Kansas – Neurosurgery – Pneumocephalus And Hemorrhage Following A Burr Hole Procedure

On 2/26/2007, 77-year-old female patient had a magnetic resonance imaging performed which revealed a left-side subdural hematoma.  The patient was admitted to a medical center where she was examined by a neurosurgeon.

On 2/27/2007, the patient underwent surgery for evacuation of a left parietal and frontal subdural hematoma through a burr-hole procedure performed by the neurosurgeon.

The neurosurgeon, as the attending physician and supervisor for all medical personnel assisting with the burr hole procedure, was responsible to the patient for all his actions as well as those who assisted with the procedure.  A traumatic injury to the substance of the patient’s brain occurred, which resulted in hemorrhaging of her brain.

Following surgery, the patient exhibited aphasia and right-sided hemiparesis.  A computed tomography scan was performed on 2/27/2007, which showed new areas of pneumocephalus and hemorrhage in the brain.

The operative report dictated by the neurosurgeon on 2/27/2007, which is the same day the surgery took place, described the neurosurgeon’s placement of two burr holes and the drainage of fluid from each. It also described the placing of a Jackson-Pratt drain and what was variously described as gentle or careful irrigation of the sites.

However, an addendum typed by the neurosurgeon on 6/5/2007 stated that a surgical technician directed what was termed as a “forceful irrigation” into the left-frontal burr hole site while the neurosurgeon had his back turned.  It also stated that when the neurosurgeon inspected the left parietal burr hole site for placement of the drain, he noted a small piece of brain tissue draining out of the site with the residual irrigation.  The addendum further stated that the subdural space was nearly absent when it had been open moments before and the neurosurgeon did not believe he could safely place the drain into that site.  The addendum noted the neurosurgeon’s observation of what was termed “small amount of bleeding” from the surface of the underlying brain.  Finally, the addendum stated that the neurosurgeon believed there was no injury to, or penetration of, the substance of the brain by the neurosurgeon.

On 2/27/2007, after the surgery, the neurosurgeon advised the family of the patient that “everything went great.”

On 2/27/2007, after the surgery, a CT scan was ordered by the neurosurgeon, which indicated a pneumocephalus and associated hemorrhage had developed in the parenchyma of the patient’s left frontal region of the brain.  The neurosurgeon failed to timely advise concurrent and subsequent treatment providers or the patient’s family about the pneumocephalus and associated hemorrhage and he failed to document that an injury had occurred until the neurosurgeon filed his addendum to the operative report filed on 6/5/2007.

On 2/28/2007, an MRI was ordered by the neurosurgeon, which indicated a large hematoma in the left frontal lobe.  Later that day, the neurosurgeon ordered a second post-operative CT scan, which confirmed a pneumocephalus deep in the parenchyma and a growing area of hemorrhage.

On 2/28/2007, the neurosurgeon advised the patient’s family that her condition, which was deteriorating, was likely caused by a stroke.  The neurosurgeon did not mention the incident later described in his own addendum to the operative report or alternative causes for the patient’s deterioration.

Also on 2/28/2007, the patient was seen by an internist.  Upon observing the patient’s condition, the internist suggested the patient be seen by a neurologist.

On 3/1/2007, the patient was seen by a neurologist.  Upon reviewing the imaging scans and examining the patient, the neurologist suspected an injury to the brain had occurred and discussed his suspicion with the neurosurgeon.  Thereafter, the neurologist’s concerns were submitted to risk management in an incident report stating that after surgery there was evidence of a pneumocephalus inside the parenchyma of the brain, which showed progressive hemorrhage.  The incident report requested the surgery department review the case.

Despite his conversation with the neurologist, the neurosurgeon failed to advise any of the patient’s concurrent and subsequent treatment providers about the injury and the neurosurgeon still did not document that an injury or an incident during surgery had occurred until he wrote his addendum on 6/5/2007.

On 3/2/2007, the risk manager at the medical center and the neurosurgeon had a conversation about the patient’s surgery. The risk manager directed the neurosurgeon to inform the patient’s family of the injury that occurred during surgery.  Later that day, the neurosurgeon informed the patient’s son about the injury that had occurred three days earlier.

The Board judged that the neurosurgeon’s conduct to be below the minimum standard of competence give his failure to recognize the significance of the injury that had occurred to the patient during the operation, especially after reviewing the first post-operative CT scan on 2/27/2007, as well as the CT scans and MRI that occurred on 2/28/2007 and 3/1/2007 respectively.  The neurosurgeon failed to timely advise the patient’s concurrent and subsequent treatment providers of the injury that had occurred during the burr hole evacuation surgery.  The neurosurgeon failed to timely advise the patient’s family about the injury to the patient.

The Board also judged that the neurosurgeon’s conduct the be below the minimum standard of competence in that he maintained false records. The neurosurgeon failed to document within his operative report dated 2/27/2007 that a surgical incident had occurred during the burr hole evacuation surgery that he performed.  On 6/5/2007, the neurosurgeon documented within the patient’s medical record that a surgical technician directed what was termed as a “forceful irrigation” into the left-frontal burr hole site while the neurosurgeon had his back turned.  The neurosurgeon failed to document within the patient’s medical record that the surgical incident that had occurred during the burr hole evacuation surgery was causing the patient’s neurological deficits.

The Board ordered the neurosurgeon’s license to be suspended for two years.  Before the neurosurgeon would be reinstated to practice medicine he would have to pay a fine of $20,000.

State: Kansas


Date: February 2014


Specialty: Neurosurgery, Neurology


Symptom: N/A


Diagnosis: Post-operative/Operative Complication, Neurological Disease


Medical Error: Procedural error, Ethics violation, Failure of communication with other providers, Failure of communication with patient or patient relations, Lack of proper documentation


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 4


Link to Original Case File: Download PDF



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