.
There is no joint replacement for the facet joints of the spine. Experimental work in this area is often reported in the media, but these reports are a long way ahead of reality.
The only option for facet joint wear and tear is pain management.
Pain management takes many forms.
Non-medical options include active and passive therapies. Active pursuits such as physical strength training, or exercise work by training muscles to hold your joints in such a way as to avoid pain. There are certain postural philosophies that help in a similar way. You can find these in books written by Robin McKenzie, and Hamilton Hall. Active therapy is the safest way to achieve long term pain relief.
Passive therapies are physiotherapy, chiropractic, osteopathy, massage etc. These all rely on someone doing something to you. These have only been shown to be useful for short periods. They never provide long term relief. However there is nothing wrong with short term relief if you have the time and money to have continued treatments.
Medical pain management takes 3 forms. Psychological, Medication and
Procedural.
Psychological treatment is not my area of expertise but involves getting you to accept that the underlying condition is not dangerous, and therefore the pain itself is a problem that should be accepted and managed .
Medication is just that. It is the use of drugs to remove pain. Anti-inflammatories are the most commonly used, but probably don't provide any long term benefit. They are useful in short bursts of a few weeks. Long term anti-inflammatory drugs are dangerous and not recommended. Panadol can be useful if taken every 4 hours, for a maximum of 4000mg (8 tablets) per day. Stronger medication is addictive and should only be used after surgery or by experts in medical pain management.
Procedural options are limited. Spinal fusion for back pain has been shown to be useful in only about 70% of cases were all other options have failed. It is a big operation that takes 12 months to get over, and only about 5-10% of patients get back to work, even if their pain is improved. So it is a last resort.
Radiofrequency neurotomy(RFN) (using electricity to damage a nerve's ability to conduct information), is a low risk, rapid recovery procedure that is performed as a day procedure. Most patients return to work in a week. Most have long term benefit. Properly performed it has an extremely low risk of side-effects.
How RFN is performed.
You are given a general anaesthetic. You are rolled onto your stomach on a special table. Using an X-ray machine the facet joints are identified. Local anaesthetic is placed in the skin. Under X-ray guidance a large needle is used to put a fine wire against the facet joint. The nerve that supplies the joint with pain sensations lies here. The wire has a small current placed down it first. This does not cause any damage but makes muscles move. You are asleep, but we can see your muscles moving. If there is no evidence of incorrect placement, then a stronger current is placed down the wire. This heats the nerve to 75 degrees. Remember that it takes 100 degrees to cook an egg, so the nerve is not destroyed. Like a long day in the sun makes you skin turn red, a 75 degree heating causes the nerve to stop conducting pain. Just like a sun burn, eventually you regrow new nerve fibres and the nerve starts working again. This takes 12 to 36 months.
So if this is so easy and so safe why doesn't every one get this procedure?
It doesn't always work. In the laboratory this should always work, but the human body is more complex than a lab. If this RFN doesn't work I won't be able to tell you specifically why.
The reasons are:
a. That there can be multiple nerves sending pain messages.
b. That sometimes the nerves are in different positions, (there is no way of seeing them on an X-ray),
c. That sometimes other structures are causing the pain.
d. That sometimes pain is caused by multiple worn out parts of the body, and dealing with only one, doesn't allow me to removal all of your pain.
The result of this procedure can be improved by putting you through a series of trial injections to assess your suitability. This requires two sets of injections over 2 weeks followed by the RFN. If either of the first two injections fails then you don't get the RFN. Effectively this means doing the whole procedure 3 times, which is expensive in both time and money. However it does mean a 96% effectiveness rate.
I take a more practical approach. I just do the RFN. It works 75% of the time in patients like you. This means that 25% of patients do not get a good response. I do this very carefully. If it doesn't work the first time, its not worth repeating. It means that I cannot help some people. They have to rely on other options of pain management.
SOME PATIENTS ARE NOT BETTER , SOME PATIENTS CAN BE WORSE.
COMPLICATIONS
I will try to cover the most serious. However you must note that I will not cover everything. An absolutely comprehensive list is NOT possible. The unexpected can always occur; I cannot warn you about everything.
Adverse risk rate I would estimate to be around 1 in 5000.
I have never had a complication of this procedure.
This does not mean that it won't happen.
An adverse Event can be something simple such as a skin infection that resolves with tablet antibiotics, or it may be something extremely dangerous such as a blood clot, or heart attack.
People have died having an anaesthetic, however the risk of this is about 1 in 100,000 (American Society of Anaesthesiologists Grade 1). To put this in perspective the risk of a fatal car accident in a year is about 1 in 17,000. Or five times more likely. All deaths have been related to underlying medical problems that get worse under anaesthesia.
It is theoretically possible to make you quadriplegic by damaging all the nerves below the level of the injection. This has happened only once that I can find reported in medical literature, so I cannot put a percentage on this risk. I believe that this was a gross negligent error in technique and I do not believe this is really a risk.
Risks of all Orthopaedic Procedures
Death
Heart Attack
Stroke
Blood Clots
Bleeding requiring blood transfusion
Blood transfusion causing infection with hepatitis or AIDS
Lung failure: breathing difficulties
Kidney failure: unable to make urine, requiring dialysis
Liver failure: usually caused by an unexpected reaction to a medication
Bowel paralysis (ileus): a temporary condition caused by fasting and operating through the abdomen
Superficial Nerve injury - this occurs in the skin when an incision is made causing permanent numbness.
Major Nerve Injury - In spinal procedures, damage to a single nerve in the spinal canal can have permanent paralysing effects on a group of muscles. This is rare, but usually irreversible.
Failure to improve.
Despite a technically perfect procedure it can be possible that your symptoms may not improve. I give no guarantee that the surgery will improve any or all of your symptoms. However I believe strongly that you will get better. I would not do the procedure otherwise.
Infection
Some infections are simple to treat. Other infections are a disaster, requiring repeat surgery. Long term antibiotics may also be required.
Your risk to the operating team.
During a procedure it is possible for one of the operating team to cut themselves on a needle or other sharp object that has your blood on it. Blood can transmit infection from you to the staff member. There are drugs that can be given to the staff member to stop infection but they can only be given if your blood is tested for possible infection. I require you to give permission for taking and testing of your blood in the unlikely event that such an injury occurs. The blood will be tested for Hepatitis, and the Aids Virus (HIV). If you don't feel that you can give this permission then please discuss this with me. Your signature on this document serves as permission for this testing.
I have covered what I think is the most dangerous and the most concerning. If you have anything else you would like to discuss you can do so by contacting me.
SUMMARY
This document is a consent form.
You must read it thoroughly. I have sent a copy to your GP. I would strongly suggest that you have a friend, or relative read this with you. You may even wish to get a lawyer to read it.
If you have any concerns you should not proceed with the procedure and I would advise you to get another opinion from another spinal surgeon. Public hospitals with fully trained spinal surgeons include the AUSTIN HOSPITAL, THE ROYAL MELBOURNE HOSPITAL, MONASH MEDICAL CENTRE, and THE ALFRED HOSPITAL. All of these hospitals have public clinics you could visit. There are both neurosurgeons and other orthopaedic surgeons in Melbourne who do spinal surgery you could see privately.
As I have told you I am an orthopaedic surgeon who has done extra training in spinal surgery. I am not the oldest, or the most experienced surgeon in Melbourne. However I am very well qualified and experienced in this procedure.
Your signature on this letter, with initials on every page must be returned to the hospital on the day of surgery. You should keep a copy for yourself. Your signature is acknowledgement of that you have read and understood the document; that you request the proposed surgery, and that you give me permission to perform the surgery and the Hospital to look after you during and after the surgery.
Kind regards
Mr Michael Knight .............................................
MBBS FAOA
Dear ,
Your medical diagnosis is:
Developmental Scoliosis of the Thoracolumbar Spine.
In plain English this means:
During the growth phase of your early adolescence your spine did not grow straight. It curved by growing more on one side than the other.
If you think of the "Leaning Tower of Pisa" the the whole structure starts to lean over, and cannot straighten itself up. However more than this there is a twist or rotation causing this change in shape.
The spine normally has a gentle curve backward (lordosis) and forward (kyphosis), that you can only see from side on. From the front the spine should be straight up and down.
You are now curved in both front-to-back and side-to-side directions, and this makes it a 3 dimensional problem.
This imbalance in the spine results in the entire body falling to one side. Therefore the muscles have to try to pull it up straight again. This is very tiring, and painful. It is one of the reasons you are so tired and in pain.
Unfortunately once these changes occur they do not "heal" You cannot just get better. You either learn to accommodate your "new" shape, or else you have to have surgery to correct it.
I have made this diagnosis based on my examination of you, the story you have told me, and the imaging available.
I am able to offer you 2 choices of treatment.
First option.
Continue to manage the problem non-surgically. That would mean gradually decreasing your activity; both social and physical, to meet you level of disability. You will need to rely on medication, and psychological interventions.
The use of physical therapy, chiropractic, and alternative health interventions have not been shown to be useful in the correction of spinal scoliosis, based on controlled trials in the scientific literature. They may give you short term pain relief, and this is not a bad thing, but they cannot provide you with a permanent cure.
Once growth stops the use of braces or strapping CANNOT improve the curve. Bracing and strapping is not a treatment for adults under any circumstances.
With this condition non-surgical treatment is ALWAYS the safest alternative.
There can be no surgical complications if there is no surgery.
Left untreated your condition cannot deteriorate to the point you can no longer care for yourself. The curve may get worse, but you will NEVER be paraplegic if you never have surgery.
Curve progression almost never occurs with curves less than 50 degrees. When curve progression does occur, it is usually less than 1 degree per year. This is why it is only worth while x-raying the spine every 5 years in adults.
In patients over the age of 50, wear and tear changes in the spine can accelerate curve deterioration. Secondary changes resulting in nerve compression can occur in this age group. However having surgery in early adulthood should not be considered preventative, as wear and tear changes will still occur as the spine ages, and re-operation rates in the elderly are NOT less if they have had surgery earlier in life.
Non-operative treatment is the usual treatment for this condition in most patients.
You should strongly consider non-operative treatment as the first line of treatment, and the best treatment for most people.
Only if your life is constantly miserable and painful should you consider surgery for this condition.
Second option.
Undergo scoliosis correction.
The Operation
In this operation you are given an anaesthetic. There is a team of people (up to 8) looking after you.
You will be completely asleep. While you are asleep a drainage tube (urinary catheter will be placed in your bladder. At least two “drips” (intravenous and intra-arterial catheters) will be placed in your upper limbs.
You will be rolled onto your side on a special table. A cut (incision) will be made in the middle of your chest. The front of the spine will be accessed behind the lung. The joints of the spine will be removed, and this will make the spine more mobile and allow correction of its shape. Metal Screws and Rods and bone graft maybe used to hold this correction. Your chest will be sutured and a tube will remain draining the chest.
You will be rolled onto your stomach on a special table.
An incision (cut) will be made over the midline of your back over the location of your problem. A portable x-ray machine will be used to make sure I know which level of the spine I am operating upon.
I will push the muscles off the spinal bones (vertebrae) and I will remove some of the bone knobs/spurs, ligaments and joints to allow the spinal bones to move independently of each other. A very large amount of the bone from the small joints of your back is removed. This process will cause bleeding. We will give you fluid to replace the blood, but may need to give you some blood from the blood bank. The blood you lose is recycled during the surgery, and you get about 50% back.
The nerves will be protected during the surgery. We will use spinal cord monitoring to check that your spinal cord is still functioning normally during the surgery. If the monitoring shows that there is a change in your spinal cord functioning during the surgery, then the correction will be abandoned. You will be left with the same curve as before.
The spine will be more wobbly (unstable) once all this bone is removed. This is intentional. This allows me to correct the shape of your spine.
I shall put large strong screws into the spinal bones. Usually 2 screws in each bone.
Then I shall join each of the screws on the right to a rod, and each of the screws on the left to a separate rod. The rods have been shaped to form the normal curve of the spine. This means that as the screws are attached to the rods you will start to straighten up.
I do not guarantee that you will be entirely straight, indeed this is not usually possible. The idea is to get you straighter and balanced, so that your head sits over your pelvis.
The metal ladder that I create to straighten you will not last for more than 2 years if something else doesn't take over. What you need is a living, self repairing bony ladder, to reinforce the metal.
Therefore I shall take the bone I have already removed and some extra bone like material, and mix them together in a grinder. This makes a bony putty. This is called bone graft. I place this in a different location at the edge of the spine, away from the nerves. This bone graft forms a solid bridge between the vertebrae. Sometimes this is as solid as bone; sometimes it is more like a strong ligament (gristle) between the bones. It adds further stability to the spine in the long term.
The wound is then washed out to remove any bacteria that has fallen in from your skin, and closed with sutures (stitches). Most of the suture is dissolvable and below the skin. Sometimes we use removable suture in the skin, and this may need to be removed.
You will be rolled onto your back and woken up. Once you are awake enough to breathe for yourself you will be transferred to the recovery room. Once you are awake enough to move your legs I shall ring your nominated next of kin and tell them that you are OK.
The Outcome:
Immediately after the surgery you will not be too sore because you will have lots of medication in your system. As this wears off the pain will increase. Many people describe the second 24 hrs as very painful. One of my patients said it was like a truck had run over him. This settles quickly, and you will be provided with lots more pain relieving medication. The day after surgery you will be expected to get up and stand. You are allowed to walk, or sit; however you probably will not feel like it. Each day you will be asked to do more moving, and you will have less pain. Once you can safely and comfortably get to the toilet the urinary catheter will be removed. Once you can safely move around the ward you will be assessed for rehabilitation.
There are several main stages in recovery. These are guidelines, and you should remember that every one is different.
Day 1 to 7 after surgery: Pain, nausea, difficulty with moving. Most patients wish they had not had surgery.
Day 7 to 21 after surgery: Gradually getting over the surgical pain. More movement. A sense of relief that everything will be OK, although everything is still difficult.
Day 21 to 6 weeks after surgery. Every day is still dominated by the operation and recovery. You are at home, you get frustrated, and your family are probably wondering if you are ever going to get back to normal. Often still on some drugs for mild to moderate pain.
Somewhere about 6- 8 weeks. Suddenly you have a day where you forget you have had an operation. These days become more frequent and you know that you are much better than before.
Week 12 to 18 months. Slow, gradual improvement. Your goal posts change. You forget how disabled you were, and you want to be better all the time. As you progressively increase your level of activity, you also have ongoing back pain. This is normal because you are retraining all of those muscles that have been affected by the scoliosis for all those years. Eventually you get as good as you can be. This is about 18 months after surgery.
Scarring: This is not cosmetic surgery. The wounds are large and obvious. If you are concerned about this, then you should seek another opinion as I do not do keyhole spine surgery for this condition.
COMPLICATIONS
SOME PATIENTS ARE NOT BETTER WITH SURGERY, SOME PATIENTS CAN BE WORSE. About 5% of spinal fusion operations are complicated by an adverse outcome. That is something happens that was not expected, and requires extra treatment.
I will try to cover the most serious complications. However you must note that I will not cover everything. An absolutely comprehensive list is NOT possible. The unexpected can always occur; I cannot warn you about everything.
Adverse risk rate I would estimate to be around 5%. This means that one in every twenty operations incurs an unexpected outcome.
This can be something simple such as a skin infection that resolves with tablet antibiotics, or it may be something extremely dangerous such as a blood clot, or heart attack.
Death
People have died having this surgery, however the risk of this is about 1 in 100,000 (American Society of Anaesthesiologists Grade 1). To put this in perspective the risk of a fatal car accident in a year is about 1 in 10,000. Or ten times more likely. Death comes from bleeding or blood clot, or heart failure.
Paraplegia
It is possible to make you paraplegic by damaging all the nerves below the level of the surgery.This means you would NEVER WALK AGAIN.
You would have no feeling below your waist. You would also not be able to control your bladder or bowel, and would lose normal sexual function. Paraplegia is irreversible. This is quoted as 1 in 1000 operations.
Partial paraplegia, or paraparesis is also possible. This is where some of the spinal cord functioning is lost, and some is maintained. This is still a permanent disability. This is also quoted as 1 in 1000 operations.
This means that 998 patients do not have this complication, and one is paraplegic and one is partially paraplegic.
Paraplegia does not occur because of surgical error. It occurs despite taking every known precaution and using every possible preventative measure. We believe that it occurs because when we straighten out the spine, the blood supply to the spinal cord is decreased, and this causes part of the spinal cord to die. This is why it is a permanent problem.
We cannot predict who will have this problem. If we could, then we wouldn't operate on those individuals, and there wouldn't be this complication.
Paraplegia or partial paraplegia is always much much worse than having a curved spine.
Dural Tear
The nerves of the spinal canal are enclosed in a fine skin. This is called the dura. This dura keeps the nerves and spinal cord, and brain floating in a bath of fluid called Cerebrospinal Fluid (CSF). It is possible to tear or cut this dura (durotomy) , without damaging the nerves directly. This occurs in about 1 in 200 first time operations and 1 in 10 revision operations. This causes a loss of CSF. These incidental durotomies can be repaired, or sealed. The body makes up the lost fluid in 48 hrs. However during this 48 hours you may have a very severe headache, and you will be required to remain flat in bed. Very rarely the dura doesn't seal up, and further surgery is required to prevent the CSF from leaking continuously.
Risks of all Orthopaedic Surgery
Death
Heart Attack
Stroke
Blood Clots in the legs (Deep Venous Thrombosis)
Blood Clots in the lungs (Pulmonary Embolus)
Bleeding requiring blood transfusion
Blood transfusion causing infection with hepatitis or AIDS
Lung failure: breathing difficulties
Kidney failure: unable to make urine, requiring dialysis
Liver failure: usually caused by an unexpected reaction to a medication
Bowel paralysis (ileus): a temporary condition caused by fasting and operating through the abdomen
Superficial Nerve injury - this occurs in the skin when an incision is made causing permanent numbness.
Major Nerve Injury - In spinal surgery damage to a single nerve in the spinal canal can have permanent paralysing effects on a group of muscles. This is rare, but usually irreversible.
Failure to improve.
Despite a technically perfect operation it can be possible that your symptoms may not improve. I give no guarantee that the surgery will improve any or all of your symptoms. However I believe strongly that you will get better. I would not do the surgery otherwise.
Your curve correction will be as accurate and as balanced as possible. However I do not give any guarantee that it will make you as straight as you would like, or as straight as predicted.
If your spinal cord monitoring shows potential spinal cord injury, then the curve correction will be abandoned, and you will have the same curve as before the surgery, with a big scar down your back, and nothing to show for it.
Infection
Some infections are simple to treat. Other infections are a disaster, requiring repeat surgery and removal the implants. Long term antibiotics may also be required.
Your risk to the operating team.
During surgery it is possible for one of the operating team to cut themselves on a needle or other sharp object that has your blood on it. Blood can transmit infection from you to the staff member. There are drugs that can be given to the staff member to stop infection but they can only be given if your blood is tested for possible infection. I require you to give permission for taking and testing of your blood in the unlikely event that such an injury occurs. The blood will be tested for Hepatitis, and the Aids Virus (HIV). If you don't feel that you can give this permission then please discuss this with me. Your signature on this document serves as permission for this testing.
I have covered what I think is the most dangerous and the most concerning. If you have anything else you would like to discuss you can do so by contacting me.
SUMMARY
This document is a consent form.
You must read it thoroughly. I have sent you extra copies to give to your GP. I would strongly suggest that you have a friend, or relative read this with you. You may even wish to get a lawyer to read it.
If you have any concerns you should not proceed with the surgery and I would advise you to get another opinion from another spinal surgeon. Public hospitals with fully trained spinal surgeons include the AUSTIN HOSPITAL, THE ROYAL MELBOURNE HOSPITAL, MONASH MEDICAL CENTRE, and THE ALFRED HOSPITAL. All of these hospitals have public clinics you could visit. There are both neurosurgeons and other orthopaedic surgeons in Melbourne who do spinal surgery you could see privately.
As I have told you, I am an orthopaedic surgeon who has done extra training in spinal surgery. I am not the oldest, or the most experienced surgeon in Melbourne. However I am very well qualified and experienced in this surgery.
Your signature on this letter, with initials on every page must be in my office before the day of surgery. You should keep a copy for yourself. Your signature is acknowledgement of that you have read and understood the document; that you request the proposed surgery, and that you give me permission to perform the surgery and the Hospital to look after you during and after the surgery.
You also give permission for your information to be used for medical research, with a guarantee by law that your personal details will not be divulged, unless compelled by that same law. (Privacy Act 2014)
Yours Sincerely,
Mr Michael Knight
MBBS FAOA
Signature: ...................................................
Date:.............../.................../......................
CONSENT FOR AN OPERATION:
Multilevel Lumbar Decompression and Fusion
Dear ,
Your medical diagnosis is:
Degenerative lumbar spine scoliosis, with associated central and foraminal stenosis causing neurogenic claudication.
In plain English this means:
Ageing has caused wear and tear of the disc joints (intervertebral discs) and the small joints (facet joints) of your spine.
This wearing out causes two separate problems.
The first problem is the spine has lost its normal straight up and down structure.
If you think of the "Leaning Tower of Pisa" the foundation have softened so the whole structure starts to lean over, your spine is doing the same thing.
The spine normally has a gentle curve backward and forward, that you can only see from side on. From the front the spine should be straight up and down.
You are now curved in both directions, and this makes it a 3 dimensional problem.
This imbalance in the spine results in the entire body falling to one side. Therefore the muscles have to try to pull it up straight again. This is very tiring, and painful. It is one of the reasons you are so tired and in pain.
The second problem relates to the nerves.
The skeletal spine carries nerves from the brain to the rest of the body. These nerves rely on having enough space to travel down the spinal canal , and also little windows (foraminae) to escape from. A blockage of either of the spinal canal or the windows is called stenosis. This stenosis causes nerve pain.
As the spine wears out knobs of bone (osteophytes or bone spurs) to form around the spinal joints. These knobs point in toward the spinal cord putting pressure on it. This pressure is increased when you stand or walk. This causes pain, numbness and altered feeling in the back, the buttocks, and also in the legs. This is caused by temporary nerve damage that goes away when you sit down again.
If the pain/numbness/tingling does not improve with sitting or laying then this indicates some ongoing nerve damage. Any loss of bladder or bowel control is an EMERGENCY. This requires immediate surgery or the loss can be permanent.
Unfortunately once these changes occur they do not "heal" You cannot just get better. You either learn to accommodate your "new" shape, or else you have to have surgery to correct it.
I have made this diagnosis based on my examination of you, the story you have told me, and the imaging available.
I am able to offer you 2 choices of treatment.
First option.
Continue to manage the problem non-surgically. That would mean gradually decreasing your activity; both social and physical, to meet you level of disability. You will need to rely on medication, and psychological interventions.
The use of physical therapy, chiropractic, and alternative health interventions have not been shown to be useful in the correction of spinal scoliosis, based on controlled trials in the scientific literature. They may give you short term pain relief, and this is not a bad thing, but they cannot provide you with a permanent cure.
With this condition non-surgical treatment is NOT necessarily the safest alternative. While there can be no surgical complications if there is no surgery, your condition may well deteriorate to the point you can no longer care for yourself. There is no way of telling which patients will deteriorate. Deterioration in this condition is usually reversible if it is caught early, but I cannot guarantee this will be the case.
Second option.
Undergo spinal canal decompression and stabilisation.
The Operation
In this operation you are given an anaesthetic. There is a team of people (up to 8) looking after you.
You will be completely asleep. While you are asleep a drainage tube (urinary catheter will be placed in your bladder. At least two “drips” (intravenous and intra-arterial catheters) will be placed in your upper limbs. You will be rolled onto your stomach on a special table. A cut (incision) will be made in the middle of your back over the location of your problem. A portable x-ray machine will be used to make sure I know which level of the spine I am operating upon.
I will push the muscles off the spinal bones (vertebrae) and I will remove some of the bone knobs/spurs, ligaments and joints to allow the spinal canal to recover its normal volume. A very large amount of the bone from the small joints of your back is removed. This process will cause bleeding. We will give you fluid to replace the blood, but may need to give you some blood from the blood bank. The blood you lose is recycled during the surgery, and you get about 50% back.
The nerves will be protected during the surgery.
The spine will be more wobbly (unstable) once all this bone is removed. This is intentional. This allows me to correct the shape of your spine.
I shall put large strong screws into the spinal bones. Usually 2 screws in each bone.
Then I shall joint each of the screws on the right to a rod, and each of the screws on the left to a separate rod. The rods have been shaped to form the normal curve of the spine. This means that as the screws are attached to the rods you will start to straighten up.
The metal ladder that I create to straighten you will not last for more than 2 years if something else doesn't take over. What you need is a living, self repairing bony ladder, to reinforce the metal.
Therefore I shall take the bone I have already removed and some extra bone like material, and mix them together in a grinder. This makes a bony putty. This is called bone graft. I place this in a different location at the edge of the spine, away from the nerves. This bone graft forms a solid bridge between the vertebrae. Sometimes this is as solid as bone; sometimes it is more like a strong ligament (gristle) between the bones. It adds further stability to the spine in the long term.
The wound is then washed out to remove any bacteria that has fallen in from your skin, and closed with sutures (stitches). Most of the suture is dissolvable and below the skin. Only the skin suture needs to be removed. This is because removable suture has a better cosmetic result, and less infection than dissolvable skin suture or staples.
You will be rolled onto your back and woken up. Once you are awake enough to breathe for yourself you will be transferred to the recovery room. Once you are awake enough to move your legs I shall ring your nominated next of kin and tell them that you are OK.
The Outcome:
Immediately after the surgery you will not be too sore because you will have lots of medication in your system. As this wears off the pain will increase. Many people describe the second 24 hrs as very painful. One of my patients said it was like a truck had run over him. This settles quickly, and you will be provided with lots more pain relieving medication. The day after surgery you will be expected to get up and stand. You are allowed to walk, or sit; however you probably will not feel like it. Each day you will be asked to do more moving, and you will have less pain. Once you can safely and comfortably get to the toilet the urinary catheter will be removed. Once you can safely move around the ward you will be assessed for rehabilitation. Most patients go to rehabilitation.
Most patients get some immediate relief of pain/numbness/tingling. However lack of an immediate response does not mean that you will not get better. Most of the improvement in symptoms does not occur until days or weeks after the surgery. If recovery requires the nerves to regrow (in very severe cases), then it can be up to 18 months before the symptoms go away. It is very common to feel much better for a few days and then some of the symptoms come back again. This does not mean that the operation has failed. It means that the ongoing inflammation from the surgery is causing nerve irritation. As the wound heals the pain settles again. In my experience more than 90% of patients with spinal canal stenosis have significant improvement. If they didn’t I wouldn’t do the surgery.
There are several main stages in recovery. These are guidelines, and you should remember that every one is different.
Day 1 to 7 after surgery: Pain, nausea, difficulty with moving. Most patients wish they had not had surgery.
Day 7 to 21 after surgery: Gradually getting over the surgical pain. More movement. A sense of relief that everything will be OK, although everything is still difficult.
Day 21 to 6 weeks after surgery. Every day is still dominated by the operation and recovery. You are at home, you get frustrated, and your family are probably wondering if you are ever going to get back to normal. Often still on some drugs for mild to moderate pain.
Somewhere about 6- 8 weeks. Suddenly you have a day where you forget you have had an operation. These days become more frequent and you know that you are much better than before.
Week 12 to 18 months. Slow, gradual improvement. Your goal posts change. You forget how disabled you were, and you want to be better all the time. As you progressively increase your level of activity, you also have ongoing back pain. This is normal because you are retraining all of those muscles that have been affected by the scoliosis for all those years. Eventually you get as good as you can be. This is about 18 months after surgery.
Scarring: This is not cosmetic surgery. The wounds are large and obvious. If you are concerned about this, then you should seek another opinion as I do not do keyhole spine surgery for this condition.
COMPLICATIONS
SOME PATIENTS ARE NOT BETTER WITH SURGERY, SOME PATIENTS CAN BE WORSE. About 5% of spinal fusion operations are complicated by an adverse outcome. That is something happens that was not expected, and requires extra treatment.
I will try to cover the most serious complications. However you must note that I will not cover everything. An absolutely comprehensive list is NOT possible. The unexpected can always occur; I cannot warn you about everything.
Adverse risk rate I would estimate to be around 5%. This means that one in every twenty operations incurs an unexpected outcome.
This can be something simple such as a skin infection that resolves with tablet antibiotics, or it may be something extremely dangerous such as a blood clot, or heart attack.
Death
People have died having this surgery, however the risk of this is about 1 in 100,000 (American Society of Anaesthesiologists Grade 1). To put this in perspective the risk of a fatal car accident in a year is about 1 in 10,000. Or ten times more likely.
Paraplegia
It is possible to make you paraplegic by damaging all the nerves below the level of the surgery.This means you would be unable to walk, and would have no feeling below your waist. You would also not be able to control your bladder or bowel, and would lose normal sexual function. Paraplegia is irreversible. However this would be extremely rare, so rare I cannot put a percentage on this risk.
Dural Tear
The nerves of the spinal canal are enclosed in a fine skin. This is called the dura. This dura keeps the nerves and spinal cord, and brain floating in a bath of fluid called Cerebrospinal Fluid (CSF). It is possible to tear or cut this dura (durotomy) , without damaging the nerves directly. This occurs in about 1 in 200 first time operations and 1 in 10 revision operations. This causes a loss of CSF. These incidental durotomies can be repaired, or sealed. The body makes up the lost fluid in 48 hrs. However during this 48 hours you may have a very severe headache, and you will be required to remain flat in bed. Very rarely the dura doesn't seal up, and further surgery is required to prevent the CSF from leaking continuously.
Risks of all Orthopaedic Surgery
Death
Heart Attack
Stroke
Blood Clots
Bleeding requiring blood transfusion
Blood transfusion causing infection with hepatitis or AIDS
Lung failure: breathing difficulties
Kidney failure: unable to make urine, requiring dialysis
Liver failure: usually caused by an unexpected reaction to a medication
Bowel paralysis (ileus): a temporary condition caused by fasting and operating through the abdomen
Superficial Nerve injury - this occurs in the skin when an incision is made causing permanent numbness.
Major Nerve Injury - In spinal surgery damage to a single nerve in the spinal canal can have permanent paralysing effects on a group of muscles. This is rare, but usually irreversible.
Failure to improve.
Despite a technically perfect operation it can be possible that your symptoms may not improve. I give no guarantee that the surgery will improve any or all of your symptoms. However I believe strongly that you will get better. I would not do the surgery otherwise.
Infection
Some infections are simple to treat. Other infections are a disaster, requiring repeat surgery and removal the implants. Long term antibiotics may also be required.
Your risk to the operating team.
During surgery it is possible for one of the operating team to cut themselves on a needle or other sharp object that has your blood on it. Blood can transmit infection from you to the staff member. There are drugs that can be given to the staff member to stop infection but they can only be given if your blood is tested for possible infection. I require you to give permission for taking and testing of your blood in the unlikely event that such an injury occurs. The blood will be tested for Hepatitis, and the Aids Virus (HIV). If you don't feel that you can give this permission then please discuss this with me. Your signature on this document serves as permission for this testing.
I have covered what I think is the most dangerous and the most concerning. If you have anything else you would like to discuss you can do so by contacting me.
SUMMARY
This document is a consent form.
You must read it thoroughly. I have sent you extra copies to give to your GP. I would strongly suggest that you have a friend, or relative read this with you. You may even wish to get a lawyer to read it.
If you have any concerns you should not proceed with the surgery and I would advise you to get another opinion from another spinal surgeon. Public hospitals with fully trained spinal surgeons include the AUSTIN HOSPITAL, THE ROYAL MELBOURNE HOSPITAL, MONASH MEDICAL CENTRE, and THE ALFRED HOSPITAL. All of these hospitals have public clinics you could visit. There are both neurosurgeons and other orthopaedic surgeons in Melbourne who do spinal surgery you could see privately.
As I have told you, I am an orthopaedic surgeon who has done extra training in spinal surgery. I am not the oldest, or the most experienced surgeon in Melbourne. However I am very well qualified and experienced in this surgery.
Your signature on this letter, with initials on every page must be in my office before the day of surgery. You should keep a copy for yourself. Your signature is acknowledgement of that you have read and understood the document; that you request the proposed surgery, and that you give me permission to perform the surgery and the Hospital to look after you during and after the surgery.
Yours Sincerely,
Mr Michael Knight
FRACS Orthopaedic
Signature: ...................................................
Date:.............../.................../......................
,
Your medical diagnosis is:
Developmental Thoracic Kyphosis
In plain English this means:
During the growth phase of your early adolescence your spine did not grow straight. It curved by growing more on the back and less on the front.
The spine is bent forward through your thoracic spine, that is through the area of your spine where the ribs are attached.
The spine normally has a gentle curve backward and forward, that you can only see from side on. From the front the spine should be straight up and down.
You are now curved at about 90 degrees forward through your chest, and 60 degrees backward through your lumbar spine.
This imbalance in the spine results in the entire body falling to forward. Therefore the muscles have to try to pull it up straight again. This is very tiring, and painful. It is one of the reasons you are so tired and in pain.
Unfortunately once these changes occur they do not "heal" You cannot just get better. You either learn to accommodate your "new" shape, or else you have to have surgery to correct it.
I have made this diagnosis based on my examination of you, the story you have told me, and the imaging available.
I am able to offer you 2 choices of treatment.
First option.
Continue to manage the problem non-surgically. That would mean gradually decreasing your activity; both social and physical, to meet you level of disability. You will need to rely on medication, and psychological interventions.
The use of physical therapy, chiropractic, and alternative health interventions have not been shown to be useful in the correction of spinal scoliosis, based on controlled trials in the scientific literature. They may give you short term pain relief, and this is not a bad thing, but they cannot provide you with a permanent cure.
With this condition non-surgical treatment is ALWAYS the safest alternative.
There can be no surgical complications if there is no surgery.
However left untreated your condition can deteriorate to the point you can no longer care for yourself. The curve may get worse and you may well find that standing becomes almost impossible, and you are forced to use a sitting scooter to get around.
Second option.
Under go kyphosis correction.
The Operation
In this operation you are given an anaesthetic. There is a team of people (up to 8) looking after you.
You will be completely asleep. While you are asleep a drainage tube (urinary catheter will be placed in your bladder. At least two “drips” (intravenous and intra-arterial catheters) will be placed in your upper limbs. You will be rolled onto a special table.
A cut (incision) will be made in the middle of your chest. The front of the spine will be accessed behind the lung. The joints of the spine will be removed, and this will make the spine more mobile and allow correction of its shape. Metal Screws and Rods and bone graft maybe used to hold this correction. Your chest will be closed with sutures (stitches), and a tube will remain draining the chest.
Then you will be flipped over onto your stomach. An incision (cut) will be made over the midline of your back over the location of your problem. A portable x-ray machine will be used to make sure I know which level of the spine I am operating upon.
I will push the muscles off the spinal bones (vertebrae) and I will remove some of the bone knobs/spurs, ligaments and joints to allow the spinal bones. A very large amount of the bone from the small joints of your back is removed. This process will cause bleeding. We will give you fluid to replace the blood, but may need to give you some blood from the blood bank. The blood you lose is recycled during the surgery, and you get about 50% back.
The nerves will be protected during the surgery.
The spine will be more wobbly (unstable) once all this bone is removed. This is intentional. This allows me to correct the shape of your spine.
I shall put large strong screws into the spinal bones. Usually 2 screws in each bone.
Then I shall joint each of the screws on the right to a rod, and each of the screws on the left to a separate rod. The rods have been shaped to form the normal curve of the spine. This means that as the screws are attached to the rods you will start to straighten up.
The metal ladder that I create to straighten you will not last for more than 2 years if something else doesn't take over. What you need is a living, self repairing bony ladder, to reinforce the metal.
Therefore I shall take the bone I have already removed and some extra bone like material, and mix them together in a grinder. This makes a bony putty. This is called bone graft. I place this in a different location at the edge of the spine, away from the nerves. This bone graft forms a solid bridge between the vertebrae. Sometimes this is as solid as bone; sometimes it is more like a strong ligament (gristle) between the bones. It adds further stability to the spine in the long term.
The wound is then washed out to remove any bacteria that has fallen in from your skin, and closed with sutures (stitches). Most of the suture is dissolvable and below the skin. Only the skin suture needs to be removed. This is because removable suture has a better cosmetic result, and less infection than dissolvable skin suture or staples.
You will be rolled onto your back and woken up. Once you are awake enough to breathe for yourself you will be transferred to the recovery room. Once you are awake enough to move your legs I shall ring your nominated next of kin and tell them that you are OK.
The Outcome:
Immediately after the surgery you will not be too sore because you will have lots of medication in your system. As this wears off the pain will increase. Many people describe the second 24 hrs as very painful. One of my patients said it was like a truck had run over him. This settles quickly, and you will be provided with lots more pain relieving medication. The day after surgery you will be expected to get up and stand. You are allowed to walk, or sit; however you probably will not feel like it. Each day you will be asked to do more moving, and you will have less pain. Once you can safely and comfortably get to the toilet the urinary catheter will be removed. Once you can safely move around the ward you will be assessed for rehabilitation.
There are several main stages in recovery. These are guidelines, and you should remember that every one is different.
Day 1 to 7 after surgery: Pain, nausea, difficulty with moving. Most patients wish they had not had surgery.
Day 7 to 21 after surgery: Gradually getting over the surgical pain. More movement. A sense of relief that everything will be OK, although everything is still difficult.
Day 21 to 6 weeks after surgery. Every day is still dominated by the operation and recovery. You are at home, you get frustrated, and your family are probably wondering if you are ever going to get back to normal. Often still on some drugs for mild to moderate pain.
Somewhere about 6- 8 weeks. Suddenly you have a day where you forget you have had an operation. These days become more frequent and you know that you are much better than before.
Week 12 to 18 months. Slow, gradual improvement. Your goal posts change. You forget how disabled you were, and you want to be better all the time. As you progressively increase your level of activity, you also have ongoing back pain. This is normal because you are retraining all of those muscles that have been affected by the scoliosis for all those years. Eventually you get as good as you can be. This is about 18 months after surgery.
Scarring: This is not cosmetic surgery. The wounds are large and obvious. If you are concerned about this, then you should seek another opinion as I do not do keyhole spine surgery for this condition.
COMPLICATIONS
SOME PATIENTS ARE NOT BETTER WITH SURGERY, SOME PATIENTS CAN BE WORSE. About 5% of spinal fusion operations are complicated by an adverse outcome. That is something happens that was not expected, and requires extra treatment.
I will try to cover the most serious complications. However you must note that I will not cover everything. An absolutely comprehensive list is NOT possible. The unexpected can always occur; I cannot warn you about everything.
Adverse risk rate I would estimate to be around 5%. This means that one in every twenty operations incurs an unexpected outcome.
This can be something simple such as a skin infection that resolves with tablet antibiotics, or it may be something extremely dangerous such as a blood clot, or heart attack.
Death
People have died having this surgery, however the risk of this is about 1 in 100,000 (American Society of Anaesthesiologists Grade 1). To put this in perspective the risk of a fatal car accident in a year is about 1 in 10,000. Or ten times more likely. Death comes from bleeding or blood clot, or heart failure.
Paraplegia
It is possible to make you paraplegic by damaging all the nerves below the level of the surgery.This means you would be unable to walk, and would have no feeling below your waist. You would also not be able to control your bladder or bowel, and would lose normal sexual function. Paraplegia is irreversible. This is quoted as 1 in 1000 operations. However as you get older this risk increases.
Dural Tear
The nerves of the spinal canal are enclosed in a fine skin. This is called the dura. This dura keeps the nerves and spinal cord, and brain floating in a bath of fluid called Cerebrospinal Fluid (CSF). It is possible to tear or cut this dura (durotomy) , without damaging the nerves directly. This occurs in about 1 in 200 first time operations and 1 in 10 revision operations. This causes a loss of CSF. These incidental durotomies can be repaired, or sealed. The body makes up the lost fluid in 48 hrs. However during this 48 hours you may have a very severe headache, and you will be required to remain flat in bed. Very rarely the dura doesn't seal up, and further surgery is required to prevent the CSF from leaking continuously.
Risks of all Orthopaedic Surgery
Death
Heart Attack
Stroke
Blood Clots
Bleeding requiring blood transfusion
Blood transfusion causing infection with hepatitis or AIDS
Lung failure: breathing difficulties
Kidney failure: unable to make urine, requiring dialysis
Liver failure: usually caused by an unexpected reaction to a medication
Bowel paralysis (ileus): a temporary condition caused by fasting and operating through the abdomen
Superficial Nerve injury - this occurs in the skin when an incision is made causing permanent numbness.
Major Nerve Injury - In spinal surgery damage to a single nerve in the spinal canal can have permanent paralysing effects on a group of muscles. This is rare, but usually irreversible.
Failure to improve.
Despite a technically perfect operation it can be possible that your symptoms may not improve. I give no guarantee that the surgery will improve any or all of your symptoms. However I believe strongly that you will get better. I would not do the surgery otherwise.
Infection
Some infections are simple to treat. Other infections are a disaster, requiring repeat surgery and removal the implants. Long term antibiotics may also be required.
Your risk to the operating team.
During surgery it is possible for one of the operating team to cut themselves on a needle or other sharp object that has your blood on it. Blood can transmit infection from you to the staff member. There are drugs that can be given to the staff member to stop infection but they can only be given if your blood is tested for possible infection. I require you to give permission for taking and testing of your blood in the unlikely event that such an injury occurs. The blood will be tested for Hepatitis, and the Aids Virus (HIV). If you don't feel that you can give this permission then please discuss this with me. Your signature on this document serves as permission for this testing.
I have covered what I think is the most dangerous and the most concerning. If you have anything else you would like to discuss you can do so by contacting me.
SUMMARY
This document is a consent form.
You must read it thoroughly. I have sent you extra copies to give to your GP. I would strongly suggest that you have a friend, or relative read this with you. You may even wish to get a lawyer to read it.
If you have any concerns you should not proceed with the surgery and I would advise you to get another opinion from another spinal surgeon. Public hospitals with fully trained spinal surgeons include the AUSTIN HOSPITAL, THE ROYAL MELBOURNE HOSPITAL, MONASH MEDICAL CENTRE, and THE ALFRED HOSPITAL. All of these hospitals have public clinics you could visit. There are both neurosurgeons and other orthopaedic surgeons in Melbourne who do spinal surgery you could see privately.
As I have told you, I am an orthopaedic surgeon who has done extra training in spinal surgery. I am not the oldest, or the most experienced surgeon in Melbourne. However I am very well qualified and experienced in this surgery.
Your signature on this letter, with initials on every page must be in my office before the day of surgery. You should keep a copy for yourself. Your signature is acknowledgement of that you have read and understood the document; that you request the proposed surgery, and that you give me permission to perform the surgery and the Hospital to look after you during and after the surgery.
Yours Sincerely,
Mr Michael Knight
MBBS FAOA
Signature: ...................................................
Date:.............../.................../......................
Thoracic Kyphosis with Myelopathy
----------------------------
In plain English this means:
Changes have occurred to your spine that have increased the forward bending of the spine at the level of your chest. That is the part of your spine that occurs where your ribs attach. This is thoracic kyphosis.
This forward bending has resulted in a kink in the spinal canal.
The spinal cord lies in the spinal canal.
The spinal cord carries all the messages from your brain to your body and back again.
This kink in the spinal canal is putting pressure on the spinal cord, causing it to malfunction. This is myelopathy.
Unfortunately once these changes occur they do not "heal" You cannot just get better. You either learn to accomodate your "new" shape, or else you have to have surgery to correct it.
The problem for you is that the nerves cannot accommodate this forward bend, and this nerve malfunction will only get progressively worse with time. If this is a rapid or significant deterioration then you will end up losing your ability to walk, and be independent.
This progression in symptoms may not occur. However it is likely to occur. Once weakness and loss of function are present surgery may be able to stop them getting worse, but it is unlikely you will get better. Therefore you need to consider preventative surgery for this condition.
------------------
I am able to offer you 2 choices of treatment.
First option.
Continue to manage the problem non-surgically. That would mean gradually decreasing your activity; both social and physical, to meet you level of disability should you develop a disability. You will need to rely on medication, and psychological interventions for pain management. You will need a wheelchair and living support if you lose the ability to walk.
The use of physical therapy, chiropractic, and alternative health interventions have not been shown to be useful in the correction of spinal kyphosis, based on controlled trials in the scientific literature. They may give you short term pain relief, and this is not a bad thing, but they cannot provide you with a permanent cure.
With this condition non-surgical treatment is not always the safest alternative.
There can be no surgical complications if there is no surgery.
However it is expected that your condition will deteriorate to the point you can no longer care for yourself at some point in your life, if this condition is not treated.
There is no way of telling which patients will deteriorate. Deterioration in this condition is usually NOT reversible even if it is caught early.
Second option.
Undergo spinal osteotomy and stabilisation.
The Operation
In this operation you are given an anaesthetic. There is a team of people (up to 8) looking after you.
You will be completely asleep. While you are asleep a drainage tube (urinary catheter will be placed in your bladder. At least two “drips” (intravenous and intra-arterial catheters) will be placed in your upper limbs. You will be rolled onto your stomach on a special table. A cut (incision) will be made in the middle of your back over the location of your problem. A portable x-ray machine will be used to make sure I know which level of the spine I am operating upon.
I will push the muscles off the spinal bones (vertebrae) and I will remove some of the bone knobs/spurs, ligaments and joints to allow the spinal canal to recover its normal volume. A very large amount of the bone from the small joints of your back is removed. This process will cause bleeding. We will give you fluid to replace the blood, but may need to give you some blood from the blood bank. The blood you lose is recycled during the surgery, and you get about 50% back.
The nerves will be protected during the surgery.
The spine will be more wobbly (unstable) once all this bone is removed. This is intentional. This allows me to correct the shape of your spine.
I shall put large strong screws into the spinal bones. Usually 2 screws in each bone.
Then I shall join each of the screws on the right to a rod, and each of the screws on the left to a separate rod. The rods have been shaped to form the normal curve of the spine. This means that as the screws are attached to the rods you will start to straighten up.
The metal ladder that I create to straighten you will not last for more than 2 years if something else doesn't take over. What you need is a living, self repairing bony ladder, to reinforce the metal.
Therefore I shall take the bone I have already removed and some extra bone from your pelvis and mix them together. This makes a bony putty called bone graft. I place this in a different location at the edge of the spine, away from the nerves. This bone graft forms a solid bridge between the vertebrae. Sometimes this is as solid as bone; sometimes it is more like a strong ligament (gristle) between the bones. It adds further stability to the spine in the long term.
The wound is then washed out to remove any bacteria that has fallen in from your skin, and closed with sutures (stitches). Most of the suture is dissolvable and below the skin. Only the skin suture needs to be removed. This is because removable suture has a better cosmetic result, and less infection than dissolvable skin suture or staples.
You will be rolled onto your back and woken up. Once you are awake enough to breathe for yourself you will be transferred to the recovery room. Once you are awake enough to move your legs I shall ring your nominated next of kin and tell them that you are OK.
The Outcome:
Immediately after the surgery you will not be too sore because you will have lots of medication in your system. As this wears off the pain will increase. Many people describe the second 24 hrs as very painful. One of my patients said it was like a truck had run over him. This settles quickly, and you will be provided with lots more pain relieving medication. The day after surgery you will be expected to get up and stand. You are allowed to walk, or sit; however you probably will not feel like it. Each day you will be asked to do more moving, and you will have less pain. Once you can safely and comfortably get to the toilet the urinary catheter will be removed. Once you can safely move around the ward you will be assessed for rehabilitation. Most patients go to rehabilitation.
Most patients get some immediate relief of pain. However lack of an immediate response does not mean that you will not get better. Most of the improvement in symptoms does not occur until days or weeks after the surgery. If recovery requires the nerves to regrow (in very severe cases), then it can be up to 18 months before the symptoms go away. It is very common to feel much better for a few days and then some of the symptoms come back again. This does not mean that the operation has failed. It means that the ongoing inflammation from the surgery is causing nerve irritation. As the wound heals the pain settles again. In my experience more than 90% of patients with spinal canal stenosis have significant improvement. If they didn’t I wouldn’t do the surgery.
There are several main stages in recovery. These are guidelines, and you should remember that every one is different.
Day 1 to 7 after surgery: Pain, nausea, difficulty with moving. Most patients wish they had not had surgery.
Day 7 to 21 after surgery: Gradually getting over the surgical pain. More movement. A sense of relief that everything will be OK, although everything is still difficult.
Day 21 to 6 weeks after surgery. Every day is still dominated by the operation and recovery. You are at home, you get frustrated, and your family are probably wondering if you are ever going to get back to normal. Often still on some drugs for mild to moderate pain.
Somewhere about 6- 8 weeks. Suddenly you have a day where you forget you have had an operation. These days become more frequent and you know that you are much better than before.
Week 12 to 18 months. Slow, gradual improvement. Your goal posts change. You forget how disabled you were, and you want to be better all the time. As you progressively increase your level of activity, you also have ongoing back pain. This is normal because you are retraining all of those muscles that have been affected by the kyphosis for all those years. Eventually you get as good as you can be. This is about 18 months after surgery.
Scarring: This is not cosmetic surgery. The wounds are large and obvious. If you are concerned about this, then you should seek another opinion as I do not do keyhole spine surgery for this condition.
COMPLICATIONS
SOME PATIENTS ARE NOT BETTER WITH SURGERY, SOME PATIENTS CAN BE WORSE. About 5% of spinal fusion operations are complicated by an adverse outcome. That is something happens that was not expected, and requires extra treatment.
I will try to cover the most serious complications. However you must note that I will not cover everything. An absolutely comprehensive list is NOT possible. The unexpected can always occur; I cannot warn you about everything.
Adverse risk rate I would estimate to be around 10%. This means that one in every ten operations incurs an unexpected outcome.
This can be something simple such as a skin infection that resolves with tablet antibiotics, or it may be something extremely dangerous such as a blood clot, or heart attack.
Death
People have died having this surgery, however the risk of this is about 1 in 100,000 (American Society of Anaesthesiologists Grade 1). To put this in perspective the risk of a fatal car accident in a year is about 1 in 10,000. Or ten times more likely.
Paraplegia
It is possible to make you paraplegic by damaging all the nerves below the level of the surgery. This means you would be unable to walk, and would have no feeling below your waist. You would also not be able to control your bladder or bowel, and would lose normal sexual function. Paraplegia is irreversible. In your operation the risk of paraplegia can be as high as 10 percent. That is one in 10 patients have had this complication in some series. As I am operating at the level of the solid spinal cord in the middle of the chest, this is the MOST RISKY level for this surgery.
Given your age, and the nature of this problem I would expect that your risk of paraplegia is lower. Perhaps as low as 1 in 100.
However you should remember that 1 in 100 does not mean only 1% paraplegic.
It means for that one person in 100 they are permanently and devastatingly crippled, and will be in a wheel chair, and worse off in every way, for the rest of their life.
Dural Tear
The nerves of the spinal canal are enclosed in a fine skin. This is called the dura. This dura keeps the nerves and spinal cord, and brain floating in a bath of fluid called Cerebrospinal Fluid (CSF). It is possible to tear or cut this dura (durotomy) , without damaging the nerves directly. This occurs in about 1 in 200 first time operations and 1 in 10 revision operations. This causes a loss of CSF. These incidental durotomies can be repaired, or sealed. The body makes up the lost fluid in 48 hrs. However during this 48 hours you may have a very severe headache, and you will be required to remain flat in bed. Very rarely the dura doesn't seal up, and further surgery is required to prevent the CSF from leaking continuously.
Risks of all Orthopaedic Surgery
Death
Heart Attack
Stroke
Blood Clots
Bleeding requiring blood transfusion
Blood transfusion causing infection with hepatitis or AIDS
Lung failure: breathing difficulties
Kidney failure: unable to make urine, requiring dialysis
Liver failure: usually caused by an unexpected reaction to a medication
Bowel paralysis (ileus): a temporary condition caused by fasting and operating through the abdomen
Superficial Nerve injury - this occurs in the skin when an incision is made causing permanent numbness.
Major Nerve Injury - In spinal surgery damage to a single nerve in the spinal canal can have permanent paralysing effects on a group of muscles. This is rare, but usually irreversible.
Failure to improve.
Despite a technically perfect operation it can be possible that your symptoms may not improve. I give no guarantee that the surgery will improve any or all of your symptoms. However I believe strongly that you will get better. I would not do the surgery otherwise.
Infection
Some infections are simple to treat. Other infections are a disaster, requiring repeat surgery and removal the implants. Long term antibiotics may also be required.
Your risk to the operating team.
During surgery it is possible for one of the operating team to cut themselves on a needle or other sharp object that has your blood on it. Blood can transmit infection from you to the staff member. There are drugs that can be given to the staff member to stop infection but they can only be given if your blood is tested for possible infection. I require you to give permission for taking and testing of your blood in the unlikely event that such an injury occurs. The blood will be tested for Hepatitis, and the Aids Virus (HIV). If you don't feel that you can give this permission then please discuss this with me. Your signature on this document serves as permission for this testing.
I have covered what I think is the most dangerous and the most concerning. If you have anything else you would like to discuss you can do so by contacting me.
SUMMARY
This document is a consent form.
You must read it thoroughly. I have sent you extra copies to give to your GP. I would strongly suggest that you have a friend, or relative read this with you. You may even wish to get a lawyer to read it.
If you have any concerns you should not proceed with the surgery and I would advise you to get another opinion from another spinal surgeon. Public hospitals with fully trained spinal surgeons include the AUSTIN HOSPITAL, THE ROYAL MELBOURNE HOSPITAL, MONASH MEDICAL CENTRE, and THE ALFRED HOSPITAL. All of these hospitals have public clinics you could visit. There are both neurosurgeons and other orthopaedic surgeons in Melbourne who do spinal surgery you could see privately.
As I have told you, I am an orthopaedic surgeon who has done extra training in spinal surgery. I am not the oldest, or the most experienced surgeon in Melbourne. However I am very well qualified and experienced in this surgery.
Your signature on this letter, with initials on every page must be in my office before the day of surgery. You should keep a copy for yourself. Your signature is acknowledgement of that you have read and understood the document; that you request the proposed surgery, and that you give me permission to perform the surgery and the Hospital to look after you during and after the surgery.
Yours Sincerely,
Dr. Michael KNIGHT
MBBS FAOA
Signature: ...................................................
Date:.............../.................../......................
Consent for Spinal Vertebroplasty
Dear
You have the problem of unremitting pain from a vertebral crush fracture, despite conservative management.
That is: Osteoporosis (bone softening) has allowed all the lumbar vertebral bodies (spinal bone) to crush down like a foot sinking to soft sand. This is a fracture, (but not the typical fracture seen in a broken leg - that is more like a carrot being snapped in two).
This crush type of fracture is not unstable. That is your spine is not more wobbly after this fracture. There is no danger in continuing your normal activities as much as pain allows. These fractures usually heal quite well without any treatment. However some remain quite painful for months.
Unfortunately in your case the pain has plateaued. There has been no improvement in the pain, and it is now quite disabling. You have tried time, medicine and rest, but you have told me that your pain is making life quite miserable.
I have made this diagnosis based on my examination of you, the story you have told me, and the imaging available.
I am able to offer you 2 choices of treatment.
Option One.
Continue to manage the problem non-interventionally. That would mean gradually decreasing your activity; both social and physical, to meet you level of disability. You will need to rely on medication, and psychological interventions.
The use of physical therapy, chiropractic, and alternative health intervention have been shown to be useful in the management of spinal fractures, based on controlled trials in the scientific literature. They may give you short term pain relief, and this is not a bad thing, but they cannot provide you with a permanent cure.
With this condition non-interventional treatment IS ALWAYS the safest alternative. There can be no complications if there is no intervention.
Your condition may deteriorate to the point you can no longer care for yourself, but this would be very uncommon and unlikely. Your pain is likely to eventually improve, however the longer it persists the less likely this is. You may need to vary your pain management to cope with changes in pain overtime.
Option Two.
Undergo Vertebroplasty
The Procedure
In this procedure you are given an anaesthetic. You will be sedated but not completely asleep.
At least one “drip” (intravenous and possibly intra-arterial catheters) will be placed in your upper limbs. You will be rolled onto your stomach on a special table.
A portable x-ray machine will be used to make sure I know which level of the spine I am treating.
I will use a special needle to locate and push into the bone of the spine at the correct level. Then I shall put a small tube through this needle into the broken bone. Then I shall inject some liquid plastic through the tube into the bone.This will fill the bone at the fracture site. This CANNOT reform the bone.
The liquid plastic sets into a solid plastic within 10 minutes.
The procedure usually takes about 10 minutes per bone.
Once I have completed the injection I shall put a dressing over the needle holes. You will be woken up and rolled onto your back and taken to the recovery room.
The Outcome:
Immediately after the surgery you will not be too sore because you will have lot of medication in your system. As this wears off the pain may increase.
However this is not usually a very painful procedure and the pain usually settles quickly .
You will go home the same day, unless there is a medical reason to keep you overnight.
The day after surgery you will be able to get up and stand. You are allowed to walk, or sit without any restriction. Each day you will be able to do more moving, and you will have less pain.
Maximal pain relief is usually felt by 2 weeks after the procedure.
In my experience more than 80% of patients with vertebral fractures have significant improvement. If they didn’t I wouldn’t do the procedure.
Scarring: This is not cosmetic surgery. However the wounds are very small land rarely obvious. If you are concerned about wound cosmetics, then you should seek another opinion as I do promise invisible surgery.
SOME PATIENTS ARE NOT BETTER WITH VERTEBROPLASTY!
SOME PATIENTS CAN BE WORSE!
About 1 IN 100 (1%) of vertebroplasty procedures are complicated by an adverse outcome.
That is something happens that was not expected, and requires extra treatment.
I will try to cover the most serious complications. However you must note that I will not cover everything. An absolutely comprehensive list is NOT possible. The unexpected can always occur; I cannot warn you about everything.
Adverse risk rate I would estimate to be around 1%. This means that one in every 100 vertebroplasty procedures incurs an unexpected outcome.
This can be something simple such as a skin infection that resolves with tablet antibiotics, or it may be something extremely dangerous such as a blood clot, or heart attack.
Death
People have died having this procedure, however the risk of this is about 1 in 100,000 (American Society of Anaesthesiologists Grade 1). To put this in perspective the risk of a fatal car accident in a year is about 1 in 10,000. Or ten times more likely.
Paraplegia
It is possible to make you paraplegic by damaging all the nerves below the level of the vertebroplasty. This means you would be unable to walk, and would have no feeling below your waist. You would also not be able to control your bladder or bowel, and would lose normal sexual function. Paraplegia is irreversible. However this would be rare. It would be in the order of 1 in 10,000.
This would occur because of leakage of the liquid plastic into the space around the nerves, and subsequent damage to the nerves. Leakage of the plastic is relatively common. It occurs in about 25% of these procedures ,however most of the time only a tiny amount of plastic leaks, and it causes no problems. About 1 in 300 cases there is enough leakage that an open cutting operation is required to remove the plastic. I use a very sticky (Low Viscosity) plastic which makes this less likely.
Risks of all Orthopaedic Surgery
Death
Heart Attack
Stroke
Blood Clots
Bleeding requiring blood transfusion
Blood transfusion causing infection with hepatitis or AIDS
Lung failure: breathing difficulties
Kidney failure: unable to make urine, requiring dialysis
Liver failure: usually caused by an unexpected reaction to a
medication
Bowel paralysis (ileus): a temporary condition caused by
fasting and operating through the abdomen
Superficial Nerve injury - this occurs in the skin when an
incision is made causing permanent numbness.
Major Nerve Injury - In spinal surgery damage to a single
nerve in the spinal canal can have permanent paralysing
effects on a group of muscles. This is rare, but usually
irreversible.
Failure to improve.
Despite a technically perfect operation it can be possible that your symptoms may not improve. I give no guarantee that the surgery will improve any or all of your symptoms. However I believe strongly that you will get better. I would not do the surgery otherwise.
Infection
Some infections are simple to treat. Other infections are a disaster, requiring repeat surgery and removal of the implants. Long term antibiotics may also be required.
Your risk to the operating team.
During surgery it is possible for one of the operating team to cut themselves on a needle or other sharp object that has your blood on it. Blood can transmit infection from you to the staff member. There are drugs that can be given to the staff member to stop infection but they can only be given if your blood is tested for possible infection. I require you to give permission for taking and testing of your blood in the unlikely event that such an injury occurs. The blood will be tested for Hepatitis, and the Aids Virus (HIV). If you don't feel that you can give this permission then please discuss this with me. Your signature on this document serves as permission for this testing.
I have covered what I think is the most dangerous and the most concerning. If you have anything else you would like to discuss you can do so by contacting me.
SUMMARY
This document is a consent form.
You must read it thoroughly. I would strongly suggest that you have a friend, or relative read this with you. You may even wish to get a lawyer to read it.
If you have any concerns you should not proceed with the surgery and I would advise you to get another opinion from another spinal surgeon. Public hospitals with fully trained spinal surgeons include the AUSTIN HOSPITAL, THE ROYAL MELBOURNE HOSPITAL, MONASH MEDICAL CENTRE, and THE ALFRED HOSPITAL. All of these hospitals have public clinics you could visit. There are both neurosurgeons and other orthopaedic surgeons in Melbourne who do spinal surgery you could see privately.
As I have told you, I am an orthopaedic surgeon who has done extra training in spinal surgery. I am not the oldest, or the most experienced surgeon in Melbourne. However I am very well qualified and experienced in this surgery.
Your signature on this letter, with initials on every page must be in my office before the day of surgery. You should keep a copy for yourself. Your signature is acknowledgement of that you have read and understood the document; that you request the proposed surgery, and that you give me permission to perform the surgery and the Hospital to look after you during and after the surgery.
Yours Sincerely,
Dr. Michael KNIGHT MBBS FAOA
Signature: ..................................................
Date:.............../.................../......................
cc:
You have a problem of metastatic malignant deposit in your lumbar spine. This is causing the L1 vertebra to fracture. This fracture is unstable and is causing significant pain. If this fracture progresses it could potentially cause paraplegia.
That is: Multiple myeloma tumour has invaded and replaced the bone in your spine. This is occurring in many bones, however at L1 it is very extensive. This L1 tumour does not have the strength of bone. Under normal load such as stepping off a gutter, or severe bout of coughing the bone can fracture through this weakness.
If a spinal bone breaks it can push backwards on the spinal cord (the cauda equina) and cause nerve damage. This nerve damage can result in leg weakness , loss of bladder or bowel control and loss of feeling in your legs. If this happens it is an EMERGENCY. This requires immediate surgery or the loss can be permanent.
I have made this diagnosis based on my examination of you, the story you have told me, and the imaging available.
I am able to offer you 2 choices of treatment.
First option.
Continue to manage the problem non-surgically. That would mean decreasing your activity; both social and physical, to meet you level of disability. You will need to rely on medication, and psychological interventions for pain management. You will be house bound for several months.
The myeloma can then be treated with radiotherapy and chemotherapy. As the myeloma is killed off it will slowly be replaced by bone, and the spine will strengthen. This will take up to 12 months. During the first 3 to 6 months of this period you remain at risk of the L1 fracturing and causing nerve damage. If this occurs emergency surgery is possible. Emergency surgery always carries more risk, and nerve recovery cannot be guaranteed.
The use of physical therapy, chiropractic, and alternative health interventions without modern medicine have not been shown to be useful in the management of myeloma. They may give you short term pain relief, and this is not a bad thing, but they cannot provide you with a permanent cure and relying on these alone will see progression of your disease.
With this condition non-surgical treatment is NOT necessarily the safest alternative. While there can be no surgical complications if there is no surgery, your condition may well deteriorate to the point you can no longer care for yourself. Deterioration in this condition is usually reversible if it is caught early, but I cannot guarantee this will be the case.
Second option.
Undergo spinal canal decompression and stabilisation/fusion.
The Operation
In this operation you are given an anaesthetic. You will be completely asleep. While you are asleep a drainage tube (urinary catheter will be placed in your bladder. At least two “drips” (intravenous and intra-arterial catheters) will be placed in your upper limbs. You will be rolled onto your stomach on a special table. A cut (incision) will be made in the middle of your back over the location of your problem. A portable x-ray machine will be used to make sure I know which level of the spine I am operating upon. I will push the muscles off the spinal bones (vertebrae) and I will remove some of the bone knobs/spurs, ligaments and joints to allow the spinal canal to recover its normal volume behind L1 where it is being squashed by tumour. This process will cause bleeding. We will give you fluid to replace the blood, but may need to give you some blood from the blood bank. The nerves will be protected during the surgery.
You will need the spine to be fused together to keep it stable. Fusion is when the bones grow together to be one living structure. Surgery creates an environment for fusion to occur, by making the bones think they were broken apart and need to joint back up together. I use screws and rods to hold the spine in the correct position while fusion occurs. I'll inject the bones with liquid plastic to strengthen the grip of the screws to the bones. I use artificial bone, donor bone and bone stimulating chemicals to achieve fusion. Fusion takes over 12 months in many adults. Fusion is not guaranteed, and chemo/radiotherapy impair fusion.
The wound is then washed out to remove any bacteria that has fallen in from your skin, and closed with sutures (stitches). The suture is dissolvable and below the skin.
You will be rolled onto your back and woken up. Once you are awake enough to breathe for yourself you will be transferred to the recovery room. Once you are awake enough to move your legs I shall ring your nominated next of kin and tell them that you are OK.
The Outcome:
Immediately after the surgery you will not be too sore because you will have lots of medication in your system. As this wears off the pain will increase. Many people describe the first 24 hrs as very painful. One of my patients said it was like a truck had run over him. This settles quickly, and you will be provided with lots more pain relieving medication. The day after surgery you will be expected to get up and stand. You are allowed to walk, or sit; however you probably will not feel like it. Each day you will be asked to do more moving, and you will have less pain. Once you can safely and comfortably get to the toilet the urinary catheter will be removed. Once you can safely move around the ward you will be assessed for rehabilitation. Most patients go to rehabilitation. The timing of this will be determined by your chemo and radiotherapy.
Surgery DOES NOT CURE MYELOMA. This operation is to prevent paraplegia and to control pain, not to cure the multiple myeloma. You will still need chemotherapy and radiotherapy.
Most patients get some immediate relief of pain. However lack of an immediate response does not mean that you will not get better. Most of the improvement in symptoms does not occur until days or weeks after the surgery.
It is very common to feel much better for a few days and then some of the symptoms come back again. This does not mean that the operation has failed. It means that the ongoing inflammation from the surgery is causing nerve /muscle irritation. As the wound heals the pain settles again.
In my experience almost all patients with unstable spinal fractures like yours have significant improvement. If they didn’t I wouldn’t do the surgery.
Scarring: This is not cosmetic surgery. The wounds are large and obvious. If you are concerned about this, then you should seek another opinion as I do not do keyhole spine surgery for this condition.
COMPLICATIONS
SOME PATIENTS ARE NOT BETTER WITH SURGERY, SOME PATIENTS CAN BE WORSE. About 5% of spinal operations are complicated by an adverse outcome. That is something happens that was not expected, and requires extra treatment.
I will try to cover the most serious complications. However you must note that I will not cover everything. An absolutely comprehensive list is NOT possible. The unexpected can always occur; I cannot warn you about everything.
Adverse risk rate I would estimate to be around 5%. This means that one in every twenty operations incurs an unexpected outcome.
This can be something simple such as a skin infection that resolves with tablet antibiotics, or it may be something extremely dangerous such as a blood clot, or heart attack.
Death
People have died having this surgery, however the risk of this is about 1 in 10,000 (American Society of Anaesthesiologists Grade 2). To put this in perspective the risk of a fatal car accident in a year is about 1 in 10,000. Death is caused by sudden failure of your heart, or your lungs and unfortunately is almost always unpredictable and unpreventable. If we could predict or prevent we could remove the risk, but despite doing our best we cannot removal all risk.
Paraplegia
It is possible to make you paraplegic by damaging all the nerves below the level of the surgery.This means you would be unable to walk, and would have no feeling below your waist. You would also not be able to control your bladder or bowel, and would lose normal sexual function. Paraplegia is irreversible. However this would be extremely rare, so rare I cannot put a percentage on this risk.
Dural Tear
The nerves of the spinal canal are enclosed in a fine skin. This is called the dura. This dura keeps the nerves and spinal cord, and brain floating in a bath of fluid called Cerebrospinal Fluid (CSF). It is possible to tear or cut this dura (durotomy) , without damaging the nerves directly. This occurs in about 1 in 200 first time operations and 1 in 10 revision operations. This causes a loss of CSF. These incidental durotomies can be repaired, or sealed. The body makes up the lost fluid in 48 hrs. However during this 48 hours you may have a very severe headache, and you will be required to remain flat in bed. Very rarely the dura doesn't seal up, and further surgery is required to prevent the CSF from leaking continuously.
Risks of all Orthopaedic Surgery
Death
Heart Attack
Stroke
Blood Clots
Bleeding requiring blood transfusion
Blood transfusion causing infection with hepatitis or AIDS
Lung failure: breathing difficulties
Kidney failure: unable to make urine, requiring dialysis
Liver failure: usually caused by an unexpected reaction to a medication
Bowel paralysis (ileus): a temporary condition caused by fasting and operating through the abdomen
Superficial Nerve injury - this occurs in the skin when an incision is made causing permanent numbness.
Major Nerve Injury - In spinal surgery damage to a single nerve in the spinal canal can have permanent paralysing effects on a group of muscles. This is rare, but usually irreversible.
Delayed or failed wound healing. Chemotherapy and Radiotherapy slow healing.
Failure to improve.
Despite a technically perfect operation it can be possible that your symptoms may not improve. I give no guarantee that the surgery will improve any or all of your symptoms. However I believe strongly that you will get better. I would not do the surgery otherwise.
Infection
Some infections are simple to treat. Other infections are a disaster, requiring repeat surgery and removal the implants. Long term antibiotics may also be required.
Reoperation
A complication of surgery, sometimes can only be corrected by having another operation. Sometimes it can even require multiple operations.
Sometimes the progression of your disease can require further surgery.
The need for any re-operation would be thoroughly discussed and explained. Costs associated with re-operation are actively minimised.
Your risk to the operating team.
During surgery it is possible for one of the operating team to cut themselves on a needle or other sharp object that has your blood on it. Blood can transmit infection from you to the staff member. There are drugs that can be given to the staff member to stop infection but they can only be given if your blood is tested for possible infection. I require you to give permission for taking and testing of your blood in the unlikely event that such an injury occurs. The blood will be tested for Hepatitis, and the Aids Virus (HIV). If you don't feel that you can give this permission then please discuss this with me. Your signature on this document serves as permission for this testing.
I have covered what I think is the most dangerous and the most concerning. If you have anything else you would like to discuss you can do so by contacting me.
SUMMARY
This document is a consent form.
You must read it thoroughly. I have sent you extra copies to give to your GP. I would strongly suggest that you have a friend, or relative read this with you. You may even wish to get a lawyer to read it.
If you have any concerns you should not proceed with the surgery and I would advise you to get another opinion from another spinal surgeon. Public hospitals with fully trained spinal surgeons include the AUSTIN HOSPITAL, THE ROYAL MELBOURNE HOSPITAL, MONASH MEDICAL CENTRE, and THE ALFRED HOSPITAL. All of these hospitals have public clinics you could visit. There are both neurosurgeons and other orthopaedic surgeons in Melbourne who do spinal surgery you could see privately.
As I have told you, I am an orthopaedic surgeon who has done extra training in spinal surgery. I am not the oldest, or the most experienced surgeon in Melbourne. However I am very well qualified and experienced in this surgery.
Your signature on this letter, with initials on every page must be in my office before the day of surgery. You should keep a copy for yourself. Your signature is acknowledgement of that you have read and understood the document; that you request the proposed surgery, and that you give me permission to perform the surgery and the Hospital to look after you during and after the surgery.
Yours Sincerely,
Mr Michael KNIGHT
MBBS FAOA
Signature: ...................................................
Date:.............../.................../......................