Patient Name:
MRN / ID:
Date:
Diagnosis:
Planned Procedure:
Surgeon:
Assistants:
Anesthesia: General / Regional
<folded Clinical Rationale>
Brief summary of presentation and indication for surgery.
Include failed conservative treatments or progression of symptoms.
Example: Patient presents with progressive left hemiparesis and seizures. MRI shows enhancing lesion in left parietal lobe with mass effect.
</folded>
<folded Preoperative Imaging Findings>
Summarize relevant findings: MRI, CT, tractography, angio, etc.
Mention proximity to eloquent cortex, brainstem, vascular structures, or spine levels.
</folded>
<folded Surgical Objectives>
Gross total resection / decompression / biopsy / stabilization
Symptom relief / CSF diversion / histological diagnosis
Example: Maximal safe resection preserving motor cortex and arcuate fasciculus.
</folded>
<folded Approach and Technique>
Positioning: supine, prone, lateral
Surgical approach: pterional, midline suboccipital, ACDF, etc.
Key tools: navigation, ultrasound, microscope, ultrasonic aspirator
</folded>
<folded Adjuncts and Technology>
Neuronavigation
Intraoperative monitoring (MEPs, SSEPs, EMG)
5-ALA / Fluorescein / Intraop MRI / Endoscope
</folded>
<folded Risks and Mitigation Strategies>
| Risk | Mitigation Strategy |
| Bleeding | Careful hemostasis, bipolar cautery, hemostatic agents |
| Neurological deficit | IOM, gentle dissection, staged resection |
| CSF leak | Watertight dural closure, graft, sealant |
| Infection | Pre-op antibiotics, sterile technique |
</folded>
<folded Postoperative Plan>
ICU monitoring or floor depending on complexity
Early neuro exam and imaging (CT/MRI within 24–72h)
Post-op meds: steroids, antiepileptics, antibiotics
Physical therapy / Occupational therapy / Discharge planning
</folded>
<folded Contingency Plans>
What if the lesion is non-resectable?
What if neurophysiological alerts are triggered?
Backup strategies for bleeding or intraoperative findings
</folded>