CERVICAL POSTERIOR STABILIZATION (LATERAL MASS / PEDICLE SCREW)

Informed Consent Form

Form No: AOF-016	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 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 about matters concerning 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 many circumstances, it should not be considered 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 situations of legal and medical necessity, you may refuse to be informed or 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 all your doubts regarding the procedure in question have been resolved by the physician.

2. General Information About the Disease and Its Treatment

Fractures and dislocations developing due to trauma may cause compression on the spinal cord or nerve roots. Likewise, as a result of bony compressions (calcification-osteophyte) or ligament thickening that occur due to ageing, compression may occur in the neck region in the spinal canal or in the openings through which the nerve roots exit. As a result of these compressions, weakness-paralysis in the hands and feet, loss of fine motor skills, sensory changes, and urinary and bowel problems may arise. This surgery is performed with the aim of relieving the pain that occurs after a fracture or fracture-dislocation of the spine or degenerative changes, correcting the alignment of the spine, and relieving the compression occurring on the nerve roots and/or the spinal cord.

In order to expose the bony part over the injured region of the spine, my doctor will make an incision in the skin at the back of the neck, back or lower back at the relevant level, will retract the surrounding muscles to the side and, if necessary, will remove the bone fragments compressing the nerve root and spinal cord with techniques such as laminectomy or hemilaminectomy, or will try to restore them to their original position. Then, fixation is performed with titanium screws and rods placed through the bony structure called the pedicle or into the bony structure called the lateral mass in the neck region. For the vertebrae to fuse to one another, after the fusion procedure is performed with bones taken from the trauma site, or bones taken through a separate incision from the pelvic bone, or bones obtained from a bone bank or of cadaveric origin, the anatomical layers will be closed in accordance with the proper technique.

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 doctor, accepting all risks and not having this surgery,
Accepting all risks and follow-up with computed tomography or magnetic resonance imaging.
Waiting for the bone fractures to heal by prolonged bed rest or by wearing a neck collar
Trying to relieve pain or muscle spasm through medication therapy,
Performing decompression and stabilization through an anterior (from the front region of the neck) approach
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 have also been 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 aim of eliminating the complaints and with the expectation of preserving or improving the function of the nervous system. WITH THE SURGERY TO BE PERFORMED; the aim is to relieve the neural structures under compression, to provide spinal stabilization, to eliminate or reduce pain, and, through the surgical treatment to be applied, 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 your complaints such as pain-spasm.

5. Estimated Duration of the Surgery

The duration of the procedure to be performed may vary according to the condition of the disease and of the patient, and is on average .….......... - .….......... hours. In addition, the procedures to be performed on patients before and after the surgery by the anesthesia doctors are not included in this duration. The procedure may take longer than the stated duration depending on the condition 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 the benefits of the surgical procedure to be performed, there are also risks that may arise.

Anesthesia risk: There are risks during and after local and general anesthesia procedures (due to the position given to the patient during the surgery). In addition, in every form of anesthesia and in sedation, there are also 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 case of bleeding, additional treatment or 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 in the bleeding area 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: Nervous system functions may deteriorate after the surgery due to problems such as bleeding at the surgical site, brain edema (pressure on the brain as a result of fluid accumulation) or vasospasm (narrowing of the vessels).
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 leading to 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 this surgery, there is a risk that pain, numbness, loss of muscle strength or other complaints may not be relieved.
Increase in the pain complaint: Although rare, the pain complaint 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).
Nerve tissue and/or spinal cord injury: Although rare, it may occur unexpectedly during or after surgery. This condition may cause weakness in the arms and/or legs and respiratory distress.
Instability in the neck: A deformity may develop in the neck after the surgery. An additional surgical intervention for cervical spine instability may be required.
Recurrence: Some of the complaints may reappear in the early or late period after surgery, and in this case an additional surgical intervention may also be required.
Respiratory difficulty: Respiratory distress may occur through brainstem damage during surgery, through the compressive effect of a clot on the brainstem or spinal cord after surgery, 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 in the arms and/or legs 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.
Misplacement of the screws: The screws may sometimes not be placed in the desired location. For this reason, there may be weakness in the screws. If the screws are placed too far anteriorly, death due to injury to a major vessel or internal organs may occur. If the screws are placed toward the spinal canal, they may lead to paralysis due to compression of the nerve root or spinal cord. Degeneration may be seen in the adjacent segments below or above the stabilized segments.
Non-union of the vertebrae (failure to fuse): After the fracture and dislocation of the spine have been attempted to be corrected, despite the bones taken from the trauma site, or bones taken through a separate incision from the pelvic bone, or bones obtained from a bone bank or of cadaveric origin, the vertebrae may not adhere to one another, and this condition may lead to various spinal deformities and/or pain.
Breakage of the screws and rods: Sometimes, in the postoperative period, breakage of the screws or rods may occur, and they may need to be removed with a new surgery.
I have also understood the possibility that, during my surgery, in the face of an unexpected situation such as bleeding, injury to an adjacent tissue or organ, etc., my doctor may perform other procedures required for my health apart from 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. If spinal instability persists, the compression on the spinal cord and nerve roots may increase; progressive neurological loss may develop.

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, fluid therapies, medications specific to your disease) will be given according to the reason for your admission or newly developing conditions. During the use of medications, side effects may emerge 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 protective antibiotic therapy is applied with the aim of reducing the risk of surgical site infection. USE OF BLOOD-THINNING MEDICATION: If you are using anticoagulant, blood-thinning medications, different medication therapies or blood products may be given to you to counteract the effects of these medications. SPINAL CASES: In case of severe pain after spinal operations, medications sold under a green (controlled-substance) prescription, which may cause dependence, may be used. After spinal surgeries, in cases of unchanged weakness in the arms and legs, or of newly developing weakness, 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 emerge in patients, mental health-regulating medications recommended by a psychiatrist may be used. These medications may damage the heart, kidneys and other organs. In addition to these, medications related to anesthesia are used. The general anesthetic 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 narcotics/intoxicants. The effects of the use of these substances before and after the surgery have been explained to me by my doctor and recommendations have been 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, 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. Anesthesia risks are higher in patients who smoke; 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 success average. In addition, smoking may adversely affect bone fusion.

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. Patient-Specific Section

The patient's individual 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

Not accepting the application of 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/hospitals capable of performing the treatment/surgery in question.

I have received information about 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 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 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 CERVICAL POSTERIOR STABILIZATION (LATERAL MASS / PEDICLE SCREW) 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 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 possibility 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 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 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 his/her own handwriting, his/her individual specific circumstances (allergies, medications used, previous surgeries, etc.). If there are no specific circumstances, it is sufficient to write "NONE".

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

	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 himself/herself if over 18 years of age; from the patient himself/herself and additionally from his/her legal representative if between 15-18 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 note "I have read it" written by hand.
This form must bear the signatures of the physician providing 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.
Dual consent note: In cases applied together with decompression (laminectomy/foraminotomy), AOF-005 is co-signed; in cases combined with an anterior approach, AOF-003 is co-signed (see Form Combination Guide).
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).