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John H. Shin and Ajit A. Krishnaney

Idiopathic ventral spinal cord herniation is a rare condition that has been increasingly reported in the last decade. The natural history and optimal management have yet to be defined. Therefore, debate exists regarding the pathogenesis and surgical management of this condition. The purpose of this review article is to further educate neurosurgeons about the surgical techniques and outcomes associated with treating this rare and often misdiagnosed condition.

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Ron I. Riesenburger, G. Alexander Jones, Marie Roguski and Ajit A. Krishnaney


The goal of this study was to characterize the anatomy relevant to placement of crossing C-2 translaminar screws, including morphometric data, and to evaluate the risk of violating the vertebral artery (VA) during the screw placement. Placement of bilateral crossing C-2 translaminar screws has become an increasingly popular method for dorsal C-2 instrumentation as it is felt to avoid the known risk of VA injury associated with C1–2 transarticular screw fixation and C-1 lateral mass–C-2 pars screw fixation.


The source images from 50 CT angiograms of the neck obtained from October to November 2007 were studied. Digital imaging software was used to measure lamina thickness and maximum screw length, perform angulation of screw trajectories in the axial plane, and evaluate the potential for VA injury. In cases where the VA could be injured, the distance between the maximal screw length and artery was measured. Logistic regression was performed to evaluate lamina width, axial angle, and screw length for predicting the potential for VA injury.


Mean lamina thickness, axial angle, and maximal screw length were determined for 100 laminae, and a potential for VA injury was noted in 55 laminae. The anatomically defined ideal screw length was longer in laminae with potential for VA injury than in laminae with no apparent risk (35.2 vs 33.6 mm, p = 0.0131). Only increasing optimal screw length was noted to be a statistically significant predictor of potential VA injury (p = 0.0159). The “buffer zone” (the distance between an optimally placed screw and the VA) was 5.6 ± 1.9 mm (mean ± SD, range 1.8–11.4 mm). A screw limited to 28 mm in length appeared to be safe in all laminae studied.


Crossing C-2 translaminar screws have been reported to be safe and effective. In addition to morphometric characteristics, the authors have found that screws placed in this trajectory could jeopardize the vertebral arteries in the foramen transversarium or the C1–2 interval. A C-2 translaminar screw limited to 28 mm in length appeared to be safe in all 100 screw trajectories studied in this series.

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John H. Shin, Michael P. Steinmetz, Edward C. Benzel and Ajit A. Krishnaney

Ossification of the posterior longitudinal ligament is a common cause of radiculopathy and myelopathy that often requires surgery to achieve decompression of the neural elements. With the evolution of surgical technique and a greater understanding of the biomechanics of cervical deformity, the criteria for selecting one approach over the other has been the subject of increased study and remains controversial. Ventral approaches typically consist of variations of the cervical corpectomy, whereas dorsal approaches include a wide range of techniques including laminoplasty, laminectomy, and laminectomy with instrumented fusion. Herein, the features and limitations of these approaches are reviewed with an emphasis on complications and outcomes.

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Vikram B. Chakravarthy, Hana Yokoi, Daniel J. Coughlin, Mariel R. Manlapaz and Ajit A. Krishnaney

Enhanced recovery after surgery (ERAS) protocols have been shown to be effective at reducing perioperative morbidity and costs while improving outcomes. To date, spine surgery protocols have been limited in scope, focusing only on specific types of procedures or specific parts of the surgical episode. The authors describe the creation and implementation of one of the first comprehensive ERAS protocols for spine surgery. The protocol is unique in that it has a comprehensive perioperative paradigm encompassing the entire surgical period that is tailored based on the complexity of each individual spine patient.

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Michael P. Steinmetz, Jared Miller, Ann Warbel, Ajit A. Krishnaney, William Bingaman and Edward C. Benzel


The cervicothoracic junction (CTJ) is the transitional region between the cervical and thoracic sections of the spinal axis. Because it is a transitional zone between the mobile lordotic cervical and rigid kyphotic thoracic spines, the CTJ is a region of potential instability. This potential for instability may be exaggerated by surgical intervention.


A retrospective review of all patients who underwent surgery involving the CTJ in the Department of Neurosurgery at the Cleveland Clinic Foundation during a 5-year period was performed. The CTJ was strictly defined as encompassing the C-7 vertebra and C7–T1 disc interspace. Patients were examined after surgery to determine if treatment had failed. Failure was defined as construct failure, deformity (progression or de novo), or instability. Variables possibly associated with treatment failure were analyzed. Statistical comparisons were performed using the Fisher exact test.

Between January 1998 and November 2003, 593 CTJ operations were performed. Treatment failed in 14 patients. Of all variables studied, failure was statistically associated with laminectomy and multilevel ventral corpectomies with fusion across the CTJ. Other factors statistically associated with treatment failure included histories of cervical surgery, tobacco use, and surgery for the correction of deformity.


The CTJ is a vulnerable region, and this vulnerability is exacerbated by surgery. Results of the present study indicate that laminectomy across the CTJ should be supplemented with instrumentation (and fusion). Multilevel ventral corpectomies across the CTJ should also be supplemented with dorsal instrumentation. Supplemental instrumentation should be considered for patients who have undergone prior cervical surgery, have a history of tobacco use, or are undergoing surgery for deformity correction.

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Cervical spinal cord delivery of a rabies G protein pseudotyped lentiviral vector in the SOD-1 transgenic mouse

Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2004

Kiana Tanase, Qingshan Teng, Ajit A. Krishnaney, James K. Liu, Mary E. Garrity-Moses and Nicholas M. Boulis

Object. Lentiviral vectors may constitute a vehicle for long-term therapeutic gene expression in the spinal cord. In amyotrophic lateral sclerosis, spinal cord sclerosis and altered axonal transport pose barriers to therapeutic gene distribution. In the present study the authors characterize gene expression distribution and the behavioral impact of the rabies G (RabG) protein pseudotyped lentiviral vector EIAV.LacZ through cervical spinal cord injection in control and Cu/Zn superoxide dismutase—1 (SOD-1) transgenic mice.

Methods. Seven-week-old SOD-1 transgenic mice and their wild-type littermates underwent exposure of the cervicomedullary junction and microinjection of RabG.EIAV.LacZ or vehicle. The Basso-Beattie-Bresnahan locomotor score, grip strength meter, and Rotarod assays were used to assess the effects of disease progression, spinal cord microinjection, and lentiviral gene expression. Spinal cords were removed when the mice were in the terminal stage of the disease. The distribution of LacZ gene expression was histologically evaluated and quantified.

Direct cervical spinal cord microinjection of RabG.EIAV.LacZ results in extensive central nervous system uptake in SOD-1 transgenic mice; these findings were statistically similar to those in wild-type mice (p > 0.05). Gene expression lasts for the duration of the animal's survival (132 days). The SOD-1 mutation does not prevent retrograde axonal transport of the vector. Three behavioral assays were used to demonstrate that long-term gene expression does not alter sensorimotor function. In comparison with normative data, vector injection and transgene expression do not accelerate disease progression.

Conclusions. Direct spinal cord injection of RabG.EIAV vectors represents a feasible method for delivering therapeutic genes to upper cervical spinal cord and brainstem motor neurons. Distribution is not affected by the SOD-1 mutation or disease phenotype.

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Wajd N. Al-Holou, Thomas J. Wilson, Zarina S. Ali, Ryan P. Brennan, Kelly J. Bridges, Tannaz Guivatchian, Ghaith Habboub, Ajit A. Krishnaney, Giuseppe Lanzino, Kendall A. Snyder, Tracy M. Flanders, Khoi D. Than and Aditya S. Pandey


Gastrostomy tube placement can temporarily seed the peritoneal cavity with bacteria and thus theoretically increases the risk of shunt infection when the two procedures are performed contemporaneously. The authors hypothesized that gastrostomy tube placement would not increase the risk of ventriculoperitoneal shunt infection. The object of this study was to test this hypothesis by utilizing a large patient cohort combined from multiple institutions.


A retrospective study of all adult patients admitted to five institutions with a diagnosis of aneurysmal subarachnoid hemorrhage between January 2005 and January 2015 was performed. The primary outcome of interest was ventriculoperitoneal shunt infection. Variables, including gastrostomy tube placement, were tested for their association with this outcome. Standard statistical methods were utilized.


The overall cohort consisted of 432 patients, 47% of whom had undergone placement of a gastrostomy tube. The overall shunt infection rate was 9%. The only variable that predicted shunt infection was gastrostomy tube placement (p = 0.03, OR 2.09, 95% CI 1.07–4.08), which remained significant in the multivariate analysis (p = 0.04, OR 2.03, 95% CI 1.04–3.97). The greatest proportion of shunts that became infected had been placed more than 2 weeks (25%) and 1–2 weeks (18%) prior to gastrostomy tube placement, but the temporal relationship between shunt and gastrostomy was not a significant predictor of shunt infection.


Gastrostomy tube placement significantly increases the risk of ventriculoperitoneal shunt infection.

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Samuel T. Chao, Taisei Kobayashi, Edward Benzel, Chandana A. Reddy, Glen H. J. Stevens, Richard A. Prayson, Iain Kalfas, Richard Schlenk, Ajit Krishnaney, Michael P. Steinmetz, William Bingaman, Joseph Hahn and John H. Suh


The goal in this study was to determine the role of radiation therapy (RT) in the treatment of spinal myxopapillary ependymomas (MPEs).


Thirty-seven patients with histologically verified spinal MPEs were reviewed. Kaplan-Meier analyses and Cox proportional hazard regression were used to determine what patient and treatment factors influenced overall survival (OS) and recurrence.


At the time of initial diagnosis, the median age was 33 years and the Karnofsky Performance Scale score was 80. In 86.5% of cases, the most common presenting symptom was pain. All patients received surgery as their initial treatment. Nine patients also received RT along with surgery, with a median total dose of 50.2 Gy. The mean survival time was 12.2 years; however, only 4 of 37 patients had died at the time of this study. None of the patient or treatment parameters significantly correlated with OS. Sixteen patients (43.2%) were found to have a recurrence, with a median time to recurrence of 7.7 years. None of the patient or treatment parameters correlated with recurrence-free survival for an initial recurrence. The median time to the second recurrence (recurrence following therapy for initial recurrence) was 1.6 years. Use of RT as salvage therapy after initial recurrence significantly correlated with longer times to a second recurrence. The median recurrence-free survival time before the second recurrence was 9.6 years for those who received RT versus 1.1 years for those who did not receive RT (p = 0.0093). None of the other parameters significantly correlated with a second recurrence.


Radiation therapy may have a role as salvage therapy in delaying recurrences of spinal MPEs.