As the device was out of specification, it generally cannot be excluded that the device has contributed to the event.However, considering the minor deviations of the device, it is very unlikely that the device actually has contributed to this event.From our experience we suspect, that maybe the pinning technique has been not optimal as described in the instruction manual: "adjust the skull clamp to the width of the patient's head in the manner that the two skull pins in the rocker arm are equidistant from the centerline of the head and the single skull pin at the extension assembly is in line with this centerline.".
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