Case Prep Template: [PROCEDURE NAME]

One-Liner

[Age]yo [M/F] with [diagnosis/presentation] presenting with [chief complaint/duration] planned for [procedure].

Case / Approach Snapshot

Anatomy at risk: [corridor/level-specific neural, vascular, bony, CSF, and soft-tissue structures]
Operative steps: [positioning, exposure, key maneuver, verification, closure]
Rescue plans: [bleeding, neurologic change, wrong target/level, CSF leak, hardware/reconstruction issue, staged or alternate plan]
Figures: [open-access/public-domain/local figures and linked operative videos]
Papers: [seminal papers, modern reviews/trials/guidelines, PubMed links]

History of Present Illness

Chief complaint:
Duration/onset:
Progression:
Associated symptoms:
Prior treatments:
Functional status (KPS/mRS):

Past Medical History

Hypertension
Diabetes mellitus
Coronary artery disease / prior MI
Atrial fibrillation
Prior stroke/TIA
Seizure history
DVT/PE history
Bleeding disorder / coagulopathy
Prior cranial/spine surgery
Allergies (especially latex, antibiotics, contrast):
Medications (anticoagulants, antiplatelets, steroids):
Other:

Imaging Review

CT/CTA

Bone anatomy / craniotomy planning
Vascular anatomy
Calcification / hyperostosis

MRI (T1, T1+Gad, T2, FLAIR, DWI, MRA/MRV)

Lesion location:
Lesion size:
Relationship to eloquent cortex:
Relationship to major vessels:
Enhancement pattern:
Edema:
Mass effect / midline shift:
Hydrocephalus:

Angiography (if applicable)

Vascular supply:
Venous drainage:
Collateral circulation:
Relationship to parent vessels:

Thin-cut MRI/CT loaded to navigation
Fiducials planned / surface registration
DTI tractography (if near white matter tracts)
fMRI (if near eloquent cortex)

Labs

CBC (Hgb, Plt)
BMP (Na, K, Cr, Glucose)
Coagulation (PT/INR, PTT)
Type and screen / crossmatch
TSH, cortisol, prolactin, GH, IGF-1 (if pituitary)
Pregnancy test (if applicable)
Other:

Neurological Examination

Mental Status

Alertness/orientation:
Language (fluency, comprehension, repetition, naming):
Memory:

Cranial Nerves

II: Visual acuity, visual fields, fundoscopy
III, IV, VI: EOM, pupils
V: Facial sensation, masseter
VII: Facial symmetry/strength
VIII: Hearing (Weber, Rinne)
IX, X: Palate, gag, voice
XI: SCM, trapezius
XII: Tongue

Motor

Upper extremity (deltoid, biceps, triceps, wrist ext/flex, grip, interossei):
Lower extremity (iliopsoas, quads, hamstrings, tibialis anterior, gastroc, EHL):
Tone:
Pronator drift:

Sensory

Light touch:
Pinprick:
Proprioception:
Vibration:

Reflexes

Biceps / Triceps / Brachioradialis:
Patellar / Achilles:
Babinski:
Hoffmann:

Coordination/Gait

Finger-to-nose:
Heel-to-shin:
Gait:
Romberg:

Surgical Planning

Case Logistics, OR Needs & Orders

Typical bed: [Outpatient / PACU then floor / step-down / ICU] based on airway, neurologic risk, EBL, monitoring needs, and comorbidities.
OR setup: confirm table/bed, positioning devices, imaging/navigation, microscope/endoscope/fluoroscopy, implant trays, blood availability, and specialty co-surgeons before patient enters the room.
Special needs: arterial line, Foley, neuromonitoring, MAP/BP target, dexamethasone/steroid plan, antiepileptic plan, antibiotics, anticoagulation reversal/restart, and disease-specific monitoring (DI, drains, airway, swallow, ICP).
Immediate postop orders: disposition, neuro-check frequency, HOB/activity/brace, diet/swallow status, imaging timing, drain/EVD/shunt settings, DVT prophylaxis timing, pain/nausea regimen, labs, antibiotics, steroid taper, and consults/follow-up.

Diagnosis & Indication

Working diagnosis:
Surgical indication:
Goals of surgery:
Alternative treatments considered:

Position

Patient position:
Head position (rotation, flexion/extension, lateral tilt):
Skull clamp pin placement:
Table configuration:
Pressure points padded:
Arms positioned:

Incision

Incision type:
Key landmarks:
Skin preparation:
Hair management:

Approach

Craniotomy/approach name:
Burr hole locations:
Bone flap dimensions:
Key anatomical landmarks:

Critical Anatomy & Structures at Risk

1. 2. 3. 4. 5.

Key Surgical Steps

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Equipment & Instrumentation

Microscope
Endoscope
Navigation (loaded and registered)
Ultrasound
High-speed drill
Ultrasonic aspirator (CUSA)
Bipolar forceps
Microsurgical instruments
Clips / clip appliers
Hemostatic agents
Dural substitute
Bone fixation (plates/screws)
Implants (shunt, stimulator, cage, screws):
Special:

Monitoring

SSEPs
MEPs (transcranial)
EMG (cranial nerves: ___)
BAER
Direct cortical/subcortical stimulation
EEG / ECoG
Doppler (for VAE)

Anesthesia Considerations

Arterial line
Central line
Foley catheter
Lumbar drain
Mannitol / hypertonic saline
Dexamethasone
Anticonvulsant prophylaxis
Antibiotics (cefazolin ___ g)
Paralytic considerations (monitoring)
Blood products available
Special (awake, sitting position, etc.):

Potential Complications & Contingencies

1. 2. 3.

Operative Note Template

Preoperative Diagnosis:

Postoperative Diagnosis:

Procedure:

Surgeon: Assistant: Anesthesia: General endotracheal

Estimated Blood Loss: Fluids: Specimens: Drains: Complications: Implants:

Indications: The patient is a [age]yo [M/F] with [diagnosis] presenting with [symptoms]. Preoperative imaging demonstrated [findings]. After discussion of risks, benefits, and alternatives, the patient elected to proceed with surgical intervention.

Description of Procedure: After informed consent was verified and the surgical site was marked, the patient was brought to the operating room and placed supine on the operating table. General endotracheal anesthesia was induced without complication. [Neuromonitoring electrodes were placed and baseline signals obtained.] [Arterial line and Foley catheter were placed.]

The patient was positioned [position]. The head was secured in a [Mayfield/horseshoe] head holder with [pin placement details]. All pressure points were padded. [Navigation was registered with surface/fiducial registration and accuracy confirmed.] A time-out was performed confirming patient identity, procedure, site, and laterality.

The [area] was prepped and draped in the standard sterile fashion. [Preoperative antibiotics were administered.] [Mannitol ___ g was given.]

Incision: A [type] incision was made [location/landmarks]. [Scalp flap details.] [Temporalis muscle handling.]

Craniotomy/Exposure: [Burr holes placed at __. Craniotomy performed with __. Bone flap elevated. Epidural hemostasis achieved with ___.] OR [Exposure details for spine.]

Dural opening: The dura was opened in a [curvilinear/C-shaped/cruciate] fashion [based on ___]. Dural tacking sutures were placed. [CSF was encountered and drained.]

Intradural/Intraparenchymal procedure: [Detailed surgical steps — arachnoid dissection, cistern opening, lesion identification, microsurgical technique, extent of resection, clip application, etc.]

Hemostasis: Meticulous hemostasis was achieved with [bipolar cautery, Surgicel, Gelfoam, etc.]. The surgical cavity was irrigated and inspected.

Closure: The dura was closed [primarily/with graft] in [running/interrupted] fashion using [suture type]. [Dural sealant was applied.] The bone flap was replaced and secured with [plates and screws/sutures]. The [galea/fascia] was closed with [suture]. The skin was closed with [staples/sutures/subcuticular]. A sterile dressing was applied.

Postoperative: The patient was awakened from anesthesia, extubated, and transferred to the [ICU/PACU] in [stable/satisfactory] condition. [Neuromonitoring signals remained stable throughout.] The patient was moving all extremities [symmetrically/with baseline deficits] on emergence.

Postoperative Plan

ICU admission / step-down / floor
Neuro checks q1h x 24h, then q2h
Head of bed elevation (30 degrees)
Postoperative imaging (CT head ___ hours)
DVT prophylaxis (SCDs immediately, chemical in ___ hours)
Pain management
Dexamethasone taper
Seizure prophylaxis (duration: ___)
Activity restrictions
Diet
Drain management (EVD/JP/subgaleal):
Follow-up (clinic __ weeks, imaging __ months)