OT notes · Orthopaedics

Scoliosis correction (posterior instrumented fusion)

Usual anaesthesia
General anaesthesia with neuromonitoring (SSEP and MEP)
Position
Prone on a Jackson table, Relton-Hall frame or bolsters, abdomen hanging free
Setting
elective

Operative note template for posterior instrumented spinal fusion for scoliosis, with a filled example for an adolescent idiopathic right thoracic curve corrected with all pedicle screws under neuromonitoring.

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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

  • spinal cord or nerve root injury with weakness or paralysis
  • loss of neuromonitoring signals needing a wake-up test or removal of implants
  • bleeding and blood transfusion
  • screw malposition needing revision
  • wound infection
  • non-union (pseudarthrosis) and implant failure
  • incomplete correction or imbalance of trunk and shoulders
  • junctional kyphosis above or below the fusion
  • numbness of the outer thigh from hip pad pressure
  • loss of spinal movement in the fused segment

Pre-operative details for this operation

  1. Diagnosis and curve typeidiopathic / other; Lenke type with lumbar and sagittal modifiers
  2. Cobb anglesstanding and bending (or traction) for each curve; thoracic kyphosis T5-T12
  3. Planned fusion levelsupper and lower instrumented vertebrae (UIV, LIV) and why; stable sagittal vertebra; number of ribs and lumbar vertebrae counted
  4. MRI whole spineDone: normalDone: abnormal (state)Not needed (typical curve)needed for atypical pain, neurological signs, left thoracic curve, onset before 10 years, rapid progression
  5. Baseline neurological examinationpower, sensation, abdominal and deep tendon reflexes
  6. Blood grouped and cross-matchedunits reserved
  7. Weightfor drug doses
  8. Neuromonitoring team and implant set confirmed

Anaesthesia and position

  1. AnaesthesiaGeneral endotracheal
  2. NeuromonitoringSSEP and MEPSSEP onlyNone: wake-up test plannedbaseline signals, name of electrophysiologist
  3. Blood pressure plantarget MAP during exposure and during correction
  4. Tranexamic acid and intrathecal morphinedrug, dose, time, who gave it
  5. PositionJackson tableRelton-Hall frameLongitudinal rollsabdomen free, ASIS padded, eyes checked, shoulders abducted not more than 90 degrees, strap across buttocks
  6. Warming and urinary catheter

Operative findings

  1. Levels confirmedimage and counting method, done early
  2. Bone qualityGoodSoft
  3. Posterior elementsspina bifida occulta, abnormal pedicles
  4. Screw stimulation thresholdsany screw below 6 mA and what was done
  5. Neuromonitoring eventstime, change, action taken, recovery
  6. Correction obtainedon final images: coronal, sagittal, shoulder and LIV tilt

Procedure (steps)

  1. Skin preparation and incisionantiseptic; midline incision (slightly curved for larger curves), levels
  2. Subperiosteal exposurespinous processes, laminae, facets, to tips of transverse processes, levels; ligaments and facet capsules above and below the fusion kept intact
  3. Early level checkimage with marker to confirm UIV and LIV
  4. FacetectomiesUltrasonic bone cutterOsteotomeBurrlevels; thoracic two cuts, lumbar one cut; superior articular process kept
  5. Posterior releasespinous processes, interspinous ligaments, ligamentum flavum removed (partial / complete); posterior column osteotomies if stiff (levels)
  6. Pedicle screwsFreehandFluoroscopy guidedComputer-assisted guidancestarting points, track checked for breach of all walls, length measured; screws per level and side
  7. Screw checkstimulation thresholds and AP/lateral images before rods
  8. Rods measured and contouredmaterial, diameter, length; concave rod bent with more kyphosis than convex
  9. Correction manoeuvreSingle rod: rod rotation with serial reducersDual rod reductionwhich rod first, reducers, rod rotation, direct vertebral derotation levels, distraction (thoracic) or compression (lumbar)
  10. Second rod and final tighteningset screws to manufacturer torque; cross-links if used
  11. Neuromonitoring after correction / wake-up testSignals unchangedChange: actionWake-up test normal
  12. Final imagesAP, lateral and oblique fluoroscopy for screw position and correction
  13. Decortication and graftingburr size; local autograft, iliac crest or allograft, volume; open canal covered with gelatin sponge
  14. Thoracoplasty (if done)ribs and length removed

Closure, drains and dressing

  1. Muscle and fasciasuture material and size
  2. Subcutaneous and skinsuture material, size, subcuticular
  3. DrainNoneSubfascial suction drain
  4. Dressing
  5. Neurological examination on wakingboth legs moved on command before leaving OT

Specimens and implants

  1. Pedicle screwsmake, material, list of each level and side with diameter x length, uniaxial or polyaxial, lot numbers, stickers pasted
  2. Rodsmaterial (titanium / cobalt chrome), diameter, length, lot numbers
  3. Set screws, cross-links, hooksnumber and lot numbers
  4. 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 at once if new weakness
  2. Monitoring and wardrecovery, then ward or HDU as ordered
  3. Breathingincentive spirometry often
  4. Analgesiadrug, dose, frequency; monitoring after intrathecal morphine
  5. Antibioticonly if prescribed: drug, dose, stop time
  6. Mobilisationsit up on the day of surgery, walk on day 1; brace not routinely needed
  7. Catheter and drainremoval plan
  8. InvestigationsHb on day 1
  9. X-raystanding PA and lateral whole spine before discharge or at first visit
  10. School and sportschool at 3 to 4 weeks, competitive sport at about 3 months

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: Ms. A.S., 14 years, 46 kg, with adolescent idiopathic scoliosis, right thoracic curve T5-T11 of 58 degrees (bending 32 degrees), Lenke 1A with normal kyphosis, and right rib hump.

Case details

Date: 18/05/2026. Elective spine list. OT 1.

In OT 08:00. Induction 08:10. Neuromonitoring baselines 08:45. Skin incision 09:10. Closure completed 13:40.

Surgeon: Dr C. (consultant). First assistant: Dr A. (3rd-year resident, Orthopaedics), did the exposure, facetectomies, left-side screws T8 to L1 and closure. Second assistant: Dr B.

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

Indication and pre-op

Indication: progressive right thoracic AIS, 58 degrees (42 degrees one year ago), cosmetic deformity. Lenke 1A N. Normal neurological examination with symmetrical abdominal reflexes. MRI whole spine normal.

Plan: T4 to L1 posterior fusion. L1 is the stable sagittal vertebra and the last vertebra touched by the CSVL. 12 rib-bearing and 5 lumbar vertebrae counted on X-ray.

Hb 12.6 g/dl. Two units cross-matched.

Consent: general, procedure-specific, implant, blood transfusion and anaesthesia consent taken in Telugu from both parents, patient's assent taken. Neurological injury, bleeding, infection, screw revision and incomplete correction explained.

WHO checklist sign in and time out done. Weight 46 kg. Inj cefazolin 1.4 g IV (30 mg/kg, below the adult 2 g dose) at 08:55, repeated at 12:55. Tranexamic acid given by anaesthetist as per unit protocol.

Intrathecal preservative-free morphine 230 microgram (5 microgram/kg) drawn up by the anaesthetist and given by the surgeon before incision.

Anaesthesia and position

General endotracheal anaesthesia, drugs chosen by anaesthetist to allow MEP monitoring. SSEP and MEP needles placed by electrophysiologist, baselines normal. Foley catheter placed. Forced-air warmer.

Prone on Jackson table, head in head holder with mirror, eyes free, ASIS padded on hip pads, abdomen free, shoulders abducted less than 90 degrees, strap across buttocks.

Parts painted with chlorhexidine-alcohol from the neck to the buttocks and draped. MAP kept 50 to 60 mmHg during exposure.

Procedure

Slightly curved midline incision from T3 to L2. Dissection in the midline with cautery, subperiosteal exposure of spinous processes, laminae and facets out to the tips of the transverse processes T4 to L1. T3-T4 and L1-L2 interspinous ligaments and facet capsules kept intact.

Levels confirmed early with markers on T4 and L1 and fluoroscopy, counted from the sacrum and from T12 rib.

Findings: good bone quality, no spina bifida occulta, apex at T8 with rotation to the right.

Facetectomies T4-T5 to T12-L1 with osteotome: two cuts in the thoracic facets, one cut at T12-L1. Spinous processes T5 to T12 and interspinous ligaments removed. Ligamentum flavum thinned with a wide rongeur, not removed fully.

Pedicle screws, freehand: start point burred, 2.0 mm drill advanced slowly to 20 mm, ball-tip probe checked all five walls, 3.2 mm reamer to 5 mm beyond planned length, rechecked, length measured against the screw. Left (concave) screws at every level T4 to L1. Right (convex) screws at T4, T5, T8, T9, T12, L1, uniaxial at T8, T9 and L1.

All screws stimulated above 8 mA. AP and lateral fluoroscopy: all screws within pedicles, no tips crossing the midline.

Left rod (cobalt chrome 6.0 mm) cut long and bent with more kyphosis than the right. Placed with serial reducers, spine brought slowly to the rod, rod rotated. MAP raised to 80 mmHg before correction.

Direct vertebral derotation at T8-T9 and at L1. Distraction on the left between thoracic screws. Set screws tightened. Right rod (cobalt chrome 6.0 mm) bent with less kyphosis and placed, apical screws on the left loosened and retightened after seating.

Neuromonitoring: SSEP and MEP unchanged after correction. Wake-up test not needed. No cross-links.

Final AP, lateral and oblique fluoroscopy: screws in position, curve corrected to about 18 degrees on the table image, thoracic kyphosis kept, L1 horizontal.

All exposed laminae and transverse processes decorticated with a 3 mm burr. Local autograft from spinous processes and facets (about 20 ml) with 30 ml crushed cancellous allograft laid along the decorticated bone, more at the upper and lower ends. Areas of open canal covered with gelatin sponge.

Closure

Muscle and fascia closed in two layers with running barbed polydioxanone (PDS) No. 1. Subcutaneous layers with poliglecaprone (Monocryl) 2-0. Skin with subcuticular Monocryl 3-0. No drain.

Sterile dressing applied. Patient woken and moved both legs and feet on command before leaving OT.

Specimens and implants

Specimens: none.

Pedicle screws (titanium, polyaxial unless stated): left T4 to T7 5.0 x 35 mm, left T8 to T11 5.5 x 40 mm, left T12 and L1 6.0 x 45 mm. Right T4, T5 5.0 x 35 mm, right T8, T9 5.5 x 40 mm uniaxial, right T12 6.0 x 45 mm, right L1 6.0 x 45 mm uniaxial. Total 16 screws, 16 set screws.

Rods: cobalt chrome 6.0 mm, left 340 mm and right 335 mm after cutting. Allograft 30 ml. All lot numbers and stickers pasted on the implant sheet.

End of procedure

Estimated blood loss: 700 ml. Transfusion: none. Hb at end 10.4 g/dl (arterial gas).

Fluoroscopy time recorded by radiographer.

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

No intra-operative complications. No neuromonitoring alerts.

Patient shifted to post-anaesthesia care unit in stable condition. Pulse 96/min, BP 110/68 mmHg.

Post-op orders

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

Respiratory rate and sedation score monitoring after intrathecal morphine as per ward protocol.

Incentive spirometry frequently while awake.

Analgesia as per unit protocol.

Sit up in bed tonight. Walk with physiotherapist on day 1. No brace.

Catheter removal on day 1.

Hb on day 1.

Standing PA and lateral whole spine X-ray before discharge. School from 3 to 4 weeks, competitive sport at about 3 months.

Signature

Dr A., JR-3, Orthopaedics, for Dr C. Reg. no. ________. 18/05/2026, 14:00.

Must document for this operation

  • Fusion levels planned and done, with how the levels were confirmed on the table. About 10 percent of adolescent idiopathic scoliosis (AIS) patients have an abnormal number of vertebrae, so the note must show how levels were counted.
  • Neuromonitoring baselines, any alerts with the action taken, and the result after correction or the wake-up test. If the patient wakes with a deficit, this record shows when it happened and what was done.
  • A full implant list: each screw by level, side, size and type, rods with material and length, with lot numbers. Revision, implant removal or a recall needs exact implant details.
  • Screw stimulation thresholds and any screw revised. A low threshold suggests a pedicle breach, so the note must show it was acted on.
  • The correction manoeuvre and the correction seen on the final images. This is the baseline for judging later loss of correction or junctional problems.
  • Neurological examination of both legs on waking. It separates a deficit present at the end of surgery from one that develops later on the ward.

Common mistakes in these notes

  • Writing 'T4 to L1 instrumentation done' without a screw-by-screw list.
  • Leaving out neuromonitoring findings, or writing only 'monitoring normal' with no baseline.
  • Not recording the leg examination on waking.
  • Not recording drug doses by weight for a child (antibiotic, intrathecal morphine).
  • Leaving out graft type and volume.

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))
  • Separate informed consent is needed before transfusion of blood or blood components, as well as for anaesthesia and surgery. (NABH Hospital Standards 5th ed., PRE.2(g))
  • 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)
  • Notes written after discharge have no legal value, and a correction must strike through the whole line and be rewritten with date and time. (Thomas J, Indian J Urol 2009;25(3):384-8)

Sources

  • Vaccaro AR, Baron EM, eds. Operative Techniques: Spine Surgery. 4th ed. Elsevier; 2025, Procedure 24, Posterior thoracolumbar fusion techniques for adolescent idiopathic scoliosis (Illingworth KD, Skaggs DL), pp. 206-224.e2.
  • Saghieh S, Weinstein SL, Hoballah JJ, eds. Operative Dictations in Orthopedic Surgery. Springer; 2013, Ch 1, Posterior spinal fusion with instrumentation (Weinstein SL), pp. 3-7.
  • 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 30 mg/kg IV in children (adult 2 g), within 60 min before incision, redose after 4 h. Weight-based dosing section: children over 40 kg get the weight-based dose unless it exceeds the adult dose, so the adult dose is the ceiling. academic.oup.com/ajhp/article/70/3/195/5112717
  • Operative Techniques: Spine Surgery 4e, Procedure 24, printed p. 210: MAP 50-60 mmHg during dissection and 75-80 mmHg or higher during correction; tranexamic acid used; intrathecal Duramorph 5 microgram/kg (maximum 250 microgram) given by the surgeon before incision.

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.

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