Operative Note – Neurosurgery (Cranial or Spinal)

Operative Note – Neurosurgery (Cranial or Spinal) Procedure Performed: [document exact surgical procedure name, anatomical site, laterality, urgency (elective/emergency), and date/time of operation] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Surgical Team: [include names and roles of the primary surgeon, assistant(s), anaesthetist, and nursing/support staff] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Preoperative Diagnosis: [record clinical and radiological diagnosis or indication for surgery] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Anaesthesia and Positioning: [document type of anaesthesia used, patient positioning, use of head clamp or spinal supports, and precautions taken] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Surgical Approach and Technique: [describe incision site, bone removal or exposure method, intraoperative navigation, microscope/endoscope use, decompression or resection technique, instrumentation, or fusion method] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Intraoperative Findings: [document relevant pathology encountered such as tumor size, hemorrhage, adhesions, malformation, spinal instability, or dural tears] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Specimens and Implants: [list any tissue sent for pathology or microbiology, and describe any implants placed including screws, plates, spacers, cages, or shunts] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Intraoperative Complications: [note any events such as bleeding, neural injury, hardware misplacement, CSF leak, or anaesthetic complications] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Blood Loss and Fluid Management: [record estimated blood loss, fluids administered, transfusion details, and urine output if relevant] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Postoperative Plan: [outline transfer destination (ICU/ward), post-op imaging, antibiotics, pain management, steroids, neurological monitoring, wound care, or drain management] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)