INTERVENTIONAL PAIN TREATMENT — FACET / TRANSFORAMINAL / EPIDURAL INJECTION

Informed Consent Form

Form No: AOF-008	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 concerning your health. If you wish, all information and documents concerning your health can be given to you or to a relative you consider 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 state of health, your physician may give you different or additional information. After learning the benefits and possible risks of diagnostic procedures, medical treatments and surgical interventions, accepting or not accepting the procedures to be performed is your own decision. Except in cases of legal or medical necessity, you may refuse to be informed or you may 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 regarding the procedure in question have been resolved by your physician.

2. General Information About the Disease and the Treatment

Facet Joint Injection: this is the procedure of injecting a depot steroid and a local anesthetic into and around the facet joints — the joints that connect the vertebrae at the back of the spine — in order to relieve / reduce pain originating from these joints. The procedure is performed under sterile conditions by visualizing the facet joints with C-arm fluoroscopy or ultrasonography. When your doctor considers it necessary, it may be applied together with an epidural steroid injection. Epidural steroid injection is a non-surgical interventional pain treatment procedure used to relieve pain that develops in the neck, arm, lower back and leg regions as a result of compression and irritation of the nerves. It is used to bring pain under control in conditions such as disc hernias (lumbar–cervical disc herniation), disc slippage and narrow spinal canal. With the epidural injection, a drug mixture is administered around the damaged spinal nerve via the epidural space, containing a long-acting depot steroid and also a local anesthetic to provide relief in the early period and to prevent subsequent reflex activity. Although the effect of epidural steroid administration varies from patient to patient, the aim of the injection is, by reducing or eliminating the pain, to enable the patient to return to normal life and, if necessary, to participate comfortably in a physical therapy and exercise program. What is an epidural steroid injection? The injection contains a long-acting depot steroid and a local anesthetic agent. Via the epidural space, the drug reaches the compressed or affected spinal nerve and relieves the pain by reducing the inflammation and edema in that area, thereby eliminating the pressure and irritation on the nerve. The intervention is performed under sterile conditions and under local anesthesia

Application techniques: 1) Interlaminar technique: Entering through the midline of the spine, the drug is administered into the epidural space; the drug spreads freely around the nerves. 2) Transforaminal technique: The drug is administered around the affected nerve by entering with a needle through the opening (foramen) where the problematic spinal nerve exits the spine; it is an intervention targeted at the nerve intended for treatment, and it is performed under continuous radiological imaging with C-arm fluoroscopy control.

What must be done before the intervention: If you have flu, sinusitis or a similar infection that began on the day of the intervention or earlier, or if you have a high fever even of undetermined cause, be sure to inform your doctor before the intervention. Blood-thinning medications such as Aspirin, Coraspin and medications containing ginkgo biloba must be stopped 10 days beforehand. Anticoagulant medications used in special situations (Coumadin, Plavix, etc.) must also be stopped at least 1 week beforehand, after consulting the physician who prescribed these medications to you and obtaining their approval. If you have heart, diabetes or blood-pressure medication that you must take continuously, consult your doctor and ask how you should take the medications. On the day of the intervention, bring with you your most recent imaging examinations (MRI – EMG – Tomography). Be sure to come with a companion who can accompany you; do not come alone.

For whom the intervention is not performed: The intervention is not performed on patients who have an active infection during the intervention period; who are pregnant or possibly pregnant; who have a bleeding-clotting disorder; who have an infection at the intervention site; and who do not consent to the intervention being performed.

3. Alternatives to the Surgery, If Any

As alternatives to the surgery, I have considered the following options: • To accept all the risks and not undergo the recommended treatment or injection. • To try to relieve the pain or muscle spasm with medication. • To try to relieve the complaints with physical therapy methods. • To try to relieve the complaints with algology (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

A reduction in the patient's pain is expected after the procedure.

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 carried out before and after the operation by the anesthesia doctors 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. In patients with diabetes, a disturbance of blood sugar control may be observed for 1-2 weeks; additional medication may rarely be required.

Among patients who receive an epidural steroid injection, according to the literature there is a possibility of infection occurring at a frequency of one in 40-60 thousand patients; however, by performing the intervention in the operating room under absolutely sterile conditions and with the additional precautions taken, this probability is reduced to the lowest possible level.
Very rarely, a temporary headache may occur. Nerve damage is also a very rarely seen condition.
Fluid retention in the body may occur due to the steroid used. This can be prevented by following a salt-free diet as far as possible during the first week.
While all of the above is information found in medical textbooks and in the literature, all necessary precautions are taken for the safety of the intervention and all of the risks listed are reduced to a minimum. Although the risks and complications of this intervention are few, there may be specific complications related to the placement of the needle and to the injection. I have understood and I accept all of the risks written above that may occur during and after the surgical procedure to be performed on me.

7. Consequences of Not Undergoing the Surgery

The patient's existing complaints and clinical condition may not improve, and a worsening may occur.

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 it. 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 the procedure 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, side effects, how they are to be used).

9. Lifestyle Recommendations Critical for the Patient's Health

Tobacco and Tobacco Products: It was 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. 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 your treatment/surgery will be lower than the general average success rate.

Follow your doctor's recommendations (exercise, nutrition program, etc.) and, if one has been requested, 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

Circumstances specific to the patient are recorded at the end of the form under Section 14 — Signatures.

11. How to Access Medical Help 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 / to hospitals able to perform the treatment/surgery in question.

I have received information on how, when needed, I can access medical help on the same matter (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 Physician 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 of my questions regarding this intervention have been answered. Therefore, I give my consent to INTERVENTIONAL PAIN TREATMENT — FACET / TRANSFORAMINAL / EPIDURAL INJECTION and to any different or additional surgical and supplementary treatment interventions that my doctor considers necessary.

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.

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 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 was told to me.
My doctor has answered all my questions.
My doctor explained everything written here to me, point by point, in a clear, understandable and explanatory manner that I could comprehend.
I know the meaning of the Informed Consent form.
I was 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 contents of the Informed Consent form.
All 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 his/her own handwriting, his/her personal circumstances (allergies, medications used, previous surgeries, etc.). If there is no special circumstance, writing "NONE" is sufficient.

B) Handwritten Declaration

The patient writes the following sentence in his/her 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 Physician	Dr. Özgür Akşan

Notes

Consent is obtained from the patient himself/herself if over 18 years of age; from the patient himself/herself and additionally from his/her legal representative if between 15 and 18 years of age; and from the legal representative in the case of a patient who is unconscious or under 15 years of age and lacking the capacity to decide, and in medical emergencies.
All pages of the Information and Consent form must be signed by the person concerned, who must also write "I have read it" on them.
This form must without fail bear the signatures of the physician who provided the information, the patient himself/herself 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).