Patellar osteochondritis dissecans: maturation-dependent patellofemoral joint characteristics.

BACKGROUND: The likelihood of healing of osteochondritis dissecans decreases with skeletal maturity and there are theories that abnormal biomechanical forces contribute to the development and progression of these lesions. OBJECTIVE: To characterize, according to regional skeletal maturity, the morphology and alignment indices of the patellofemoral joint on MRI in patients with patellar osteochondritis dissecans. MATERIALS AND METHODS: MRI examinations of patients with patellar osteochondritis dissecans obtained between January 2008 and May 2023 were retrospectively reviewed to determine regional skeletal maturity, osteochondritis dissecans lesion size and location, patellar and trochlear morphology (Wiberg/Dejour classifications), and to calculate trochlear sulcus angles, trochlear depth index, lateral trochlear inclination, Insall-Salvati index, Caton-Deschamps index, patellar tendon-lateral trochlear ridge, and tibial tubercle-trochlear groove distances. Values were compared between skeletally immature and mature groups. RESULTS: Sixty-eight children (22 girls, 46 boys, age: 14.0 ± 1.7 years) yielded 74 knees with patellar osteochondritis dissecans lesions, 14 (19%) of which were skeletally mature. The most common anatomic location was over the central patella [median ridge (34/74 - 46%) on the axial images and over the middle third (45/74 - 61%) on the sagittal images]. Overall, mean trochlear sulcus angle (high, 151 ± 11°), trochlear depth index (low, 2.8 ± 1.4 mm), and Insall-Salvati index (borderline, 1.3 ± 0.1) were abnormal for the entire sample. Skeletally mature knees were significantly more likely to have higher (more dysplastic) Dejour types when compared to skeletally immature knees (p < 0.01). Knees in the mature group, compared to immature, had significantly more abnormal mean lateral trochlear inclination (15 ± 8° vs. 19 ± 6°, p = 0.03) and patellar tendon-lateral trochlear ridge distance (5.55 ± 4.31 mm vs. 2.89 ± 4.69 mm, p = 0.04). Half of the knees had ≥ 4 abnormal features that predispose to patellofemoral maltracking; mature knees were significantly (p = 0.02) more likely to have a higher number of abnormal features (> 6 features, 7/14, 50.0%) versus immature knees (0-3 features, 33/60, 55.0%). CONCLUSION: In children with patellar osteochondritis dissecans, abnormal patellofemoral morphology and alignment indices were common in all patients and more severe in mature knees.

Patella and Trochlea Osteochondritis Dissecans: Demographics and Treatment Paradigms.

OBJECTIVE: Previous research on patellar and trochlear groove osteochondritis dissecans (OCD) is limited by small sample sizes. This study aims to describe the presentation of patients with OCD lesions of the patella and trochlea and characterize the outcomes of operative and nonoperative treatments. METHODS: This retrospective cohort study identified all patients from a single institution from 2008 to 2021 with patellar and/or trochlear OCD lesions. Patients were excluded from the study if surgical records were unavailable or if the patient had knee surgery for a different injury at index surgery or in the 12 months postoperative. Minimum follow-up was 12 months. Outcomes included a return to sports (RTS), pain resolution, radiographic healing, and treatment "success" (defined as full RTS, complete pain resolution, and full healing on imaging). RESULTS: A total of 68 patients (75 knees) were included-45 (60%) with patellar OCD and 30 (40%) with trochlear. Of the patients, 69% were males. The median age at knee OCD diagnosis was 14 years. At the final follow-up, 62% of knees (n = 44) recovered sufficiently to allow a full RTS and 54% of knees (n = 39) had full pain resolution. Of the 46 knees with radiographic imaging at least 1 year apart, 63% had full healing of the lesion. There was no significant difference in RTS, pain resolution, radiographic healing, or overall success when comparing treatments. CONCLUSIONS: This study provides valuable epidemiologic demographic and outcome data regarding the scarcely reported patellar and trochlear OCD. While over half of patients fully returned to sports and reported full pain resolution, a large proportion continued to experience symptoms over a year after presentation. Future research should aim to better define the treatment algorithms for these OCD subtypes. LEVEL OF EVIDENCE: Level III.

Descriptive Epidemiology of Isolated Distal Radius Fractures in Children: Results From a Prospective Multicenter Registry.

INTRODUCTION: More than 1 in 4 pediatric fractures involves the distal radius. Most prior epidemiologic studies are limited to retrospective, single center investigations, and often include adults. This study aims to describe the contemporary epidemiology of pediatric distal radius fractures using prospectively collected data from a multicenter Pediatric Distal Radius Fracture Registry. METHODS: Patients aged 4 to 18 years diagnosed with a distal radius fracture from June 2018 through December 2019 at 4 tertiary care pediatric centers were screened and enrolled in this prospective longitudinal cohort study. Patients were excluded if they presented with bilateral distal radius fractures, polytrauma, or re-fracture. Demographic information, mechanism of injury, fracture characteristics, associated injuries, and procedural information were recorded. All radiographs were reviewed and measured. Descriptive statistics and bivariate analyses were performed. RESULTS: A total of 1951 patients were included. The mean age was 9.9±3.3 years, and 61.3% of patients were male ( P <0.001). Most injuries occurred during a high-energy fall (33.5%) or sports participation (28.4%). The greatest proportion of fractures occurred during the spring months (38.5%). Torus fractures (44.0%) were more common than bicortical (31.3%) or physeal (21.0%) fractures. Of the physeal fractures, 84.3% were Salter-Harris type II. Associated ulnar fractures were observed in 51.2% of patients. The mean age at injury was higher for patients with physeal fractures (11.6±2.9 y) than patients with torus or bicortical fractures (9.4±3.1 and 9.6±3.1 y, respectively; P <0.001). Thirty-six percent of distal radius fractures underwent closed reduction and 3.3% underwent surgical fixation. Patients treated with closed reduction were more likely to be male (68.7% vs. 57.2%; P <0.001), obese (25.3% vs. 17.2%; P <0.001), and have bicortical fractures (62.2% vs. 14.5%; P <0.001). CONCLUSIONS: Distal radius fractures in children have a male preponderance and are most likely to occur in the spring months and during high-energy falls and sports. Physeal fractures tend to occur in older children while torus and bicortical fractures tend to occur in younger children. LEVEL OF EVIDENCE: Level I-prognostic.

How Much Will My Child's ACL Reconstruction Cost? Availability and Variability of Price Estimates for Anterior Cruciate Ligament Reconstruction in the United States.

BACKGROUND: Despite recent policy efforts to increase price transparency, obtaining estimated prices for surgery remains difficult for most patients and families. PURPOSE: Assess availability and variability of cost and self-pay discounts for pediatric anterior cruciate ligament (ACL) reconstruction in the United States. METHODS: This was a prospective study using scripted telephone calls to obtain price estimates and self-pay discounts for pediatric ACL reconstruction. From July to August 2020, investigators called 102 hospitals, 51 "top-ranked" pediatric orthopaedic hospitals and 51 "non-top ranked" hospitals randomly selected, to impersonate the parent of an uninsured child with a torn ACL. Hospital, surgeon, and anesthesia price estimates, availability of a self-pay discount, and number of calls and days required to obtain price estimates were recorded for each hospital. Hospitals were compared on the basis of ranking, teaching status, and region. RESULTS: Only 31/102 (30.3%) hospitals provided a complete price estimate. Overall, 52.9% of top-ranked hospitals were unable to provide any price information versus 31.4% of non-top-ranked hospitals ( P =0.027). There was a 6.1-fold difference between the lowest and highest complete price estimates (mean estimate $29,590, SD $14,975). The mean complete price estimate for top-ranked hospitals was higher than for non-top-ranked hospitals ($34,901 vs. $25,207; P =0.07). The mean complete price estimate varied significantly across US region ( P =0.014), with the greatest mean complete price in the Northeast ($41,812). Altogether, 38.2% hospitals specified a self-pay discount, but only a fraction disclosed exact dollar or percentage discounts. The mean self-pay discount from top-ranked hospitals was larger than that of non-top-ranked hospitals ($18,305 vs. $9902; P =0.011). An average of 3.1 calls (range 1.0 to 12.0) over 5 days (range 1 to 23) were needed to obtain price estimates. CONCLUSION: Price estimates for pediatric sports medicine procedures can be challenging to obtain, even for the educated consumer. Top-ranked hospitals and hospitals in the Northeast region may charge more than their counterparts. In all areas, self-pay discounts can be substantial if they can be identified but they potentially create an information disadvantage for unaware patients needing to pay out-of-pocket. STUDY DESIGN: Economic; Level of Evidence II. WHAT IS KNOWN ABOUT THE SUBJECT: Previous studies have highlighted the importance of value-based health care decisions and deficits of price transparency in various fields including pediatric and orthopaedics procedures. WHAT THIS STUDY ADDS TO EXISTING KNOWLEDGE: This study is the first to examine availability and variability of health care cost in pediatric sports medicine and the first to assess availability and magnitude of self-pay discounts, setting expectations for the uninsured patient incurring large out-of-pocket expenses.

Implicit Racial Bias in Pediatric Orthopaedic Surgery.

INTRODUCTION: Racial and ethnic minority patients continue to experience disparities in health care. It is important to understand provider-level factors that may contribute to these inequities. This study aims to evaluate the presence of implicit racial bias among pediatric orthopaedic surgeons and determine the relationship between bias and clinical decision making. METHODS: A web-based survey was distributed to 415 pediatric orthopaedic surgeons. One section measured for potential implicit racial bias using a child-race implicit association test (IAT). IAT scores were compared with US physicians and the US general population using publicly available data. Another section consisted of clinical vignettes with associated questions. For each vignette, surgeons were randomly assigned a single race-version, White or Black. Vignette questions were grouped into an opioid recommendation, management decision, or patient perception category for analysis based on subject tested. Vignette answers from surgeons with IAT scores that were concordant with their randomized vignette race-version (ie, surgeon with pro-White score assigned White vignette version) were compared with those that were discordant. RESULTS: IAT results were obtained from 119 surveyed surgeons (29% response rate). Overall, respondents showed a minor pro-White implicit bias ( P <0.001). Implicit bias of any strength toward either race was present among 103/119 (87%) surgeons. The proportion of pediatric orthopaedic surgeons with a strong pro-White implicit bias (29%) was greater than that of US physicians overall (21%, P =0.032) and the US general population (19%, P =0.004). No differences were found in overall opioid recommendations, management decisions, or patient perceptions between concordant and discordant groups. CONCLUSION: Most of the pediatric orthopaedic surgeons surveyed demonstrated implicit racial bias on IAT testing, with a large proportion demonstrating strong pro-White bias. Despite an association between implicit bias and clinical decision making in the literature, this study observed no evidence that implicit racial bias affected the management of pediatric fractures. LEVEL OF EVIDENCE: Level IV.

Mortality in Early-Onset Scoliosis During the Growth-friendly Surgery Era.

INTRODUCTION: Early-onset scoliosis (EOS) is a spinal deformity that occurs in patients 9 years of age or younger. Severe deformity may result in thoracic insufficiency, respiratory failure, and premature death. The purpose of this study is to describe the modern-day natural history of mortality in patients with EOS. METHODS: The multicenter Pediatric Spine Study Group database was queried for all patients with EOS who are deceased, without exclusion. Demographics, underlying diagnoses, EOS etiology, operative and nonoperative treatments or observation, complications, and date of death were retrieved. Descriptive statistics and survival analysis with Kaplan-Meier curves were performed. RESULTS: There were 130/8009 patients identified as deceased for a registry mortality rate of 16 per 1000 patients. The mean age at death was 10.6 years (range: 1.0 to 30.2 y) and the most common EOS etiology was neuromuscular (73/130, 56.2%; P<0.001). Deceased patients were more likely be treated operatively than nonoperatively or observed (P<0.001). The mean age of death for patients treated operatively (12.3 y) was older than those treated nonoperatively (7.0 y) or observed (6.3 y) (P<0.001) despite a larger deformity and similar index visit body mass index and ventilation requirements. Kaplan-Meier analysis confirmed an increased survival time in patients with a history of any spine operation compared with patients without a history of spine operation (P<0.0001). Operatively treated patients experienced a median of 3.0 complications from diagnosis to death. Overall, cardiopulmonary related complications were the most common (129/271, 47.6%; P<0.001), followed by implant-related (57/271, 21.0%) and wound-related (26/271, 9.6%). The primary cause of death was identified for 78/130 (60.0%) patients, of which 57/78 (73.1%) were cardiopulmonary related. CONCLUSIONS: This study represents the largest collection of EOS mortality to date, providing surgeons with a modern-day examination of the effects of surgical intervention to better council patients and families. Both fatal and nonfatal complications in children with EOS are most likely to involve the cardiopulmonary system. LEVEL OF EVIDENCE: Level IV-therapeutic.

Elevated expression of activated TH2 cells and milk-specific TH2 cells in milk-induced eosinophilic esophagitis.

BACKGROUND: Eosinophilic esophagitis (EoE) is an allergic inflammatory disease that is triggered by food allergens and characterized by progressive esophageal dysfunction. Esophageal biopsy specimens are characterized by eosinophilia and expression of TH2 cytokines. OBJECTIVE: To ascertain whether TH2 cells can exist in the peripheral blood in patients with milk-induced EoE. METHODS: Peripheral blood mononuclear cells from 20 children with milk-induced EoE were collected during active EoE (EoE-A) while consuming milk and inactive EoE (EoE-I) while not consuming milk, and 8 healthy patients without EoE were used as controls. The samples were analyzed for T-cell phenotype, including intracellular cytokines before and after incubation with milk antigens and assessed by flow cytometry. RESULTS: We found a significant increase in CD4+ TH2 cells in the peripheral blood of patients with EoE-A compared with the controls. Furthermore, we observed a significant mean (SD) increase in the activation marker of CD154+ T cells (0.17% [0.047%]) in patients with EoE-A compared with control patients (0.034% [0.007%]) and EoE-I (0.025% [0.008]). These CD4+ T cells expressed significantly increase levels of TH2 cytokines (interleukins 4, 5, and 13) compared with the EoE-I and control groups. CD3+CD4+CD154+IL-5+ cells were significantly increased by milk antigens in both milk-induced EoE-A (0.050% [0.008%] to 0.079% [0.017%]) and EoE-I (0.0045% [0.002%] to 0.014% [0.008%]) compared with the controls (0.008% [0.003%] to 0.003% [0.001%]). CONCLUSION: Our findings indicate that in EoE peripheral T cells have specific activation to milk allergens.

Implicit Race Bias in Pediatric Patients: Understanding Patient Perspectives.

INTRODUCTION: Implicit racial bias has been well studied in adults, including among orthopaedic surgeons, through the Implicit Association Test (IAT). Recent studies suggest implicit race bias is also present among children. Explicit racial preference has been studied in children through The Clark Doll Test since the 1930s. The purpose of this study was to determine whether implicit and explicit racial biases are present among pediatric orthopaedic patients. METHODS: A prospective, cross-sectional survey was administered to pediatric orthopaedic patients aged 7 to 18 years at clinics in a tertiary pediatric hospital setting. The survey included a Clark Doll Test to determine whether pediatric patients expressed explicit bias, followed by a race IAT to determine whether pediatric patients expressed implicit bias. Preference and magnitude of implicit bias as demonstrated on the IAT was calculated using standard D-scores. RESULTS: A total of 96 patients were consented and included in this study. Overall, pediatric patients demonstrated a slight pro-White implicit bias (M = 0.22) on IAT testing. Pediatric patients who identified as White or European American and Hispanic or Latinx both had the strongest pro-White implicit bias (M = 0.35). Patients who identified as Black or African American demonstrated no implicit racial bias (M = -0.13) on IAT testing. No notable explicit bias was observed in participants of any racial background. DISCUSSION: This study contributes evidence that pediatric orthopaedic patients express implicit racial bias on IAT testing, with an overall slight pro-White bias. It also provides insight into the dissociation of implicit and explicit racial bias in childhood and adolescence. CONCLUSION: We encourage future research on implicit bias among pediatric patients in the orthopaedic community to provide a better understanding and possible solutions to bias-related challenges in health care.

A Corresponding Point Measurement System Provides Reliable Measurement of Displacement for Medial Epicondyle Fractures.

Little consensus exists on the best method for evaluation and management of pediatric medial epicondyle fractures because of an inability to reliably evaluate fracture displacement with standard imaging techniques. This study aimed to determine the performance of various radiographic views in evaluating displaced medial epicondyle fractures when using a standardized measurement methodology. Methods: Ten fellowship-trained pediatric orthopaedic surgeons assessed fracture displacement in 6 patients with displaced medial epicondyle fractures using radiographic views (anteroposterior, lateral, axial, internal oblique [IO], and external oblique [EO]) and computed tomographic (CT) views (axial, 3-dimensional [3D] horizontal, and 3D vertical). Raters used a corresponding point method for measuring displacement. For each image, raters measured the absolute displacement, categorized the percent of displacement relative to the size of the fragment and fracture bed, and indicated a treatment option. Interobserver reliability was calculated for each view. Bland-Altman plots were constructed to evaluate the bias between each radiograph and the mean of the CT methods. Results: For absolute displacement, anteroposterior and EO views showed almost perfect interobserver reliability, with an interclass correlation coefficient (ICC) of 0.944 for the anteroposterior view and an ICC of 0.975 for the EO view. The axial view showed substantial reliability (ICC = 0.775). For the displacement category, almost perfect reliability was shown for the anteroposterior view (ICC = 0.821), the axial view (ICC = 0.911), the EO view (ICC = 0.869), and the IO view (ICC = 0.871). Displacement measurements from the anteroposterior, axial, and EO views corresponded to the measurements from the CT views with a mean bias of <1 mm for each view. However, the upper and lower limits of agreement were >5 mm for all views, indicating a substantial discrepancy between radiographic and CT assessments. Treatment recommendations based on CT changed relative to the recommendation made using the anteroposterior view 29% of the time, the EO view 41% of the time, and the axial view 47% of the time. Conclusions: Using a corresponding point measurement system, surgeons can reliably measure and categorize fracture displacement using anteroposterior, EO, and axial radiographic views. CT-based measurements are also reliable. However, although the mean difference between the radiograph-based measurements and the CT-based measurements was only about 1 mm, the discrepancy between radiographic views and CT-based methods could be as large as 5 to 6 mm. Level of Evidence: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Morphometric analysis of the proximal thoracic pedicles in Lenke II and IV adolescent idiopathic scoliosis: an evaluation of the feasibility for pedicle screw insertion.

PURPOSE: Pedicles on the concave side of the proximal thoracic (PT) curve in adolescent idiopathic scoliosis (AIS) patients with Lenke II and IV deformities tend to be narrow and dysplastic, making pedicle screw (PS) insertion challenging. The aim of this study was to evaluate the feasibility for PS placement in these patients using pedicle chord length, diameter, and channel morphology. METHODS: In this retrospective study, 56 consecutive AIS patients with Lenke II or IV curves who underwent instrumented posterior spinal fusion (PSF) were studied. The mean age at surgery was 14.8 years and the mean PT curve measured 45°. Two independent investigators evaluated all visible pedicles from T1 to T6 vertebral levels using axial images from intraoperative computed tomography-guided navigation recording the pedicle: (1) maximum transverse diameter 'd' at the isthmus, (2) maximum chord length 'l', and (3) qualitative assessment of the channel morphology (types A-D). RESULTS: Two hundred and sixty-eight concave and 264 convex pedicles were measured. The mean 'd' of the concave pedicles at T3 and T4 was < 3.0 mm, compared to > 5.0 mm for the convex counterparts (p < 0.001). Of all concave pedicle channels, 48% had morphology characteristics that were riskier for PS cannulation (type C or D) compared to 2% of all convex pedicle channels (type A or B) (p < 0.001). CONCLUSION: Almost half of all concave pedicles have morphologic characteristics that make them too small to accommodate a PS. Though PSs could be inserted using an in-out-in technique in these patients, alternative fixation anchors may improve strength and safety.

Are Patient Outcomes Affected by the Presence of a Fellow or Resident in Lumbar Decompression Surgery?

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The aim of this study was to determine whether the presence of a fellow or resident (F/R) compared to a physician assistant (PA) affected surgical variables or short-term patient outcomes. SUMMARY OF BACKGROUND DATA: Although orthopedic spine fellows and residents must participate in minimum number of decompression surgeries to gain competency, the impact of trainee presence on patient outcomes has not been assessed. METHODS: One hundred and seventy-one patients that underwent a one- to three-level lumbar spine decompression procedure at a high-volume academic center were retrospectively identified. Operative reports from all cases were examined and patients were placed into one of two groups based on whether the first assist was a F/R or a PA. Univariate analysis was used to compare differences in total surgery duration, 30-day and 90-day readmissions, infection and revision rates, patient-reported outcome measures (Short Form-12 Physical Component Score and Mental Component Score, Oswestry Disability Index, Visual Analog Scale [VAS] Back, VAS Leg) between groups. Multiple linear regression was used to assess change in each patient reported outcome and multiple binary logistic regression was used to determine significant predictors of revision, infection, and 30- or 90-day readmission. RESULTS: Seventy-eight patients were included in the F/R group compared to 93 patients in the PA group. There were no differences between groups for total surgery time, 30-day or 90-day readmissions, infection, or revision rates. Using univariate analysis, there were no differences between the two groups pre- or postoperatively (P > 0.05). Using multivariate analysis, presence of a surgical trainee did not significantly influence any patient reported outcome and did not affect infection, revision, or 30- and 90-day readmission rates. CONCLUSION: This is one of the first studies to show that the presence of an orthopedic spine fellow or resident does not affect patient short-term outcomes in lumbar decompression surgery. LEVEL OF EVIDENCE: 3.

Circulating miR-155-5p as a Novel Biomarker of Lumbar Degenerative Disc Disease.

MINI: Circulating microRNAs provide an insight into current disease states. Comparing patients with degenerative disc disease to healthy controls, patients with disc disease were found to have significantly downregulated levels of miR-155-5p. This marker was found to be an accurate diagnostic predictor for the presence of degeneration (P = 0.006). STUDY DESIGN: Case-control study measuring differential gene expression of circulating microRNA (miRNA) in patients with degenerative disc disease (DDD). OBJECTIVE: To identify miRNA dysregulation in serum samples of patients with DDD compared to healthy controls (HC). SUMMARY OF BACKGROUND DATA: Early DDD can be a difficult diagnosis to make clinically, with lack of positive and specific findings on physical exam or advanced imaging. miRNAs are a class of molecules that act as gene regulators and have been shown to be dysregulated in local degenerative disc tissue. However, to date no studies have identified dysregulation of serum miRNA in patients with DDD. METHODS: Whole blood samples were obtained from 69 patients with DDD and 16 HC. Patient-reported outcomes were collected preoperatively and degree of DDD was classified using Pfirrmann grade on preoperative imaging. Differential gene expression analysis using a screening assay for several hundred miRNAs and further characterization for five specific miRNAs (miR-16-5p, miR-21-5p, miR-142-3p, miR-146a-5p, and miR-155-5p) was performed. In addition, a pro-inflammatory cytokine multiplex assay and bioinformatics analysis were done. RESULTS: The initial screening assay showed 13 miRNA molecules that were significantly dysregulated in DDD patients, with miR-155-5p showing significant downregulation (p = 0.027) and direct interactions with the pro-inflammatory cytokine IL-1ß, and the tumor suppressor genes p53 and BRAF. Analyzing the whole cohort, miR-155 showed an almost four-fold downregulation in DDD patients (-3.94-fold, P < 0.001) and was the sole miRNA that accurately predicted the presence of disc degeneration (P = 0.006). Downregulation of miR-155 also correlated with increased leg pain (P = 0.018), DDD (P = 0.006), and higher Pfirrmann grade (P = 0.039). On cytokine analysis, TNF-α (0.025) and IL-6 (P < 0.001) were significantly higher in DDD patients. CONCLUSION: Serum miR-155-5p is significantly downregulated in patients with DDD and may be a diagnostic marker for degenerative spinal disease. LEVEL OF EVIDENCE: N/A.

Case-control study measuring differential gene expression of circulating microRNA (miRNA) in patients with degenerative disc disease (DDD). To identify miRNA dysregulation in serum samples of patients with DDD compared to healthy controls (HC). Early DDD can be a difficult diagnosis to make clinically, with lack of positive and specific findings on physical exam or advanced imaging. miRNAs are a class of molecules that act as gene regulators and have been shown to be dysregulated in local degenerative disc tissue. However, to date no studies have identified dysregulation of serum miRNA in patients with DDD. Whole blood samples were obtained from 69 patients with DDD and 16 HC. Patient-reported outcomes were collected preoperatively and degree of DDD was classified using Pfirrmann grade on preoperative imaging. Differential gene expression analysis using a screening assay for several hundred miRNAs and further characterization for five specific miRNAs (miR-16-5p, miR-21-5p, miR-142-3p, miR-146a-5p, and miR-155-5p) was performed. In addition, a pro-inflammatory cytokine multiplex assay and bioinformatics analysis were done. The initial screening assay showed 13 miRNA molecules that were significantly dysregulated in DDD patients, with miR-155-5p showing significant downregulation (p = 0.027) and direct interactions with the pro-inflammatory cytokine IL-1ß, and the tumor suppressor genes p53 and BRAF. Analyzing the whole cohort, miR-155 showed an almost four-fold downregulation in DDD patients (−3.94-fold, P < 0.001) and was the sole miRNA that accurately predicted the presence of disc degeneration (P = 0.006). Downregulation of miR-155 also correlated with increased leg pain (P = 0.018), DDD (P = 0.006), and higher Pfirrmann grade (P = 0.039). On cytokine analysis, TNF-α (0.025) and IL-6 (P < 0.001) were significantly higher in DDD patients. Serum miR-155-5p is significantly downregulated in patients with DDD and may be a diagnostic marker for degenerative spinal disease. Level of Evidence: N/A.

How do spinopelvic parameters influence patient-reported outcome measurements after lumbar decompression?

BACKGROUND CONTEXT: Spinopelvic parameters indicative of sagittal imbalance include a pelvic tilt (PT) greater than 20° and a mismatch between pelvic incidence (PI) and lumbar lordosis (LL) greater than 10°. However, unlike in fusion surgery, the relationship between spinopelvic parameters and patient-reported outcome measurements (PROMs) in patients undergoing lumbar decompression surgery for neurologic symptoms is less clear. PURPOSE: To determine whether PROMs are affected by the amount of residual (postoperative) PI-LL mismatch or PT in patients undergoing one- to three-level lumbar decompression surgeries. DESIGN: Retrospective cohort study (Level of Evidence: III). PATIENT SAMPLE: Patients undergoing between one to three levels of lumbar decompression surgery at a single, academic institution. OUTCOME MEASURES: PROMs-including the PCS-12, MCS-12, ODI, and VAS Back and Leg pain scores-and radiographic measurements of spinopelvic parameters. METHODS: Patients were separated into groups based on a postoperative PI-LL mismatch of ≤10° or >10° and a postoperative PT<20° or ≥20°. Absolute PROM scores, the recovery ratio (RR) and the percentage of patients achieving Minimum Clinically Important Difference between groups were compared and a multiple linear regression analysis was performed. RESULTS: A total of 167 patients were included, with 27 patients in the PI-LL>10° group and 91 patients in the PT≥20° group. All groups exhibited significant improvement after surgery for each PROM included (p<.05) except for MCS-12 scores in the PI-LL≤10° group and both PT groups. Comparing between groups, all patients were similar with respect to preoperative scores, postoperative scores, change in scores, recovery ratios, and percentage change in Minimum Clinically Important Difference, except that patients with PT≥20° had higher pre- and postoperative VAS Back scores (p=.036 and p=.024, respectively). With multiple linear regression, postoperative PI-LL>10° and PT≥20° were not significant predictors of worse outcomes for any measured PROM. CONCLUSIONS: Patients with postoperative measurements PI-LL>10° and PT≥20° without instability had similar PROMs at 1 year after limited lumbar decompression when compared to patients without a spinopelvic mismatch.