Cauda equina syndrome (CES) is often defined as a complex of symptoms and signs consisting of low back pain, bilateral sciatica, lower extremity weakness, saddle anesthesia, and bowel and bladder dysfunction. CES is considered to be neurosurgical emergency. Delayed or missed diagnosis of CES can result in serious morbidity and neurological sequelae. However, the diagnosis of CES is often difficult when one or more of these symptoms are absent or when these symptoms develop asymmetrically or incompletely. We report a case of urinary retention and sphincter dysfunction without sciatica or motor weakness following an L3 burst fracture in a 52-year-old male and discuss the atypical presentation of CES and treatment of traumatic CES.
Anesthesia ; Cauda Equina* ; Diagnosis ; Emergencies ; Humans ; Low Back Pain ; Lower Extremity ; Lumbar Vertebrae ; Male ; Middle Aged ; Polyradiculopathy* ; Sciatica ; Spine* ; Urinary Bladder ; Urinary Retention

Gas-containing (emphysematous) infections of the abdomen, pelvis, and extremities are well-known disease entities, which can potentially be life-threatening. They require aggressive medical and often surgical treatment. In the neurosurgical field, some cases of gas-containing brain abscess and subdural empyema have been reported. Sometimes they progress rapidly and even can cause fatal outcome. However, gas-containing spinal epidural abscess has been rarely reported and clinical course is unknown. We report on a case of rapidly progressive gas-containing lumbar spinal epidural abscess due to Enterococcus faecalis in a 72-year-old male patient with diabetes mellitus.
Abdomen ; Aged ; Brain Abscess ; Diabetes Mellitus ; Empyema, Subdural ; Enterococcus faecalis ; Epidural Abscess* ; Extremities ; Fatal Outcome ; Humans ; Male ; Pelvis ; Spine

Idiopathic hypertrophic pachymeningitis (IHP) is a rare disease, and it is characterized by chronic progressive inflammatory fibrosis and thickening of the dura mater with resultant compression of the spinal cord or neural structure without any identifiable cause. It can occur in the intracranial or spinal dura mater alone or as a craniospinal form. The spinal form is rarer than the cranial form and the craniospinal form is extremely rare. We report a rare case of IHP in the craniocervical junction involving both the cranial and spinal dura mater and discuss the diagnosis and management of the disease.
Diagnosis ; Dura Mater ; Fibrosis ; Meningitis* ; Rare Diseases ; Spinal Cord

PURPOSE: The primary objective of this study was to examine the changes of basal cortisol and DHEA levels present in saliva and serum with age, and to determine the correlation coefficients of steroid concentrations between saliva and serum. The secondary objective was to obtain a standard diurnal rhythm of salivary cortisol and DHEA in the Korean population. MATERIALS AND METHODS: For the first objective, saliva and blood samples were collected between 10 and 11 AM from 359 volunteers ranging from 21 to 69 years old (167 men and 192 women). For the second objective, four saliva samples (post-awakening, 11AM, 4PM, and bedtime) were collected throughout a day from 78 volunteers (42 women and 36 men) ranging from 20 to 40 years old. Cortisol and DHEA levels were measured using a radioimmunoassay (RIA). RESULTS: The morning cortisol and DHEA levels, and the age-related steroid decline patterns were similar in both genders. Serum cortisol levels significantly decreased around forty years of age (p < 0.001, when compared with people in their 20s), and linear regression analysis with age showed a significant declining pattern (slope= -2.29, t= -4.297, p < 0.001). However, salivary cortisol levels did not change significantly with age, but showed a tendency towards decline (slope= -0.0078, t= -0.389, p=0.697). The relative cortisol ratio of serum to saliva was 3.4 - 4.5% and the ratio increased with age (slope=0.051, t=3.61, p < 0.001). DHEA levels also declined with age in saliva (slope= -0.007, t= -3.76, p < 0.001) and serum (slope= -0.197 t= -4.88, p < 0.001). In particular, DHEA levels in saliva and serum did not start to significantly decrease until ages in the 40s, but then decreased significantly further at ages in the 50s (p < 0.001, when compared with the 40s age group) and 60s (p < 0.001, when compared with the 50 age group). The relative DHEA ratio of serum to saliva was similar throughout the ages examined (slop = 0.0016, t = 0.344, p = 0.73). On the other hand, cortisol and DHEA levels in saliva reflected well those in serum (r = 0.59 and 0.86, respectively, p < 0.001). The highest salivary cortisol levels appeared just after awakening (about two fold higher than the 11 AM level), decreased throughout the day, and reached the lowest levels at bedtime (p < 0.001, when compared with PM cortisol levels). The highest salivary DHEA levels also appeared after awakening (about 1.5 fold higher than the 11 AM level) and decreased by 11AM (p < 0.001). DHEA levels did not decrease further until bedtime (p=0.11, when compared with PM DHEA levels). CONCLUSION: This study showed that cortisol and DHEA levels change with age and that the negative slope of DHEA was steeper than that of cortisol in saliva and serum. As the cortisol and DHEA levels in saliva reflected those in serum, the measurement of steroid levels in saliva provide a useful and practical tool to evaluate adrenal functions, which are essential for clinical diagnosis.
Adult ; Age Factors ; Aged ; Analysis of Variance ; *Circadian Rhythm ; Dehydroepiandrosterone/blood/*metabolism ; Female ; Humans ; Hydrocortisone/blood/*metabolism ; Male ; Middle Aged ; Saliva/*metabolism

PURPOSE: The primary objective of this study was to examine the changes of basal cortisol and DHEA levels present in saliva and serum with age, and to determine the correlation coefficients of steroid concentrations between saliva and serum. The secondary objective was to obtain a standard diurnal rhythm of salivary cortisol and DHEA in the Korean population. MATERIALS AND METHODS: For the first objective, saliva and blood samples were collected between 10 and 11 AM from 359 volunteers ranging from 21 to 69 years old (167 men and 192 women). For the second objective, four saliva samples (post-awakening, 11AM, 4PM, and bedtime) were collected throughout a day from 78 volunteers (42 women and 36 men) ranging from 20 to 40 years old. Cortisol and DHEA levels were measured using a radioimmunoassay (RIA). RESULTS: The morning cortisol and DHEA levels, and the age-related steroid decline patterns were similar in both genders. Serum cortisol levels significantly decreased around forty years of age (p < 0.001, when compared with people in their 20s), and linear regression analysis with age showed a significant declining pattern (slope= -2.29, t= -4.297, p < 0.001). However, salivary cortisol levels did not change significantly with age, but showed a tendency towards decline (slope= -0.0078, t= -0.389, p=0.697). The relative cortisol ratio of serum to saliva was 3.4 - 4.5% and the ratio increased with age (slope=0.051, t=3.61, p < 0.001). DHEA levels also declined with age in saliva (slope= -0.007, t= -3.76, p < 0.001) and serum (slope= -0.197 t= -4.88, p < 0.001). In particular, DHEA levels in saliva and serum did not start to significantly decrease until ages in the 40s, but then decreased significantly further at ages in the 50s (p < 0.001, when compared with the 40s age group) and 60s (p < 0.001, when compared with the 50 age group). The relative DHEA ratio of serum to saliva was similar throughout the ages examined (slop = 0.0016, t = 0.344, p = 0.73). On the other hand, cortisol and DHEA levels in saliva reflected well those in serum (r = 0.59 and 0.86, respectively, p < 0.001). The highest salivary cortisol levels appeared just after awakening (about two fold higher than the 11 AM level), decreased throughout the day, and reached the lowest levels at bedtime (p < 0.001, when compared with PM cortisol levels). The highest salivary DHEA levels also appeared after awakening (about 1.5 fold higher than the 11 AM level) and decreased by 11AM (p < 0.001). DHEA levels did not decrease further until bedtime (p=0.11, when compared with PM DHEA levels). CONCLUSION: This study showed that cortisol and DHEA levels change with age and that the negative slope of DHEA was steeper than that of cortisol in saliva and serum. As the cortisol and DHEA levels in saliva reflected those in serum, the measurement of steroid levels in saliva provide a useful and practical tool to evaluate adrenal functions, which are essential for clinical diagnosis.
Adult ; Age Factors ; Aged ; Analysis of Variance ; *Circadian Rhythm ; Dehydroepiandrosterone/blood/*metabolism ; Female ; Humans ; Hydrocortisone/blood/*metabolism ; Male ; Middle Aged ; Saliva/*metabolism

Leg swelling in patients with paraplegia due to spinal cord injury (SCI) occurs for various reasons, including heterotopic ossification (HO), deep vein thrombosis (DVT), fracture, or cellulitis. The clinical presentations of these conditions may overlap in part or in whole and it may occasionally be difficult to distinguish. Of these conditions, DVT and subsequent pulmonary embolism remain significant causes of morbidity and mortality in patients with SCI. Therefore, a prompt diagnostic work-up, particularly for DVT, is essential in patients with SCI, who present with leg swelling. Here, we report a case of leg swelling in a paraplegic patient, resulting from HO mimicking DVT and discuss the differential diagnosis.
Cellulitis ; Diagnosis, Differential ; Humans ; Leg* ; Mortality ; Ossification, Heterotopic* ; Paraplegia ; Pulmonary Embolism ; Spinal Cord Injuries ; Venous Thrombosis*

OBJECTIVE: Methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-resistant coagulase negative staphylococci (MRCNS) are major causes of neurosurgical infection. Nasal colonization of MRSA is the most important risk factor and MRSA screening can be a screening method to identify MRSA and MRCNS colonization. We retrospectively evaluated prophylactic effect of vancomycin on MRSA or MRCNS surgical site infection (SSI) after cranioplasty following decompressive craniectomy (DC) after traumatic brain injury (TBI) in MRSA carriers. METHODS: The study included 21 patients who were positive in MRSA screening before cranioplasty. These patients underwent DC after TBI and subsequent cranioplasty with autologous bone. The patients were separated into SSI group and no SSI group according to the development of SSI due to MRSA or MRCNS after cranioplasty. Mean follow-up period after cranioplasty was 23.5+/-22.8 months (range, 3 to 73 months). The rate of MRSA or MRCNS SSI and factors including the prophylactic preoperative antibiotics were compared between groups. RESULTS: The rate of MRSA or MRCNS SSI was 23.8% (5/21 patients). Mean time from cranioplasty to confirm the SSI was 19.6+/-10.9 days (6 to 63 days). The rate of MRSA or MRCNS SSI was significantly different from the use of preoperative prophylactic antibiotics (p=0.047). MRSA or MRCNS SSI developed in 1 of 13 patients (7.6%) who received vancomycin and in 4 of 8 patients (50%) who received 3rd generation cephalosporin. CONCLUSION: Preoperative MRSA screening and administration of vancomycin as a preoperative prophylactic antibiotic should be considered in MRSA carriers who are scheduled to cranioplasty to reduce MRSA or MRCNS SSI.
Anti-Bacterial Agents ; Brain Injuries* ; Coagulase ; Colon ; Decompressive Craniectomy ; Follow-Up Studies ; Humans ; Mass Screening ; Methicillin Resistance* ; Methicillin-Resistant Staphylococcus aureus* ; Retrospective Studies ; Risk Factors ; Staphylococcal Infections ; Staphylococcus ; Surgical Wound Infection ; Vancomycin*

In this investigation, we made a study of the efficacy of luteolin (a flavonoid found in plants such as vegetables, herbs and fruits) on vascular contractibility and to elucidate the mechanism underlying the relaxation. Isometric contractions of denuded muscles were stored and combined with western blot analysis which was conducted to assess the phosphorylation of myosin phosphatase targeting subunit 1 (MYPT1) and phosphorylation-dependent inhibitory protein for myosin phosphatase (CPI-17) and to examine the effect of luteolin on the RhoA/ROCK/CPI-17 pathway. Luteolin significantly alleviated phorbol ester-, fluoride- and thromboxane mimetic-elicited contractions regardless of endothelial nitric oxide synthesis, implying its direct effect on smooth muscle. It also significantly alleviated the fluoride-elicited elevation in pCPI-17 and pMYPT1 levels and phorbol 12,13-dibutyrate-elicited in-crease in pERK1/2 level, suggesting depression of ROCK and PKC/MEK activity and ensuing phosphorylation of MYPT1, CPI-17 and ERK1/2. Taken together, these results suggest that luteolin-elicited relaxation includes myosin phosphatase reactivation and calcium desensitization, which seems to be arbitrated by CPI-17 dephosphorylation via ROCK/PKC inhibition.

A standardized protocol for the isolation of cell-free DNA (cfDNA) from cerebrospinal fluid (CSF) is lacking. Therefore, we established a cfDNA isolation protocol optimized for clinical CSF specimens, integrating acceptable modifications and using artificial CSF generated from remnant CSF spiked with reference cell-free tumor DNA (ctDNA). We compared the isolation yields of in vitro diagnostic (IVD)-certified column-based (CB) and magnetic beadbased (MB) isolation. Furthermore, we modified both methods, including pre- and postelution steps. To confirm ctDNA integrity and quantify the variant allele frequency after isolation, we performed droplet digital PCR (ddPCR) targeting IDH1 R132C in the reference ctDNA. MB isolation had a higher yield than CB isolation (P < 0.0001), and post-isolation vacuum increased the final concentration in both methods, with little effect on cfDNA integrity. Our study provides a protocol to maximize CSF-ctDNA concentrations in IVD testing and future studies.

A 39-year-old renal transplant recipient was admitted for evaluation of pancytopenia which developed gradually 10 months ago. He received renal transplantation 10 years ago and maintained relatively good renal function. Since 1 year before admission, he showed progressive decline of hematocrit, WBC count and platelet. Initial bone marrow biopsy showed erythroid hypoplasia, and second bone marrow biopsy revealed myelodysplasia. Clinical course was fatal. In conclusion, if patients with long term azathioprine treatment show progressive pancytopenia, one should suspect the possibility of myelodysplastic syndrome.
Adult ; Azathioprine* ; Biopsy ; Blood Platelets ; Bone Marrow ; Hematocrit ; Humans ; Kidney Transplantation ; Myelodysplastic Syndromes* ; Pancytopenia ; Transplantation*