craniocervical instability

The pathological threshold for the degree of translation of the basion with respect to the odontoid process between flexion and extension is 2mm, and any amount of translation greater than 1mm is capable of producing symptoms7. 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. Symptomatic improvement with traction can help determine whether a patient with abnormal measurements will benefit from craniocervical fusion surgery. Most of us have experienced rapid heart rates after vigorous exertion or exercise. atlanto-axial subluxation : atlantoaxial rotatory fixation will cause C1 lateral mass asymmetry relative to the dens. The following tests can be used to measure cervical instability but little is known about the diagnostic accuracy of upper cervical spine instability tests: Sharp-Purser test; Transverse Ligament Stress Test; Cervical flexion-rotation test; Neck Flexor Muscle Endurance Test and Craniocervical flexion test [9][10][11][12][13] Patients sometimes describe the feeling that their head is too heavy for their neck to support (bobble-head). 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). I am a co-founder of the Centeno-Schultz Clinic which was established in 2005. 12 Kim, Louis J., et al. Complex Posterior Fossa revisions. It happened so quickly. Risks of both methods include vertebral artery injury, and a slightly increased risk for segmental instability below the fusion, along with the standard risks of any surgical procedure, such as bleeding, infection, and complications from anesthesia. 16 Henderson, F C, et al. A retroflexed odontoid occurs when the odontoid is bent backwards, often compressing the front of the brain stem. The major ligaments involved are the Alar, Transverse and Accessory ligaments. tachycardia An unusually rapid heart beat. "[5], It is not unusual for CCI to co-occur with other structural neurological abnormalities such as atlantoaxial instability (AAI) and chiari malformation (CM).[41][14]. Bolognese reports that treatment of craniocervical instability typically begins with more conservative medical management, such as neck bracing, activity limitation, physical therapy (including isometrics, sagittal balance, core strengthening and cardio), and pain management. This page was last edited on November 30, 2022, at 11:59. A subset of patients can develop clinical instability of the craniocervical junction associated with pain and neurological dysfunction, potentially warranting treatment with occipitocervical fixation (OCF). The occipito-atlantic joint allows for about half of the cervical spines ability to flex and extend (tilt forward and backward). It is frequently co-morbid with atlanto-axial instability, Chiari malformation[1] and tethered cord syndrome. Possible explanations include. Craniocervical instability is usually diagnosed through neuro-anatomical measurement using radiography. The impact of craniocervical instability can range from minor symptoms to severe disability, with some patients being bed-bound. Dizziness or imbalance is a feature related to the fact that the upper neck is a major contributor to balance (4). [4][54][3][56][53] Common complications include screw failure, wound infection, dural tear and cerebrospinal fluid leakage[3] In some cases revision surgery is needed to treat infection or to remove hardware. A symptom of postural orthostatic tachycardia syndrome (POTS). Interestingly, during the flexion of the normal spine, it stretches 17% of its length. [53] Screw and rod fixation methods have lower complication rates and higher rates of successful fusion. Adv Otorhinolaryngol. This distance should not be more than 12 mm. This surgery may be done through the mouth or the nose[18]. Your Grabb Oakes Measurement: What Does It Mean? Fortunately, there are many natural and non-invasive treatment options to relieve your atlas pain. White III,. 2023 ICD-10-CM Range M00-M99. Because ligaments are too weak, muscles tend to tense up in order to compensate, so they get exhausted. It also helped me understand the corrective procedures needed. Every day can feel like your brain is stuffed full of cotton. Neuropathology of the Brainstem and Spinal Cord in End Stage Rheumatoid Arthritis: Implications for Treatment.Annals of the Rheumatic Diseases, U.S. National Library of Medicine, Sept. 1993, . Elevated heart rate may occur as the vagus nerve gets irritated by the extra motion in the upper neck. Complex management issues. However, surgical intervention via a craniocervical fusion is indicated when the following criteria are met: Severe headache or neck pain >7/10 Often times this is very helpful in the evaluation of patients with CCI. A stiff neck can cause pain, tightness, popping, and clicking noises and sensations and affect daily activities. When the doctor and patient alike are not knowledgeable about these conditions and the additional symptoms that often accompany them, these more complex cases are often treated with a standard decompression, which can actually weaken the stability of the craniocervical junction more, and result in an increase of symptoms rather than a clinical improvement. Lets dig in. Craniocervical instability symptoms Cervicocranial syndrome Headaches Neck pain Double vision Memory loss Dizziness Vertigo Ringing in the ears Speech difficulties Difficulty swallowing Sleep apnea Snoring or frequent awakening Choking on food Numbness in arms or legs Unsteady walking Clumsyness Weakness in arms, hands or legs In a previous blog, I reviewed the 7 main criteria used in establishing the diagnosis of cranial cervical instability. Unfortunately, traditional MRI and CT studies do not evaluate the upper cervical spine or alar and transverse ligaments. Many describe feeling like they have a bobble-head. Pain is typically localized at the base of the skull and aggravated with flexion and rotation. 2016;17(1):441. The pain can interrupt your sleep and erode your quality of life. The exact cause of brain fog is unknown. Because of this, these vertebrae lack the same amount of stability as the remainder of the spine, and ligaments are largely responsible for their stability[8]. Craniocervical instability (CCI) is a pathological condition of increased mobility at the craniocervical junction, the area where the skull meets the spine. Milhorat et al. Little research on outcomes exists. We use advanced imaging and treatment options to diagnose and manage your condition. It involves the injection of a patients own bone marrow-derived stem cells into the damaged alar, transverse ligaments. This results in excruciating pain close to your neck, skull, and shoulders. This is an x-ray examination that is recorded in which the patient is put through various movements including bending the neck forward, backward, and to the side. Likewise, at the C1-C2 joint, instability in the form of AAI can cause an excessive uncovering of the joint facets. [44][45][46] Others have argued that these radiological measurements are "not accepted internationally as indicating instability. Published 2016 Oct 21. doi:10.1186/s12891-016-1284-4. This is especially important considering that, according to Chiari expert Paolo Bolognese, M.D., [with revision surgeries], the results are not as good as if you had done the posterior decompression well the first time.[3]. In the patient community, the term "CCI" is often used in reference to both Craniocervical Instability and Atlantoaxial Instability (AAI). Lower cervical spine disorders can usually be distinguished clinically (based on level of spinal cord dysfunction) and by neuroimaging. Craniocervical Instability (CCI) is a medical condition where the strong ligaments that hold your head to your upper neck are loose or lax (1). Neurosurg Rev 42:915-936. Like instability, a kyphotic clivoaxial angle is often seen in patients with connective tissue disorders and, A heavy headache (often referred to as feeling like a bobblehead or feeling like the head is a bowling ball), A Chiari-type pressure headache aggravated by, Facial pain or numbness Occasionally, including, Vision problems, including double vision and downward, In more severe cases, non-epiform seizures have also been documented. Since then, others, including Jen Brea and Julie Rehmeyer, have been diagnosed and undergone surgery, while others [] ", "Tendon Injury and Fluoroquinolone Use: A Systematic Review", "Craniocervical spinal instability after type 1 Arnold Chiari decompression: a case report", "REVIEW OF THE 2013 CSF RESEARCH COLLOQUIUM & CONSENSUS ON CRANIOCERVICAL INSTABILITY Bobby Jones CSF", "Computed tomography evaluation of the normal craniocervical junction craniometry in 100 asymptomatic patients", "Angular craniometry in craniocervical junction malformation", "Rheumatoid arthritis of the cervical spine: surface-coil MR imaging", "Videoed Presentation at: ASAP Chiari & Syringomyelia Conference Paolo Bolognese, MD "Complex Chiari. The flow of sensorimotor retraining strategy is recommended: 1. It frequently co-occurs with atlantoaxial instability (AAI). 1.Offiah CE, Day E. The craniocervical junction: embryology, anatomy, biomechanics and imaging in blunt trauma. It is that ringing or buzzing sound that slowly improves the next day over several hours. Every day can feel like your brain is stuffed full of cotton. This is the American ICD-10-CM version of M53.2 - other international versions of ICD-10 M53.2 may differ. The hardware may be placed in the front (anterior) or the back( posterior) of the cervical spine. Clin Med (Lond). 2007, . [4] More recently, physicians have reported an increased prevalence of CCI in patients with hereditary disorders of connective tissue such as Ehlers Danlos Syndromes (EDS). 2016, . Craniocervical instability, however, implies an instability between the head and atlantal vertebra (the C1). "Craniocervical Instability (CCI), also known as the Syndrome of Occipitoatlantialaxial Hypermobility, is a structural instability of the craniocervical junction which may lead to a pathological deformation of the brainstem, upper spinal cord, and cerebellum. Regrettably, many of these patients undergo extensive, costly GI evaluations only are told that their examinations and studies are normal. Based on the cervical pain and the necessity to perform a diagnosis the patient the lesion was approached. What are the most common Craniocervical Instability Symptoms? Symptoms in cervical vertigo. Examples of diagnostic injections include: In many cases due to the severity of the symptoms patients are not able to complete their domestic or professional responsibilities. This condition is called tinnitus. An important cranial nerve also lies just deep to the occipital condyles, making precise screw placement extremely important. 10 Henderson, Sr. , Fraser C. Neurological Management of Hereditary Disoders of Hypermobility Connective Tissue Disorders. Ehlers-Danlos Society Annual Conference 2015. 1.Offiah CE, Day E. The craniocervical junction: embryology, anatomy, biomechanics and imaging in blunt trauma. Employment, relationships, and joy often times are eroded. Craniocervical instability (CCI) occurs when the craniocervical junction at the base of the brainstem becomes 'shaky'. Craniocervical instability is a problem that can lead to soreness and pain in the neck and head, and being familiar with the influence of this issue is critical for serving to. [2] This can lead to stretching and/or compression of the brainstem, upper spinal cord, or cerebellum and result in myelopathy, neck pain and a range of other symptoms. These ligaments include the alar, transverse, accessory, apical dens, and others. 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 . GI problems can be due to structural and functional problems within the gut itself. ", "Severe posttraumatic craniocervical instability in the very young patient. Later that day or the next morning, moving across the room may have seemed almost impossible and took herculean power. It refers to an excessive degree in mobility of the joints and junctions in the craniocervical area, mainly due to a ligamentous hyperlaxity. When should I worry about it? When a person suffers from craniocervical instability or CCI, the strong ligaments that hold their head to their upper neck are lax or loose (2). In the case of the craniocervical region, its understanding becomes even more challenging, since its anatomy and physiology are more complex and it is more mobile. Severity can vary and in severe cases, patients are confined to their beds. 2013, . All diagnostic injections are performed under ultrasound or x-ray or both. Craniocervical instability, if left untreated, can result in a progression in symptoms and injury to the cervical discs, facets, muscles, and nerves. If you or a loved one sustained an injury and have symptoms that include headache, dizziness, and brain fog which is unresponsive to conservative care you may have cranial cervical instability. These studies are useful to identify instability. 47 6 thatphanom.techno@gmail.com 042-532028 , 042-532027 Risk factors include injury, prior history of neck and musculoskeletal pain, jobs that require a lot of desk work, low social support, job insecurity, physical weakness, and poor computer station setup. Case-based review Later these 20 measurements got reduced to 14 measurements. Biesinger E. and Vertigo caused by disorders of the cervical vertebral column. Craniocervical Instability (CCI) also known as Syndrome of Occipitoatlantialaxial Hypermobility, is a potential complication that people with EDS (and other connective tissue disorders) can experience. It is important to view the body as a whole and there are multiple potential physical findings in the neck, head, shoulder, and low back in patients with cranial cervical instability. At Dr Gilete we are experts in Ehlers Danlos surgery, craniocervical instability EDS,neuro and spine disorders related to EDS and whiplash. Craniocervical & Atlantoaxial Instability, Stenosis & Disc Degeneration - Coming Soon, American Syringomyelia & Chiari Alliance Project (ASAP), The clivoaxial angle is measured by drawing a line along the posterior (back, or when lying more horizontal, the top) side of the lower clivus and intersecting that line with a line drawn on the posterior side of the axis. Have you ever had a challenging all-day hike, athletic endeavor, or worked a double shift and felt exhausted the next day? A perpendicular line is then drawn from the center of this line to the dura of the brain stem. 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). The measurements to diagnose craniocervical instability are: Alternatively, craniocervical instability can be diagnosed if a trial of cervical traction, typically using a halo fixation device, results in a significant alleviation of symptoms. from lying down to sitting up). The Alar ligament provides stability for your head and neck. Other important measurements involving ventral brain stem compression for a kyphotic clivo-axial angle and/or retroflexed odontoid include the Grabb-Oakes and Harris measurements. 14 Bono, C M, et al. II, ME/CFS and FibromyalgiaCraniocervicalInstability Surgery Effectiveness Poll, "Awake fiberoptic orotracheal intubation using a modified Guedel airway in a patient with craniocervical instability and an anticipated difficult airway - A case report -", "Neurological and spinal manifestations of the EhlersDanlos syndromes", "Surgical Outcomes and Complications after Occipito-Cervical Fusion Using the Screw-Rod System in Craniocervical Instability", "Occipitocervical Fusion: An Updated Review", "Cranio-cervical Instability in Patients with Hypermobility Connective Disorders", "Have you ruled out Chiari as a cause of your CFS", "Craniocervical instability, Atlantoaxial Instability, Myalgic Encephalomyelitis, ME, CFS", "Occipitoaxial spinal interarticular stabilization with vertebral artery preservation for atlantal lateral mass failure", "Histology of the craniocervical junction in chronic rheumatoid arthritis: a clinicopathologic analysis of 33 operative cases", "Treatment of craniocervical instability using a posterior-only approach: report of 3 cases", "Basilar invagination: craniocervical instability treated with cervical traction and occipitocervical fixation. Measurement Techniques for Upper Cervical Spine Injuries: Consensus Statement of the Spine Trauma Study Group.Spine., U.S. National Library of Medicine, 1 Mar. Craniocervical instability (CCI) is a medical condition where there is excessive movement of the vertebrae at the atlanto-occipital joint and the atlanto-axial joint, that is, between the skull and the top two vertebrae (C1 and C2). I have been a patient with severe pain and know firsthand the limitations of traditional orthopedic surgery. The pain can shoot up into the base of the skull, top of the head, frontal area or behind the eyes. Synovitis is characterized by infiltration of innate and adaptive immune cells; joint destruction is a consequence of activation of synovial fibroblasts, which acquire aggressive, inflammatory, invasive features, associated with increased chondrocyte catabolism and synovial osteoclastogenesis.Neck pain is the most frequent symptom of spinal . What Are the Long Term Effects of Untreated Whiplash? The 2023 edition of ICD-10-CM M53.0 became effective on October 1, 2022. [64][65][43], Five ME/CFS patients diagnosed with CCI (some also had EDS) reported to have experienced remarkable improvements and even remission of their ME/CFS symptoms following OCF-surgery. This is not your normal headache caused by your in-laws or excessive consumption of alcohol. What Is the Alar Ligament? Lying supine can bring short-term relief. If you have been diagnosed with Craniocervical Instability, your doctors have concluded that you have a structural disorder at the back of your head where the base of your skull (the occipital bone) and C0 (the atlas) - C1 vertebrae (the axis) function together. Excessive movement between your head and neck can cause movement and damage of upper cervical facet joints, discs, nerves, and blood vessels. [3] It can be brought on by a trauma, frequently whiplash; laxity of the ligaments surrounding the joint; or other damage to the surrounding connective tissue. See if you're a Candidate for the PICL Procedure. 7 Menezes, Arnold H. Craniovertebral Junction Anomalies: Diagnosis and Management.Seminars in Pediatric Neurology, vol. The ideal tests to diagnose CCI and AAI are an upright MRI with flexion and extension and a 3D CT with rotational views, respectively[10]. What is the Alar Ligament? [4][26], More recently, physicians have reported an increased prevalence of CCI in patients with hereditary connective tissue disorders. Even worse is it does not resolve over time. The following code (s) above M53.2 contain annotation back-references that may be applicable to M53.2 : M00-M99. The letter C is associated with the numbers to designate the cervical spine. The report I got from Vicen Gilete, a Neurosurgeon from Spain who deals with . In severe cases of CCI, patients are confined to their homes and are socially isolated. The diagnosis of CCI is based on symptom presentation, a supportive history, demonstrable neurological findings and abnormal imaging. Young RM, Prasad V, Wind JJ, Olan W, Caputy AJ. Exercises, Physical Therapy, and Craniocervical Instability (CCI): What Should You Know? This is chronic fatigue, and it is one of the common symptoms associated with craniocervical instability. The level of disability is important in diagnosing craniocervical instability (CCI). Craniocervical fixation is a surgical challenge due to proximity of neurovascular structures and the wide range of motion of this region, hampering bone fusion.Craniocervical instability can originate from congenital causes,in adults,it is primarily seen in the setting of acute trauma or degenerative changes.Also,neoplasm & infection These pathologies can be approached through either a high retropharyngeal ap-proach or transoral approach. A second opinion can help determine if your recovery after surgery was normal or if you need to be concerned, particularly if you're experiencing post-surgery symptoms. Craniocervical Instability (CCI) is a medical condition where the strong ligaments that hold your head to your upper neck are loose or lax (1). 1988; 39: 44 51. doi:10.1007/s13244-016-0530-5, 2.Sobey G. Ehlers-Danlos syndrome a commonly misunderstood group of conditions. Symptoms vary and can include nausea, bloating, constipation, diarrhea, delayed motility, abdominal pain, irritable bowel-like symptoms, heartburn, and reflux. PEM may be referred to as a "crash" or "collapse" and can last for days or weeks. These types of disorders can happen at birth or develop after an injury. Clinical Biomechanics of the Spine.By Augustus A. To learn more about CCI please click on the video below. JNS JOURNAL OF Neurosurgery OFFICIAL JOURNALS OF THE AANS since 1944.Treatment of Basilar Invagination Associated with Chiari I Malformations in the Pediatric Population: Cervical Reduction and Posterior Occipitocervical Fusion | Journal of Neurosurgery: Pediatrics, Vol 101, No 2, Nov. 2004, . Its name reflects the fact that it looks like a smaller version of the cerebrum. They are almost identical to one another, and refer to upward displacement of the bones of the spine. This may be especially true in patients with cervical degenerative disease, such as ankylosing spondylitis (AS). The PICL procedure is a novel non-surgical treatment for CCI utilizing a patients own stem cells that are injected into the damaged or loose upper cervical ligaments. Modern Classification and Subclassification of Chiari Malformations.YouTube, American Syringomyelia Chiari Alliance Project, 16 Mar. 2015, . Head and upper neck disorders, which are also known as upper cervical disorders, craniovertebral junction (CVJ) abnormalities, and craniocervical disorders, occur at a critical place in your body, so you may assume that surgery is your only option.While it's true that surgery may be the sole treatment for some CVJ disorders (such as Chiari malformations), non-surgical methods may be enough . In severe cases, patients are housebound due to their level of dysfunction and symptoms. What is Craniocervical Instability or Cranial Cervical Instability? It is estimated to impact between 1,000,000 and 3,000,000 Americans. objective outcome An outcome of a clinical trial that is independent of the judgement of opinion of the assessor/clinician, e.g. Laryngoscope Investig Otolaryngol. It is more common in people with a connective tissue disease, notably Ehlers-Danlos Syndrome,[2] osteogenesis imperfecta and rheumatoid arthritis. Symptoms of craniocervical instability include occipital headache, neck pain and neurological abnormalities such as numbness, motor weakness, dizziness, and gait instability. The craniocervical junction is the area at the back of the skull which houses the brainstem, the cerebellum and the top of the spinal column. A cervical fusion surgery removes, Our bodys balancing system is compromised of three separate systems that work closely together to keep the body in balance: the eyes, inner ear, and upper cervical spine. . Soreness and pain can be debilitating. Jeff Wood's remarkable recovery from severe ME/CFS following spinal surgery to correct craniocervical instability (CCI) and other problems shocked the ME/CFS community. Wire methods are less biomechanically stable than rod methods and have high rates of dural laceration. Eye movements in patients with Whiplash Associated Disorders: a systematic review. What are the major 7 criteria for diagnosing craniocervical instability? 2017;8(1):2947. They are: In 2015 a nonsurgical treatment option for cranial cervical instability was developed at the Centeno-Schultz Clinic. Other symptoms reported in patients with CCI include: Established risk factors for CCI include physical trauma, infection, inflammatory disease, neoplasms and congenital disorders. Injury that causes torn tissue in ligaments or skull supporting muscles. An uncovering of the facets that exceeds 20% is considered pathological. The neck of composed of 7 boney building blocks that are numbered from 1-7. Patients with CCI can struggle with memory, concentration, and ability to complete tasks. Neck stiffness can occur at the base of the head, down to the shoulders. Report of three cases", "Occipital cervical stabilization using occipital condyles for cranial fixation: technical case report", "MRI video diagnosis and surgical therapy of soft tissue trauma to the craniocervical junction", "Occult hypermobility of the craniocervical junction: a case report and review", "Nontraumatic Atlanto-occipital and Atlantoaxial Rotatory Subluxation: Case Report", "Non-Traumatic Atlanto-Occipital and Atlanto-Axial Dislocation: A Case Report", "Structural odontoid lesions in craniovertebral tuberculosis: a review of 15 cases", "Craniovertebral junction abnormalities in Down syndrome", "Craniocervical instability in the setting of os odontoideum: assessment of cause, presentation, and surgical outcomes in a series of 279 cases", "Oral Fluoroquinolones and Risk of Mitral and Aortic Regurgitation", "Spontaneous cervical artery dissection: a fluoroquinolone induced connective tissue disorder? Examples include upright MRI with upright flexion/extension. Craniocervical Instability can also result as a complication of Chiari decompression surgery, when too much bone is removed from the skull, resulting in the instability of the skull on the top of the spine [6]. The major ligaments involved are the Alar, Transverse and Accessory ligaments. Craniocervical junction abnormalities are congenital or acquired abnormalities of the occipital bone, foramen magnum, or first two cervical vertebrae that decrease the space for the lower brain stem and cervical cord. The information provided at this site is not intended to diagnose or treat any illness.From MEpedia, a crowd-sourced encyclopedia of ME and CFS science and history. Less appreciated is the fact that many patients with Craniocervical instability (CCI) can also have significant GI problems. Remember the ringing in your ears after a loud rock concert or highly charged sporting event? The major ligaments involved are the Alar, Transverse and Accessory ligaments. Instability can result either from lax ligaments and other connective tissues, soft bones (also seen in HDCTs) or from something like pannus formation, where repeated rubbing together of the joints causes a build-up of granulated tissue around bony structures and changes the way certain bones lie in relationship to one another[5]. Case report", "Utility of the clivo-axial angle in assessing brainstem deformity: pilot study and literature review", "Cervical medullary syndrome secondary to craniocervical instability and ventral brainstem compression in hereditary hypermobility connective tissue disorders: 5-year follow-up after craniocervical reduction, fusion, and stabilization", "Syndrome of occipitoatlantoaxial hypermobility, cranial settling, and Chiari malformation Type I in patients with hereditary disorders of connective tissue", "MRI video diagnosis and surgical therapy of soft tissue trauma to the craniocervical junction - ProQuest", "Clinical management of cranio-vertebral instability after whiplash, when guidelines should be adapted: A case report", "Occult Hypermobility of the Craniocervical Junction: A Case Report and Review", "New Diagnostic Tools Can Contribute to Better Treatment of Patients with Chronic Whiplash Disorders", "Instrumented arthrodesis for non-traumatic craniocervical instability in very young children", "Secondary tinnitus as a symptom of instability in the upper cervical spine: Operative management", "Deformative stress associated with an abnormal clivo-axial angle: A finite element analysis", "Posterior Instrumentation for Occipitocervical Fusion", "Ehlers Danlos, complex Chiari and cranio-cervical fixation: how best should we treat patients with hypermobility? Problems can be due to structural and functional problems within the gut itself shoulders... Judgement of opinion of the brain stem biesinger E. and Vertigo caused by your in-laws or excessive of... Based on level of disability is important in diagnosing craniocervical instability last edited on November 30, 2022 at. And backward ) done through the mouth or the next morning, moving across the may. Less biomechanically stable than rod methods and have high rates of successful fusion to perform a diagnosis patient! For about half of the skull, top of the facets that exceeds 20 is... Radiological measurements are `` not accepted internationally as indicating instability 2016,

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