ENDOSCOPIC SPINE SURGERY

Informed Consent Form

Form No: AOF-002	Rev. No / Date: 2026 v09 / 10.07.2026

PATIENT PROTOCOL NO	DATE
Turkish ID / Passport No	DATE OF BIRTH
PATIENT'S FULL NAME	SEX
DIAGNOSIS	(wide single cell)

1. Dear Patient,

It is your most natural right to be informed about your medical condition and about all medical / surgical treatments and diagnostic procedures proposed to you for the treatment of your illness. After learning the benefits and possible risks of medical treatments and surgical interventions, it is again your own decision to consent or not to consent to the procedure to be performed. The purpose of this explanation is not to frighten or worry you, but to involve you more consciously in the decisions to be made about your health. If you wish, all information and documents concerning your health can be given to you or to a relative you deem appropriate. Although this form has been designed to meet the needs of most patients under most circumstances, it should not be regarded as a document containing the risks of all forms of treatment. Depending on your personal health condition, your physician may give you different or additional information. After learning the benefits and possible risks of diagnosis, medical treatment and surgical interventions, it is your own decision to accept or not to accept the procedures to be performed. Except in cases of legal and medical necessity, you may refuse to be informed or withdraw your consent at any time. This form has been prepared to inform you about the risks of the surgery and about alternative treatment methods. Please read this form completely and carefully, and sign this consent form only after you have read it and after all your doubts about the procedure concerned have been resolved by your physician.

2. General Information About the Disease and Its Treatment

Endoscopic spine/spinal cord surgery is a modern and minimally invasive surgical method used in the treatment of diseases of the spine or spinal cord. Unlike traditional open surgeries, in this technique small incisions are made in the skin. The entry path created for the surgery is designed to cause the least possible harm to the body. A tube is inserted through the incisions made, and the procedure is performed through this tube using a thin camera (endoscope) and surgical instruments. The camera projects the surgical area onto a screen in a magnified and clear manner, allowing the surgeon to obtain a detailed view. This method can be applied in two ways: Monoportal (Single Channel/Tube) Method: A single incision is made in the skin. It is called Full Endoscopic Disc Surgery. Biportal (Double Channel/Tube) Method: Two small incisions are made in the skin. It is called Endoscopy-Assisted Spinal Disc Surgery. Your doctor will explain to you before the operation which method is suitable for you. Rarely, an unexpected situation may arise during the operation and it may become necessary to convert to open surgery. In such a case, your doctor will give you the necessary information after the operation.

Almost all procedures performed with open surgery, such as lumbar disc herniation (herniated disc of the lower back), cervical disc herniation (herniated disc of the neck), lumbar spinal stenosis (narrowing of the spinal canal in the lower back) and cervical spinal stenosis (narrowing of the spinal canal in the neck), can be performed with endoscopic (closed) spine surgery. Your doctor has evaluated your condition in detail, decided on the most appropriate surgical treatment method for you, and recommended this approach to you.

3. Alternatives to the Surgery, If Any

As alternatives to the surgery, I have considered the following options:

Not having this surgery, accepting all the risks, as my physician explained to me verbally,
Choosing one of the open surgical techniques,
Trying to relieve pain or muscle spasm through medication,
Doing exercises to strengthen the lower back and back muscles,
Trying to relieve the complaints with physical therapy methods,
Having steroid and local painkiller injections.
Trying to relieve the complaints with algological (pain medicine) treatment methods
Other possible treatment options…

I have also considered the other treatment methods explained to me by my doctor. The advantages and disadvantages of these alternative methods were also explained to me by my doctor.

4. Expected Benefits of the Surgery

The aim of surgical treatment is to eliminate the nerve compression caused by the patient's disease and to rapidly restore quality of life to the pre-operative level. The surgical procedure is essentially performed for two purposes: 1. Reduction or complete resolution of pain. 2. Improvement of, or halting the worsening of, signs of nerve compression such as loss of strength (paralysis of the foot due to nerve compression) and numbness-tingling. Among these, relief of pain is the main goal of the surgical procedure. Numbness may continue after the surgery. Loss of strength may resolve completely after the surgery, or may improve after additional treatments such as physical therapy and rehabilitation. Despite all treatment attempts, in some rare cases numbness-tingling and loss of strength may last for years after the surgery or may be permanent.

5. Estimated Duration of the Surgery

The duration of the procedure to be performed may vary according to the disease and the patient's condition, and is on average .….. - ....... hours. In addition, the procedures to be performed on patients by anesthesia doctors before and after the surgery are not included in this duration. Depending on the circumstances of the case, the procedure may take longer than the stated duration. Your doctor will give you detailed information at the end of the procedure.

6. Risks and Complications of the Surgery

In addition to its benefits, the surgical procedure to be performed also carries potential risks.

Anesthesia risk: There are risks during and after local and general anesthesia procedures (due to the position given to the patient during surgery). In addition, in every form of anesthesia and in sedation, there are also complications and harms that may occur due to the drugs. The anesthesia procedure to be applied and the related risks and complications have been explained to me, and I approve the recommended procedure in this regard.
Bleeding: Although very rare, I am aware of the existence of a risk of bleeding, which may be severe, during or after my surgery. In case of bleeding, additional treatment or a blood transfusion may be needed. In such a situation, I approve the necessary blood transfusion and other treatments. Some medications that I use and/or that must be used during my treatment may increase the risk of bleeding through drug interactions and/or side effects. In some cases, it may be necessary to use blood-thinning medications earlier than expected, and this may also increase the risk of bleeding.
Blood clot formation: Blood clots can form after any type of surgery. Clots forming in the bleeding area can obstruct blood flow and lead to complications such as pain, edema, inflammation or tissue damage. If the use of blood thinners is discontinued, the risk of clotting may increase.
Postoperative Neurological Deterioration: Nervous system functions may deteriorate after surgery due to problems such as bleeding at the surgical site.
Respiratory problems: After surgery, respiratory distress or pneumonia, which are usually temporary, may occur. Pulmonary embolism (blockage of the vessels of the lungs) may occur
Cardiac complications: The surgery carries a low risk of causing an irregular heart rhythm or a heart attack.
Death: Although very rare, there is a risk of death during or after the surgery.
Failure of the surgery
Increase in pain complaints: Although rare, pain complaints may increase after the surgery.
Infection: Infection may occur at the skin incision site, as well as in the surgical area, and even in the bone within the surgical area. Risks related to infection include meningitis (inflammation of the membranes surrounding the brain and spinal cord) and empyema-abscess formation (accumulation of pus).
Spinal cord and/or nerve root injury: Surgical treatment aims to improve, or to halt the worsening of, the neurological deficits present before the surgery (paralysis, loss of strength, loss of sensation, urinary and fecal incontinence, muscle wasting, loss of reflexes, pain and burning sensations, spasms, hoarseness, etc.); however, after the surgery these deficits may become even more severe (a picture of partial or complete paralysis) or may not improve. Even if you have no neurological deficit before the surgery, spinal cord or nerve root injury may, although rarely, occur during surgical treatment, and as a result a neurological deficit may develop after the surgery. When performed at the cervical level, the risk of spinal cord injury is particularly critical; for this reason, neuromonitoring (nerve monitoring) may be applied during the surgery.
Risk of cerebrospinal fluid leakage: After the surgery, cerebrospinal fluid may leak from the wound site to the outside. Its treatment may require a spinal (spinal cord) catheter or an additional intervention to repair the same wound site again.
Recurrence, Residual (remnant): After the surgery, symptoms may reappear and additional surgery may be required.
Loss of vision: In endoscopic (closed) spine surgery as well, damage to visual function that is usually temporary but in rare cases may progress to permanent vision loss (including blindness) may occur, due to the surgical position (prone) and the pressure changes during the procedure. This risk is higher especially in those with glaucoma (ocular hypertension) or another eye disease; these patients may require an ophthalmological evaluation before the surgery.
Injury to organs or major vessels: Although rarely seen, injury to organs or vessels within the abdominal or thoracic cavity may occur. These risks can lead to death.
I have also understood that, in the event of an unexpected situation during my surgery such as bleeding, injury to adjacent tissue or organs, etc., my doctor may perform other procedures necessary for my health beyond the planned procedure, and I approve this.

I have understood and accept all of the risks written above that may occur during and after the surgical procedure to be performed on me.

7. Consequences If the Surgery Is Not Performed

The patient's current complaints and clinical condition may not improve, and may worsen.

8. Important Characteristics of the Medications to Be Used

If you have a previously identified drug allergy, you must inform your physician and nurse about it. During your current treatment process, medications appropriate to the patient's medical condition (painkillers, antibiotics, medications supporting the circulation and the heart, blood products, intravenous fluid treatments, medications specific to your disease) will be given according to the reason for hospitalization or newly developing conditions. During the use of medications, side effects may occur and cause damage to the heart, kidneys and other organs. New medications will be added to the treatment to correct organ damage. PROPHYLAXIS: Before and after your surgery, appropriate preventive antibiotic treatment is administered in order to reduce the risk of surgical site infection. USE OF BLOOD-THINNING MEDICATIONS: If you are using anticoagulant, blood-thinning medications, you may be given different drug treatments or blood products to counteract the effects of these medications. SPINAL CASES: In case of severe pain after spinal operations, medications sold under a special controlled prescription ("green prescription"), which may be addictive, may be used. After spinal surgeries, in cases where weakness in the arms and legs does not change, or where new weakness develops, anti-edema (edema-reducing) medications may be used. In this case, the blood sugar balance may be disturbed. INTENSIVE CARE-DELIRIUM: In elderly patients and during long intensive care stays, mental health-regulating medications recommended by a psychiatrist may be used for psychological symptoms that may arise in patients. These medications can damage the heart, kidneys and other organs. In addition to these, anesthesia-related drugs are used. The general anesthesia (narcosis) drugs given during surgery may have toxic (poisonous) effects / side effects on organs such as the lungs, heart, brain, kidneys and liver. For this reason, DANGER OF DEATH may arise. I have informed my doctor about all my known allergies. I have also informed my doctor about the prescription medications I use, over-the-counter medications, herbal medicines, dietary supplements, illegal drugs, alcohol and sedatives/narcotics. The effects of using these substances before and after surgery were explained to me by my doctor, and recommendations were made. During my stay in the hospital, I received information about the important characteristics of the medications to be used for diagnosis and treatment (what they are used for, their benefits, their side effects, how they are to be used).

9. Lifestyle Recommendations Critical for the Patient's Health

Tobacco and Tobacco Products: It has been explained to me that smoking tobacco and tobacco products (cigarettes, hookah, cigars, pipes, etc.) before or after my surgery may prolong my recovery process. Anesthesia risks are higher in patients who smoke, and death due to anesthesia is seen more frequently. If you smoke, you should know that the success of the treatment/surgery will be lower than the general average success rate.

Follow your doctor's recommendations (exercise, nutrition program, etc.) and, if applicable, do not neglect your outpatient follow-up visit on the date requested of you.

I have received information about what I need to do regarding my lifestyle after my treatment/surgery (diet, bathing, medication use, mobility status and/or restrictions).

10. Patient-Specific Section

Patient-specific personal circumstances are recorded at the end of the form under Section 14 — Signatures.

11. How to Access Medical Assistance on the Same Matter When Needed

Refusing the treatment/surgery is a decision you make of your own free will. If you change your mind, you may personally reapply to our hospital/hospitals capable of performing the treatment/surgery in question.

I have received information on how to access medical assistance on the same matter when needed (my own physician, a different physician, the clinic where I was treated, and in emergencies, 112).

12. Permissions

I authorize the Head of the Surgical Team, Responsible Specialist Doctor Dr. Özgür Akşan, and his team to perform my surgery.

I understand that this intervention is aimed at eliminating my complaints and is performed with the intention of preserving or improving the function of the nervous system. I confirm that my doctor has explained all of the above information, that I have understood this information, and that all my questions regarding this intervention have been answered. Therefore, I give my consent for ENDOSCOPIC SPINE SURGERY and for all different or additional surgeries and additional treatment interventions deemed necessary by my doctor.

Use of tissue: Any tissue not required for medical diagnosis may be used for medical research within the framework of ethical rules. I consent to the use of any tissue, medical device or body parts that may have been removed during the surgical procedure.

Medical research: I consent to the review of clinical information from my medical records for the advancement of medical study, medical research and doctor training, provided that confidentiality rules are observed.

Photographs/Observers: I consent to the photographing or video recording of the surgery to be performed for scientific, medical or educational purposes, provided that the images do not reveal my identity.

13. Consent Confirmation

I know the alternative treatment methods and their risks.
I know the risks and side effects of the intervention.
I know the probability of success and failure.
I know what may happen if I do not receive treatment.
I understand that the procedure to be performed may not carry a guarantee of cure.
I have understood everything that has been told to me.
My doctor has answered all my questions.
My doctor explained everything written here to me one by one, in a clear, understandable and explanatory manner that I could understand.
I know the meaning of the Informed Consent form.
I have been informed about the approximate cost of the treatment.
I am making this decision of my own free will.
I had enough time before the intervention to obtain a second opinion within a reasonable period.
I have read and understood the content of the Informed Consent form.
All blanks on this form were filled in before I signed it, and I received a copy.

14. Signatures

A) Patient-Specific Circumstances

The patient writes, in their own handwriting, their personal circumstances (allergies, medications used, previous surgeries, etc.). If there are no special circumstances, writing "NONE" is sufficient.

B) Handwritten Declaration

The patient writes the following sentence in their own handwriting:

"I have read this form carefully, I have been informed about THE SURGERY TO BE PERFORMED, my questions have been answered, and I give my consent to this procedure of my own free will."

C) Signatures

	Full Name	Signature	Date / Time
Patient
Legal Representative / Relative <br>(Degree of relationship: ……………………)
Head of the Surgical Team, Responsible Specialist Doctor	Dr. Özgür Akşan

Notes

Consent is obtained from the patient themselves if over 18 years of age; from the patient and additionally from their legal representative if between 15 and 18 years of age; and from the legal representative in the case of an unconscious patient, a patient under 15 years of age lacking decision-making capacity, and in medical emergencies.
All pages of the Information and Consent form must be signed by the person concerned, with the words "I have read it" written.
This form must bear the signatures of the physician providing the information, the patient themselves and/or the patient's legal representative.
This form must be printed in two copies, and after both are signed, one must be given to the patient and the other placed in the patient's file.
This form has been prepared based on Nöroşirürjide Aydınlatılmış Rıza Formları [Informed Consent Forms in Neurosurgery] (2025, ISBN 978-605-4149-28-5), published by the Türk Nöroşirürji Derneği (Turkish Neurosurgical Society).