ANTERIOR CERVICAL DISCECTOMY SURGERY

Informed Consent Form

Form No: AOF-003	Rev. No / Date: 2026 v09 / 10.07.2026

PATIENT PROTOCOL NO	DATE
TURKISH ID / PASSPORT NO	DATE OF BIRTH
PATIENT'S NAME–SURNAME	SEX
DIAGNOSIS	(wide single cell)

1. Dear Patient,

It is your most natural right to be informed about your medical condition and about all the medical / surgical treatments and diagnostic procedures recommended 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 whether 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 regarding 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 prepared 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 whether or not to accept the procedures to be performed. Except in situations 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 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 regarding the procedure in question have been resolved by your physician.

2. General Information About the Disease and Its Treatment

The spine consists of a series of interconnected bones called vertebrae. The vertebrae are connected to each other by a disc and two small joints called "facet" joints. The disc, made up of strongly bonded tissues connecting one vertebra to another, acts like a cushion or shock absorber between the vertebrae. The disc and the facet joints allow you to move, bend, and rotate your neck and back. The disc consists of a tough outer layer called the "annulus fibrosus", which may become damaged, and a gel-like central structure called the "nucleus pulposus". With aging, the central structure of the disc may begin to lose its water content, which can lead to deterioration in the disc's functions. Just as deterioration may occur in the central layer of the disc, damage and tears may also occur in the outer layer. In this case, the central structure of the disc may protrude through the tear in the outer layer toward the canal through which the nerves and the spinal cord pass. This condition is called a disc herniation (hernia). When this event occurs in the neck, it is called a cervical disc herniation (neck hernia). A cervical disc herniation can press on the nerves and cause pain radiating into the arms, aching, loss of sensation or loss of strength. Anterior cervical discectomy is a procedure performed to relieve the pain, numbness and/or weakness associated with cervical disc disease. Between the bones of the spine there are soft, jelly-like structures called discs, which act as natural shock-absorbing cushions. The surgery is performed to relieve pressure on the spinal cord or nerve roots in the upper cervical region. The soft portion located in the middle part of the discs may, for various reasons, herniate through the relatively harder disc wall surrounding it and press on the neighboring nerves.

Bone spurs that form around degenerated discs may also sometimes increase the pressure on the nerves and the spinal cord. It has been explained to me that if I do not undergo surgery, these complaints of mine may continue and may even increase. I am aware that the procedure is performed to relieve the pain, numbness and/or weakness I feel in my arm, my hand or other affected areas. With this surgery, an attempt will be made to relieve the pressure caused by the herniation on the spinal cord and/or nerve roots in the neck region. I know that during this surgery, the herniated discs and bone spurs at the affected neck level will be removed through a skin incision made at the front of the neck. I have understood that, after the disc is removed, my doctor may need to use a small, previously prepared bone graft or cage to fuse and stabilize the upper and lower vertebrae to each other, or a disc prosthesis to preserve motion. If additional stabilization of the spine is required, I accept that my doctor may also perform the following additional interventions: Fixing the space opened between the vertebrae with a small bone graft; Fixing the space opened between the vertebrae with a small bone graft and a small screwed-on metal plate. If a fusion is performed, I know and accept that the bone to be used will be obtained from the following sources: From my own pelvic (hip) bone; From a bone bank; A PEEK, carbon-fiber or titanium cage filled with bone taken from the surgical site. I know that the purpose of this surgery is to relieve complaints and findings such as pain, numbness and loss of strength in my arm and/or hand.

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 verbally explained to me by my doctor,
Follow-up with computed tomography or magnetic resonance imaging, accepting all the risks.
Trying to relieve pain or muscle spasm through medication,
Applying neck traction therapy
Doing exercises to strengthen the neck muscles
Trying to relieve the complaints with physical therapy methods
Having steroid and local pain-relief injections
Undergoing posterior (back of the neck) cervical laminectomy or laminoplasty surgery
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

It is an improvement in the patient's current neurological condition and complaints. The surgery is performed with a view to eliminating the complaints and with the expectation of preserving or improving the function of the nervous system. WITH THE SURGERY TO BE PERFORMED: To relieve the neural structures under pressure, To eliminate or reduce pain

The aim is for the neurological deficits present before the surgery (paralysis, loss of strength, numbness, loss of reflexes, urinary incontinence, etc.) and complaints such as pain and spasm to be completely resolved by the surgical treatment to be performed, or for their worsening to be halted.

5. Estimated Duration of the Surgery

The duration of the procedure to be performed may vary depending on the disease and the patient's condition, and is on average .….......... - .….......... hours. In addition, the procedures to be performed on patients by the 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 possible 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 complications and harms that may occur due to the medications. 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 the event of bleeding, additional treatment or a blood transfusion may be needed. In such a case, I approve the necessary blood transfusion and other treatments. Some medications that I use and/or that need to 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 may form after any type of surgery. Clots forming at the bleeding site may 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: Due to problems such as bleeding at the surgical site, nervous system functions may deteriorate after the surgery.
Risk of cerebrospinal fluid leakage: After the surgery, cerebrospinal fluid may leak from the wound site to the outside. For its treatment, a spinal (spinal cord) catheter or an additional intervention to repair the same wound site again may be required.
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: After Cervical Anterior Microdiscectomy Cage and Prosthesis surgery, there is a risk that pain, numbness, loss of muscle strength or other complaints may not be relieved.
Increase in the complaint of pain: Although rare, the complaint of pain may increase after the surgery.
Infection: Infection may occur at the skin incision site, as well as in the surgical field, and even in the bone within the surgical field. Risks related to infection include meningitis (inflammation of the membranes surrounding the brain and spinal cord) and empyema-abscess formation (accumulation of pus).
Injury to nerve tissue and/or the spinal cord: Although rare, this may occur unexpectedly during or after surgery. This condition may cause weakness in the arm and/or leg, and breathing difficulty.
Recurrence: In the early or late period after surgery, some of the complaints may reappear, and in this case an additional surgical intervention may be required.
Breathing difficulty: Breathing difficulty may occur during surgery due to brainstem damage, and after surgery due to the pressure effect of a clot on the brainstem or spinal cord, through lung infection (pneumonia) and through the effect of a clot in the pulmonary artery (pulmonary embolism). Additional treatment may be required.
Stroke (paralysis): Although rare, weakness of the arm and/or leg may develop during or after surgery following the lodging of air or a clot from the veins into the brain. Additional treatment may be required.
Non-Union (Failure of Fusion) of the Vertebrae: After a vertebra or vertebrae are removed, despite the bone or cages placed in their stead, the vertebrae may fail to fuse together, and this condition may lead to various spinal deformities and/or pain.
Hoarseness: There is a small but present risk of injury to the recurrent laryngeal nerve. As a result of this condition, temporary or permanent hoarseness and dysphonia may occur. An injury that may occur to the vagus nerve may lead to paralysis of the diaphragm.
Due to injuries to the esophagus and the windpipe, infection that may result in death, wound discharge, and repeat surgeries may be required
Paralysis: A stroke may occur as a result of injury to and stretching of the carotid artery during or after the surgery.
The implants placed during the surgery may lead to conditions such as breakage, displacement, failure to fulfill their function, allergy and infection. For this reason, their removal or replacement may be required.
Risks related to internal fixation (plating): Performing metal plating to strengthen the fusion carries the following additional risks: Loosening of the screws, displacement of the plate and the resulting need for an additional intervention, The possibility of damaging the surrounding tissues while the plate is being placed.
If a graft is taken from the pelvic bone, the bone fragment taken from the pelvic bone or the cage is placed into the space created in the vertebrae, and its fusion with the healthy vertebrae above and below is achieved. This intervention carries the following risks: injury to the nerve on the side of the thigh and, related to this, numbness may occur in the thigh region on the side from which the bone was taken, and this may be permanent; there may be impairment of normal walking; injury to the abdominal wall may occur and, related to this, an additional intervention may be required; failure of the fusion to unite; it must be known that the placed bone graft may become displaced and slip inward or outward, and that this may press on the spinal cord or the esophagus. In addition, if a bone graft obtained from a bone bank or synthetic bone is used, the probability of the fusion failing is higher.
I have also understood the possibility that, during my surgery, in the face of an unexpected situation such as bleeding, injury to a neighboring tissue or organ, etc., my doctor may perform other procedures necessary for my health besides the planned procedure, and I approve this. I have understood and accept all the risks written above that may occur during and after the surgical procedure to be performed on me.

7. Consequences to Be Faced If the Surgery Is Not Performed

The patient's current complaints and clinical condition may not improve, and there may be a worsening.

8. Important Characteristics of the Medications to Be Used

If you have a previously identified drug allergy, you must inform your physician and your nurse about this. During your current treatment process, medications appropriate to the patient's medical condition (painkillers, antibiotics, medications supporting the circulation and the heart, blood products, IV fluid treatments, medications specific to your disease) will be given depending on the reason for admission or on newly developing conditions. During the use of medications, side effects may arise 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 with the aim of reducing the risk of surgical site infection. USE OF BLOOD-THINNING MEDICATION: If you are using anticoagulant, blood-thinning medications, you may be given different medication treatments or blood products to counteract the effects of these medications. SPINAL CASES: In the event of severe pain after spinal operations, medications sold under a controlled ("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 medications may be used. In this case, the blood sugar balance may be disturbed. CERVICAL CASES-SSM: After the surgery, appropriate medications to reduce spinal cord edema and to increase the nourishment of the spinal cord (anti-edema medications, medications supporting the circulation) may be used. In this case, the blood sugar balance may be disturbed. INTENSIVE CARE-DELIRIUM: In elderly patients and during prolonged intensive care stays, for psychological symptoms that may arise in patients, mental health-regulating medications recommended by a psychiatrist may be used. These medications may cause damage to the heart, kidneys and other organs. In addition to these, medications related to anesthesia are used. The anesthetic (narcosis) medications given during the 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 the use of these substances before and after the 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 Patient Health

Tobacco and Tobacco Products: It has been explained to me that smoking tobacco and tobacco products (cigarettes, waterpipe, cigars, pipe, etc.) before or after my surgery may cause my recovery process to be prolonged. In patients who smoke, anesthesia risks are higher, 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 clinic check-up 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 restriction status).

10. Section Specific to the Patient

The patient's individual, person-specific 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 to undergo the treatment/surgery is a decision you will make of your own free will. If you change your mind, you may personally reapply to our hospital/to 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 received treatment, 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 performed with a view to eliminating my complaints and with the intention of preserving or improving the function of the nervous system. I confirm that my doctor has explained all the information above, that I have understood this information, and that all my questions regarding this intervention have been answered. Therefore, I give my consent for ANTERIOR CERVICAL DISCECTOMY 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 give my consent to the use of any tissue, medical device or body parts that may have been removed during the surgical procedure.

Medical research: I give my 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.

Photography/Observers: I consent to the surgery to be performed being photographed or video-recorded for scientific, medical or educational purposes, provided that the images do not reveal my identity.

13. Consent Verification

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 am not treated.
I understand that the procedure to be performed may carry no guarantee of cure.
I have understood everything that has been told to me.
My doctor has answered all my questions.
My doctor explained to me what is written here, item by item, in a clear, understandable and explanatory manner that I could comprehend.
I know the meaning of the Informed Consent form.
I have been informed about the approximate cost of the treatment.
I am deciding of my own free will.
I had enough time, a reasonable period before the intervention, to obtain a second opinion.
I have read and understood the content of the Informed Consent form.
All the blanks on this form were filled in before I signed it, and I have received a copy.

14. Signatures

A) Patient-Specific Circumstances

The patient writes, in their own handwriting, their person-specific 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

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

Notes

Consent is obtained from the patient themselves if they are over 18 years of age; from the patient themselves and additionally from their legal representative if the patient is 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 party concerned, with the word "read" ("okudum" — I have read it) written on them.
This form must without fail 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).