VERTEBRAL ARTERY INJURY DURING ANTERIOR DECOMPRESSION OF THE CERVICAL SPINE

VERTEBRAL ARTERY DECOMPRESSION A OF RETROSPECTIVE MICHAEL D. KENNETH From Ten SMITH, Minnesota patients who viewed to assess Center, ...
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VERTEBRAL

ARTERY

DECOMPRESSION A

OF

RETROSPECTIVE

MICHAEL

D.

KENNETH

From

Ten

SMITH,

Minnesota

patients

who

viewed

to assess

Center,

EMERY,

subsequent body

electrocoagulation (1), or open Five patients

but

most

exposure

of

(4),

tumour

them

vertebral

ossification

The final control of (3), direct exposure

(2), open

suture

We

or tumour,

of

direct

found

arterial

to be safe, quick and reliable. Careful particularly in pathologically weakened

by a thorough

relationships

(2),

transosseous

resolved.

as in infection avoided

All had been for spondylitic

ligament (1), nonunion of a (1). The use of an air drill had

(1),

and control

is best

DUDLEY,

placement of a haemostatic clip (3). had postoperative neurological deficits,

use of the air drill,

bone,

ALBERT

USA

outcome. resection

been responsible for most injuries. haemorrhage had been by tamponade and

is essential. knowledge

artery,

the

the

injury

Arterial

of the anatomical canal,

spinal

and

the

1993; 75-B :410.-S. Accepted3O

July

The anterior spinal cord neoplastic,

1992

approach and nerve infective,

potential paralysis,

complications dysphagia,

syndrome,

oesophageal

obstruction haematoma

due to (Smith

1978,

Graham

1989;

for decompression roots is widely used or post-traumatic

reported include vocal cord to the carotid artery, Homer’s

injury

perforation, acute and 1989;

S. E. Emery, MD Department of Orthopaedics, Abington Road, Cleveland, A. Dudley, Four East Baltimore,

MD Madison Maryland

nerve

root

exposure or nerve relief

Emery,

Greater

M. Leventhal, MD Department of Orthopaedics, Clinic, 869 Madison Avenue, Correspondence ©I993 British 030l-620X/93/3522

410

should

South,

Suite

be sent

Editorial Society $2.00

Surgery,

3091

Baltimore

University Memphis, to Dr M. of Bone

Medical

602,

Minneap-

University,

1074

Centre,

Avenue,

Baltimore,

of Tennessee and Campbell Tennessee 38103, USA. D. Smith. and

Joint

Surgery

and

Bohlman

or

spinal

canal

decompression

without

of the dura or manipulation of the spinal cord roots. It results in little epidural fibrosis. Direct

of anterior The

compression

use

is assured,

and

incision

gives

of a transverse

Sepic 1984; In contrast

the uncertain accounts control little

Greenspring

Smith

or

arthrodesis a cosmetic

and often imperceptible scar, and most of the complications of the anterior approach do not detract from the excellent long-term clinical results (Williams, Allen and Harkess 1968; White et al 1973; Bohlman 1977; Gore and

Case Western Reserve Ohio 44106, USA.

Orthopaedic 2121 1, USA.

K. J. Murray, MD, PhD NeurosurgicalOncology, Maryland 21204, USA.

Avenue

respiratory

Despite these theoretical complications, anterior procedures have been successful and are popular. The approach allows for anterior discectomy and thorough

McAfee to this,

et al 1987). laceration of the

Vertebral artery because of the difficulty 24th

and

retropharyngeal oedema Robinson 1958 ; Whitecloud

during an anterior decompression complication. Such injuries have in the literature, probably because

M. D. Smith, MD Minnesota Spine Centre, 606 ohs, Minnesota 55454, USA.

of the cervical for spondylitic, problems. The

1991).

is easy.

body.

J Bone Joint Surg [Br] Received 18 June 1992;

SPINE

PATIENTS

iatrogenic injury to a vertebral decompression were rethe mechanisms of injury, their operative

or myelopathy

suture

TEN

Minneapolis,

posterior longitudinal (2), or osteomyelitis

of the fracture

CERVICAL

cervical

the

ANTERIOR

LEVENTHAL

a partial vertebral

radiculopathy

DURING

suffered

and

undergoing

E.

MARVIN

anterior

management,

OF

SANFORD

Spine

during

THE

REVIEW

J. MURRAY,

artery

INJURY

has

been

the avoidance injury. Spinal decompressions inadvertent We sources

published

to guide

or intraoperative surgeons who should be

had

an

grave and are good

There

exposure of the artery and of the to penetrating neck injuries, but

laceration have reviewed who

particularly haemorrhage,

consequences.

of the surgical of bleeding due

artery

is a very serious received little attention they are infrequent.

laceration is of controlling

neurological

vertebral

of the ten iatrogenic

artery. We aimed to controlling haemorrhage,

the

vertebral patients

THE JOURNAL

surgeon

in

artery. from a variety

injury

determine to discover

risk factors, and to develop guidelines for the avoidance

spinal

management of such an perform anterior cervical prepared to manage an

of

the

the best means the mechanism

anatomical of such injuries. OF BONE

AND

of

vertebral of and

and

surgical

JOINT

SURGERY

VERTEBRAL Table

1. Details

ARTERY

of ten patients

with

INJURY

iatrogenic

DURING

injury

ANTERIOR

to a vertebral

DECOMPRESSION

OF

THE

CERVICAL

411

SPINE

artery S

Case

Age (yr)

Follow-up (mth)

Diagnosis

Procedure bone

10

43

Aneurysmal

Corpectomy

CS, C6

Right

Right

24

Spondylitic

myelopathy

Corpectomy

C3, C4, CS

Left

Right

Coarse

air drill

3

52

18

Old nonunion Spondylosis

of a dens fracture with myelopathy

Corpectomy

C2

Right

Left

Coarse

air drill

4

38

2

Corpectomy

C6, C7

Right

Right

Instrumentation

Discectomy

C5-6

Right

Left

Instrumentation

Corpectomy

C4, CS, C6

Right

Left

Coarse

air drill

Corpectomy

CS, C6

Right

Right

Coarse

drill

Corpectomy

C3

5

52

34

Spondylitic

6

55

12

OPLL

7

86

67

Spondylitic

abscess

radiculopathy with

cervical

C5, C6

Cause

68

epidural

myelopathy

Injury

I

and

with

Arterial

2

Osteomyelitis myelopathy

cyst

Approach

with

C6 myelopathy

myelopathy

Metastatic

cancer

C3

Instrumentation

8

75

2

Right

Right

Cavitron

9

67

31

Pseudarthrosis

C6-7

Hemicorpectomy

C6, C7

Right

Right

Diamond

10

43

12

Pseudarthrosis

C5-6

Hemicorpectomy

CS, C6

Right

Right

Coarse

burr burr

Estimated Case

Level

ofinjury

bked (ml)

Management

I

Mid

third

Avitene,

2

Mid

third

Direct

electrocoagulation

3

Lower

third

Direct clips

electrocoagulation,

4

Lower

third

Avitene,

5

Upper

third

Direct distal

exposure vascular exposure,

6

Mid

third

Direct

gelatin

gelatin

sponge

proximal

sponge

Mid

third

Transosseous

ligation

Mid

third

Transosseous

ligation,

9

Disc

space

Exposure

10

Disc

space

Gelatin

incision,

and

proximal

distal

vascular

None

Artery

None

No

3

Upper airway tracheostomy. later

4

Immediate embolisation None

5

6

OPLL* dural absence, dural patch and graft

Emergency fusion Cl to CS one week angiography

CSF fistula. reinsertion

Reoperation

None

for

fossa

intact

Posterior

fossa

intact

with

dysphagia circulation at 6 months

Severe Marked

CS root damage None

1000

CS root damage which resolved

cranial

with signs

with

mild deltoid

with

deltoid

No pain

posterior

or functional

No pain difficulty

limitations

II myelopathy,

or functional

chronic

limitations,

Persistent

mild

needs

central

ofdaily

cord

syndrome,

No pain,

No

Death

at 2 months

9

None

No

Death

due to unrelated

causes

10

None

No

No pain

or functional

limitations

75-B,

No. 3, MAY

1993

minor

deltoid

lost to follow-

no pain,

weakness : disseminated

disease

swallowing

living

No

VOL.

renal

Drug abuser, left hospital against advice, up Overhead activities increase vertigo meet

ligament

weakness

Comments

None

longitudinal

paralysis

None

None

of the posterior

paralysis

hemiplegia.

and biceps

8

ossification

palsies

Persistent Vocal cord

prominent

7

0

nerve

and dysarthria. insufficiency.

quadraparesis cerebellar

No pain, Nurick with dialysis

Posterior

No

infarction

1000

no pseudoaneurysm

Collateral flow present, fossa intact

and

None Cerebellar

Transient posterior resolved

angiogram

patent,

complications

None

1700

300

Postoperative

Neurological

4500

2300

tamponade

I

postoperative

clips

ligation

2

obstruction. Posterior

and

2000

500

complications

Non-neurological

vascular

electrocoagulation

by vertebrectomy, sponge

and distal

tamponade

proximal

7

2300 400

by separate clips

8

Case

tamponade

km

cancer at 33 months

able

to

M. D. SMITH,

412

PATIENTS We

AND

made

S. E. EMERY,

A. DUDLEY,

METHODS

a retrospective

review

of medical

records

at

K. J. MURRAY,

M. LEVENTHAL

provided prompt temporary control, but in case 6, severe hypovolaemia led to cardiac arrest before temporary control of the haemorrhage allowed adequate restoration

the authors’ four medical centres, all being referral centres for complex and tertiary spinal care, and identified ten patients who had had vertebral artery

of blood volume. Methods of definitive

laceration during an anterior operation of the cervical spine (C2 to C7). We with congenital vascular malformations,

an extended waiting period. In these bleeding had ceased, but blood loss had (2300 ml and 4500 ml) and the operations

arterial shows

injuries or aneurysmal the details of the ten

surgeons surgeons). of one patients

involved Four

on the lower part excluded patients post-traumatic

vascular patients.

(three neurosurgeons, of the authors had

4, the

lesions. Table I There were nine

six orthopaedic personal experience

by four other associates with this paper.

All

the operations had been similar technique with anterolateral the common carotid neurovascular the trachea nine right the surgeon.

performed using exposure, medial sheath and lateral

a to to

and oesophagus. The side of the approach, and one left, was based on the preference of During the study period from January 1986

to May 1990, about 1 195 tions had been performed were unable to determine

anterior cervical spine operaby the five authors, but we the other four surgeons’ case

loads. The approximate incidence was 0.5%. The first author (MDS) studied records and the operative notes

in the

authors’

(7 hours

and

followed

by

controlled In

case each ; the fifth of two cases. Thus, six of the were under the direct care of one of the authors;

the other four were managed who did not wish to be involved

packing

cases

radiographs for risk factors, intraoperative errors, and neurological sequelae. Follow-up reports were obtained at the various centres, usually by the responsible operating surgeon, and included a physical examination and radiographs.

despite

Follow-up

averaged

24 months,

with

never returned for patient (case 8) died metastases. Neither apparent complication.

two

patients

having

abuser (case 4) at two months and

removal of halo fixation, and one after two months from disseminated of these had paralysis or any other The other eight patients were

followed for at least one year, and none needed further operations for the cervical spine disorder that prompted the index operation. None had late worsening of any neurological complications at the time of discharge, and all with

iatrogenic

neurological

least some recovery. Findings. In all cases, unaware vertebral unexpected gelatin (Avitene

of the

close

the

injuries operating

proximity

of his

artery : the first indication and profuse bleeding. sponges, ; Medchem

bone

wax, Products,

have surgeon

shown had

dissection

In cases

gently

removed

had

placement,

patients,

either

or there

severe postoperative of arterial control

been

and

this

bleeding

had

had

after

two patients the been considerable were prolonged

10 tamponade

bone-graft

1 and

been

had concern

haemorrhage, and been undertaken,

probably caused later. A separate necessary There

the spinal longitudinal

in case were

clinically

5 to provide no

detectable

arterial

embolisation patients

only

or

patients one alone.

had

of them Because

soon had

a direct

after the operation. postoperative neurological

four

Case nerve

3 suffered a Wallenberg’s and bulbar dysfunction al

Four

postoperative haemorrhage, this an uncomplicated prophylactic

lems,

et

diagnosed had been

adequate exposure. of recurrent bleeding

cases

angiography, but treated by tamponade

possibility of had undergone

as

injuries incision

pseudoaneurysm.

of the patient Five

nerve root left-sided

complication

1980).

An

of

the

prob-

arterial

injury.

syndrome (lower cranial with cerebellar findings: MRI

scan

showed

a large

infarction (Fig. 1), but the patient’s speech, swallowing have improved over the 18-month One patient (case 5) had persistent ataxia and

vertigo with positional changes of the head, which were thought to be due to impaired posterior circulation; resolution has been slow and incomplete. Cases 7 and 9 had root injuries due to blind suture placement, and had rapid and nearly complete recovery. The fifth patient, case 6, had a severe quadraparesis, which is still dense but recovering slowly one year later. This patient had ossification of the posterior longitudinal ligament and a grade 4 myelopathy (Nurick 1972). She had absence ofthe dura and a postoperative cerebrospinal fluid fistula. postoperative

These other problems quadraparesis.

could

have

caused

her

been to the

of trouble Tamponade

and fibrillated Woburn, Mass)

at

In case

varied.

by suture ligation in cases 7, 8 and 9, by metallic clips in cases 3, 5 and 6 and by exposure and electrocoagulation in case 2. In cases 7 and 8 the sutures had been passed blindly through bone using a stout curved needle above and below the area of the arterial injury ; these sutures

cerebellar gait and follow-up.

RESULTS

been

tamponade

possible methods

Schellhas

less than one year. One intravenous-drug left hospital against medical advice

8 hours). immediate

had postoperative (case 4) had been

in detail the medical with all pertinent

had

the bleeding. another seven

recurred about direct

control

material

was with

collagen usually

DISCUSSION Before

200 these

this patients occurred

study,

we would

would during

have

not

have

arterial

anticipated

vertebrectomy

THE JOURNAL

that

lacerations.

OF BONE

for AND

Most spinal JOINT

1/ of

cord

SURGERY

VERTEBRAL

ARTERY

INJURY

DURING

ANTERIOR

DECOMPRESSION

OF

THE

CERVICAL

SPINE

413

Case 3. A 52-year-old man with an old upper cervical spine fracture and progressive myelopathy. During decompression of the lateral aspect ofthe spinal canal with a motorised burr, the left vertebral artery was lacerated. A haemorrhagic cerebellar infarction resulted. Axial MRI of the skull shows an ischaemic area in the distribution of the posterior inferior cerebellar artery.

decompression anterior

a more

-

discectomy.

extensive

use

complex

procedure

Vertebrectomy

of motorised

burrs

in tight

three common reasons for the apparent : the motorised dissection width of the bone and disc removal bone of the pathologically

lateral softened

Anatomy.

The

subclavian

or

transversarium

lateral

to

through the base

vertebral

of the infection

artery

the sixth

the

surgical

originates and

and

enters

Before

teal

this,

of C7, but usually The

artery

passes

foramina until it reaches level it curves posteriorly to

enter the foramen transversarium part of the ring of the atlas and

in the perforates

posterolateral the posterior

membrane to pass through the foramen It then joins the opposite vertebral artery to basilar artery, which supplies most of the and cerebellum. The artery is most vulnerable C7, laterally at C3 to C7, and posteriorly at

Cl andC2. Operative

technique.

With

the

anatomy must wide.

in

mind,

the

be performed To deviate

in from

the midline or to remove bone wider than is necessary risks a laceration, particularly if there is ectasia of the vertebral artery (Fig. 2). The location of the insertions of longus colli may help to maintain orientation. SubperiosVOL.

75-B,

No. 3, MAY

1993

dissection

the anterior posteriorly.

cervical spine of a patient injury. It is apparent that The corpectomy defect is of the fibular strut graft.

of their

the

defect needed 3). The bone and straight anteroposterior tomy

cortex,

then

medial

borders

is performed

surface of the vertebral body The width between the two

represents

usually

any

removed Kerrison

atlantoaxial magnum. form the brainstem anterior to

removal of bone and disc material the midline and not be excessively

Case 2. Anteroposterior radiograph of the who sustained a right-sided vertebral artery the surgeon lost his midline orientation. eccentric as shown by the lateral placement

was

from the the foramen

vertebra.

process

dissection.

a series of transverse of the axis. At this

the

confines,

spinal canal or tumour.

cervical

to the transverse

a simple

requires

lacerations became was off midline ; the was excessive ; or the

artery

innominate of

it is anterior

part from

than

usually

appropriate

width

osteophytes,

be extended

of the

corpec-

for spinal canal decompression (Fig. disc material is then removed in a direction. The posterior vertebral and

the

using a diamond burr, punches as needed.

needed, using The vertebral

until

begins to curve dissected flaps

laterally

to the

small diamond artery should

(Raynor 1983). We verified the safety by studying 25 preoperative, axial CT scans of patients

disc

fine The

material

are

curettes, and decompression

also

microcan

uncovertebral

joints,

burrs or Kerrison be above this

punches. dissection

as

ofthis technique of dissection myelographically enhanced, who were about to undergo

anterior decompression and fusion. We measured the distances from the floor of the spinal canal to the artery, from the anticipated lateral wall of the decompression to the artery, and the necessary width of through the middle portion of the vertebral CS and

C6 (Fig.

3). The

average

width

decompression bodies at C4,

of the spinal

cord

414

M. D. SMITH,

Fig.

S. E. EMERY,

A. DUDLEY,

K. J. MURRAY,

M. LEVENTHAL

3

Diagram of the landmarks used to measure the width of the corpectomy needed for adequate spinal canal decompression. The vertical lines are based on the medial borders of the longus colli muscles. The horizontal line is at the most anterior aspect of the dissection on the floor of the canal showing the lateral position of the arterial foramina.

at these levels was The average lateral needed

to

1 3.7, 1 3.8 and 1 3.3 mm respectively. dissection ofthe longus colli insertion

provide

decompression at all levels,

thus

a

ical landmarks margin of safety.

motorised burr. can be performed

that we A small

irrigation,

foramina. Preoperatively, the

for

an

vertebral

the

should the

angiography

note

CT

should

artery is prophylactic

displaced, measures

such placement

as its exposure for of encircling vascular

sion,

precautions (Fig. 4). In the exposure difficult exposure effective, inflatable compression

would

or

the position

MRI

scans

presence

been

of vigorous

dilated, before

;

bleeding

if the

in cases the

,

9

unplanned

of the vertebral artery presents a serious and problem. Our best results were with direct of the artery ; blind placement of sutures was but caused nerve root palsies. The use of an balloon catheter of the vessel

to provide temporary within the foramen

external transver-

1988).

foramen or complete allow the muscles ; retracted

also

distal These

1 4 and

laterally operation

severe of the

haemorrhage interferes artery (Hatzitheofilou

et

the arterial injury is on the same side as the original approach, exposure may be facilitated by further lateral dissection of the longus colli and longus capitus beyond the transverse process to expose the

al

When

transversarium. In these circumstances partial transection of the sternocleidomastoid may surgeon easier retraction laterally of the other the carotid sheath could also be mobilised and medially or laterally as necessary (Riley 1989).

Partial removal ofthe rim of the foramen

additional decompres-

the proximal and loops or sutures.

valuable

to

in the Burkus Fig. 4).

be considered

tortuous, or may be needed

have

sarium is possible when with the orderly exposure

safely used to perform a of the lateral recesses of the risk of entering the arterial

on

cyst extends after the anteriorly.

a

be

surgeon

arteries

4

Axial preoperative CT scan. An aneurysmal bone around the foramen transversarium. An angiogram revealed that the artery was tortuous and displaced

with a 5 mm with continuous

determine if the arteries are ectatic or are involved tumour or infection (Lindsey, Piepmeier and 1985; Bohlman et al 1986; Born et al 1988: Preoperative

Fig.

adequate

This shows that using the anatom-

have described, diamond burr,

then

can

generous decompression canal with very small

of

guide

of the central canal was less than 3 mm leaving at least S mm of bone between

the artery and the central corpectomy

saline

lateral

allow

wider

longus colli transversarium exposure

muscle and the anterior with rongeurs will

(Verbiest

sternocleidomastoid

muscle

has

be re-approximated

at the

time

been

1969). divided,

of wound

If

the

it should

closure,

and

the cosmetic results should be acceptable (Southwick and Robinson 1957). If the injury is on the contralateral side and adequate visualisation is not obtained through the initial incision, the operating surgeon could either extend the present incision beyond the midline and expose the artery beyond the contralateral sternocleidomastoid (as described Some one

above) other

vertebral

or make published artery THE

a separate incision. work supports the

can JOURNAL

be

ligated OF BONE

without AND

JOINT

idea

that

serious SURGERY

VERTEBRAL

(McCormick

consequences

of

ARTERY

our

ligated posterior

seven

related

to the

INJURY

1983;

Perry

patients had circulation.

DURING

1989),

neurological This rate

ANTERIOR

but

three

deficits is greater

that reported by Golueke et al (1987) (six of 23) or Hatzitheofilou et al (1988) (four of 20). These authors were reporting the results of traumatic lacerations in

DECOMPRESSION Golueke P,Sclafani and management. Gore

than

younger tolerate

patients unilateral

who were more likely to be able to ligation. An additional factor is arterial

dominance.

In patients

with

sided artery part of the

is usually the blood supply

asymmetry,

arterial

the left-

larger and provides to the hindbrain.

the greater Ligation or

prolonged

OF

THE

CERVICAL

S, PhilllpsT, J Trauma

DR, Sepic SB. Anterior protruded discs : a review 1984; 9:667-71.

et al. Vertebral artery 1987; 27:856-65.

C, Demetriades approaches

injury

cervical fusion for of one hundred forty-six

Graham JJ. Complications of cervical spine. Second ed. Philadelphia, etc: Hatzitheofilou Surgical

415

SPINE

D,

to vertebral

degenerated patients.

spine injury. J. B. Lippincott, injuries.

M, Franklin

7:234-7. Lindsey RW, PiepmeierJ, BurkusJK. an adventitious finding after [Am] 1985; 67-A :806-8.

Tortuosityofthe cervical trauma.

McAfee PC, Bohlman HH, Riley LH Jr, retropharyngeal approach to the upper part J BoneJoint Surg[Am] 1987; 69-A:1371-83.

vertebral artery: J Bone Joint Surg et al. The of the cervical

McCormick

We would prefer repair rather than ligation artery (Perry 1989 ; De Los Reyes et al 1990), and

Nurick S. The natural history and results of surgical treatment spinal cord disorder associated with cervical spondylosis.

Reyes absence vein

et al (1990) of the left grafting

describe vertebral

after

an

a patient with a congenital artery who required bypass right vertebral lacera-

iatrogenic

tion. This was not possible in any of our patients. anterior exposure does not allow for direct repair laceration of the posterior or posteromedial arterial No benefits commercial article.

in any party

form have been related directly

An of a wall.

received or will be received or indirectly to the subject

from a of this

J. 1988;

Br J Surg

occlusion by retraction ofa left vertebral artery in patients with this vascular pattern increases the likelihood ofcerebellar or brainstem infarction (Bohlman and Eismont 1981 ; Berguer 1985; Bohlman et al 1986). of the De Los

or Spine

In : The cervical 1989 :831-7.

J, Stewart

Meissas artery

: diagnosis

WF.

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RN, ed. Livingstone,

The

anterior spine. clinical 1983 III:

24 1-4. of the Brain

1972; 95:101-8. Perry

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MO. Injuries of the ed. Vascular surgery. Saunders, 1989:604-12.

brachiocephalic Vol. 2. Third

RB. Anterior or posterior anatomical and radiographic surgery 1983; 12:7-13. LH

Jr. Anterior

cervical

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ed.

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approach evaluation

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to the cervical and comparison.

to the lower Philadelphia,

cervical etc : J.

W.

RB, B.

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Schellhas KP, Latchaw injuries following

RE,

Wendling

cervical

LR,

Gold

LHA.

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JAMA

Vertebrobasilar 1980; 244:

1450-3. Smith

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