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[21] Hinkley and Jaremko reported significant improvements in pain, function, and disability in 81 injured workers treated with 360 fusion for low back pain and positive discography. They noted a 95-100% fusion rate and 91% patient satisfaction.[42] Clinical studies of patients with chronic back pain provide strong evidence that psychological distress is an important risk factor for having poor outcomes after spine surgery.[43,44] Other studies have shown that both the inability to work for long periods and inability to find a job after rehabilitation are factors underlying failure to return to work.[45,46] In one selleck kinase inhibitor study, 50% pain reduction was achieved in Resminostat for seeking early retirement, thus being psychologically inclined to adopt the disabled role.[25] Retrospective studies on scoliosis as well as longitudinal studies on lumbar fusion have suggested that lower lumbar fusions predispose patients to problems in the adjacent motion segments.[48,49,50,51,52] In our study, the B Twin allowed an excellent restoration of lordosis, but the distress in the adjacent level was much higher and the facetary syndrome and accelerated degeneration in the adjacent level was double (two-times higher) in comparison with those in the autologus bone group. The disadvantage of classical 360 fusion is that it requires two surgeries (one anterior and one posterior) and that it may require an additional surgery later to remove the instrumentation.[53] A total of 36% patients in the autologus bone group and 53% patients in the B Twin group developed lumbar pain that was needed some kind of treatment in the first 3-years follow-up. Selleckchem Dorsomorphin Although we achieve a good fixation at the affected segment with circumferential fusion, it may not translate in terms of good clinical outcomes, particularly, pain control. With this study, we felt that the question of whether or not circumferential fusion should be the preferred treatment for FBSS is an option and not the solution, and it therefore needs further investigation to resolve the specific pain that disabilitates the patient and not to restore all the bone architecture and foramen diameters.[26] Conclusion Circumferential lumbar fusion is a useful procedure for FBSS patients.