Munir Elias 20-12-2013

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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 not mentioned.


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 exits.


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 financially.



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 admission.


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 hours.


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 was 1/60



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 luxurious 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.

Leica HM500

Leica HM500
The World's first and the only Headmounted Microscope.
Freedom combined with Outstanding Vision, but very bad video recording and documentation.

TRUMPF TruSystem 7500

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 .


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