Description of Event or Problem · 1
THIS FEMALE PT, APPROXIMATELY (B)(6), PRESENTED FOR TREATMENT WITH HISTORY OF ARACHNOIDITIS AND ADHESIONS WHICH ARE BOTH THOUGHT BY THE SURGEON TO HAVE CONTRIBUTED TO THIS EVENT. DURING LAMINECTOMY AND TISSUE RESECTION TO DECOMPRESS THE LUMBAR SPINE AT L3-4, A DURAL TEAR OCCURRED. THIS EVENT OCCURRED WHILE PERFORMING THE PROCEDURE WITHOUT THE REQUIRED EPIDUROGRAM. DURING USE OF THE RONGEUR AT THE END OF THE CASE, THE DURA WAS TORN AND A SMALL AMOUNT OF CSF WAS OBSERVED COMING OUT OF THE TROCAR. THE TROCAR WAS REMOVED, THE WOUND SUTURED AND PT RECOVERED AND WAS DISCHARGED HOME. PT CALLED IN THE NEXT DAY ON (B)(6) COMPLAINING OF HEADACHE AND VOMITING, BUT CONTINUED TO EAT AND DRINK FLUIDS. DAY 3 AFTER THE PROCEDURE, THE PT PRESENTED STILL COMPLAINING OF SAME SYMPTOMS AND WAS TREATED USING A 20CC BLOOD PATCH. FOLLOWING TREATMENT, THE PT WAS OBSERVED, REPORTED FEELING BETTER, AND WAS SUBSEQUENTLY RELEASED. THE EVENING OF THE 4TH POSTOPERATIVE DAY, THE PT WAS READMITTED TO THE HOSP COMPLAINING OF HEADACHE AND WAS SCHEDULED FOR LAMINECTOMY AND DURAL REPAIR. NO SUBSEQUENT REPORT OF THE OUTCOME OF THAT PROCEDURE HAS BEEN RECEIVED AT THIS TIME.