Most of the site will reflect the ongoing surgical activity of Prof. Munir Elias MD., PhD. with brief slides and weekly activity. For reference to the academic and theoretical part, you are welcome to visit
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06-JULY-1997 MUSTAFA HASAN FARES AL-RAKH 18 YEARS
OSTEOMYELITIS OF THE SKULL BASE WITH CAVERNOUS THROMBOPHLEBITIS.
Rejection of the bone cement
is not that serious event in such location as in
the maxillary sinus anterior wall. The resulting
deterioration of the patient could be to the
mentioned trauma with subsequent escalation of
the osteomyelitis of the skull base and the
overlying sellar and parasellar venous channels.
The patient had fever with meningism. This was
due to meningoencephalitis. Talking about
rejection have meaning if the even took place
the firs weeks or months after surgery.
The presence of active
osteomyelitis was the indication for surgical
debridement to take control over the infection.
Postoperative infection have
place in 2-5% of all extrabdominal and 20% in
abdominal cases. This usually happens during the
first three months after surgery. This patient
came 13 months after first performed surgery.
Iodine is not used for
surgical cleaning for decades. Betadine or
Povidone are used instead.
With the available facilities
a that time, there were no perfect rejection and
immunological studies to give the perfect
picture of the patient.
The case ended with that the
patient could win the case legally and I paid
50.000 JD in compensation 07-March-2014.
Lessons for the life
Do not ever trust a bad
neurosurgeon even as an assistant, because of his
stupid maldeformed documentations can lead you
to a disaster. The assistant neurosurgeon was
poor in English and he wrote the operative
note, in Arabic that the left eye was burned by
iodine. All the mentioned steps of surgery were
To decrease the infection
rate after surgery, certain measures must be
taken, for more details
click here. But here it is not the case. The
patient came with fully blown osteomyelitis of
the skull base with pus discharge all over the
If your lawyer is weak and
not understandable, then you will certainly
loose your case, even if he is your brother.
If the legal system is not
competent with the case, it can be
manipulated and the truth will be lost.
When you work in public
sector, such as the MOH in the third world, you are completely
exposed to any problem, because the government
is not covering you legally and
The patient was operated by me
08-October-1995 for fibrous dysplasia of the
skull base with massive left parasellar
extension reaching the left maxilla deforming
the face. The patient then came 26-June-1997
claiming that he suffered trauma 8 months ago,
after that he started to suffer pain in the left
maxillary area. At this time he showed signs of
rejection of the artificial bone with pus coming
from the mouth, nose and both eyes. The patient
was advised to undergo debridement of the wound
and covered with antibiotics. He was reluctant
and came many times and all the times escaped
The patient was given admission 29-July-1996, 19-August-1996,
admitted 10-March-1997 and discharged against
medical advice 12-March-1997, 20-March-1997, where the record confirming the
presence of maxillary abscess, 23-June-1997, 26-June-1997 and
was admitted that time and septic wok up and
antibiotic treatment was started but he escaped
against medical advice in 03-July-1997. The
patient then came 04-July-1997 after
considerable deterioration during the last 24
On examination the day before surgery the
patient was febrile with deteriorating level of
consciousness with signs of meningism. Exposure
keratitis of both eyes was noticed. A huge
amount of pus is coming from the nose, mouth and
both eyes. Neuro-radiologic investigations
showed osteomyelitis of the skull base with
thrombophlebitis of the cavernous sinuses.
The eyes of the patient were closed by gauzes
after chloramphenicol eye ointment was applied
to the eyes and the mouth cavity was prepared.
Draping around the oral cavity after meticulous
washing with saline and diluted Povidone. The
gingival approach was refreshed and most of the
osteomyelitic bone was debride. After completion
of the surgery, the draping was removed and the
cover from the eye. It was noticed that the left
eye got severe reaction and an ophthalmologist
was consulted and advised to irrigate the eye
with saline and close the eye with wet gauze.
The surgery took 5 hours.
The patient was extubated,
but after 5 hours, he started to complain of
difficult breathing due to massive swelling of the
oral cavity, for what he was kept in ventilator
for 4 days until the swelling subsided.
The patient was advised to be
transferred to ophthalmological department
but he refused and left the hospital
14-July-1997, to be followed by ophthalmologist.
From ophthalmological records
later, he was seen 31-July-1997 and the
examination confirmed the presence of
conjunctival ulcer of the left eye with
decreased vision left eye 6/18. The right eye
was normal. He was advised to be admitted but he
refused. The patient then came 07-August-1997,
09-August-1997 and 19-August-1997 and in this
last visit the patient was totally
uncooperative. The patient then came
24-August-1997 and during examination, the ulcer
healed, but the visual acuity of the left eye
Due to this incident and other conditions,
during which the neurosurgeons asking you for
help and you run to help them, and coming to the
operating room to find that the operated patient
is dead for sufficient time, and turn to be
responsible for the death of the diseased, and
give money to the relatives of the last to ease
the conflicts, by the time I took another
strategies. I am working in one hospital for 12
years. I never response to any neurosurgeon
asking for help. I think thousand times before
proceeding with difficult cases and try to go
out if the other side ( the patient or his
family) are candidates for trouble making. Even
with long preoperative discussions some of the
patients change their attitude after surgery.
The old man or woman with wheelchair and CCS or
LCS needs to return as young and better than
Mikhail Baryshnikov and
Anna Pavlova in their young years.
I am a neurosurgeon, and I am supposed to live in
style, but due to these incidents, I am all the
time depressed and spent all
my money over the year improving the
intraoperative monitoring system until I
regained the intraoperative MRI with Skyra 3
tesla with all clinical applications with Inomed
ISIS 32 channel IOM and a lot of microsurgical
and documentation systems.
After any surgery, I usually spend double time in
documenting and revising the performed surgery
and publishing it to the whole world with
detailed description and discussion in my personal websites,
as this one.
Skyra MRI with all clinical applications in the run since 28-Novemeber-2013.
The World's first and the only Headmounted Microscope.
Freedom combined with Outstanding Vision, but very bad video recording and
After long years TRUMPF TruSystem 7500 is running with in the neurosuite at
Shmaisani hospital starting from 23-March-2014
Notice: Not all operative activities
can be recorded due to lack of time.
Notice: Head injuries and very urgent surgeries are also
escaped from the plan .