When neurosurgeon José Hinojosa finally removed the needle from four-year-old Sara’s brain, the twenty people in the operating room at the Sant Joan de Déu pediatric hospital began to applaud. It was the happy end of a nightmare that had started 44 hours earlier at a dentist’s office in the Eixample district, in Barcelona, ??in a banal intervention to cure a cavity.
“It is not usual to applaud in the operating room. It was the way to release the tension accumulated in a complex operation in which we did something that we had never done before and on which Sara’s future depended”, remembers Hinojosa.
The cavity was located on the right jaw, in the lower part of the mouth. It was deep and anesthesia was applied to treat Sara without pain. Montse, her mother, stood behind her and held her head so she wouldn’t move during the puncture.
“When the dentist removed the syringe, it didn’t have a needle,” remembers Montse. “I asked him: where is the needle?”. She was stuck. Two more dentists went to try to remove it, but the more they touched it, the more it sank. “After a while they told us they were sending us to Sant Joan de Déu. They called an ambulance, which put on the siren, and they took us straight to the emergency room.”
By a lucky coincidence, one of the dentists had been a faculty colleague of Josep Rubio, head of the maxillofacial surgery service at Sant Joan de Déu. After seeing that he couldn’t get the needle out, he called her for advice and sent her X-rays of Sara’s mouth via WhatsApp. It was Rubio, who was at a conference in Tenerife that Wednesday afternoon, who told him to take Sara to Sant Joan de Déu and who called the hospital to have her treated immediately.
“When we arrived, everything seemed under control. Sara’s face was still numb. She wasn’t in pain and she wasn’t scared. They took her away and told us: ‘now we’re going to take the needle out of her,'” recounts Montse. “We waited and, when they came back, they told us: ‘we couldn’t; we have to do a CT scan to see where it is.”
After testing her, it was decided that Sara would be admitted accompanied by her parents. They should operate on him. “Thursday morning they told us that it couldn’t be that day and that they would operate on her on Friday in order to have an operating room equipped with a CT scan,” remembers Josep Maria, Sara’s father. Dr. Rubio, who had planned to stay at the congress in Tenerife until Friday, returned early to take charge of the operation.
“Friday at eight o’clock in the morning they came to find Sara in the room to take her to the operating room,” explains Montse. “At ten o’clock they called us and I thought: ‘that’s it, everything will have gone well’. The heads of maxillofacial surgery, neurosurgery and anesthesia were waiting for us. They told us: ‘the needle has moved, it has reached the brain’. They told us that it was necessary to do a different operation than they had planned, that they had never seen such a case, that they did not know how long it would take, it could be eight or nine hours, and they warned us that there was a risk of injuring someone artery or some nerve during the operation. The world fell on top of me.”
What had happened up until then in the operating room was that Rubio had decided to do a CT scan before starting the operation to make sure the needle was still in the same place. “It’s a very fine type of needle and if it had moved, it would have been like looking for a needle in a haystack,” recalls the surgeon. And indeed he had moved.
Since it was not attached to anything, it had migrated pushed by the movements of the muscles, with such bad luck that it had slipped through the foramen ovale, one of the small holes through which nerves and blood vessels pass at the base of the skull. By Friday morning the needle was lodged under the right temporal lobe. If it had not been extracted, “it would have continued to migrate into the interior of the brain, driven by the subtle impulses of heartbeat and breathing; it could have caused serious damage and would have been more difficult to extract”, reports José Hinojosa, head of neurosurgery at Sant Joan de Déu.
Hinojosa that morning was in another hospital operating room about to begin a less complex operation. “I spoke with Dr. Rubio and we saw that Sara’s case required a completely different approach than what had been planned,” explains the neurosurgeon. “We decided what we would do and how, and we reorganized the teams to attend to all patients.”
The surgery began by making an incision of several centimeters on the right side of Sara’s head. The incision was made in an area usually covered with hair to avoid a visible scar. “We had to open the meninges to access the needle,” explains Hinojosa. “The intervention was done in a hybrid operating room, which allows us to do angiography and angioTAC, and with the help of neuronavigation. There are few hospitals with operating theaters equipped to perform such an operation. This allowed us to locate the needle exactly where we expected it to be.”
It was then, when Hinojosa removed the needle, that the surgeons, radiologists, anesthesiologists, nurses, janitors and the coordinator who were in the operating room burst into applause. “It was an exciting time; there was an extra voltage load in this operation. The most important thing is that we managed to remove the needle without hurting Sara. He will not have any neurological sequelae”, emphasizes the neurosurgeon.
They called Montse and Josep Maria at half past three in the afternoon. Dr. Rubio had come out of the operating room to tell them that the needle had been removed and that the brain had not been damaged. An hour later Dr. Hinojosa came out. “He told us that they were sewing it up, that everything had gone perfectly”, remembers Montse.
They could see her at seven in the afternoon. Sara was in the hospital, with her head bandaged, her face swollen, with eight lines connected in different parts of her body, and with her stuffed Hello Kitty cat. Montse stayed the night with her. The next morning she was transferred to the hospital, where she was admitted for a week to administer intravenous antibiotics and monitor the postoperative evolution.
– Mom, can I do the pin? Sara asked so she could get up.
Montse told him no.
Sara insisted:
– Mom, I want to make the pin!
– Well, let him do it – said Dr. Hinojosa. What can limit it is pain. If he doesn’t limit her, he can.
Sara has a good memory of the week she spent in the hospital. She spent more time in the playroom than in her room, she was allowed to play when she felt like it and friends from Escola Entença, her teacher, the headmistress, the father of a a classmate who is a cook and who brought her a potato omelette… “They may seem like minor details, but they have been important so that Sara has not been left with any trauma from this experience”, thanks Montse.
On Friday, eight days after she entered the emergency room by ambulance, Dr. Hinojosa, whom Sara now calls Pepe, went to see her in the room and said: “Monday, at school. Normal life”. He left the hospital with his head still bandaged and the only thing he wouldn’t be able to do for a few weeks was go to the pool so that the scar would just form properly.
His case is so exceptional that it has been presented at the congress of the Spanish Society of Pediatric Neurosurgery, held in February in Baeza (Jaén). The Sant Joan de Déu team, led by Hinojosa and Rubio, will soon publish it in a scientific journal.
“We want to emphasize that Sara’s case is not a reason to stop taking children to the dentist or to be afraid of putting them under anesthesia when it is necessary to avoid pain,” declares Hinojosa. The lesson that can be drawn, according to the neurosurgeon, is that “in medical procedures sometimes unexpected things happen; the important thing is that we are ready to solve them”.
