OT notes · Orthopaedics

Lumbar decompression and instrumented fusion (laminectomy / discectomy / TLIF)

Usual anaesthesia
General anaesthesia with endotracheal intubation
Position
Prone on a Wilson frame, Jackson table, knee-chest frame or chest rolls, abdomen free
Setting
elective

Operative note template for posterior lumbar decompression (laminotomy, discectomy or laminectomy) with or without pedicle screw fixation and interbody fusion, with a filled example for an open L4 laminectomy and L4-L5 TLIF for degenerative spondylolisthesis.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • dural tear with leak of spinal fluid
  • nerve root injury with leg weakness, numbness or pain
  • screw in a wrong position needing revision
  • wound infection or disc space infection
  • bleeding and blood transfusion
  • non-union of the fusion or implant failure
  • leg pain or back pain not fully relieved
  • thrombosis in the legs
  • pressure sores or eye problems from lying prone
  • future problems at the level next to the fusion

Pre-operative details for this operation

  1. Clinical indicationradicular pain side and root, neurogenic claudication distance, deficit (power, sensation), bladder and bowel status, duration of conservative treatment
  2. ImagingMRI level and type of compression; standing and flexion-extension X-rays for slip or instability; transitional vertebra noted and how levels are counted
  3. Planned levels and sidee.g. L4 laminectomy, left L4-L5 TLIF, L4-L5 pedicle screws; mark side on skin
  4. Anticoagulants and antiplateletsdrug and date stopped
  5. Blood grouped and cross-matchedunits reserved
  6. Implant set, C-arm and microscope availablescrew system, cage type and sizes

Anaesthesia and position

  1. AnaesthesiaGeneral endotracheal
  2. PositionProne on Wilson frameProne on Jackson / radiolucent tableKnee-chest (Andrews) frameProne on chest rollspressure points padded, eyes free, abdomen free
  3. Urinary catheterFoley catheterNot needed
  4. ImagingC-arm side; level localised by lateral X-ray with a marker
  5. MagnificationOperating microscopeLoupes and headlight

Operative findings

  1. Level confirmedhow: marker on spinous process with lateral image; name the image count method
  2. Compression foundextruded / protruded / sequestrated disc, thick ligamentum flavum, facet hypertrophy, lateral recess or foraminal stenosis, slip
  3. Nerve rootswhich roots, how compressed, free at end (probe passes, root moves at least 1 cm medially)
  4. DuraIntact, no leak on ValsalvaTear: size and repair
  5. Bone quality and pedicle breachsoft / good; any breach found on feeling the track

Procedure (steps)

  1. Skin preparation, draping and local infiltrationantiseptic; local anaesthetic with adrenaline: drug, strength, volume
  2. Incision and exposureMidline openParamedian tubular (MIS)Midline unilateral (microdiscectomy)length, subperiosteal exposure unilateral or bilateral, to facets or tips of transverse processes; facet capsule above the fusion preserved
  3. Level confirmationmarker and lateral X-ray or fluoroscopy before any bone is removed
  4. DecompressionLaminotomyLaminectomyUndercutting of opposite sideMedial facetectomy / foraminotomylevels and extent; ligamentum flavum removed; tools (burr, Kerrison size)
  5. Discectomyannulotomy type, fragments removed, disc space irrigated, pituitary not beyond about 15 mm into the disc
  6. Nerve roots checkedprobe passes along root and into foramen; root mobile
  7. TLIF: facetectomy and disc preparation (if fusing)side; total facetectomy; superior articular process removed; traversing root retracted, exiting root not retracted; endplate cartilage removed
  8. TLIF: graft and cagegraft type (local bone, allograft, substitute) placed anteriorly; trials; cage material, height, length; countersunk 3 to 5 mm below the posterior margin; AP and lateral images
  9. Pedicle screwsOpen freehand with C-armPercutaneous with Jamshidi needle and guidewireentry point, feeler check of all walls, each screw level, side, diameter and length
  10. Rods and final tighteningrod material, diameter, length, compression or distraction, cross-link
  11. Posterolateral graft (if done)transverse processes and pars decorticated; graft source
  12. Final checksfinal AP and lateral images; roots free; Valsalva for CSF leak; haemostasis
  13. Local antibiotic or fat graft (if used)e.g. vancomycin powder with dose, fat graft over dura

Closure, drains and dressing

  1. DrainSubfascial suction drainNone
  2. Fascia and supraspinous ligamentsuture material, size, interrupted or figure-of-eight
  3. Subcutaneous layersuture material and size
  4. SkinSubcuticularStaplesSkin glue
  5. Neurological check after wakingpower in both legs recorded before leaving OT

Specimens and implants

  1. Disc and ligament specimenSent for HPENot sent
  2. Pedicle screwsmake, material, each level and side with diameter x length, lot numbers, stickers pasted
  3. Rods and set screwsmaterial, diameter, length, lot numbers
  4. Interbody cagemake, material, height x length, lot number
  5. Bone graft or substitutesource, product and lot number

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Neurological chartingpower and sensation of both legs, frequency; call if new weakness
  2. Drainrecord output and colour; clear watery fluid may mean CSF leak
  3. Catheterremoval time, and record voiding after removal
  4. Analgesiadrug, dose, frequency
  5. Antibioticonly if prescribed: drug, dose, stop time
  6. Mobilisationwalk as much as possible from the day after surgery or earlier; no bending, lifting or twisting for 3 months after fusion
  7. Thromboprophylaxisearly mobilisation, stockings, drug if prescribed
  8. X-raystanding AP and lateral before discharge (fusion cases)
  9. Wound care and suture plandressing change day, suture or staple removal

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mr. R.J., 58 years, with neurogenic claudication at 100 metres and left L5 radicular pain for 18 months, not better after 6 months of physiotherapy, drugs and one epidural injection. MRI: L4-L5 grade 1 degenerative spondylolisthesis with severe central and left lateral recess stenosis. Flexion-extension X-ray: 4 mm movement.

Case details

Date: 10/06/2026. Elective spine list. OT 1.

In OT 08:30. Induction 08:40. Skin incision 09:20. Closure completed 12:35.

Surgeon: Dr C. (consultant). First assistant: Dr A. (3rd-year resident, Orthopaedics), did the exposure, the right-side screws and the closure. Second assistant: Dr B.

Anaesthetist: Dr D. Scrub nurse: Sr E. Radiographer: Mr F.

Indication and pre-op

Indication: L4-L5 degenerative spondylolisthesis with stenosis and left L5 radiculopathy. Power left EHL 4/5, other muscles 5/5. Sensation reduced over left L5 dermatome. Bladder and bowel normal.

Five lumbar vertebrae, no transitional vertebra. Clopidogrel stopped on physician's advice, last dose 03/06/2026. Hb 13.4 g/dl. Two units cross-matched.

Consent: general, procedure-specific, implant and anaesthesia consent taken in Hindi from the patient, son as witness. Dural tear, nerve injury, screw revision, infection, non-union and incomplete relief explained.

Left side of lower back marked. WHO checklist sign in and time out done. Inj cefazolin 2 g IV at 09:05, before skin incision.

Anaesthesia and position

General endotracheal anaesthesia. Foley catheter placed.

Log-rolled prone on a Wilson frame, abdomen free, eyes and face free of pressure, all pressure points padded. C-arm from the right.

Parts painted with chlorhexidine-alcohol and draped. Level marked with fluoroscopy.

Procedure

Midline incision 10 cm over L4 and L5 spinous processes. Fascia opened in the midline and paraspinal muscles elevated subperiosteally on both sides to the tips of the L4 and L5 transverse processes. L3-L4 facet capsules preserved.

Level confirmed with a clamp on the L4 spinous process and a lateral fluoroscopy image counted from the sacrum.

Pedicle screws: entry at the junction of the transverse process line and the pars, opened with a burr, track made with a blunt pedicle probe under AP and lateral fluoroscopy, all walls and the floor felt with a ball-tip feeler, tapped. Screws placed at L4 and L5 on both sides.

Laminectomy: L4 spinous process and lamina removed with rongeur and high-speed burr. Thick ligamentum flavum removed with 3 mm and 4 mm Kerrison rongeurs. Dura protected with cottonoid patties.

Left TLIF: left L4-L5 total facetectomy with osteotome. Superior articular process of L5 removed to the level of the L5 pedicle. Left exiting L4 root seen and not retracted. Traversing left L5 root retracted gently medially.

Findings: severe central and left lateral recess stenosis at L4-L5 from ligamentum flavum and facet hypertrophy. Left L5 root flattened and red. Disc bulging but not extruded.

Box annulotomy with No. 15 blade lateral to the dural sac. Disc and cartilaginous endplates removed with pituitary rongeurs, shavers and curettes. Disc space distracted with trials. Local bone from the laminectomy and facet cleaned, morselised and packed anteriorly into the disc space.

PEEK cage 10 mm high and 26 mm long packed with local bone and inserted, countersunk about 4 mm below the posterior vertebral margin. Position checked on AP and lateral fluoroscopy.

Right L4-L5 medial facetectomy and foraminotomy done. Both L5 roots and the left L4 root free. Ball probe passes along each root and into the foramina.

Titanium rods 5.5 mm x 50 mm, contoured into lordosis, placed and set screws tightened. Final AP and lateral images: screws within pedicles, cage in position, slip reduced.

Valsalva manoeuvre by anaesthetist: no CSF leak. Wound irrigated with saline. Haemostasis with bipolar cautery and gelatin sponge.

Closure

Subfascial suction drain 14 Fr brought out on the right.

Fascia closed with interrupted polyglactin 910 (Vicryl) No. 0. Subcutaneous layer with continuous Vicryl 2-0. Skin with subcuticular poliglecaprone (Monocryl) 3-0.

Dressing applied. Patient turned supine and woken. Both legs moving on command: power left EHL 4/5, all other groups 5/5, same as before surgery.

Specimens and implants

Ligamentum flavum and disc material: not sent for HPE (degenerative disease), discarded as yellow category waste.

Pedicle screws (titanium, polyaxial): L4 right 6.5 x 45 mm, L4 left 6.5 x 45 mm, L5 right 6.5 x 45 mm, L5 left 6.5 x 45 mm.

Rods: titanium 5.5 x 50 mm, two. Cage: PEEK 10 x 26 mm, one. All lot numbers and stickers pasted on the implant sheet.

End of procedure

Estimated blood loss: 550 ml (suction 400 ml plus mops). No transfusion.

Fluoroscopy time recorded by radiographer.

Mop, needle, patty and instrument count correct, confirmed by scrub nurse.

No intra-operative complications. No dural tear.

Patient shifted to post-operative ward in stable condition. Pulse 88/min, BP 126/78 mmHg.

Post-op orders

Power and sensation of both legs charted with every set of vitals. Inform the doctor on duty at once if new weakness.

Drain output 8-hourly. Report clear watery drain fluid.

Remove catheter on day 1 morning and record time of first void.

Analgesia as per unit protocol. Restart clopidogrel only on consultant advice.

Sit up and walk with physiotherapist from day 1. No bending, lifting or twisting for 3 months.

Stockings, and calf pumps till walking well.

Standing AP and lateral X-ray of the lumbar spine before discharge.

Dressing check on day 2.

Signature

Dr A., JR-3, Orthopaedics, for Dr C. Reg. no. ________. 10/06/2026, 12:55.

Must document for this operation

  • How the level was confirmed, with the image and how vertebrae were counted. The technique chapters require a marker image before bone is removed, and the note is the only proof that the level was checked.
  • Each screw by level, side, diameter and length, with cage and rod details and lot numbers. The revision surgeon needs exact implants, and implant batch numbers are needed for any recall.
  • The roots decompressed and how their freedom was checked. If leg pain persists, the next surgeon needs to know which roots and foramina were explored.
  • Whether the dura was intact or torn and how a tear was repaired. A known tear changes the post-op plan, and an unrecorded tear is hard to defend later.
  • Neurological status of both legs after waking, before leaving OT. It separates a new deficit from one that was present before surgery, which matters clinically and legally.
  • Which parts were done by the resident and which by the consultant. US CMS and Joint Commission standards ask who did each significant step, such as exposure, screw placement and closure, and a teaching hospital note should do the same.

Common mistakes in these notes

  • Writing 'L4-L5 fixation done' with no list of screw sizes per level and side.
  • Not recording how the level was confirmed.
  • Not recording the post-op neurological examination of the legs.
  • Leaving out whether there was a dural tear.
  • Writing 'adequate decompression' without naming the roots and levels checked.

Indian practice and paperwork

  • The batch and serial number of every implant must be recorded in the patient's record, the OT implant master logbook and the discharge summary. (NABH Hospital Standards 5th ed., MOM.10(d))
  • If an extra level is decompressed or fused beyond what the written consent covers, it is defensible only if it was needed to save life or preserve health and could not wait (Samira Kohli v. Dr Prabha Manchanda, Supreme Court, 2008). Write the reason in the note. ((2008) 2 SCC 1)
  • Name every anaesthetist in the note: a hospital was held negligent when the operation note left out the name of one of two anaesthetists. (Thomas J, Indian J Urol 2009;25(3):384-8)
  • In a Mumbai audit of 153 orthopaedic operation notes, closure details were recorded in 17 percent and estimated blood loss in 59.5 percent. (Tuteja S et al., Indian J Orthop 2022;56(12):2223-2227)

Sources

  • Azar FM, Beaty JH, eds. Campbell's Core Orthopaedic Procedures. 2nd ed. Elsevier; 2024, Technique 10, Minimally invasive transforaminal lumbar interbody fusion (Campion CE); Technique 11, Microscopic lumbar diskectomy (Campion CE, Williams KD), pp. 36-45.
  • Saghieh S, Weinstein SL, Hoballah JJ, eds. Operative Dictations in Orthopedic Surgery. Springer; 2013, Ch 18 Laminotomy and partial discectomy; Ch 19 Central lumbar decompression (Sheikh Taha AM); Ch 20 Posterolateral interspinal fusion with pedicle screws (Khoury JG), pp. 58-67.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Spinal procedures with or without instrumentation: cefazolin (strength A). Table 1: cefazolin 2 g IV (3 g if 120 kg or more) within 60 min before incision, redose after 4 h. academic.oup.com/ajhp/article/70/3/195/5112717

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

Videos of this operation

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

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