Welcome, Friend!

It looks like you're new here. If you want to get involved, click one of these buttons!

Veritas-Health LLC has recently released patient forums to our Arthritis-Health web site.

Please visit http://www.arthritis-health.com/forum

There are several patient story videos on Spine-Health that talk about Arthritis. Search on Patient stories
Protect anonymity
We strongly suggest that members do not include their email addresses. Once that is published , your email address is available to anyone on the internet , including hackers.

All discussions and comments that contain an external URL will be automatically moved to the spam queue. No external URL pointing to a medical web site is permitted. Forum rules also indicate that you need prior moderator approval. If you are going to post an external URL, contact one of the moderators to get their approval.
Attention New Members
Your initial discussion or comment automatically is sent to a moderator's approval queue before it can be published.
There are no medical professionals on this forum side of the site. Therefore, no one is capable or permitted to provide any type of medical advice.
This includes any analysis, interpretation, or advice based on any diagnostic test

Operations Report - it's available to you

Cath111CCath111 Posts: 3,702
edited 06/11/2012 - 8:43 AM in Back Surgery and Neck Surgery
Hi all.

I just wanted to let you know, especially those new to spine surgery, that you can call your hospital and get an operations report that has all the notes that were taken during your surgery by your surgeon and assistant, and many times the neuromonitor who continually tested your nerves during your procedure. You can usually find the form you need to fill out on your hospital's website and can mail the request in. It's generally free, but depending on the hospital, you may have to pay a minimal price. There should also be a number you can call to make sure you fill out the form properly, although it's usually pretty clear-cut.

Although it probably won't tell you much more than you already know, it is an interesting report that can (and in my case did) reiterate that my surgeon found more issues than originally thought before he went in. It should also show all the hardware that has been inserted into your spine and what was else may have been used to fill in disc space, etc.

Especially for those that are keeping records of your treatments, etc., it's a good thing to keep with your other records, like your MRI report, etc. I've never needed this OR for anything, but like having it available to me so I know exactly what they did while I was in lala land.

It might also be valuable information to have on hand for those of you who are seeking another surgeon after already having surgery and trouble with your current surgeon.

Just thought I'd let you know. Although it's sometimes difficult to understand all the language and such, at the very least, it's interesting to know exactly what they did and what they used during your surgery.



  • Good advice. Also, for anyone who is not already doing so, make a file and get records of all tests, written radiology reports for any imaging tests, EMGs, etc. You never know when you may need this information, and it will save you a lot of time if all your records are in your possession.

    Recently when authorization for surgery was denied by my insurance company, it took me awhile to get my records from a specialist I had consulted with in Chicago. It slowed down my ability to file my appeal by about three weeks. I had all testing and imaging records, but hadn't thought about getting the office notes, etc. from a doctor I ended up not using.

    So, like the boy and girl scouts, be prepared! You never know when you might need something from your past medical treatments.
  • Good advice on the record keeping, which I am trying to do already, for insurance & disability purposes. I didn't know about the surgery notes. My fusion operation took almost 12 hours and I get the impression that I was close to 'checking out', but I'm not sure. I wonder what complications they had and now if I can get this report, maybe I'll find out!! Great tip Cath!!

  • Thanks Cath.. That is a great idea.. I know pretty much how my surgery went but I think it would be great to have along with all of my MRI's and discogram.. I never even thought about that.. Plus it would be interesting just to read it..

    Aaron- Wow... 12 hours.. What levels did you have fused.. Are you sure you want to know if you almost "checked out"? That is really scarey to even think about.. Did your dr say something to make you think that or was it just a feeling you had when you woke up? Well I am glad that you made it through and are here to tell your story...
  • My hospital charges per page. How many pages did your report contain? Just so I can get a ball park figure.
  • hiya cath
    thank you for the info..i do get all my mri's and test disc or reports..all this time i never knew that i could get that..
    i will be doing so tomorrow for sure..thanks lady you always teaching my something...
    my medical journals getting very heavy..
    have good day
    neck,bone spurs pain started 04, back issues and fusion l4,l5 06~hardware removed.
    good few yrs. 09 pain sharp, numbness feet,legs, diagnosed fibro, neurop. legs.lung issues.
    daily goal do good thing for someone.
  • I've done this a few times now and I was kinda disappointed by what I read. Very rarely do you learn anything new or dramatic. A few years back my dad had a surgery where the surgeon cut the mamory artery which sent blood flying everywhere. We were told this by at least two people who were in the OR. Amazingly there was no mention of this in the report so I am leary about the accuracy.

    It is good to have for your records in case something comes up in the future. And heaven knows we spineys do seem to have future issues.

  • I have to say, it's good advice.
    I started keeping my MRI Discs & Radiology reports, mainly b/c I thought I wanted to have them in case I had an emergency. I knew that I needed them b/c the hospital who took them is not digitally connected to the hospitals my ambulatory care would take me too.

    Well, I then wanted a 2nd opinion from eCleveland clinic as well as a few other surgeons. It seems the key information to keep in your own file are:

    MRI and related reports
    Operative Report (surgical)
    Final Office visit report (i.e. for me it was the 3-month check up).

    So much easier to have it on hand.
    Thanks for the reminder...I have my 3-month check up coming up and I need to get my Surgical report from my doctor.

    oh - -> I was able to request the surgical report directly from my surgeon's office and just had to sign paperwork and pick it up in person. It's been free. The only thing I've paid for was a copy of XRays but it was worth the $5. Plus, if you keep your medical expenses (including OTC), you may even be able to include it at tax time if it exceeds a certain dollar amount.
  • My cervical Operation Report was three pages and my lumbar Operation Report was two pages. The hospital has a department for records only and they asked me to send the application for the reports in and that they'd either call me for payment or just send the reports if they were free. I received them within seven days and they didn't cost me anything.

    I also have all my pre- and post-op xrays on disc and my MRI reports.

    One day I'll put them all in a binder or something, but for now I have everything in what I call my "Surgery Bag". It's getting a bit full now that I've had two surgeries, so I'll get it all organized one day.

    Kris is right in that there's not usually any drama, but there are a lot of things I've found that I was never told (or to freaked out to remember) that I saw on my Op Report. Like for my cervical, they put my head in a traction device to keep my head from moving while they did the incision, etc. Then added 5 lbs. of pressure to drill out the disks, etc., and then changed the pressure to 20 lbs. while they filled in the disc areas.

    Then, like I said, the additional problems they found during my lumbar surgery which explains why my incision is 7" long for a one-level fusion.

    They get fairly detailed so at least you learn some things and I found it very interesting. Additionally, it's marked at the end of the report who the surgeon was (which we know), who the assistant was, who the neuromonitor was and who received copies of the report, like your PCP.

    I especially like the end part where they mark down how well you did and accepted the operation well. :-)

  • ..at the end where they state "A clean dressing was applied..."
    I mean, what other kind of dressing would they use?! LOL!

    I read mine so many times I could probably re-do all the procedures myself, using a rear-view mirror & a magnifying glass....

    Good advice to get them all & keep a file. Just saw a new NS last month & he read everything b4 my appt. Helped him to suggest a CT scan & MRI for me in June, when I see him again. He thinks something's amiss, & the reports helped him understand just what was done, how it was done, why, etc. He was very candid & even commented on my other NS' methods--wasn't critical of him, just mentioned that things could have been done differently & perhaps that accounts for some of my chronic pain. Cryptic, at best, but if not for the OR reports, he wouldn't have know exactly what WAS done/how/why etc.

    So get them. They are very valuable in many ways.


  • SpineAZSpineAZ WiscPosts: 1,084
    The Operative Report can be soooo valuable years later! My orthopedic spine surgeon was thrilled when I was able to provide him my 1987 and 1993 lumbar surgery operative reports. It told him more than my MRIs did as he really knew what had been done and what he could expect when he opened me up (type of hardware, etc). So I urge everyone to get every operative report and keep it forever. You never know when it will come in handy and make your treatment a bit more smooth.
    2 ACDFs, 2 PCDF, 3 LIFs; Rt TKR; Rt thumb fusion ; Lt thumb arthroplasty; Ehlers Danlos 
  • dilaurodilauro ConnecticutPosts: 9,842
    Having copies of all of your medical records is so very valuable.

    All the information regarding your sessions, treatments, surgeries, etc is available to you.
    Yes, there is a charge for some of those items.

    For the medical hospital records, I was charged 9 cents a page. Its hard to say how many pages you need. Most surgical reports are going to be under 10 pages. Doctor visits, progress notes, PT evauls, etc can run into hundreds of pages depending on how long you have been dealing with the medical problem.

    MRI,X-Ray results are always available on a CD. First copy is generally free. I have a box of about 30 CDs containing the original MRI or X-Ray, plus copies I make.

    I have EMG, Bonescan, etc results.

    My folder is pretty big and when I go see a doctor or someone new, I copy of some of that big package.

    Record keeping is IMPORTANT. Not only for the pure medical aspect, but I know if patients that won some legal cases based on having all the information at hand
    Ron DiLauro Spine-Health System Administrator
    I am not a medical professional. I comment on personal experiences
    You can email me at: rdilauro@veritashealth.com
  • Angela Talley..what makes me think I almost left the planet is this. Surgery went way too long, I found out that after they had closed the surgery (and I was still under anesthesia) they had to open me back up and do something to control bleeding (?). Pretty good bleeding I'm guessing because it required 6 units of whole blood and 4 units of platelets. Now, that may be all normal and good, but I really get the impression that something went wrong. I also (and this will sound silly) think I had an out of body experience. I really think I could see myself laying there, face down, being worked on. Stupid as it sounds, there ya go!

    And yea, if indeed it was a close call, I'd want to know. It was already a close enough call to change my life..for the better. I'm a much more positive person, less materialistic and very much more appreciative of family, gardens, cats and life in general. I don't worry about the dumb s&^$ like I did. I'm happy, on my way to being healthy (still healing) and breathing. Yea, I'd want to know !

    Aloha nui loa,
  • I'm not a doc of course but that sure does sound like a whole lot of blood to replace..I'm glad that you made it through that.. Did you ask your doc what was making you bleed so badly.. Since your surgery lasted so long I would guess that they had to spend alot of time getting the bleeding stopped.. What levels did you have fused? When I had my surgery my Dr said he was amazed at how little blood I loss during the surgery to bad I can't say the same about after.. I lost alot of blood in my drain and ended up with a blood transfusion on my 3rd day in the hospital.. The day after my surgery I could not stand up without turning green (the nurse said green and then freaked out and made me lay down) and being so weak I couldn't stand on my legs.. Well they realized what it was and gave me some blood and it made a world of differance.. The next day I was of course still in alot of pain but I had so much more energy and I could stay awake and talk.. I never realized how much things can mess with you body when they are just a few numbers lower or higher then they should be in your body.. And I also don't think that you having a "out of body experience" sounds weird.. But I am glad that everything turned out good for you and that you are healed up and back on your feet in no time.. Bye
  • I decided that this was a good time to pop this post back to the top as a reminder to members that they can (and should) get their operations reports after their surgeries.

    Good stuff to keep with all your CT/MRI/Injection paperwork.

  • Cath,

    After my second surgery I went back and got all 5 of them. Interesting..As you can see, I have different hardware in my fusions right? According to the operative notes, they are the SAME!?! Interesting huh? I've still yet to see anyone else with this wing thing - I think I know why...el crack! :)

    PCTF C4 - T2, Laminectomies C5, C6 & C7. Severe Palsy left arm/hand.

  • Sometimes there are surprises in the surgical report.

    I got a copy of mine because I felt that something had happened that the surgeon hadn't told me about.

    He said everything went 'fine'. Several nurses and the physio had indicated that my surgery (and incision) had been bigger than planned.

    When I read the report, it was clear that he had started to work on the level above the intended surgery! He then realised his mistake (no spondylolisthesis there) and rechecked the correct level and proceeded to work there.

    When I asked him about it, he said he had to remove more bone than planned due to very severe stenosis. Said there was no mistake!
    His report said that he 'inadvertantly' cut into the level above, and found no spondylolisthesis or stenosis there, so rechecked and moved down to the correct level.

    Needless to say, he asked me why I had got a copy of the surgery report!!

    I would count my surgery as successful, but I do feel disappointed that he wasn't up front with me.
  • Jellyhall,

    See, I kind of feel that way about my 'wing thing' and my NS. When I pointed out the cracked vertebra, and both me and my husband explained the loading difference between the types of hardware - hence maybe the cause for the crack. He totally discounted us and the crack! It took an ENT, yes, and ENT to confirm yes that is cracked, and yes it is moving!

    My hubby wants my next surgery with another surgeon. He was not impressed with my NS, as in the past he was very open and honest, verses evasive and dismissive!

    Jelly, let me ask you. *Should* you need surgery again, would you go to the same surgeon, or switch? Just curious. :)

    PCTF C4 - T2, Laminectomies C5, C6 & C7. Severe Palsy left arm/hand.
  • MetalneckMetalneck Island of Misfit toysPosts: 1,364
    I just got my surgical report and found out what I didn't know for 2.5 years. I remember that I was to have two days of surgery ... and I remember that the doc came in and said he wanted to do some more .... a fourth surgery ... on a third day. I just got my records and discovered that the entire placement of my cage was done on that third day and wasn't originally planned. He removed all my autograft spacers and went for the cage. Don't know why but I am glad he did.

    Curious ....

    Spine-health Moderator
    Welcome to Spine-Health  Please read the linked guidelines!!

  • The surgical report is so important to obtain as is the final office visit before you are 'released'.

    It's not to say "hey buddy you screwed up" but it's to really have a record of what they did. It's your medical record. Key word, YOURs.

    I have a copy of my MRI, Radiology report that goes with the MRI, the surgical (or operative) reports, and the final office visit notes. Quite frankly, it's ok to ask for all the office visit notes.

    I got my reports after the 2nd surgery at the 6 week mark. I told my surgeon, I hoped I never saw him again and that in fact if I had another issue, I would track him down but should he retire or should I move...I wanted the records. He said "Absolutely! I think all patients should ask for that...makes it much easier if something comes up in the future".

    Thanks for bumping this to the top!
  • I was just thinking if I could/should do that and BOOM, there is your post. I always get doctor's dictations and reports, (MRI/CT on cd's) so I had just thought to myself, wouldn’t hurt to have the OR report, never know if you may need in the future. Especially, like many above said, my surgery "plan" and actual surgery differed. But in my surgeons’ defense, they did tell me there is always room for change in the "PLAN" once you are on the OR table, which is what happened to me.
    Not to mention my incision is much longer then what I was told, wonder if there was an oops, wrong level......

    I will be requesting mine on Monday. Thanks!
  • My cervical OR was very clear cut and was almost exactly as my surgeon had told me, other than when it stated that "she understood the off-label use of bone morphogenic protein infused and its advantages for a 3-level fusion." I don't remember discussing this with my doc, but in my hazy state having my first surgery ever, maybe we did. But I sure don't remember it. However, I would've agreed to it because I trust my surgeon.

    But my lumbar was a different story. He had told me in the hospital that things were worse than he thought once he got in there and after reading my report, he was right on. My spine was much more unstable than he had thought and he also noted worse stenosis and facet hypertrophy and had to cut more bone than he first intended. Thus, my back scar is 7" for a one-level fusion.

    You can find this kind of information in the beginning where it says PREOPERATIVE DIAGNOSIS: where it states what the surgeon told you about why you're having the surgery and then right after is POSTOPERATIVE DIAGNOSIS: which tells you what they really found in there and what they did different than what was originally diagnosied or expected.

    It's also interesting that my OR said, "She failed nonsurgical treatment and understood the potential of adjacent segment degeneration and potential additional surgery in the future and wished to proceed with the above stated procedure." Well, he didn't tell me that before the surgery and in fact when I asked him about it after the surgery, he said the chance of it happening was minimal and very unlikely. Hmmmmm.

    I also read something very interesting. I think we all know that they have a nerve monitor person in the operating room while they do the surgery to make sure no nerves are adversely affected during the procedure, but in my OR, it also said that after they placed the screws, they hooked each one up to some thingy and put an electrical current through it to make sure that the screw wasn't pressing on any nerves. Kind of like jump-starting a car. Very interesting and I though that was so cool.

    Glad you guys found this a good reminder. I think too many people don't realize that you can get your OR and how easy it is to get. I even lost my cervical one so after my lumbar surgery almost two years later, I requested both my lumbar and cervical ORs and they still had the cervical one on file and sent me both at no charge.

  • Jellyhall,

    Thanks so much for your reply to my question. :) My hubby and I talked some more, and if this crack doesn't heal *and* it is determined to be caused by the loading difference, I will use another surgeon. Dunno still tossing it around. My NS is a talker if my husband is there, not so much one on one with just me.

    I just have reservations about another surgeon too (for the correction/fix) as many don't like going in to fix someone else's mess! Grrr... I'm glad I got the OR reports though, not just to see what they do to you, but to see that with different hardware, it is listed as plates and screws...go figure! Maybe I will get with the hospital for the other reports? I only have my NS's report. Things that make you go hummmmm.... Thanks Cathie - didn't think that others make reports - makes sense. :)

    PCTF C4 - T2, Laminectomies C5, C6 & C7. Severe Palsy left arm/hand.
  • I think that my surgeon is a very good surgeon, but doesn't have very good communication skills.

    Before I had even met him, there were several people who shared with me that he didn't have a good reputation as an effective communicator! (Patients, nurses, doctors and physiotherapists). I felt that his surgical skills were more important.

    When I met him I was pleasantly surprised as our meeting went much better than I was expecting. I just think that after the surgery, he didn't want to get into detailed discussion about it. Then when I wanted specifically to talk about the surgery report, he felt very awkward! He is used to being right, and was very uncomfortable with having made a mistake.

    If I had to have surgery again with him, I think that I would be able to go ahead with it.

    However,........ I have been referred to a surgeon to look into my neck, and I have asked to see another surgeon. The reason is more about wanting to see someone who I feel I can talk to than not trusting his surgical skills. (This other surgeon is also good, I believe.)

    My first surgeon was an orthapedic spinal surgeon and the other one I will be seeing is a neuro spinal surgeon. The second one also does minimally invasive surgery. I wouldn't want a very long incision on my neck!!
    (Wow! I can believe that I have talked about an incision on my neck! I am really hoping that it doesn't come to that this time!!) :jawdrop:
  • I hadn't gotten Operation Reports in some time. But initially did have the report for my first C-Spine surgery the ACDF with bone implant and removal of bone spurs. There were no surprises to me surgeon relayed info about the additional level they had to do, third level, rather than just two because of another osteophyte (bone spur) and degeneration that did not clearly show up on the scan.

    So I did find it interesting to read the Operation Report and got a copy.

    More recently I have used the Operation Report from my hand surgery in which two procedures were done (1) carpal tunnel release and (2) basal thumb joint arthroscopy with a tendon ligament implant from arm used into the basal joint, a new technique being used at the time in 2000 versus the synthetic implants.

    It has been valuable to have with the neuropathic damage I have going on in that same hand from initial C-Spine nerve root compression and in seeing OS's for nerve damage and dysfunction in elbow/hand/wrist/fingers/ and thumb. The Operation Report notes was with medical reports on the hand surgery done in 2000 AND the OS did read the Operation Report for the detail of what was done with the thumb and the ligament.

    So, yes these are instrumental and useful to have especially complex, innovative procedures that may need to be understood later by an OS or NS.

    Thanks, Cath, for bringing this to focus for others who may not have thought of it or even known the actual reports were available and smart to have and useful as well!

  • j.howiejj.howie Brentwood, Ca., USAPosts: 1,730
    about my first surgery. I know I went into the white light. And was above the table looking at myself and the staff with bells and alarms going off. Thinking, this is so peaceful, just let me be. A nurse made a big boo boo by telling my wife a little about it. Said i had a rough time and they had to flush
    all drugs out of my system. And start anew. Then when she realized she said too much. She started back tracking. I've always been curious about just how long I "flat lined"
    Click my name to see my Medical history
    You get what you get, not what you deserve......I stole that from Susan (rip)
    Today is yours to embrace........ for tomorrow, who knows what might be starring you in the face!
Sign In or Register to comment.