The existence and importance of an accelerated adjacent segment disc degeneration (ASD) after lumbar fusion have previously not been demonstrated by RCTs. The objectives of this study were, to determine whether lumbar fusion in the long term accelerates degenerative changes in the adjacent disc and whether this affects the outcome, by using a prospective randomised design. A total of 111 patients, aged 18-55, with isthmic spondylolisthesis were randomised to exercise (EX, n = 34) or posterolateral fusion (PLF, n = 77), with (n = 37) or without pedicle screw instrumentation (n = 40). The minimum 10 years FU rate was 72%, with a mean FU time of 12.6 years (range 10-17 years). Three radiographic methods of ASD quantification were used, i.e. two digital radiographic measurement methods and the semi quantitative UCLA grading scale. One digital measurement method showed a mean disc height reduction by 2% in the EX group and by 15% in the PLF group (p = 0.0016), and the other showed 0.5 mm more disc height reduction in the PLF compared to the Ex group (ns). The UCLA grading scale showed normal discs in 100% of patients in the EX group, compared to 62% in the PLF group (p = 0.026). There were no significant differences between instrumented and non-instrumented patients. In patients with laminectomy we found a significantly higher incidence of ASD compared to non laminectomised patients (22/47 vs. 2/16 respectively, p = 0.015). In the longitudinal analysis, the posterior and anterior disc heights were significantly reduced in the PLF group, whereas in the EX group only the posterior disc height was significantly reduced. Except for global outcome, which was significantly better for patients without ASD, the clinical outcome was not statistically different in patients with and without ASD. In conclusion, the long-term RCT shows that fusion accelerates degenerative changes at the adjacent level compared with natural history. The study suggests that not only fusion, but also laminectomy may be of pathogenetic importance. The clinical importance of ASD seems limited, with only the more severe forms affecting the outcome.

Type of fusion, PLIF or PLF, does not affect the 2-year outcome of surgical treatment of adult isthmic spondylolisthesis. Despite the theoretical advantages of PLIF, no improvement on patient outcome compared with posterolateral fusion could be demonstrated, questioning the need of anterior support in short lumbar fusions.

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The present study shows that patients working before surgery have a more favorable outcome. Also male gender and regular exercise are indicators of a better outcome after fusion. Female patients not working, not exercising or, if these factors are not known, with nonorganic PDs, should be informed about their suboptimal chances of an excellent outcome after fusion.

Purpose -The use of brand ambassadors is a quite recent phenomenon, even in the business world. This paper aims to explore the employment of ambassador networks as a place marketing and place development tool. This is done by identifying various kinds of networks, understanding how networks are governed, and pinning down the motivations and expectations of network members. Design/methodology/approach -The study used interviews and a survey to collect empirical material. The research process employed an approach with many inductive elements, deemed appropriate given that research into the topic is scant. Findings -The study identified four main dimensions of networks and, on this basis, we outline a typology with four main categories of networks. One major finding is that ambassador networks are seen not only as a communication channel, but also as a development resource. That means they are seen as enhancing the general competitiveness of the place involved. The networks are also seen as a resource for mobilising local citizen pride. Another finding was that ambassadors value getting access to first-hand information about the place much more than the opportunity of taking part in meetings and events and forming new relationships.Research limitations/implications -The findings are in line with the perspective of the place brand as a "relational brand network", extending place branding beyond a matter of just one-way communication. It is somewhat surprising that ambassadors value getting access to information more than interaction, given that other research puts such a high value on interaction and dialogue as value-creating factors. Practical implications -Based on the observations in the study, it is argued that ambassador networks have the potential to constitute an integral component of place brand management. Originality/value -Research on the application of ambassador networks in place marketing seems to be scant, not to say non-existent. The present study relates to the implementation of place branding, and can hopefully contribute to a more efficient practice as well as a better theoretical understanding.