DIAGNOSTIC LUMBAR PUNCTURE

Informed Consent Form

Form No: AOF-010	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 the medical / surgical treatment and all 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 about matters concerning your health. If you wish, all information and documents regarding 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 whether or not to accept the procedures to be performed. Except in situations of legal or 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 Operation and about alternative treatment methods. Please read this form completely and carefully, and sign this consent form only after you have read it and all your doubts regarding the procedure in question have been resolved by the physician.

2. General Information About the Disease and Treatment

Lumbar Puncture: This is a method used to examine the fluid that circulates in the cavities within the brain and around the spinal cord. Cerebrospinal fluid (CSF) is the fluid surrounding the brain and spinal cord and is produced in special regions of the brain called 'ventricles'. CSF flows downward from the ventricles into the space around the spinal cord. It is usually clear and contains small amounts of protein and sugar (glucose). A lumbar puncture (LP) may need to be performed in order to detect the signs of various diseases (infection, haemorrhage, tumour, metabolic-degenerative disorders, multiple sclerosis, etc.), to measure the pressure inside the skull, or to administer treatment. It is the diagnostic method used in cases with suspected meningitis (infection of the membranes of the brain), encephalitis (infection of the brain tissue), or subarachnoid haemorrhage (bleeding between the membranes of the brain). It assists diagnosis in certain other neurological diseases. Before the procedure, in order to prevent certain complications that may develop during the procedure (herniation; the brain tissue shifting through the spinal canal and causing a series of events that may go as far as death), an eye fundus examination will be performed and, depending on its result, a Computed Brain Tomography scan will be obtained if necessary. During a lumbar puncture, the patient is laid on their side or seated. An antiseptic solution is applied to the back. A local anaesthetic may sometimes be injected into the skin. Then, at the level of the hip bones, below the point where the spinal cord ends, a thin needle is inserted into the lower back. The needle is gently advanced until the CSF is reached. The CSF is drained into special sterile tubes for testing. Sometimes the lumbar puncture procedure is difficult. The likelihood of difficulty with lumbar puncture is higher in people who have had back surgery, those with a deformity of the back such as scoliosis (curvature), very obese patients, and children.

3. Alternatives to the Operation, If Any

As alternatives to the operation, I have considered the following options: • To accept all the risks and not have the recommended treatment or injection performed. • There is no other technical alternative to the procedure. • 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 Operation

The aim is to achieve the intended diagnostic or therapeutic purpose.

5. Estimated Duration of the Operation

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 carried out by the anaesthesia doctors before and after the operation 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 Operation

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

Anaesthesia risk: There are risks during and after local and general anaesthesia procedures (due to the position given to the patient during the operation). In addition, in every form of anaesthesia and in sedation, there are complications and harms that may arise from the drugs used.
Bleeding: Although very rare, I am aware of the existence of a risk of bleeding, which may be severe, during or after my operation. In the event of bleeding, additional treatment or a blood transfusion may be needed. The use of medications such as anti-inflammatory drugs may increase the risk of bleeding. Bleeding may occur at the procedure site and, as a result, depending on the severity of the bleeding, a haematoma (blood-filled swelling) may develop. As a result of compression of the spinal cord due to this condition, weakness in the legs and paralysis may develop, although very rarely.
Blood clot formation: Blood clots can form after any type of operation. Clots forming at the bleeding site can obstruct blood flow and lead to complications such as pain, oedema, inflammation, or tissue damage.
Spinal cord injury: Although very rare, paralysis due to spinal cord injury may occur during the operation.
Cardiac complications: The operation carries a low risk of causing an irregular heart rhythm or a heart attack.
Death: Rarely, through herniation (the brain tissue shifting through the spinal canal and causing a series of events that may go as far as death) and, secondary to this, respiratory and cardiac arrest, there is — although very rare — a risk of death during or after the operation.
Failure of the operation: The procedure may fail due to anatomical difficulty. In such a case, the procedure may have to be repeated.
Pain: Headache and low back pain may occur after lumbar puncture.
Infection: Infection may occur at the skin incision site, as well as in the operative field, and even in the bone within the operative field. Risks associated with infection include meningitis (inflammation of the membranes surrounding the brain and spinal cord) and empyema-abscess formation (accumulation of pus).
Nerve root injury: Nerve root injury may cause pain in the leg, weakness in the related muscle groups, and sensory disturbances in the related dermatomes.
Risk of cerebrospinal fluid leakage: After the operation, cerebrospinal fluid may leak from the wound site to the outside. Its treatment may require a spinal catheter or an additional intervention to repair the same wound site.
Respiratory problems: After the operation, respiratory distress, which is usually temporary, or pneumonia may occur. Pulmonary embolism (blockage of the blood vessels of the lungs) may occur.
A shift (herniation) of a part inside the brain may occur. In this case, the patient's consciousness may become impaired or breathing may stop. Respiratory arrest may lead to the patient's death.
Blood may collect between the membranes surrounding the spinal cord; this blood may press on the spinal cord, and this condition may lead to permanent or temporary paralysis. 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 of Not Undergoing the Operation

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. 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 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, and 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 operation may cause my recovery process to be prolonged. Anaesthesia risks are greater in patients who smoke, and death due to anaesthesia is seen more frequently. If you smoke, you should know that the success of your treatment/operation will be lower than the general average success rate.

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

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

10. Patient-Specific Section

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 the treatment/operation 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/operation 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 authorise the Head of the Surgical Team, Responsible Specialist Doctor Dr. Özgür Akşan, and his team to perform my operation.

I understand that this intervention is performed with the aim of 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 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 for DIAGNOSTIC LUMBAR PUNCTURE and for all different or additional operations and supplementary treatment interventions that my doctor deems 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 doctor training, provided that the rules of confidentiality are observed.

Photography/Observers: I consent to the photographing or video recording of the operation 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 likelihood of success and failure.
I know what may happen if I do not receive treatment.
I understand that the procedure to be performed may carry no 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, 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 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 blank spaces 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 person-specific circumstances (allergies, medications used, previous operations, etc.). If they have no special circumstances, it is sufficient to write "NONE".

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 OPERATION 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 Doctor	Dr. Özgür Akşan

Notes

Consent is obtained from the patient themselves if over 18 years of age; from the patient themselves 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 who lacks decision-making capacity, and in medical emergencies.
All pages of the Information and Consent form must be signed by the person concerned, writing "I have read it".
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).