We view and approach the spine as aFunctional Spinal Unit. It can take many months to fully recover from spinal fusion surgery 13. A spine surgeon will use more bone, known as a bone graft, to encourage bone fusion. In addition, nerve damage is a rare, but possible long term effect of having a spinal fusion 13. But study results are mixed when the cause of the back or neck pain is unclear. What is the success rate of fusion surgery? and transmitted securely. There is also a chance of developing symptoms at of the disc levels either above or below the fused vertebrae, termed Adjacent Segment Disease (ASD). Regrettably, as a result of these forces, the hardware can break creating spinal instability and pain. The general idea is to move the bones of the spine (vertebrae) back into anatomical alignment and then fuse the bones in place to form a solid bone. PMC J Pain Res. . Spinal fusion can be used to: Spinal fusion is generally safe. Unfortunately, after the surgery, the pain never changed. Spine (Phila Pa 1976) 2000; 25:801803. Over the long term, additional surgery for pseudarthrosis (10%) occurred in the early follow-up period, and for adjacent segment degeneration (21%), which occurred linearly during the >10-year follow-up period. Abstract To determine the long-term effects of lower lumbar fusion, 94 subjects were catalogued from medical records. Spine (Phila Pa 1976) 2012;37:6776. It has been estimated that about of patients will have symptoms from problems at an adjacent disc by 10 years after surgery. Yes! Read More. July 2014.. http://www.ncbi.nlm.nih.gov/pubmed/24980585. As with any form of surgery, laminectomy carries a risk of some side effects. Because there are a significant number of variables involved including the specific surgical approach, preoperative MRI, and x-ray finding, the results from pressuring the disc, patients age, medical history, and the parameters studied. This article does not include a complete list of all potential risks and complications: as with all surgeries, it is advisable to fully review the potential risks and complications with the treating surgeon prior to having ACDF surgery. Some potential risks of cervical spine surgery include: Reactions to the anesthesia . Sandwiched between each of the spinal bones is a disc. What complications can occur as a direct result of a lumbar fusion? Even when spinal fusion relieves symptoms, it doesn't prevent future back pain. 7.Ho, S., Kim, S., Ha, S. et al. The likelihood of this result becomes even more frequent with fusions of three or more levels. Two- to seventeen-year follow-up. Degeneration: One of the most common issues young patients that have spinal fusion is the development of "adjacent level degeneration" which is the breakdown of the. When they take cells from the adipose tissue, it is called Minimally Manipulated Adipose Tissue (MMAT) transplant. Why would this occur? Only after your doctor can establish the source of your discomfort will they offer spinal fusion surgery. There are 5 spinal bones in the low back which are numbered from top to bottom L1, L2, L3, L4, and L5. Mayo Clinic is a not-for-profit organization. Spinal fusion is a major surgery where one or more of the spinal bones are fused together using screws, bolts, and plates. Anterior cervical discectomy and fusion (ACDF) versus cervical disc arthroplasty (CDA) for two contiguous levels cervical disc degenerative disease: a meta-analysis of randomized controlled trials. This is to keep your spine properly aligned and reduce the risks of complications 2. Make a donation. This lasts 3-4 days on average. 2017 Apr;26(4):985-997. doi: 10.1007/s00586-016-4655-5. Image illustrates unilateral sacroiliac (SI) fusion procedure using a system that provides a principles-based fusion, maximizing the concepts of joint preparation, compression and stability. The doctor takes these cells from the patients adipose (fat) tissue and bone marrow. The disc is then removed and the area is packed with bone and often times a spacer. This, in turn, can create spinal instability and pain. SI joint fusion surgery is considered only after those options have been exhausted. The disc between the spinal bones is often times removed and replaced with bone or a spacer. Anybody who has fusion surgery can develop SI dysfunction. You may have acute chest discomfort, shortness of breath, or coughing if this happens. If they break off and migrate to the lungs, they represent a serious threat. A recent study looked at the effects of single-level lumbar fusion on spine muscle health (7). The dysphagia usually resolves within days, but there is a risk that it can last weeks to months. Loss of height (stature). Summary of background data: 2017 May;26(5):577-585. doi: 10.3171/2016.10.SPINE16317. The two most that you need to know are Adjacent Segment Disease and spinal muscle injury. This is in turn can lead to spine instability and additional injuries including degeneration and arthritis. VA is a recent patient seen in the clinic who experienced this complication. For a few days, many patients may not be able to resume a typical solid food diet. No bending, lifting, or twisting. Director of Regenerative Interventional Spine Medicine This content does not have an English version. 1. A Bibliometric Analysis of the Top 100 Cited Articles in Anterior Cervical Discectomy and Fusion. To assess the long-term, >10-year clinical outcomes of anterior cervical discectomy and fusion (ACDF) and to compare outcomes based on primary diagnosis of disc herniation, stenosis or advanced degenerative disc disease (DDD), number of levels treated, and preexisting adjacent level degeneration. The Mayo Clinic indicates you will most likely be in the hospital for 2 to 3 days after surgery 13. Learn How Bone Growth Therapy Can Help You, Get a Comprehensive Evaluation from Mayo Clinic's Spine Care Experts. We view and approach the spine as a Functional Spinal Unit. Possible Side Effects of Long-Term Spinal Cord Injury - New Mobility I've developed numbness and tingling in my fingers that gets worse after pushing up hills. Anterior surgical treatment for cervical degenerative radiculopathy: a prediction model for non-success. The following are some of the potential dangers and problems of spinal fusion: Its critical that you carefully follow your doctors recommendations regarding the warning signs of blood clots and infection. Union versus nonunion after posterolateral lumbar fusion: a comparison of long-term surgical outcomes in patients with degenerative lumbar spondylolisthesis, Reoperation rate after instrumented posterior lumbar interbody fusion: a report on 1680 cases. The age, overall health, and physical condition of a patient influence how soon they recuperate and return to their normal activities. Following a doctors orders and adhering to post operative instructions are extremely necessary to minimize the risk of complications in the weeks and months following surgery. The surgery is joining two bones together, so there is a risk for decreased range of motion, indicates the AAOS, but they note that most patients will not notice a difference. What causes spinal fusion to fail? "Mayo," "Mayo Clinic," "MayoClinic.org," "Mayo Clinic Healthy Living," and the triple-shield Mayo Clinic logo are trademarks of Mayo Foundation for Medical Education and Research. PRP and stem cell treatment options can accelerate your healing and do not have the complications or significant downtime associated with L5 S1 fusion surgery.\. J Bone Joint Surg Am 1998; 80:941951. The two that you most need to know about are Adjacent Segment Disease and Spinal Muscle Injury. Spinal fusion may be recommended by your doctor to address the following conditions: Fill out the form below to schedule your FREE virtual consultation. The MRI is a cross-section image. The disc between the spinal bones is often times removed and replaced with bone or a spacer. Being active is a central part of my life as I enjoy time skiing, biking, hiking, sailing with my family and 9 grandchildren. Hematoma or seroma causing airway compromise. The sacroiliac (SI) joint is a common but underrecognized source of continuing back pain in patients who have surgical fusions for the treatment of back pain. Spinal Fusion Implant Failure. Clinical Overview: Chronic low back pain in adults. More research is needed to fully understand all of the risk factors involved so that this can better be prevented in the future. The device entered clinical use in late 2017. All can require additional surgery. My passion and specialization are in the evaluation and treatment of cervical disc, facet, ligament and nerve pain, including the non-surgical treatment of Craniocervical instability (CCI). Patients must stay in the hospital for a period of recuperation and supervision following a spinal fusion. Part 8: lumbar fusion for disc herniation and radiculopathy. Inadequate symptom relief after the surgery, Failure of bone graft healing to create a fusion (a non-union, or pseudarthrosis), Temporary or persistent swallowing (medically known as dysphasia), Potential speech disturbance from injury to recurrent laryngeal nerve that supplies the vocal cords, Damage to the spinal cord (about 1 in 10,000). So far, the outcomes are promising. The risks of spine surgery include: damage to a spinal nerve unsuccessful treatment, which can lead to pain that persists after surgery a return of back pain, particularly after spinal. Ringing in the ears (tinnitus) Hearing loss Blurred or double vision Sensitivity to light (photophobia) Nausea and vomiting Neck pain or stiffness Seizures When to see a doctor Tell your health care provider if you develop a headache after a spinal tap or spinal anesthesia especially if the headache gets worse when you sit up or stand. Possible complications include: Infection. Some patients with this ailment have no symptoms, while others have back, neck, arm, or leg discomfort. Trials. Unfortunately, lumbar fusion significantly compromises the health and integrity of these muscles. Accessed Nov. 22, 2022. Eur Spine J. If you follow all your surgeon's instructions, you can expect a smooth spinal fusion recovery that relieves your back pain and any previous numbness or tingling. Global Spine J. Office hours: 7am 5pm, Knee Hurts When I Bend It and Straighten It, Burning Pain on Outside of Knee When Kneeling, Muscle Pain After Cervical Fusion Surgery, Basal Joint Arthritis or CMC / Carpometacarpal Arthritis, Common Craniocervical Instability Symptoms, Perc-FSU Trusted Alternative to Spinal Fusion, Perc-ACLR - Regenexx Treatment for ACL Tear, Regenexx Non-Surgical Alternative to Cervical Fusion, Perc-CT SR Alternative to Carpal Tunnel Surgery, Non-surgical Disc Bulge or Herniated Disc Treatment, Regenexx Alternative to Ankle Fusion Surgery, Perc-CMC Alternative to CMC Joint Surgery. Lets dig in. Why? L5 S1 Fusion refers to the level of the surgery. 1992;17(8):940-2. I quit a successful career in anesthesia and traditional pain management to pursue and advance the use of PRP and bone marrow concentrate for common orthopedic conditions. The .gov means its official. 2005;30(12):1441-5; discussion 1446-7. Spinal fusion complications long-term can be broken down into two major categories: Failure of the procedure itself (failed fusion) and complications arising as a result of the fusion. The surgeon uses bone grafts or metal implants to attach the . When surgery is indicated, Mayo Clinic uses a new, minimally invasive SI fusion implant developed by researchers at Mayo Clinic and CoorsTek Medical and approved by the Food and Drug Administration. This affects patients with large and progressive curves (over 70 degrees) that compress the lungs. This consequence is extremely uncommon. The incidence of hardware failure in one study was an alarming 36% (7). A prospective study comparing decompression with decompression and intertransverse process arthrodesis. The likelihood of this result becomes even more frequent with fusions of three or more levels. Accessed Nov. 18, 2022. A surgeon can get to the spine from the front, known as an anterior spinal fusion. The most common risk of any of the modern spine fusion surgery techniques is the failure to relieve lower back pain symptoms following the surgery. The spinal muscles provide critical stability and support for the spine. Study design: This author has been verfied for credibility and expertise. "No single test can perfectly diagnose the condition," Dr. Cross says. Disclaimer. In your procedure, your spine surgeon may utilize one type of bone graft or a mix of them. https://doi.org/10.1186/s12891-020-3104-0. The information is produced and reviewed by over 200 medical professionals with the goal of providing trusted, uniquely informative information for people with painful health conditions. A prospective study comparing decompression with decompression and intertransverse process arthrodesis. By far the most common complication following surgery is difficulty with swallowing, medically known as dysphagia. Lumbar spine fusion: what is the evidence. Spinal fusion is a major surgery where one or more spinal bones (vertebrae) are fused together using screws, bolts, and or plates. Adjacent Segment Disease After Posterior Lumbar Interbody Fusion: A Case Series of 1000 Patients. The esophagus lies directly in front of the spine and needs to be mobilized and retracted during surgery, which can cause difficulty swallowing. Absolutely. In our clinic we routinely see patients who have had one, two or even three spinal fusions but develop or continue to have SI joint pain. Although spinal fusion is a surgical procedure used to stabilize and join two or more vertebrae together, it can still cause issues in the long run. Please enable it to take advantage of the complete set of features! To learn more about this tragic complication please click on the video below. Long-term follow-up of one hundred and twenty-two patients. Infection. Mayo Clinic on Incontinence - Mayo Clinic Press, NEW The Essential Diabetes Book - Mayo Clinic Press, NEW Ending the Opioid Crisis - Mayo Clinic Press, FREE Mayo Clinic Diet Assessment - Mayo Clinic Press, Mayo Clinic Health Letter - FREE book - Mayo Clinic Press, Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic School of Continuous Professional Development, Mayo Clinic School of Graduate Medical Education, Katelyn beats scoliosis with new innovative surgery, Mayo Clinic Q and A: Cervical disk replacement, Sharing Mayo Clinic: Complex spine surgery helps Belinda Purdy walk again, Mayo Clinic Q and A: Scoliosis treatment options, Mayo Clinic Minute: When spine surgery is the answer, Mayo Clinic Minute: Scoliosis is not just for kids. Results: 2022 Oct 11;15:3137-3156. doi: 10.2147/JPR.S375720. Only after your doctor can establish the source of your discomfort will they offer. 1991 Jul; 73(6):802-8. https://www.ncbi.nlm.nih.gov/pubmed/2071615/. doi: 10.1371/journal.pone.0149312. These structures work with one another in a highly specialized and dependent manner. 5..Greiner-Perth R, Boehm H, Allam Y, Elsaghir H, Franke J. Reoperation rate after instrumented posterior lumbar interbody fusion: a report on 1680 cases. Spine (Phila Pa 1976). 2004 Nov 15;29(22):2516-20. https://www.ncbi.nlm.nih.gov/pubmed/15543064. The disc is named for the two spinal bones it is sandwiched between. Kwon B, Kim DH, Marvin A, et al. J Am Acad Orthop Surg Glob Res Rev. All Rights Reserved | Website by WP Flare, Spinal fusion is a surgical procedure in which two or more vertebrae are permanently joined. Rates vary depending upon the specific type of lumbar spinal fusion procedure. Schedule a Telemedicine consult and learn from a board-certified, fellowship-trained physician what options are available. Having a spine that doesn't move in places puts more strain on the areas around the fused part. Pain at the bone graft site. (2) 2 years after lumbar fusion 40% of patients were unsure/dissatisfied with the outcomes reporting ongoing back pain and limited daily function (3) Another study demonstrated that the overall failure rate of lumbar spine surgery was estimated to be 10%46% (4). Twenty-four were not located and 8 were deceased. The most common causes of a failed lumbar fusion are nonunion, hardware breaking, and hardware becoming loose. J Bone Joint Surg Am. The hardware can also cause neurological damage. How to Heal a Herniated Disc Naturally: Know the Truth! Spinal cord stimulation risks and precautions About 30% to 40% of people experience one or more complications. Trends in lumbar spinal fusion A literature review. Any use of this site constitutes your agreement to the Terms and Conditions and Privacy Policy linked below. The information is produced and reviewed by over 200 medical professionals with the goal of providing trusted, uniquely informative information for people with painful health conditions. Allscripts EPSi. There are several reasons for this. Outcomes following anterior cervical discectomy and fusion: the role of interbody disc height, angulation, and spinous process distance. Then the spine might need more surgery in the future. Reoperation rate after instrumented posterior lumbar interbody fusion: a report on 1680 cases, Adjacent Segment Disease After Posterior Lumbar Interbody Fusion: A Case Series of 1000 Patients. A blood clot can move through the circulation and end up in the lungs on rare occasions. Asian Spine J. The pain was so severe that you agreed to a lumbar fusion. Next Page: Youll be laying down with a blood pressure cuff on your arm and a cardiac monitor on your chest during the treatment. In a small percentage of men who have an anterior fusion, an infrequent complication results in difficulties with ejaculation following spine fusion surgery. 8600 Rockville Pike Electrode failure and migration are the most common. Therefore for the very best results, the spine and all its parts need to be evaluated and treated together. About 3.4% to 10% of people. For those who choose spinal surgery, they must realize it takes time to heal. Collectively about 1 in 10 patients who have a low back fusion will need a second surgery to fix non-union or hardware failure (8). Chang PY, Chang HK, Wu JC, Huang WC, Fay LY, Tu TH, Wu CL, Cheng H. J Neurosurg Spine. 2008;17(8):11071112. Patients frequently need to wear a back brace after they leave the hospital to keep their spine in good alignment. Why would a lumbar fusion fail? J Bone Joint Surg Am. 4. See Potential Risks and Complications of ACDF Surgery. His low back MRI is below and is most significant for the death of the critical low back muscles. 4.Mohi Eldin MM, Ali AM. The doctor used live imaging, such as X-rays or ultrasounds, to spot the exact location of the transplant. Success rates vary depending upon the parameters examined. His low back MRI is below and is most significant for the death of the critical low back muscles. ACDF leads to significantly improved outcomes for all primary diagnoses and was sustained for >10 years' follow-up. https://www.uptodate.com/contents/search. Veritas Health, LLC, 520 Lake Cook Road, Suite 350, Deerfield, IL, 60015, Failed Back Surgery Syndrome (FBSS): What It Is and How to Avoid Pain after Surgery, Postoperative Care for Spinal Fusion Surgery, Scoliosis Surgery: Potential Risks and Complications, Treatment for Failed Back Surgery Syndrome Video, Diagnostic Studies, Patient History, and Physical Exams for Spinal Fusion, Additional Spinal Fusion Surgery Factors and Considerations, Back Surgery Video: How Spinal Fusion Stops Back Pain, What Causes Buttock Muscle Pain and How to Relieve it, Piriformis Syndrome: When the Symptoms Indicate a Medical Emergency, Massage to Reduce Buttock Muscle Pain from Piriformis Syndrome, Suffering from Lumbar Spinal Stenosis? Tell your health care provider about medicines you take. This is done to eliminate uncomfortable motion or restore spinal stability. Blood clots, bleeding, and pain at the surgical site are potential complications of spinal fusion, according to the AAOS 13. There are many reasons for this to occur. Spinal fusion is a surgical procedure in which two or more vertebrae are permanently joined. Indications for L5 S1 fusion are debilitating pain and dysfunction arising from degenerative disc disease, slipped disc, fractures, recurrent herniation, sciatica, scoliosis, and spinal canal narrowing. This is done to eliminate uncomfortable motion or restore spinal stability. government site. Would you like email updates of new search results? Bethesda, MD 20894, Web Policies Accessed Nov. 22, 2022. UCLA Alumni. Mjset C, Solberg TK, Zwart JA, Smstuen MC, Kolstad F, Grotle M. Acta Neurochir (Wien). These treatments are used to restore spine stability, cure spinal deformity (such as scoliosis), and bridge space produced after a spinal decompression procedure by removing a spinal part. The technique the surgeon uses depends on where the bones to be fused are on the spine, the reason for the spinal fusion, and possibly, general health and body shape. Various procedures for doing spinal fusion surgery have been devised by surgeons. 2017 Feb;42(2):E5. The disc is an important shock absorber. Mayo Clinic; 2021. Pflugradt is a freelance writer and registered dietitian with experience in clinical nutrition and outpatient counseling for diabetes management and weight loss. Bleeding. In the example shown, a damaged disk is removed, a bone graft is inserted, and plates and screws hold the bones together. Although major loss of the strength and sensation to the legs or loss of bowel or bladder control can occur, it is rare. July 2014.. http://www.spine-health.com/search/google/fusion?query=fusion&cx=000920495788068656876%3Ag_h27naqu74&cof=FORID%3A10&sitesearch=. "The SI joint is often glossed over as a pain generator, especially in people who have had spinal fusion and experience continued pain," says William W. Cross III, M.D., an orthopedic surgeon at Mayo Clinic in Rochester, Minnesota. Chou R. Subacute and chronic low-back pain: Surgical treatment. Ami TR. Spinal fusion has been used to manage a variety of disorders of the lumbar spine, including tumors, spinal instability, deformity and stenosis. The greater the patients size and the more fused segments, the greater the risk of implant failure. These complications can be avoided by avoiding fusion surgery in the first place. Screws are used in lumbar fusion to stabilize the spine. Is a Spine Fusion Major Surgery? Prospective cohort study with >10-year follow-up. The long-term side effects of spinal fusion surgery are mentioned below: Since the components used in this surgery involve screws, plates, and blots, there is a chance that this hardware used can fail and produce further complications such as hardware failure, spinal muscle injury and adjacent segment disease. Preoperative adjacent-level disc degeneration, pseudarthrosis, and secondary operations were analyzed. Eur Spine J. 5.3k views Answered >2 years ago. Medical implants come in a variety of forms, sizes, and styles all of which are meant to treat spinal diseases in individuals of all ages. To reduce the risk of infection, antibiotics are given to the patient before, during, and after the operation. There is the possibility that the surgery is not successful in treating the pain and the symptoms return. Objective: Epub 2022 Dec 8. Check out these best-sellers and special offers on books and newsletters from Mayo Clinic Press. You have to employ these principles to achieve durable, long-term outcomes that are going to return patients to a much greater quality of a life.". Fusion surgery removes this important shock absorber placing additional stress and forces on the discs and facet joints above and below the level of the fusion. The functional spinal unit is the comprehensive approach utilized at The Centeno-Schultz Clinic, in Broomfield, Colorado right between Boulder and Denver. Oct. 4, 2022. An official website of the United States government. Chronic pain causes changes in your brain and nervous system. It is important to note, however, that the absence of degenerative changes in the SI joint does not eliminate the SI joint as a potential pain generator.". The doctor will want to monitor the patients reactions to the anesthetic and operation at first. The hardware may be placed in the front (anterior) or the back (posterior) of the spine. The procedure employed by the surgeon is determined by the position of the fused vertebrae, the cause for the fusion, and, in certain cases, your overall health and body form. Copyright 2023 Leaf Group Ltd., all rights reserved. Fracture types. Treatment of hardware failure often requires additional surgery to remove the broken hardware and replace it. J Am Acad Orthop Surg Glob Res Rev. Bookshelf "It is interesting to note that this test is often normal during postoperative follow-up, making it a great marker for diagnosis and successful treatment.". Its critical that you carefully follow your doctors recommendations regarding the warning signs of blood clots and infection. A small amount of bleeding is to be expected, although it is rarely severe. Brunicardi FC, et al. Conclusion: 2016 Feb 12;11(2):e0149312. So, l5 s1 surgery success rates would reflect in those statistics. Chronic (long-term) pain: A herniated disc, causing nerve damage, is the most common cause of chronic pain after a TLIF. All rights reserved. BMC Musculoskelet Disord 21, 73 (2020). Premature feeling of fullness in the stomach (hunger satiety). This helps to reduce pain, weakness, numbness, and tingling associated with spinal stenosis. Screws are used in lumbar fusion to stabilize the spine. 2.Tsutsumimoto T, Shimogata M, Yoshimura Y, Misawa H. Union versus nonunion after posterolateral lumbar fusion: a comparison of long-term surgical outcomes in patients with degenerative lumbar spondylolisthesis. 1999-2023 Veritas Health, LLC. https://orthoinfo.aaos.org/en/treatment/spinal-fusion. Treatment options for back pain include PRP and a patients own bone marrow-derived stem cells. This is a real problem, with an incidence of 9% (9). Location: 5741 S Fort Apache Rd suite 100, Las Vegas, NV 89148, USA, 2023 Cellaxys. Adjacent Segment Disease After Posterior Lumbar Interbody Fusion: A Case Series of 1000 Patients. Cauthen JC, Kinard RE, Vogler JB, et al. Transforaminal lumbar interbody fusion. Spinal fusion can help address malformations in the spine, such as a lateral curvature (scoliosis). On the right, the yellow arrows point to dark healthy spine muscles that were present prior to the surgery. Vertebrae are the small, interlocking bones of the spine. Metal plates, screws or rods might hold the bones together. "But with force transfer after spinal fusion, the SI joints can move a couple of millimeters," he says. To stabilize the spine, screws are placed into the spinal bones above and then below the disc that is removed. But as with any surgery, spinal fusion carries some risks. Hardware Longevity and Failure Any medical procedure that depends upon installing foreign and unnatural hardware into the body comes with additional risks and related questions: What type of material is being used? Spinal fusion is a major surgery where one or more spinal bones (vertebrae) are fused together using screws, bolts, and or plates. 2022. 2004 Nov 15;29(22):2516-20. Spinal fusion often works no better than nonsurgical treatments for back pain with a cause that's not clear. A rigid fusion of the spinal bones prevents further growth in . All spine fusion surgeries have the potential for complications. This content does not have an English version. Lumbar fusion surgery has become increasingly popular. 303-429-6448 If you see any of these signs or symptoms, call your doctor immediately. 2013;7:5659. Preventing movement helps to prevent pain. Causes The AAOS indicates that physical activity too soon after surgery can result in pseudarthrosis, which may prompt a second surgery 13. B. Neurological deficits almost all resolved. So to summarize, following are some of the most common potential long-term side effects of scoliosis surgery: Nerve damage Back pain Loss of flexibility Limited range of motion Hardware malfunction Adverse reaction to hardware Loss of strength in the spine Strained muscles surrounding the spine A spine that's more prone to injury
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