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 ending to a nightmare that had started 44 hours earlier in a dentist's office in the Eixample district of 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 we had never done before and on which Sara's future depended,” Hinojosa recalls.
The cavity was located in the right jaw, in the lower part of the mouth. It was deep and anesthesia was applied to treat Sara painlessly. Montse, her mother, stood behind her and held her head so she wouldn't move during her puncture.
“When the dentist removed the syringe, it didn't have a needle,” Montse recalls. “I asked him: where is the needle?” She was stuck. Two other dentists came to try to get her out, but the more they touched her, the more she sank. “After a while they told us that they were sending us to Sant Joan de Déu. “They called an ambulance, which turned on the siren, and they took us directly to the emergency room.”
By a fortunate coincidence, one of the dentists had been a faculty colleague of Josep Rubio, head of the maxillofacial surgery service at Sant Joan de Déu. Seeing that he couldn't remove the needle, he called him for advice and sent him x-rays of Sara's mouth via WhatsApp. It was Rubio, who was at a conference in Tenerife that Wednesday afternoon, who told her to take Sara to Sant Joan de Déu and who called the hospital so they could treat her immediately.
“When we arrived, everything seemed under control. Sara's face was still numb. She was not in pain nor was she scared. They took her away and told us: 'now we'll remove the needle,'" Montse says. “We stayed waiting and, when they came back, they told us: 'We couldn't; We have to do a CT scan to see where it is.”
After doing the test, it was decided that Sara would stay hospitalized accompanied by her parents. She would have to be operated on. “On Thursday morning they told us that that day couldn't happen and that we had to wait until Friday to have an operating room equipped with CT,” recalls Josep Maria, Sara's father. Dr. Rubio, who had planned to stay at the Tenerife congress until Friday, returned early to perform the operation.
“On Friday at eight in the morning they came to look for Sara in the room to take her to the operating room,” explains Montse. “At ten o'clock they called us and I thought: 'She's here, everything must 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 we had to do a different intervention than the one they had planned, that they had never seen a case like this, that they did not know how much time they would need, it could be eight or nine hours, and they warned us that there was a risk of injuring an artery or something. nerve in the operation. “The world fell on me.”
What had happened until then in the operating room was that Rubio had decided to do a CT scan before starting the intervention to make sure that the needle was still in the same place. “It is 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.
Not being 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. On Friday morning the needle was lodged under the right temporal lobe. If it had not been removed, it “would have continued migrating into the brain, pushed by the subtle impulses of the heartbeat and breathing; she 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 was in another hospital operating room that morning about to begin a less complex intervention. “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 were going to do and how, and we reorganized the teams to care for all the patients.”
The surgery began by making an incision several centimeters long on the right side of Sara's head. The incision was made in an area usually covered with hair to avoid leaving a visible scar. “We had to open the meninges to access the needle,” explains Hinojosa. “The intervention was performed in a hybrid operating room, which allows us to perform angiography and CT angiography, and with the help of neuronavigation. There are few hospitals with operating rooms equipped to perform such an intervention. “This allowed us to locate the needle right where we expected it to be.”
It was then, when Hinojosa removed the needle, that the surgeons, radiologists, anesthetists, nurses, orderlies and the coordinator who were in the operating room burst into applause. “It was an exciting moment; There was an extra load of tension in this operation. The most important thing is that we managed to get the needle out without hurting Sara. She will not have any neurological sequelae,” highlights the neurosurgeon.
They called Montse and Josep Maria at half past two 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 stitching her up, that everything had gone perfect,” Montse recalls.
They could see her at seven in the afternoon. Sara was in the ICU, with her head bandaged, her face swollen, with eight tubes connected to as many 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 ward, where she was admitted for a week to be administered antibiotics through a vein and to monitor her postoperative evolution.
-Mom, can I do a handstand? -Sara asked as soon as she could get up.
Montse told him no.
Sara insisted:
-Mom, I want to do a handstand!
"Well, let him do it," said Dr. Hinojosa. What can limit it is pain. If you don't limit it, you can do it.
Sara has good memories of the week she spent in the hospital. She spent more time in the games room than in the room, they let her do her handstand when she felt like it, and friends from Escola Entença, her teacher, the director, the father of a classmate who is a cook, went to see her. He brought 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 entering the emergency room in an emergency ambulance, Dr. Hinojosa, whom Sara now calls Pepe, went to see her in her room and told her: “On Monday, at school. Normal life". She left the hospital with her head still bandaged and the only thing she couldn't do for a few weeks would be go to the pool so the scar could finish forming properly.
His case is so exceptional that it was 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 to give them anesthesia when it is necessary to avoid pain,” declares Hinojosa. The lesson that can be drawn, according to the neurosurgeon, is that “in medical acts sometimes unforeseen events occur; The important thing is that we are prepared to solve them.”
