CUBITAL TUNNEL SYNDROME SURGERY

Informed Consent Form

Form No: AOF-007	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 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 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 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 covering 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 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

Compression of a nerve by surrounding tissues may cause pain, numbness, weakness or loss of function. The fundamental problem is the compression of the nerve by the surrounding tissue. This condition may occur after an injury, after an illness, or due to repetitive movements. I have received detailed information from my doctor about the content of the surgery to be performed on me: [Mark the appropriate one] • Compression of the median nerve at the wrist • Compression of the ulnar nerve at the elbow • Compression of the ulnar nerve at the wrist • Compression of the anterior interosseous nerve in the forearm. I know and accept that during surgery my surgeon will make a skin incision in the relevant area and release the nerve concerned. I am aware that the intended aim is to release the compressed nerve and thereby relieve my complaints.

3. Alternatives to the Surgery, If Any

As alternatives to the surgery, I have considered the following options: • As explained to me verbally by my physician, accepting all risks and not undergoing this surgery, • Attempting to relieve pain or muscle spasm through medication,

Attempting to reduce the complaints with immobilization methods such as splints etc.,
Attempting to relieve the complaints with physical therapy methods,
Having steroid and local pain-relief injections.
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 the expectation of eliminating the complaints and of preserving or improving the function of the nervous system. WITH THE SURGERY TO BE PERFORMED; To relieve the neural structures under compression. To eliminate or reduce pain. The aim is to completely resolve, or to halt the worsening of, the neurological deficits present before the surgery (paralysis, loss of strength, numbness, loss of reflexes, urinary incontinence, etc.) and complaints such as pain and spasms, through the surgical treatment to be applied.

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 the anesthesiologists before and after the surgery are not included in this duration. The procedure may take longer than the stated duration depending on the circumstances of the case. 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). Furthermore, in every form of anesthesia and in sedation, there are also complications and harms that may arise from 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. Certain 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 may form after any kind 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.
Respiratory problems: After the surgery, respiratory distress or pneumonia, which is usually temporary, may occur. Pulmonary embolism (blockage of the blood 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.
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 associated with infection include the formation of empyema-abscess (accumulation of pus).
Recurrence, Residual (Remnant): After the surgery, symptoms may reappear and additional surgery may be required.
Loss of function: After the intervention, there may be a reduction in or complete loss of the patient's existing functions.
Failure of re-innervation: The most frequently encountered complication in peripheral nerve anastomoses is the failure of reinnervation to occur within the expected period (6-8 months). This may be due to the inadequacy of the sutures placed in the nerve, as well as to excessive tension at the repair site or to excessive delay after the trauma. If there is no sign of reinnervation within the expected period, the suture site should be explored and, if necessary, neurolysis and/or resection and anastomosis are performed.
I have also understood that, in the event of an unexpected situation during my surgery, such as bleeding, injury to an adjacent tissue or organ, 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 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, intravenous fluid therapies, medications specific to your disease) will be given according to the reason for admission 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, different drug treatments or blood products may be given to you to counteract the effects of these medications. INTENSIVE CARE-DELIRIUM: In elderly patients and during prolonged intensive care stays, mental health-regulating medications recommended by a psychiatrist may be used for psychological symptoms that may arise in patients. These medications may cause damage to the heart, kidneys and other organs. In addition to these, anesthesia-related medications are used. The narcotic (general anesthesia) 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, a 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 narcotics/intoxicants. 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 have received information about the important characteristics of the medications to be used for diagnosis and treatment (what they are used for, their benefits, 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, hookah, cigars, pipes, etc.) before or after my surgery may cause my recovery process to be prolonged. 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 appointment 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

Circumstances specific to the patient 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 will make of your own free will. If you change your mind, you may personally re-apply 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 am being treated, and, in emergencies, 112).

12. Permissions

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

I understand that this intervention is intended to eliminate my complaints and to preserve or improve 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 CUBITAL TUNNEL SYNDROME SURGERY and for all different or additional surgeries and supplementary 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 physician education, provided that confidentiality rules are observed.

Photography/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 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 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 has explained to me what is written here, item by item, in a clear, understandable and explanatory manner that I can comprehend.
I know the meaning of the Informed Consent form.
I have been informed about the approximate cost of the treatment.
I am making my decision of my own free will.
I had sufficient 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 the blanks in 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 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 permission for this procedure of my own free will."

C) Signatures

	Full Name	Signature	Date / Time
Patient
Legal Representative / Relative <br>(Degree of kinship: ……………………)
Head of the Surgical Team, Responsible Specialist Physician	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 word "read" written on them.
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).