title: Penetrating injury of the brain by the burr of a high-speed air drill during craniotomy: case report.
abstract: The most critical complications of craniotomy are caused by the plunging of a skull drill, and there have been no reports of penetrating brain injury caused by the broken burr of a high-speed air drill during craniotomy. Left orbitofrontal craniotomy was performed to clip two aneurysms in a 44 year old man. While cutting the lateral orbital rim with the burr of an Ultra Power surgical drill system, the burr broke off and penetrated the frontal lobe down to the falx cerebri. There were no discernible contusion or haemorrhage in the brain. The accident occurred because a long burr for the angled attachment of a Surgairtome was erroneously attached to the angled attachment of an UltraPower surgical drill. The mismatch between the steel strength and torque of the two burrs designed for different drill systems seemed responsible for breakage of the burr. We learned a valuable lesson from this failure: that all new instruments, including high-speed air drills, must be studied carefully so that staff become thoroughly familiar with their handling.
authors.affiliation: Department of Neurosurgery, East Tokyo Metropolitan Hospital, Tokyo, Japan.
authors.forename: M
authors.initials: M
authors.lastname: Ito
authors.forename: T
authors.initials: T
authors.lastname: Sonokawa
authors.forename: H
authors.initials: H
authors.lastname: Mishina
authors.forename: K
authors.initials: K
authors.lastname: Sato
mesh_terms: D000328:Adult; D003399:Craniotomy / Q000009:adverse effects* / Q000295:instrumentation*; D004868:Equipment Failure; D005547:Foreign Bodies; D020197:Head Injuries, Penetrating / Q000209:etiology*; D006801:Humans; D002532:Intracranial Aneurysm / Q000601:surgery*; D008297:Male; D013345:Subarachnoid Hemorrhage / Q000601:surgery; D013525:Surgical Instruments / Q000009:adverse effects*