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We report the case of a 71-year-old male with poorly controlled diabetes mellitus who presented with lower extremity edema and acute renal failure. He was diagnosed with nephrotic syndrome secondary to minimal change disease (MCD). Treatment with steroids was withheld due to concern for hyperglycemia in the context of his poorly controlled diabetes mellitus. A week after discharge, he was subsequently re-hospitalized four times within a month with pleural effusions, dyspnea, and fever. Work up revealed isolated pleural cryptococcosis, demonstrated on two separate admissions. There was neither evidence of disseminated disease nor immunocompromising condition. Immunosuppression was not initiated for the treatment of MCD in the setting of poorly controlled diabetes and active infection. After six months of treatment with fluconazole 400 mg/day, the nephrotic syndrome, renal failure, and cryptococcal pleuritis resolved. This case is the first to our knowledge of isolated pleural cryptococcosis associated with nephrotic syndrome. The patient’s course lends further support to the hypothesis that there may be causal relationship between cryptococcosis and nephrotic syndrome.

Background During cranioplasty after decompressive craniectomy, the temporalis muscle is firmly attached to the dural patch and intermixed with fibrotic tissue leading to considerable difficulty in dissecting the plane between the dura, galea and the temporalis muscle. This leads to increased surgical time, intraoperative blood loss, risk of complications and also affects rehabilitation. We have developed the "dhaga technique," which aids in preserving the plane between the muscle and dura in order to improve outcomes. Here we describe our technique and also compare the "dhaga technique" with the generally accepted standard procedure. Methods A retrospective review was carried out of all patients undergoing cranioplasty following decompressive craniectomy either through the "dhaga technique" or the institutional standard (control group). Both techniques were compared using intra operative blood loss, duration of surgery and any complications as study variables. Results There were 133 patients were included in the study. The control group included 68 patients who underwent the procedure according to institutional standard, and 65 patients were included in the "dhaga technique group." Both groups were well matched for baseline characteristics. Patients in the "dhaga technique" group had statistically significant lower operating time ( P value = 0.037) and intra operative blood loss ( P value = 0.025). However, there was no significant difference in complications. Conclusion The utilization of "dhaga technique" can potentially improve outcomes and reduce costs by decreasing operative time and blood loss. Moreover, the temporalis muscle preservation in the "dhaga technique" may also enhance aesthetic outcomes and chewing, which were not assessed in this study. There were no differences in complication between the two techniques.

Study Design: Retrospective case series. Purpose: The objective of our study was to determine the change in management brought about by magnetic resonance imaging (MRI) of the cervical spine in alert and awake patients with facet dislocation and spinal cord injury presenting within 4 hours after injury. Overview of Literature: Spinal cord injury is a common clinical entity. The role of MRI is well established in evaluating spinal trauma. However, the time at which MRI should be used is still controversial. Methods: Retrospective data from 2002-2010 was evaluated. All of the alert and awake patients with spinal cord injury, based on clinical examination with facet dislocation diagnosed on lateral cervical spine X-rays, were included. A questionnaire was also conducted, the data of which consisted of demographic details including age and sex, the mechanism of injury, clinical examination, X-ray findings, MRI findings, whether or not surgery was performed and the time elapsed since injury. Data was analyzed using SPSS ver. 17.0. Continuous variables such as age were expressed in terms of mean ± standard deviation. Categorical variables such as change in management, X-ray/MRI findings and neurological motor level were assessed in terms of percentage. Results: Fifty patients participated in our study. All these patients had spinal cord injury with defined motor levels. The mean age was 35.5 ± 8.95 years (range, 20 to 52 years). Fifty percent showed a motor level at C6 level. None of the patients required any change in management based on the MRI. Conclusions: MRI of the spine in awake patients within 4 hours after injury does not change the management of patients. However, we can hypothesize that such patients can proceed to traction without waiting for the MRI.

Study D Design: This is a case series. Pupose: We wanted to identify variations in the practice patterns among neurosurgeons and orthopedic surgeons for the management of spinal disorders. Overview o of L Literature: Spinal disorders are common in the clinical practice of both neurosurgeons and orthopedic surgeons. It has been observed that despite the availability of various guidelines, there is lack of consensus among surgeons about the management of various disorders. Methods: A questionnaire was distributed, either directly or via e-mail, to the both the neurosurgeons and orthopedic surgeons who worked at 5 tertiary care centers within a single region of Korea. The surgeons were working either in private practice or in academic institutions. The details of the questionnaire included demographic details and the specialty (orthopedic/neurosurgeon). The surgeons were classified according to the level of experience as up to 5 years, 6-10 years and > 10 years. Questions were asked about the approach to lumbar discectomy (fragmentectomy or aggressive disc removal), using steroids for treating discitis, the fusion preference for spondylolisthesis, the role of an orthosis after fusion, the preferred surgical approach for spinal stenosis, the operative approach for spinal trauma (early within 72 hours or late > 72 hours) and the role of surgery in complete spinal cord injury. The data was analyzed using SPSS ver 16. p-values < 0.05 were considered to be significant. Results: Of the 30 surgeons who completed the questionnaire, 20 were neurosurgeons and 10 were orthopedic surgeons. Statistically significant differences were observed for the management of spinal stenosis, spondylolisthesis, using an orthosis after fusion, the type of lumbar discectomy and the value of surgical intervention after complete spinal cord injury. Conclusions: Our results suggest that there continues to exist a statistically significant lack of consensus among neurosurgeons and orthopedic spine surgeons when considering using an orthosis after fusion, the type of discectomy and the value of intervention after complete spinal injury.