SPINE20 recommendations 2023: One Earth, one family, one future WITHOUT spine DISABILITY.

Introduction: The purpose is to report on the fourth set of recommendations developed by SPINE20 to advocate for evidence-based spine care globally under the theme of "One Earth, One Family, One Future WITHOUT Spine DISABILITY". Research question: Not applicable. Material and methods: Recommendations were developed and refined through two modified Delphi processes with international, multi-professional panels. Results: Seven recommendations were delivered to the G20 countries calling them to:-establish, prioritize and implement accessible National Spine Care Programs to improve spine care and health outcomes.-eliminate structural barriers to accessing timely rehabilitation for spinal disorders to reduce poverty.-implement cost-effective, evidence-based practice for digital transformation in spine care, to deliver self-management and prevention, evaluate practice and measure outcomes.-monitor and reduce safety lapses in primary care including missed diagnoses of serious spine pathologies and risk factors for spinal disability and chronicity.-develop, implement and evaluate standardization processes for spine care delivery systems tailored to individual and population health needs.-ensure accessible and affordable quality care to persons with spine disorders, injuries and related disabilities throughout the lifespan.-promote and facilitate healthy lifestyle choices (including physical activity, nutrition, smoking cessation) to improve spine wellness and health. Discussion and conclusion: SPINE20 proposes that focusing on the recommendations would facilitate equitable access to health systems, affordable spine care delivered by a competent healthcare workforce, and education of persons with spine disorders, which will contribute to reducing spine disability, associated poverty, and increase productivity of the G20 nations.

Anterior To Psoas lumbar and lumbosacral combined with posterior reconstruction in Adult Spinal Deformity: A bicentric European study.

Introduction: Lateral lumbar fusion via the trans-psoas approach is popular in adult deformity reconstruction. To overcome its limitations (neurological damage to the plexus and lack of applicability to the lumbosacral junction), a modified anterior-to-psoas (ATP) approach has been described and used. Research question: To investigate the results of ATP lumbar and lumbosacral fusion, in a cohort of adult patients treated with combined anteroposterior approaches for adult spinal deformity (ASD). Materials and methods: ASD patients surgically treated at two tertiary spinal centres were followed up. Forty patients were treated with combined ATP and posterior surgery: 11 with open lumbar lateral interbody-fusions (lumbotomy LLIF) and 29 with lesser invasive oblique lateral interbody-fusions (OLIF). Preoperative demographics, aetiology, clinical characteristics, and spinopelvic parameters were comparable between the two cohorts. Results: At a minimum 2-year follow-up, both cohorts showed significant improvements in patient reported outcome measures (PROMs), i.e. Visual Analogue Scale and Core Outcome Measures Index, as well as radiological parameters, with no significant differences based on the type of surgical approach. No significant differences were found in major (P â€‹= â€‹0.457) and minor (P â€‹= â€‹0.071) complications between the two cohorts. Discusson and conclusion: Anterolateral lumbar interbody fusions, whether performed via a direct or oblique approach, proved to be safe and effective adjuvants to posterior surgery in patients with ASD. No significant complication differences were noted between techniques. In addition, the anterior-to-psoas approaches limited the risks of post-operative pseudoarthrosis by providing solid anterior support to lumbar and lumbosacral segments, demonstrating a positive impact on PROMS.

Giant intradural extramedullary spinal ependymoma, a rare arachnoiditis-mimicking condition: case report and literature review.

BACKGROUND AND IMPORTANCE: Ependymomas are tumours arising from the ependymal cells lining the ventricles and the central canal of the spinal cord. They represent the most common intramedullary spinal cord tumour in adults and are very rarely encountered in an extramedullary location. Only 40 cases of intradural extramedullary (IDEM) ependymomas have been reported, all of which were diagnosed pre-operatively as IDEM ependymomas on contrast-enhanced MRI. CLINICAL PRESENTATION: We report a 23-year old male presenting with rapidly worsening signs and symptoms of spinal cord disease. A spinal MRI demonstrated a posterior multi-cystic dilatation extended between T1 and T12. Post-contrast sequences showed peri-medullar leptomeningeal enhancement and the diagnosis of spinal arachnoiditis was made. The patient underwent surgery and the spinal cord appeared circumferentially wrapped by an irregular soft tissue. The tissue was sub-totally removed and the pathological diagnosis was ependymoma WHO grade II. The patient experienced an excellent neurological recovery and no further treatments were administered. A small residue is now stable at 2.5 years follow-up. CONCLUSIONS: Giant IDEM ependymomas are rare entities and pre-operative diagnosis can be challenging in some cases. Surgery represents the main treatment option being resolutive in most cases.

Acute bilateral foot drop due to lumbar disc herniation treated by bilateral interlaminar approach: case report and literature review.

Foot drop due to lumbar disc herniation (LDH) is a relatively common finding in spinal practice. Bilateral foot drop (BFD) due to LDH is an extremely rare condition with only a few reported cases. We describe the case of a middle-aged man presenting with a rapid onset BFD with back and leg pain. Urgent MRI revealed an L4-L5 centrally located LDH with bilateral compression of the L5 nerve roots and the cauda equina centrally. About 4 h after presentation surgery was performed adopting a bilateral L4-L5 interlaminar approach and the prolapsed disc was removed. Nine months after surgery, the patient showed a complete recovery of his deficit. We discuss the advantages of this approach in this urgent situation and we compare it with other techniques.

SPINE20 recommendations 2022: spine care-working together to recover stronger.

PURPOSE: Globally, spine disorders are the leading cause of disability, affecting more than half a billion individuals. However, less than 50% of G20 countries specifically identify spine health within their public policy priorities. Therefore, it is crucial to raise awareness among policy makers of the disabling effect of spine disorders and their impact on the economic welfare of G20 nations. In 2019, SPINE20 was established as the leading advocacy group to bring global attention to spine disorders. METHODS: Recommendations were developed through two Delphi methods with international and multi-professional panels. RESULTS: In 2022, seven recommendations were delivered to the leaders of G20 countries, urging them to: Develop action plans to provide universal access to evidence-based spine care that incorporates the needs of minorities and vulnerable populations. Invest in the development of sustainable human resource capacity, through multisectoral and inter-professional competency-based education and training to promote evidence-based approaches to spine care, and to build an appropriate healthcare working environment that optimizes the delivery of safe health services. Develop policies using the best available evidence to properly manage spine disorders and to prolong functional healthy life expectancy in the era of an aging population. Create a competent workforce and improve the healthcare infrastructure/facilities including equipment to provide evidence-based inter-professional rehabilitation services to patients with spinal cord injury throughout their continuum of care. Build collaborative and innovative translational research capacity within national, regional, and global healthcare systems for state-of-the-art and cost-effective spine care across the healthcare continuum ensuring equality, diversity, and inclusion of all stakeholders. Develop international consensus statements on patient outcomes and how they can be used to define and develop pathways for value-based care. Recognize that intervening on determinants of health including physical activity, nutrition, physical and psychosocial workplace environment, and smoking-free lifestyle can reduce the burden of spine disabilities and improve the health status and wellness of the population. At the third SPINE20 summit 2022 which took place in Bali, Indonesia, in August 2022, 17 associations endorsed its recommendations. CONCLUSION: SPINE20 advocacy efforts focus on developing public policy recommendations to improve the health, welfare, and wellness of all who suffer from spinal pain and disability. We propose that focusing on facilitating access to systems that prioritize value-based care delivered by a competent healthcare workforce will reduce disability and improve the productivity of the G20 nations.

SPINE20 recommendations 2021: spine care for people's health and prosperity.

PURPOSE: The focus of SPINE20 is to develop evidence-based policy recommendations for the G20 countries to work with governments to reduce the burden of spine disease, and disability. METHODS: On September 17-18, 2021, SPINE20 held its annual meeting in Rome, Italy. Prior to the meeting, the SPINE20 created six proposed recommendations. These recommendations were uploaded to the SPINE20 website 10 days before the meeting and opened to the public for comments. The recommendations were discussed at the meeting allowing the participants to object and provide comments. RESULTS: In total, 27 societies endorsed the following recommendations. SPINE20 calls upon the G20 countries: (1) to expand telehealth for the access to spine care, especially in light of the current situation with COVID-19. (2) To adopt value-based interprofessional spine care as an approach to improve patient outcomes and reduce disability. (3) To facilitate access and invest in the development of a competent rehabilitation workforce to reduce the burden of disability related to spine disorders. (4) To adopt a strategy to promote daily physical activity and exercises among the elderly population to maintain an active and independent life with a healthy spine, particularly after COVID-19 pandemic. (5) To engage in capacity building with emerging countries and underserved communities for the benefit of spine patients. (6) To promote strategies to transfer evidence-based advances into patient benefit through effective implementation processes. CONCLUSIONS: SPINE20's initiatives will make governments and decision makers aware of efforts to reduce needless suffering from disabling spine pain through education that can be instituted across the globe.

Posterior segmental fixation for thoraco-lumbar and lumbar fractures: a comparative outcome study between open and percutaneous techniques.

PURPOSE: Showing results of open and percutaneous surgical management of traumatic AO type A3, A4 and B2 thoracic and lumbar fractures. METHODS: Retrospective comparative analysis of traditional open fusion versus percutaneous navigated fixation of thoracic and lumbar spinal fractures. Minimum 24 months follow-up to collect ODI and VAS outcome scores for comparative analysis was required. RESULTS: Fifty-seven patients with a mean age of 39 years met the inclusion criteria. Twenty-six patients were in the open group (Group O) and 31 in the percutaneous group (Group P). The majority of fractures were either type A3 or A4; there were three type B chance fractures in Group O and one in Group P. VAS and ODI scores followed comparable trends in the two groups until the final follow-up. The main statistically significant result between the two groups was blood loss, which was lower in Group P (110 versus 270 ml in Group O on average), although this did not reflect into different clinical outcomes. Similar peri-operative measures of operating time and length of stay were found between the two groups. A significantly higher degree of loss of reduction was noted at follow-up in Group P (8° versus 5° in Group O on average). CONCLUSIONS: Open and percutaneous posterior fixation techniques of thoracic and lumbar fractures in this cohort were associated with different perioperative blood losses as well as radiological measurements, but not with clinically meaningful differences in patient reported outcome measures at 24 months' follow-up.

Roy-Camille Type 3 suicidal jumper's fractures: Case series and review of the literature.

BACKGROUND: Roy-Camille reported only three patients in their Type 3 posttraumatic transverse sacral fracture (TSF) classification. A modified Roy-Camille classification has been already proposed by other authors suggesting further categorization of the TSFs as partially displaced or completely displaced to predict the rate of neurological recovery following lumbopelvic fixation. MATERIALS AND METHODS: We reported three adult cases of surgical fixation of fracture-dislocation (3A and 3B) of the sacrum due to traumatic injuries and submitted to lumbopelvic posterior reconstruction. A case of a 15-year-old male patient affected by Type 3C with vascular pelvic injury was also reported. A comprehensive literature search was performed on evaluation and management of Type 3 TSFs. RESULTS: In Type 3A, there is a minimal anterior dislocation and the reduction is feasible with good chance of recovery. In Type 3B, the anterior dislocation is severe, neurological deficits are present, reduction is difficult, and there is a risk of vascular injury both at the trauma and during the surgical reduction. In Type 3C, the anterior dislocation is massive, and the risk of vascular injury is very high requiring prompt vascular or endovascular treatment. Open reduction and posterior instrumentation are technically feasible in patients affected by Type 3 high TSFs. CONCLUSIONS: In our opinion, a modified Roy-Camille classification could be useful in the assessment of prognostic and therapeutic aspects of such fractures, In our opinion, a modified Roy-Camille classification could help assess the prognostic and therapeutic aspects of such fractures, in which the severity of the dislocation affects the surgical technique, the chance of neurological recovery, and the patient's life expectancy.

SPINE20 A global advocacy group promoting evidence-based spine care of value.

PURPOSE: The Global Burden of Diseases (GBD) Studies have estimated that low back pain is one of the costliest ailments worldwide. Subsequent to GBD publications, leadership of the four largest global spine societies agreed to form SPINE20. This article introduces the concept of SPINE20, the recommendations, and the future of this global advocacy group linked to G20 annual summits. METHODS: The founders of SPINE20 advocacy group coordinated with G20 Saudi Arabia to conduct the SPINE20 summit in 2020. The summit was intended to promote evidence-based recommendations to use the most reliable information from high-level research. Eight areas of importance to mitigate spine disorders were identified through a voting process of the participating societies. Twelve recommendations were discussed and vetted. RESULTS: The areas of immediate concern were "Aging spine," "Future of spine care," "Spinal cord injuries," "Children and adolescent spine," "Spine-related disability," "Spine Educational Standards," "Patient safety," and "Burden on economy." Twelve recommendations were created and endorsed by 31/33 spine societies and 2 journals globally during a vetted process through the SPINE20.org website and during the virtual inaugural meeting November 10-11, 2020 held from the G20 platform. CONCLUSIONS: This is the first time that international spine societies have joined to support actions to mitigate the burden of spine disorders across the globe. SPINE20 seeks to change awareness and treatment of spine pain by supporting local projects that implement value-based practices with healthcare policies that are culturally sensitive based on scientific evidence.

Trans-thoracic versus retropleural approach for symptomatic thoracic disc herniations: comparative analysis of 94 consecutive cases.

PURPOSE: The authors illustrate their results in the surgical treatment of symptomatic thoracic disc herniations (TDHs) by comparing the traditional open to the less invasive retropleural lateral approaches. METHODS: Retrospective review of 94 consecutive cases treated at a single Institution between 1988 and 2014. Fifty-two patients were males, 42 females, mean age was 53.9 years. Mean follow-up was 46.9 months (12-79 months). 33 patients were diagnosed with a giant thoracic disc herniation (GTDH). Upon admission, the most common symptoms were: motor impairment (91.4%, n = 86), neuropathic radicular pain with VAS > 4 (50%), bladder and bowel dysfunction (57.4% and 41.4% respectively) and sensory disturbances (29.7%). The surgical approach was based upon level, laterality and presence or absence of calcified lesions. RESULTS: Decompression was performed in 7 cases via a thoraco-laparo-phrenotomy and in 87 cases via an antero-lateral thoracotomy. Out of the latter cases, 49 (56%) were trans-thoracic trans-pleural approaches (TTA) and 38 (44%) were less invasive retropleural approaches (MIRA). At follow-up, there were 59.5% neurologically intact patients according to the McCormick Scale, while 64.8% and 67% had no bladder or bowel dysfunction respectively. Complications occurred in 24 patients (25.5%). Pulmonary complications were the commonest (12.7%) with pleural effusion being significantly more common in patients treated with TTA compared to MIRA (20% vs 5.2%: X2 4.13 P:0.042). Severe post-operative neuralgia (VAS 7-10) was also significantly more frequent in the TTA group (22.4% vs 2.6% X2 7.07 p 0.0078). CONCLUSIONS: MIRA is a safe and effective technique to obtain adequate TDH decompression and is associated with lower morbidity compared to TTA.

Importance of balance and profile in adult spinal reconstruction.

Long before its current understanding, the concept of balance was common among spine surgeons dealing with deformities, but it was a hard one to transfer to clinical practice. Thanks to the pioneering work of Duval-Beaupere and followers, the idea of balancing the sagittal contour of the spine has gained scientific status and is now in the armamentarium of the skilled surgeon as the single most important tool to achieve superior clinical results in adult spinal deformity surgery.

Reliability, validity and responsiveness of the cross-culturally adapted Italian version of the core outcome measures index (COMI) for the neck.

PURPOSE: Evaluation of the psychometric properties of a cross-culturally adapted questionnaire, the Core Outcome Measurement Index for neck pain (COMI-neck). METHODS: The COMI-neck was cross-culturally adapted for the Italian language using established procedures. The following psychometric properties of the instrument were then assessed in patients with chronic neck pain undergoing rehabilitation: test-retest reliability (intraclass correlation coefficient, ICC); construct validity by comparing COMI-neck with the Neck Pain and Disability Scale, a numerical pain rating scale, and the EuroQol-Five Dimension (Pearson's correlations); and responsiveness by means of Standardized Response Mean (SRM), unpaired t tests, and Receiver Operating Characteristics (ROC) curves. RESULTS: The questionnaire was completed by 103 subjects. The COMI-neck summary score displayed no relevant floor or ceiling effects. Test-retest reliability was excellent (ICC = 0.87). With one exception (symptom-specific well-being), the individual COMI items and the COMI summary score correlated to the expected extent with the scores of the reference questionnaires (r = 0.40-0.80). The mean change scores for the Italian COMI-neck differed significantly between patients with a good global outcome and those with a poor outcome (p = 0.002); SRM for the good outcome group was 1.23, and for the poor outcome group 0.40. ROC analysis revealed an area under the curve of 0.73 (95% CI: 0.62-0.85). CONCLUSIONS: This study provides evidence that the Italian version of the COMI-neck is a valid and responsive questionnaire in the population of patients examined. Its use is recommended for clinical and research purposes.

Management of catastrophising and kinesiophobia improves rehabilitation after fusion for lumbar spondylolisthesis and stenosis. A randomised controlled trial.

PURPOSE: To evaluate the effect of a rehabilitation programme including the management of catastrophising and kinesiophobia on disability, dysfunctional thoughts, pain, and the quality of life in patients after lumbar fusion for degenerative spondylolisthesis and/or lumbar spinal stenosis. METHODS: This was a parallel-group, randomised, superiority-controlled study in which 130 patients were randomly assigned to a programme consisting of exercises and cognitive-behavioural therapy (experimental group, 65 subjects) or exercises alone (control group, 65 subjects). Before treatment (T1), 4 weeks later (post-treatment analysis, T2) and 12 months after the end of treatment (follow-up, T3), all the patients completed a booklet containing the Oswestry Disability Index (ODI, primary outcome), the Tampa Scale for Kinesiophobia, the Pain Catastrophising Scale, a pain Numerical Rating Scale, and the Short-Form Health Survey. A linear mixed model for repeated measures was used for each outcome measure. RESULTS: The ODI linear mixed model revealed significant main effects of group (F(1,122.8) = 95.78, p < 0.001) and time (F(2,120.1) = 432.02, p < 0.001) in favour of the experimental group. There was a significant group × time interaction effect (F(2,120.1) = 20.37, p < 0.001). The analyses of all of the secondary outcome measures revealed a significant effect of time, group and interaction in favour of the experimental group. CONCLUSION: The rehabilitation programme, including the management of catastrophising and kinesiophobia, was superior to the exercise programme in reducing disability, dysfunctional thoughts, and pain, and enhancing the quality of life of patients after lumbar fusion for degenerative spondylolisthesis and/or LSS. The effects lasted for at least 1 year after the intervention ended.

Profunda femoris artery pseudoaneurysm following revision for femoral shaft fracture nonunion.

Femoral artery pseudoaneurysms (FAPs) have been described following internal fixation of intertrocantheric, subtrocantheric and intracapsular femoral neck fractures as well as core decompression of the femoral head. The diagnosis of FAP is usually delayed because of non-specific clinical features like pain, haematoma, swelling, occasional fever and unexplained anaemia. Because of the insidious onset and of the possible delayed presentation of pseudoaneurysms, orthopaedic and trauma surgeons should be aware of this complication. We report a case of Profunda Femoris arterial branch pseudoaneurysm, diagnosed in a 40-year-old male 4 wk after revision with Kuntscher intramedullary nail of a femoral shaft nonunion. The diagnosis was achieved by computed tomography angiography and the lesion was effectively managed by endovascular repair. The specific literature and suggestions for treatment are discussed in the paper.

Measurement of forces generated during distraction of growing-rods in early onset scoliosis.

AIM: To measure the forces applied during distraction of growing-rods in early onset scoliosis (EOS), aimed at developing a motorized elongation device. METHODS: A consecutive series of measurements were carried out to analyze the forces applied by the surgeon during distraction of single growing-rods in 10 patients affected by EOS (mean age 8.3 years; range 6 to 10 years) undergoing the first distraction 6 months following implantation of the rods. For each measurement, output from the transducer of a dedicated pair of distraction calipers was recorded at zero load status and at every 1 mm of distraction, up to a maximum of 12 mm for each of the two connected rods. RESULTS: Twenty measurements were obtained showing a linear increase of the load with increasing distraction, with a mean peak force of 485 N at 12 mm distraction and a single reading over 500 N. We did not observe bone fractures or ligament disruptions during or after rod elongations. There was one case of superficial wound infection in the cohort. CONCLUSION: The safe peak force carrying capacity of a motorized device for distraction of growing-rods is 500N.

Chronic neck pain and treatment of cognitive and behavioural factors: results of a randomised controlled clinical trial.

PURPOSE: Although there is growing evidence in favour of the bio-psychosocial approach to the treatment of persistent neck pain, it is questioned whether treating psychological factors can improve patient perceptions of disability, pain and quality of life. This randomised, controlled study with 12 months' follow-up was conducted to evaluate the efficacy of adding cognitive-behavioural principles to exercises for chronic neck pain. METHODS: Eighty patients were randomly assigned to the usual neck exercises plus cognitive-behavioural treatment (PTcb group, 40 subjects) or to treatment based on neck exercises alone (PT group, 40 subjects). Before treatment (T1), at the end of treatment (T2) and 12 months later (T3), all of the patients completed a booklet including the Neck Pain and Disability Scale, a numerical rating scale, and the Short-Form Health Survey Questionnaire (SF-36). RESULTS: The present trial failed to demonstrate its primary end point: the pre- and post-treatment difference in total NPDS scores was not statistically different between groups. Disability improved similarly in both groups over time, remaining stable until T3 in the PTcb group and slightly increasing at the same time in the PT group. Pain trends were comparable, with both groups showing an improvement between T1 and T2, and a slight worsening between T2 and T3. There were significant increases in all of the SF-36 domains except for health in general, and vitality in both groups by the end of treatment. SF-36 showed a between-group difference only for the physical activity domain (10.4; 95% CI 2.4-18.5). CONCLUSION: Disability, pain and quality of life improved at the end of treatment in both groups, without differences between them.

Spine stability after implantation of an interspinous device: an in vitro and finite element biomechanical study.

OBJECT: Interspinous devices are widely used for the treatment of lumbar stenosis. The DIAM spinal stabilization system (Medtronic, Ltd.) is an interspinous implant made of silicone and secured in place with 2 laces. The device can be implanted via posterior access with the sacrifice of the supraspinous ligament (SSL) or via lateral access with preservation of the ligament. The aim of the present work was to evaluate the role of the laces, the SSL, and the device size and positioning to determine the device's ability in reducing segmental lordosis and in stabilizing motion. METHODS: Biomechanical tests were performed in flexion and extension on 8 porcine spines implanted with the DIAM either with or without the laces and the SSL. A finite element model of the human L4-5 spine segments was also created and used to test 2 sizes of the device implanted in 2 different positions in the anteroposterior direction. RESULTS: Implantation of the DIAM induced a shift toward kyphosis in the neutral position. Laces, the SSL, and device size and placement had a significant influence on the neutral position, the stiffness of the implanted spine, and the positions of the instantaneous centers of rotation. CONCLUSIONS: The shift of the neutral position toward kyphosis may be beneficial in reducing symptoms of spinal stenosis such as radicular pain, sensation disturbance, and loss of strength in the legs. The authors recommend preservation of the SSL and the use of the fixation laces, given their relevant mechanical role. Choosing the proper device size and placement should be achieved by using a correct surgical technique.

Results of the spine-to-rib-cage distraction in the treatment of early onset scoliosis.

BACKGROUND: Growing rod systems have been used in the last 30 years for the treatment of early onset scoliosis (EOS) with variable success rates. We report the results of treatment of EOS with a newly developed hybrid rod distraction system applied to the rib cage and spine with a nonfusion technique in a prospective multicenter clinical trial. MATERIALS AND METHODS: A total of 22 patients affected by progressive EOS resistant to cast and/or brace treatment were enrolled from 2004 to 2005 after informed consent into a trial of surgical treatment with a single spine-to-rib growing rod instrumentation growing spine profiler (GSP). Curves >60 degrees Cobb in the frontal plane or bending < 50% were addressed with staged anterior annulotomy and fusion and posterior implantation of a GSP rod. Less severe and rigid curves were treated with posterior implantation of GSP only. The elongation of GSP was planned according to spinal growth. Patients were kept in a brace between elongations. RESULTS: A total of 20 patients were available to follow-up with complete data. The mean follow up is 4.1 years. Mean age at time of initial surgery was 5 years (3-8). Nine patients had staged antero-posterior surgeries, 11 posterior only surgeries. Mean spinal growth was 1.9 cm (1.5-2.3) or 0.5 cm per year. Mean coronal Cobb's angle correction was from 56 degrees to 45 degrees . Major complications affected 40% of patients and included rod failure in 6/20 and crankshaft in 5/20 (all in the anteroposterior surgery group). CONCLUSION: Treatment of EOS with spine-to-rib growing rod in the present form provides similar correction and complication rates to those published in the series considering traditional single or dual growing rod systems. Based on this, the authors recommend revision of the GSP design and a new clinical trial to test safety and efficacy.

Higher risk of dural tears and recurrent herniation with lumbar micro-endoscopic discectomy.

Existing studies on micro-endoscopic lumbar discectomy report similar outcomes to those of open and microdiscectomy and conflicting results on complications. We designed a randomised controlled trial to investigate the hypothesis of different outcomes and complications obtainable with the three techniques. 240 patients aged 18-65 years affected by posterior lumbar disc herniation and symptoms lasting over 6 weeks of conservative management were randomised to micro-endoscopic (group 1), micro (group 2) or open (group 3) discectomy. Exclusion criteria were less than 6 weeks of pain duration, cauda equina compromise, foraminal or extra-foraminal herniations, spinal stenosis, malignancy, previous spinal surgery, spinal deformity, concurrent infection and rheumatic disease. Surgery and follow-up were made at a single Institution. A biomedical researcher independently collected and reviewed the data. ODI, back and leg VAS and SF-36 were the outcome measures used preoperatively, postoperatively and at 6-, 12- and 24-month follow-up. 212/240 (91%) patients completed the 24-month follow-up period. VAS back and leg, ODI and SF36 scores showed clinically and statistically significant improvements within groups without significant difference among groups throughout follow-up. Dural tears, root injuries and recurrent herniations were significantly more common in group 1. Wound infections were similar in group 2 and 3, but did not affect patients in group 1. Overall costs were significantly higher in group 1 and lower in group 3. In conclusion, outcome measures are equivalent 2 years following lumbar discectomy with micro-endoscopy, microscopy or open technique, but severe complications are more likely and costs higher with micro-endoscopy.