Outpatient Neurosurgical Follow-Up

Date: 1 November 2024 Patient: John Smith Date of Birth: 15 March 1965 (59 years) File: JS-NSG-2024-001 Outpatient Neurosurgical Follow-Up Note Visit Context: Postoperative review following anterior cervical discectomy and fusion (ACDF) at C5-C6. Surgery performed on 1 October 2024, 31 days post-surgery. Symptoms and Patient Concerns: Patient reports significant improvement in right upper extremity radicular pain and numbness since surgery. Mild residual neck stiffness, but no severe headache, weakness, seizures, gait disturbance, or cognitive changes. Pain score using the Visual Analogue Scale: 2/10 (previously 8/10). No back or leg pain. Neurological Examination: Cranial nerves II-XII intact, symmetrical. Motor examination: 5/5 strength in all extremities bilaterally. Sensory examination: Intact to light touch and pinprick in all dermatomes, improved sensation in right C6 distribution. Coordination: Intact finger-to-nose and heel-to-shin. Reflexes: Biceps, triceps, and brachioradialis 2+ bilaterally, patellar and Achilles 2+ bilaterally. Gait: Stable, no ataxia. Wound and Recovery Status: Surgical site on anterior neck well-healed, clean, dry, and intact with minimal scar formation. No signs of infection (erythema, warmth, discharge). Patient reports good functional recovery, able to perform daily activities with minimal discomfort. Imaging and Investigations Reviewed: Postoperative cervical spine X-rays (taken 28 October 2024) reviewed, demonstrating good alignment and stable hardware at C5-C6. No evidence of instrumentation failure or adjacent segment disease. Device or Implant Review: N/A (No implanted devices other than ACDF hardware, which was reviewed on X-ray). Complications or Adverse Events: No delayed complications such as hydrocephalus, haematoma, seizure activity, or neurological deterioration observed or reported. Plan and Follow-up: Continue current activity level. Encourage neck range of motion exercises as tolerated. Next follow-up in 3 months with repeat cervical spine X-rays. Referral to physiotherapy for guided cervical strengthening and mobility. Patient advised to return sooner if new symptoms or concerns arise. Discharge from neurosurgical care pending next follow-up and radiographic stability. Clinician Specialty: Neurosurgeon