Some common risks of surgery include: Stroke. An ACDF is a type of spine surgery used to treat neck issues by removing. If i had known it was going to be such a pain after my surgery i would have looked for better options. Some patients may need to start physical therapy about a month after ACDF and continue it for a couple more months. It is FREE! No large paralabral cyst is seen. The last couple of weeks, by neck has started hurting pretty bad. and screws. Join Date: Sep 2004. Spinal fusion is a common form of back surgery used to treat several kinds of back problems, including scoliosis, vertebral weakness, and herniated discs. I know I have posted before here but just wondered if anyone else feels like this. The cervical spinal cord demonstrates normal caliber and signal without syrinx. WebIt is not uncommon to have pain in the neck following fusion surgery which slowly gets better over 12 to 18 months. I understand your concern with that image. However, nearly all cases resolve spontaneously within 2 years, thus identifying patients who require more detailed or invasive work-up is a challenging task for clinicians. I really haven't had many problems since the surgery, other than my neck being stiff. It may take weeks or months to fully recover. WebHeadaches after ACDF surgery. Findings: The thoracic vertebral bodies are aligned with normal marrow signal. An ACDF is a type of spine surgery used to treat neck issues by removing. The screw can be inserted incorrectly and advanced into a nerve or facet joint causing pain and weakness. The artificial disc was removed and an anterior cervical discectomy and fusion (ACDF) with iliac crest bone graft was performed to reconstruct the C6-C7 level. Typically this is nothing to be concerned about. Is this normal 6 months after a fusion to have these spasms in my upper back? Paraspinal tissues are intact. WebPost-laminectomy pain syndrome is a significant cause of pain and disability. Patients may continue to feel some degree of pain three to six months after spinal fusion. Physiother Theory Pract. After the procedure, the surgical area will remain inflamed as the body heals itself. Compared with the results before surgery patients had improved in pain intensity (p = 0.001), neck pain (0.001), numbness (p = 0.02) and were more 'satisfied' with having their neck problems (p = 0.01). I didn't even take any pain medication at home after my surgery because it was tolerable and I just rested and took my time in healing. The Schmorls node mentioned at T7-T8 is I believe right about where my pain is worst(lower between my shoulder blades). They should wear a WebMuscle pain after Cervical Fusion Surgery may be due to a new shoulder injury. My therapist told me it is related to my surgery (the doctor didnt do anything wrong). THANKS FOR ANY REPLY! ligamentum buckling or hypertrophy in cervical spine. THE ONLY THING MRI SHOWS IS A BOOMERANG SHAPE IN MY NECK WHERE THE TITANIUM PLATE IS. This is also how I rehabbed after my spine surgery beginning at 7 months post op with my doctor's permission, but also with the understanding that there is risk with horses. Interested in more discussions like this? The expected length of a hospital stay after an anterior cervical discectomy and fusion usually overnight for one or two level procedures. WHEN I STRETCH, IT FEELS LIKE I AM SEPERATING MY SPINE AND I HAVE INTENSE PAIN WHEN RETRACTING FROM THE STRETCH. Rothman Orthopaedic Institute offers several options for patients with spine disorders. My testing and consults were completed in a few days, and I had an answer and an offer of help. 2007 Apr;16(4):507-14. doi: 10.1007/s00586-006-0271-0. Re: ACDF surgery 6 months after! cervical disectomy fusion c4-5, c 5-6, severe cervical arthr, post anterior cervical disectomy recovery concerns, Numbness post-op c-5 c-6 cervical spine surgery, still in pain after anterior cervical disectomy, Pain in between shoulder blades following Anterior Cervical Discectomy Fushion Surgery-2 weeks Post, post ACDF 4-5,5-6 - still haveTerrible Pain, Anterior cervical fusion c3-4, c4-5, c5-6, Advise of post op symptoms Anterior Cervical Decompression, Cervical spine disectomy, fusion and titanium plate at C6-C7, 7 weeks post-op posterior cervical spine surgery, acdf 2 yrs-chronic shoulder and neck pain, Pain after anterior cervical diskectomy with fusion (ACDF), Neck, shoulder elbow pain. In an attempt to bring these individuals back into their full-speed lives again, doctors and other spine treatment providers focus on mitigating pain. You also have surgical scar tissue in an adjacent I can get sciatic pain because of my pelvis alignment shifting and do stretches for that, but after this last ride, it feels fine. Without the tests, it might have been assumed that the patients pain was due to C6-C7 possible pseudarthrosis. The cervical spinal canal is diminutive in caliberon a congenital basis. Conclusions: Hope you are", "@jenniferhunter thanks for your insight. You may even have a thoracic disc herniation (rare but possible). How are you getting along". Both herniations were central (pushing into the cord, right up the middle) and I never had numbness or tingling, just pain/tightness. Both of them, along with two physical therapists, said my issues were cervical spine which is why I had surgery. My surgeon constantly reiterates your neck is fused, its not your neck, frustrating. March 26, 2018 Three months after undergoing C5-T1 anterior cervical discectomy and fusion (ACDF), an active 60-year-old man from Florida began to experience recurrent neck and left shoulder pain. There may be a separate shoulder problem (less likely but possible) and a well done physical examination would sort this out. I HAVE STABBING PAIN BETWEEN MY SHOULDER BLADES AND SEVERE MUSCLE SPASMS AND PAIN FROM THE BASE OF MY SKULL THROUGH MY SHOULDER AND DOWN INTO MY RIGHT ARM TO MY ELBOW. Neck pain again a year after acdf surgery. It was from C4-C6 with two spacers and a plate with six screws. Its a slow healing process, but in the end, the operation may end up being successful. The cervical spinal canal is diminutive in caliberon a congenital basis. One of the biggest issues we see after surgery is scarring around the nerves (1). In some cases, however, patients go home the same day. Status post ACDF C4-C6 with decompressed canal, recesses, and foramina. According to the parameters studied 50 - 78% of those who at the 6-month follow-up were without deficit were still healthy at the 3-year follow-up. WebBackground:Dysphagia is a common complication immediately following anterior cervical spine surgery.However, its onset more than 1-year postoperatively is rare. It feel like I have done 500 pushups or really strenuous exercise every single day. Ice, electrical stimulation, massage, and other treatments may be used to make the patient more comfortable. The explanation and descriptions are easy to follow and so helpful in understanding the a variety of conditions covered.Thank you Dr Corenmen for providing such a valuable directory of information. Re: ACDF surgery 6 months after! over a year ago, ctmom83445 WebMuscle pain after Cervical Fusion Surgery may be due to a new shoulder injury. I had ACDF on C5 C6 about three weeks ago. Spine (Phila Pa 1976). Drs fail to tell patients this, instead they go by what they read in textbooks in school. He said that back is in spasms due to having suffered through 3 surgeries all within a 17 month time frame. The primary goal of surgery is to relieve your symptoms by decompressing, or relieving pressure on, the compressed nerves in your neck. My original symptoms were bilateral, symmetrical muscle aches/burning in my arms (wrists, forearms, deltoids). After ACDF, youll want to return to your favorite activities as soon as possible, and while the recovery time might be lengthy, a recent study showed that the procedure reduced arm pain in 93-100% and neck pain in 73-87% of standard patients. I am off to a pain management center today at 3. Rheumatoid arthritis of the cervical spine. There may be numbness in the arms. Late infection after an interval of time after ACDF may present with various symptoms and signs including neck pain, dysphagia, and fever accompanied with laboratory abnormalities such as elevated white blood cell count, ESR, and CRP [ 7, 17 ]. Web3 Months Post ACDF JohnyH. So many things hurt now when I move the arm that didn't before. However, nearly all cases resolve spontaneously within 2 years, thus identifying patients who require more detailed or invasive work-up is a challenging task for clinicians. If I don't get satisfactory answers with the neurosurgeon I am either going to go back to the shoulder doc ("if" the surgeon thinks it's a shoulder issue) or make an appointment with Mayo. The more I do that, the less fatigued I get after some miles of riding, and then everything is easier, even walking and climbing stairs because I built the hip, leg and back strength by using all those muscles. My range of motion is normal except that I cannot touch my chin to my chest when I tuck my head, but it is darn close. If you have already had facet injections in the area of your thoracic pain, you can generally rule them out as a pain generator. It hasn't helped. https://connect.mayoclinic.org/discussion/myofascial-release-therapy-mfr-for-treating-compression-and-pain/, https://www.mayoclinic.org/diseases-conditions/thoracic-outlet-syndrome/symptoms-causes/syc-20353988, https://trainingandrehabilitation.com/how-truly-treat-thoracic-outlet-syndrome/, https://sharing.mayoclinic.org/2019/01/09/using-the-art-of-medicine-to-overcome-fear-of-surgery/. WebAlthough relatively rare, post-operative nerve injuries may occur after cervical spine procedures. As others have mentions, drs seemed stumped by the pain issue. Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. If I do something that stresses my neck, like lifting something heavy, I tend to cheat and use my neck muscles to help, then I will get a neck spasm. If you don't get a satisfactory answer from your doctors, you may want to see a neurologist for another opinion who is not associated with the medical centers of your current doctors. A week later, Tom arrived at Dr. Kachmann's office. A cervical epidural should have yielded at least short term relief if the symptoms originated from the nerves of the spinal canal. Acta Neurochir (Wien). (around C6-C7?) The most common post-operative neural disorder is C5 nerve palsy. The average recovery time is 4 to 6 weeks. Number one, you should always be concerned about non-union of the bone graft. Do not know if that is what is causing the pain or not. A coordinator will follow up to see if Mayo Clinic is right for you. In an attempt to bring these individuals back into their full-speed lives again, doctors and other spine treatment providers focus on mitigating pain. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON. I had found the answer myself in medical literature and asked for help in bringing that to the attention of the surgeon, and none of the doctors would help with that even though I had been their patients for several years before I saw the spine surgeon. Some patients can to return to their daily activities within a week after the ACDF surgery. i was so confused and lost about which procedure i should treat my back pain with.Dr.Corenman is just so kind to make time from his schedule to help me :')! Back on feb 28 i have 2 disc fusions in my c5/7. Incorrect Screw Placement Screws and plates are utilized to stabilize the neck during Cervical Fusion Surgery. Posts: 55. It is very common to have some pain after the surgery, but when pain persists for months there are several possibilities. Initially, after the surgery, I was doing great - went back to work in a week and gradually increased gym activities. My neck is bad too, but so far PT had helped. If you have trouble breathing, call 911 or go to an emergency room immediately. If a doctor misses something, others associated with that facility don't want to challenge the current opinion. Incorrect Screw Placement Screws and plates are utilized to stabilize the neck during Cervical Fusion Surgery. I know without cervical spine surgery, my quality of life would have suffered a lot, but I got my life back and I can do most anything I want to do and have no pain except for normal muscle aches because I just rode 20 miles on a horse. I have had some shoulder issues too, a SLAP tear in the capsule in one, and a frozen shoulder in the other caused by the contrast that they injected during an MRI for shoulder instability. I CAN'T SLEEP FOR MORE THAN A COUPLE OF HOURS AT A TIME EVEN WITH SLEEPING PILLS. Some of the key findings were: WebIn the end, after recovering from anterior cervical fusion surgery, most patients report significant improvements and a decrease in pain. I have to have a fusion from T10 to my pelvis it is a big surgery. But, my low back is a mess. In some cases, however, patients go home the same day. 1. Questions about background data, pain, numbness, neck specific disability, distress, sick leave, health, symptom satisfaction and effect of and satisfaction with surgery were asked 28 patients 3 years after ACDF. My low back is fine, no problems there! I don't know if anything (other that waiting until COVID-19 urgency has passed) has changed. @lindyflock Thank you for asking. WebThe orthopedist sent Tom for an MRI and, the same day, referred him "right away" to Michael Kachmann, MD, a neurosurgeon with Mayfield Brain & Spine. Murrey D, Janssen M, Delamarter R, Goldstein J, Zigler J, Tay B, Darden B. Spine J. Core strength in the entire spine supports everything in the body including the neck. The second was c4-7. It is nerve damage. Shoulder Replacement Surgery: What to Expect. Three or four level fusion may require additional days. Hello, I am currently 6 months out from a two level ACDF (c4-c6). I wear a helmet and make sure I ride in control, or I get off if the horse's mind is somewhere else. Rotator cuff tear (supraspinatus mainly) was the predominant finding in MRI in those who didnt improve after ACDF (n=18, 25.7%, p-value: 0.001). Late infection after an interval of time after ACDF may present with various symptoms and signs including neck pain, dysphagia, and fever accompanied with laboratory abnormalities such as elevated white blood cell count, ESR, and CRP [ 7, 17 ]. It did help get rid of the pain in my left arm and neck for a little while. Connect with thousands of patients and caregivers for support, practical information, and answers. If you do have TOS, it causes compression of nerves in the brachial plexus and blood vessels where they pass between the ribs and collar bone. I did a lot of myofascial release before my surgery because I was doing this to treat the TOS, and that helped the neurosurgeon during spine surgery because my muscle was easier to retract. The only thing they would say is to get another opinion, and I did at Mayo which is where I did get help. The hospital team will monitor several metrics to determine the best time to discharge you. According to the parameters studied 50 - 78% of those who at the 6-month follow-up were without deficit were still healthy at the 3-year follow-up. I called me surgen and they told me to stop the exercises they had me doing. Under these circumstances, you may need an Anterior Cervical Discectomy and Fusion . After 7 months, I have not been able to return to work. Thoracic pain (not generated from the cervical spine) could be from disc, facet or nerve origin. It's been almost a year since my surgery. You could have thoracic outlet syndrome in addition to the other issues you mentioned and it causes arm and hand pain, and TOS is more common with spine injury patients. The risk factors for C5 nerve palsy are male gender, OPLL, and posterior cervical approaches. Following surgery the body begins its natural healing process and new bone cells grow around the graft. It generally presents with deltoid and/or WebIt is not uncommon to have pain in the neck following fusion surgery which slowly gets better over 12 to 18 months. Despite a rather small study obtained the stability of 6-month and 3-year results indicates that short-term results might be sufficient for evaluating effects of the treatment. It might. I didn't get all the muscle back in my arms and shoulders yet, but there should be some more tomorrow since I just scrubbed my horse's winter blankets outside. This surgery involves the removal of a protruding disc from the spine for relief of pressure on the spinal nerves, followed by reconstruction. I know i have arthritis and have had it since 16. Measurements have earlier been obtained before and 6 and 12 months after ACDF. I HAVE STABBING PAIN BETWEEN MY SHOULDER BLADES AND SEVERE MUSCLE SPASMS AND PAIN FROM THE BASE OF MY SKULL THROUGH MY SHOULDER AND DOWN INTO MY RIGHT ARM TO MY ELBOW. I see him on Monday to go over the images. Im being told by my surgeon this is a postural issue. I am 16 months post surgery now and life is awful. My pain was immediately gone, and my arm feels great. Recovery time after ACDF surgery generally lasts about four to six weeks. Doing PT, home exercises and even dry needling, to no avail, it always comes back. After the procedure, the surgical area will remain inflamed as the body heals itself. Severe Leg Pain After Spinal Fusion Web3 Months Post ACDF JohnyH. -No discrete labral tear. Late infection after an interval of time after ACDF may present with various symptoms and signs including neck pain, dysphagia, and fever accompanied with laboratory abnormalities such as elevated white blood cell count, ESR, and CRP [ 7, 17 ]. Physiotherapy after anterior cervical spine surgery for cervical disc disease: study protocol of a prospective randomised study to compare internet-based neck-specific exercise with prescribed physical activity. It also is normal to have some swallowing difficulty. After that, a decision is made based on if they can offer medical help, and if that is yes, they will contact you about an appointment. If you have pain early on, that can actually just be part of the operation. When I do things with friends and family, I pay the price dearly. Here are a few of the findings: CLINICAL INDICATION: Radiculopathy, cervical region ACDF spanning C3-C6. What Can, Besides A Physical Injury, Cause Collarbone And Shoulder Pain? WebThe orthopedist sent Tom for an MRI and, the same day, referred him "right away" to Michael Kachmann, MD, a neurosurgeon with Mayfield Brain & Spine. There is straightened cervical spine lordosis with preserved alignment, normal marrow signal, and no prevertebral soft tissue swelling. WebIn the end, after recovering from anterior cervical fusion surgery, most patients report significant improvements and a decrease in pain. Take care Jenniferhunter. the movement of the shoulder is being affected because of the weakness). Any ideas? It's incredibly weird, as so many movements hurt. Three or four level fusion may require additional days. Any insight regarding the CT scan image I attached and/or the summary of the shoulder MRI is greatly appreciated! March 26, 2018 Three months after undergoing C5-T1 anterior cervical discectomy and fusion (ACDF), an active 60-year-old man from Florida began to experience recurrent neck and left shoulder pain. This is the most common question after three-level cervical fusion surgery. 2009 Apr;9(4):275-86. doi: 10.1016/j.spinee.2008.05.006. Purpose: That is roughly where my pain/stiffness is located (between shoulder blades/thoracic), but Im wondering if the pain is stemming from directly below the fusion site and if that maps to my shoulder blades/rhomboid area. I really haven't had many problems since the surgery, other than my neck being stiff. One of the biggest issues we see after surgery is scarring around the nerves (1). Cervical fusion is generally considered safe, however, it is major surgery. There is no knowledge if short-term outcome in patients after anterior cervical decompression and fusion (ACDF) can be used to identify which patients have remaining deficit in long term. ALL IN ALL, I GUESS I NEEDED THE SURGERY BECAUSE OF THE HERNIATION, BUT I HAVE WORSE NECK & SHOULDER MUSCLE PAIN THAN BEFORE. Cervical fusion is generally considered safe, however, it is major surgery. This one was landed me on my behind. Connect with thousands of patients and caregivers for support and answers. Incorrect Screw Placement Screws and plates are utilized to stabilize the neck during Cervical Fusion Surgery. Of course I will be discussing this with the surgeon on Monday but wondered if anyone had thoughts on this image. (thoracic/paraspinal and trapezius pain/spasms upper/mid/lower trapezius and paraspinals. I had my TLIF surgery on 6/24/2020 by Dr. Corenman, I can not say enough good things about the Dr or his staff. Peolsson A, Peterson G, Hermansen A, Ludvigsson ML, Dedering , Lfgren H. BMJ Open. DR IS OUT OF SUGGESTIONS. But I am having excruciating muscle spasms/tightness in my thoracic spine and trapezius muscles and in between my shoulder blades. I think it's the spinal canal. 8600 Rockville Pike A number of potential diagnoses are possible. So You Can Turn Them Off And Liberate Yourself From Back And Shoulder Pain, A New Non-Drug Treatment For Cervical Dystonia. The last couple of weeks, by neck has started hurting pretty bad. They had to remove the first plate. PT, and myofascial release can help a lot, and when there is a structural problem to correct, look for the best surgeon you can find because that helps you have a successful procedure and recovery. Small central disc bulge T10-T11 without mass effect. Patients may continue to feel some degree of pain three to six months after spinal fusion. Thanks again for your response! Do not use nicotine for at least three months. Along with the neck pain, I am also having shoulder pain. I have to agree with you on the nerve burning..that just even sounds bad. Medications. People with their back and neck issues deserve to get better, get their life back, and get back to work. Take any medications that your doctor prescribes for pain and constipation. -Left long head of the biceps tendon is intact. C2-C3: No abnormality. I see my neurosurgeon on Monday, but I'm really nervous about what could be wrong. C5-C6: Canal is decompressed status post discectomy and fusion. Severe Leg Pain After Spinal Fusion Thank you. Wow, that was a big surgery too. Different Treatment Options For Neck Pain: How Effective They Are? Its a slow healing process, but in the end, the operation may end up being successful. like you i can not sleep with out taking sleeping pills, my husband says i cry in my sleep i hurt so bad. It is very common to have some pain after the surgery, but when pain persists for months there are several possibilities. Eur Spine J. My physical therapist started doing manual work on Thursday instead of the ASTYM she was doing on my arm. A CT scan however would eliminate that lack of fusion diagnosis for pain generation as the CT test is the gold standard for determining if fusion is solid or not. ACDF Recovery Tips. Hello, Gilmore06. I feel great. Epub 2011 Oct 20. Posts: 55. My pain was immediately gone, and my arm feels great. I would certainly prefer a conservative approach of course. Haglund performed a minimally invasive posterior cervical fusion with the DTRAX cervical cage system (Providence Medical Technology, Pleasanton, CA). Although the MRI mentions no mass effect, if I was your patient what would be your recommended course of action? If you had a bone graft taken from your pelvis, you may experience pain, soreness, and stiffness at the incision site. The radiology report was very similar. Epub 2006 Dec 2. I've asked my surgeon if that same procedure can be performed along my shoulder blades, sides of my neck and other shoulder as I have the same symptoms as you describe in these areas. WebTypical Physical Therapy after ACDF This is what the patient can typically expect at physical therapy: Pain relief and inflammation are the key concerns at first. Some patients may need to start physical therapy about a month after ACDF and continue it for a couple more months. WebPain in the back of the neck and between the shoulder blades is common after ACDF surgery. Reading the original post was like telling my own story to my Surgeon, Therapist and Pain Manangement Specialist - all of which tell me everything looks fine. Facet generated pain will not be demonstrated by an MRI and has to be diagnosed by facet blocks (see website). The second week after surgery I started to get headaches, not extremely intense, not a migraine, just a pressure headache. Keep in mind your body has to heal on the inside & calm down from the trauma of Number one, you should always be concerned about non-union of the bone graft. I hope we can all figure it out soon and get on with our lives. It causes pain after ACDF surgery because the bone graft and attached muscles change their biomechanics. https://trainingandrehabilitation.com/how-truly-treat-thoracic-outlet-syndrome/. Rejection of a graft or other structures. he then told me to get Physical Therapy. Surgeon said no but agreed to a CT scan, which I had done on Tuesday. I had ACDF on C5 C6 about three weeks ago. What I am not sure about is what kind of artifacts could be caused by the hardware itself on the imaging, so I don't know if the screw is pushing into the spinal canal or right up to it. For someone like me who does more than 300 ACDFs a year, being able to have this in my armamentarium to avoid having to do bigger posterior fusions or big anterior removal of plates is a huge value added.. I HAVE STABBING PAIN BETWEEN MY SHOULDER BLADES AND SEVERE MUSCLE SPASMS AND PAIN FROM THE BASE OF MY SKULL THROUGH MY SHOULDER AND DOWN INTO MY RIGHT ARM TO MY ELBOW. It is not a sharp pain but a steady dull ache like you would get from over exercising. I do have extra tightness on one side of my neck and shoulder that pulls into my rib cage. I WORK 40+ HRS A WEEK, AM VERY ACTIVE IN CHURCH ACTIVITIES, KEEP UP WITH 2 TEENAGE BOYS AND BASEBALL SCHEDULES, HAVE HORSES AND ENJOY DOING OUTDOOR THINGS, BUT I AM IN SEVERE PAIN 24/7 AND SEE NO END IN SIGHT. -Tendinosis at the insertion of the left subscapularis and supraspinatus tendons. PMC good luck to all and hope we all feel better soon. Mostly, this is hands on stretching by the therapist while you lie on the table. Hello! In younger and/or more physically fit individuals, recovery time can range anywhere from 46 weeks. 2019 Feb 19;9(2):e027387. Anterior cervical discectomy and fusion (ACDF) is a type of spine surgery used for the treatment of neck or arm pain caused by cervical radiculopathy. In an attempt to resolve the pain and return to his daily activities, he tried physical therapy, over-the-counter medications, muscle relaxants, steroids, and epidural injections, but his pain persisted. Blood Clots. You could have thoracic outlet syndrome in addition to the other issues you mentioned and it causes arm and hand pain, and TOS is more common with spine injury patients. These usually get better over the next few weeks. WebPain in the back of the neck and between the shoulder blades is common after ACDF surgery. Its a slow healing process, but in the end, the operation may end up being successful. After surgery, patients should eat soft foods and liquids until their first follow-up appointment. FOIA The patient's pain did not improve with 6 months of conservative treatment that included physical therapy and epidural injections. The screws", "@lilypaws yep, I had an ACDF. I had acdf at C5-C6. No acute fracture or acromioclavicular separation. Because of that, I requested a MRI on the cervical spine via my doc's patient portal. WebACDF surgery may be an option if physical therapy or medications fail to relieve your neck or arm pain caused by pinched nerves. It was as close to a miracle I've ever experienced. If you had a bone graft taken from your pelvis, you may experience pain, soreness, and stiffness at the incision site. Reading your post was like deja vu. To minimize discomfort, avoid sitting or lying down for long periods; change position or take a short walk every 20 minutes or so. It was important that the patient undergo diagnostic testing and facet joint injection prior to surgery, Haglund notes.
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