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Introduction
  • Epidemiology
    • incidence
      • 11,000 new cases/year in US
        • 34% incomplete tetraplegia
          • central cord syndrome most common
        • 25% complete paraplegia
        • 22% complete tetraplegia
        • 17% incomplete paraplegia
    • demographics
      • bimodal distribution
        • young individuals with significant trauma
        • older individuals that have minor trauma compounded by degenerative spinal canal narrowing
    • location
      • 50% in cervical spine
  • Mechanism
    • MVA causes 50%
    • falls
    • GSW
    • iatrogenic
      • it is estimated that 3-25% of all spinal cord injuries occur after initial traumatic episode due to improper immobilization and transport.
  • Pathophysiology
    • primary injury
      • damage to neural tissue due to direct trauma
      • irreversible
    • secondary injury
      • injury to adjacent tissue due to
        • decreased perfusion
        • lipid peroxidation
        • free radical / cytokines
        • cell apoptosis
      • methylprednisone used to prevent secondary injury by improving perfusion, inhibiting lipid peroxidation, and decreasing the release of free radicals
  • Associated conditions
    • acute phase conditions  (see below)
      • spinal shock
      • neurogenic shock 
    • associated injuries
      • closed head injuries
      • noncontiguous spinal fractures
      • vertebral artery injury
        • risk factors for vertebral artery injury include
          • atlas fractures
          • facet dislocations
        • most people with unilateral injury remain asymptomatic
        • imaging
          • magnetic resonance angiography is least invasive method
        • treatment
          • stenting only if patient is symptomatic from basilar arterial insufficiency
  • Prognosis
    • only 1% have complete recovery at time of hospital diagnosis
      • conus medullaris syndrome has a better prognosis for recovery than more proximal lesions 
Relevant Anatomy
  • See Spinal Cord Anatomy topic
Classification
  • Descriptive
    • tetraplegia
      • injury to the cervical spinal cord leading to impairment of function in the arms, trunk, legs, and pelvic organs
    • paraplegia
      • injury to the thoracic, lumbar or sacral segments leading to impairment of function in the trunk, legs, and pelvic organs depending on the level of injury. Arm function is preserved
    • complete injury
      • an injury with no spared motor or sensory function below the affected level.
      • patients must have recovered from spinal shock (bulbocavernosus reflex is intact) before an injury can be determined as complete
      • classified as an ASIA A
    • incomplete injury
      • an injury with some preserved motor or sensory function below the injury level
      • incomplete spinal cord injuries include
        • anterior cord syndrome 
        • Brown-Sequard syndrome 
        • central cord syndrome 
        • posterior cord syndrome 
        • conus medullaris syndromes
        • cauda equina syndrome 
ASIA Classification
  1. Determine if patient is in spinal shock
    • check bulbocavernosus reflex
  2. Determine neurologic level of injury
    • lowest segment with intact sensation and antigravity (3 or more) muscle function strength
    • in regions where there is no myotome to test, the motor level is presumed to be the same as the sensory level.
  3. Determine whether the injury is COMPLETE or INCOMPLETE
    • COMPLETE defined as  (ASIA A)
      • no voluntary anal contraction (sacral sparing) AND
      • 0/5 distal motor AND
      • 0/2 distal sensory scores (no perianal sensation) AND
      • bulbocavernosus reflex present (patient not in spinal shock)
    • INCOMPLETE defined as
      • voluntary anal contraction (sacral sparing)
      • sacral sparing critical to determine complete vs. incomplete
      • OR palpable or visible muscle contraction below injury level OR
      • perianal sensation present
  4. Determine ASIA Impairment Scale (AIS) Grade:       
ASIA Impairment Scale


Motor Sensory
A Complete No motor function. Complete deficit
B Incomplete  No motor function.
Incomplete deficit
C Incomplete Motor function is preserved - more than half of key muscles below the neurological level have a muscle grade less than 3. Incomplete deficit
D Incomplete Motor function is preserved - at least half of key muscles below the neurological level have a muscle grade of 3 or more. Incomplete deficit
E Normal Normal Motor Normal Sensory
 
Acute Phase Conditions
  • Neurogenic shock
    • characterized by hypotension & relative bradycardia in patient with an acute spinal cord injury  
      • potentially fatal
    • mechanism
      • circulatory collapse from loss of sympathetic tone
        • disruption of autonomic pathway within the spinal cord leads to
          • lack of sympathetic tone
          • decreased systemic vascular resistance
          • pooling of blood in extremities
          • hypotension
    • treatment
      • Swan-Ganz monitoring for careful fluid management
      • pressors to treat hypotension
  • Spinal shock
    • defined as temporary loss of spinal cord function and reflex activity below the level of a spinal cord injury.
    • characterized by
      • flaccid areflexic paralysis
      • bradycardia & hypotension (due to loss of sympathetic tone)
      • absent bulbocavernosus reflex
        • reflex characterized by anal sphincter contraction in response to squeezing the glans penis or tugging on an indwelling Foley catheter
    • timing
      • variable but usually resolves within 48 hours
      • at its conclusion spasticity, hyperreflexia, and clonus slowly progress over days to weeks
    • mechanism
      • neurophysiologic in nature
        • neurons become hyperpolarized and unresponsive to stimuli from brain
    • evaluation
      • important because one cannot evaluate neurologic deficit until spinal shock phase has resolved 
        • end of spinal shock indicated by return of the bulbocavernous reflex
        • conus or cauda equina injuries may lead to permanent loss of the bulbocavernous reflex
    • ruled out when
      • bulbocavernous reflex present
      • 48 hours has elapsed from time of injury
    • stages of spinal shock
      • Phase 1 - hyporeflexic
        • 0 to 48 hours
        • areflexia/hyporeflexic
      • Phase 2 - initial reflex return
        • 1-2 days
        • polysynaptic reflexes return (bulbocavernous reflex)
        • monosynaptic (patellar) remain absent
      • Phase 3 - initial hyperreflexia
        • 1-4 weeks
      • Phase 4 - spasticity
        • 1 to 12 months
        • characterized by altered skeletal performance
  Spinal Shock Neurogenic Shock Hypovolemic Shock
BP Hypotension  Hypotension Hypotension
Pulse Bradycardia Bradycardia Tachycardia
Reflexes / Bulbocavernosus Reflex Absent Variable/independent
Variable/independent
Motor Flaccid Paralysis Variable/independent Variable/independent
Time ~48-72 hours immediately after spinal cord injury ~48-72 hours immediately after spinal cord injury Following excessive blood loss
Mechanism Peripheral neurons become temporarily unresponsive to brain stimuli. Disruption of autonomic pathway leads to loss of sympathetic tone and decreased systemic vascular resistance. Decreased preload leads to decreased cardiac output.
 
Evaluation
  • Field treatment
    • treatment of potential spinal cord injuries begins at the accident scene with proper spinal immobilization
    • immobilization
      • immobilization should include rigid cervical collar and transport on firm spine board with lateral support devices
      • patient should be rolled with standard log roll techniques with control of cervical spine
      • spine boards should be used for transport only and patients should be removed when clinically safe
        • decubitus ulcers can occur after only 30-60 mintues on a backboard
    • athletes
      • in the setting of sports-related injuries helmets and shoulder pads should be left on until arrival at hospital or until experienced personnel can perform simultaneous removal of helmet and shoulder pads in a controlled situation
  • Initial evaluation
    • primary survey
      • airway
      • breathing
        • SCI above C5 likely to require intubation
      • circulation
      • initial survey to inspect for obvious injuries of head and spine
        • visual and manual inspection of entire spine should be performed
          • seat belt sign (abdominal ecchymoses) should raise suspicion for flexion distraction injuries of thoracolumbar spine
    • secondary survey
      • cervical spine exam
        • remove immobilization collar
        • examine face and scalp for evidence of direct trauma
        • inspect for angular or rotational deformities in the holding position of the patient's head
          • rotational deformity may indicate a unilateral facet dislocation
        • palpate posterior cervical spine looking for tenderness along the midline or paraspinal tissues
          • absence of posterior midline tenderness in the awake, alert patient predicts low probability of significant cervical injury
        • log roll patient to inspect and palpate entire spinal axis
        • perform careful neurologic exam
    • cervical spine clearance 
Initial Medical Treatment
  • Medical / Prevention
    • DVT prophlaxis
      • indications
        • most patients
        • contraindications include
          • coagulopathy
          • hemorrhage
      • modalities
        • low-molecular weight heparin
        • rotating bed
        • pneumatic compression stocking
    • cardiopulmonary management
      • careful hemodynamic monitoring and stabilization is critical in early treatment
        • hypotension should be avoided
      • implement immediate aggressive pulmonary protocols
    • decubitus ulcer prevention
  • Steroids 
    • high dose methylprednisone
      • indications
        • current indications
          • current literature and available guidelines recommend against administration due to
            • lack of clear clinical benefit
            • risk of complications 
        • historical indications
          • nonpenetrating SCI within 8 hours of injury recommended by NASCIS III
      • historical contraindications include
        • GSW
        • pregnancy
        • under 13 years
        • > 8 hours after injury 
        • brachial plexus injuries (peripheral nerve injuries)
      • technique
        • load 30 mg/kg over 1st hour (2 grams for 70kg man)
        • drip 5.4 mg/kg/hr drip
          • for 23 hours if started < 3 hrs after injury 
          • for 47 hours if started 3-8 hours after injury
      • outcomes
        • may leads to improved root function at level of injury
        • associated with significant complications
    • monosialotetrahexosylganglioside (GM-1)
      • indications
        • remains controversial
          • large multicenter RCT did not show long term benefit
          • some evidence of faster recovery
  • Reduction
    • acute closed reduction with axial traction
      • indications
        • alert and oriented patient with neurologic deficits and compression due to fracture/dislocation
          • bilateral facet dislocation with spinal cord injury in alert and oriented patient is most common reason to perform acute reduction with axial traction
      • technique
        • reasons to abort
          • overdistraction
          • worsening neurologic exam
          • failure to obtain reduction
Definitive Treatment
  • Nonoperative
    • bracing and observation
      • indications
        • most GSWs
          • exceptions listed below
  • Operative
    • surgical decompression and stabilization 
      • indications
        • most incomplete SCI (except GSW)
          • decompress when patient hits neurologic plateau or if worsening neurologically
          • decompression may facilitate nerve root function return at level of injury (may recover 1-2 levels)
        • most complete SCI (except GSW)
          • stabilize spine to facilitate rehab and minimize need for halo or orthosis
          • decompression may facilitate nerve root function return at level of injury (may recover 1-2 levels)
          • consider for tendon transfers
            • e.g. Deltoid to triceps transfer for C5 or C6 SCI 
        • GSW with
          • progressive neurological deterioration with retained bullet within the spinal canal
          • cauda equina syndrome (considered a peripheral nerve)
          • retained bullet fragment within the thecal sac
            • CSF leads to the breakdown of lead products that may lead to lead poisoning
Rehabilitation
  • Goals
    • goal is to assess and identify mechanisms for reintegration into community based on functional level and daily needs
    •  patients learn transfer techniques, self care retraining, mobility skills
  • Restoring hand function 
    • hand function is often limiting factor for many patients
    • tendon transfers can be used to restore function to paralyzed arms and hands by giving working muscles different jobs
  • Modalities
    •  functional electrical stimulation is a technique that uses electrical currents to stimulate and activate muscles affected by paralysis

Level
Patient Function
C1-C3 - Ventilator dependent with limited talking.
- Electric wheelchair with head or chin control
C3-C4 - Initially ventilator dependent, but can become independent
-
Electric wheelchair with head or chin control
C5

- Ventilator independent
- Has biceps, deltoid, and can flex elbow, but lacks wrist extension and supination needed to feed oneself
- Independent ADL’s;
electric wheelchair with hand control, minimal manual wheelchair function 

C6 - C6 has much better function than C5 due to ability to bring hand to mouth and feed oneself (wrist extension and supination intact)
- Independent living;
manual wheelchair with sliding board transfers, can drive a car with manual controls
C7 - Improved triceps strength
- Daily use of a
manual wheelchair with independent transfers
C8-T1 - Improved hand and finger strength and dexterity
- Fully independent transfers
T2-T6 - Normal UE function
- Improved trunk control
- Wheelchair-dependent
T7-T12 - Increased abdominal muscle control
- Able to perform unsupported seated activities; with extensive bracing walking may be possible
L1-L5 - Variable LE and B/B function
- Assist devices and bracing may be needed
S1-S5

- Various return of B/B and sexual function
- Walking with minimal or no assistance

 

Prognosis
  • Complete Injuries
    • improvement of one nerve root level can be expected in 80% of patients
    • improvement of two nerve root levels can be expected in 20% of patients
    • only 1% have complete recovery at time of hospital diagnosis
  • Incomplete Injuries
    • trends of improvement include
      • the greater the sparring, the greater the recovery
      • patients that show more rapid recovery have a better prognosis
      • when recovery pleateus, it rarely resumes improvement
  • Conus medullaris syndrome
    • has a better prognosis for recovery than more proximal lesions 
Complications
  • Skin problems
    • treatment is prevention
    • start in ER
      • do not leave on back board
      • start log rolling early
      • proper bedding
  • Venous Thromboembolism
    • prevent with immediate DVT prophylaxis
  • Urosepsis
    • common cause of death
    • strict aseptic technique when placing catheter
    • don't let bladder become overly distended
  • Sinus bradycardia
    • most common cardiac arrhythmia in acute stage following SCI
  • Orthostatic hypotension
    • occurs as a result of lack of sympathetic tone
  • Autonomic dysreflexia 
    • potentially fatal
    • presents with headache, agitation, hypertension
    • caused by unchecked visceral stimulation
      • check foley
      • disimpact patient
  • Major depressive disorder
    • ~11% of patients with spinal cord injuries suffer from MDD 
    • MDD in spinal cord injury patients is highly associated with suicidal ideation in both the acute and chronic phase.
 
 

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Questions (40)
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(OBQ04.154) Which of the following scenarios would be most appropriate for posterior deltoid-to-triceps transfers? Review Topic

QID: 1259
1

Axillary nerve injury

11%

(425/3763)

2

C6 ASIA A Spinal Cord Injury with 5/5 biceps and 4/5 brachioradialis

67%

(2520/3763)

3

Erb's palsy with waiters tip deformity

6%

(213/3763)

4

C5 ASIA C Spinal Cord Injury with 3/5 deltoid and 2/5 biceps

3%

(130/3763)

5

C5 ASIA D Spinal Cord Injury with 4/5 deltoid and 4/5 biceps

12%

(449/3763)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(OBQ11.225) A 49-year-old male fell from a height of 10 feet while cleaning his roof. He sustained the isolated injury shown in Figures A and B. Upon transfer from the outside hospital 10 hours later, he has 0/5 motor strength in bilateral lower extremities, no sensation distal to umbilicus, and an intact bulbocavernosous reflex. He has no perianal sensation or rectal tone. He received no medical management at the outside hospital. Which of the following is the most appropriate use of methylprednisolone in this patient.? Review Topic

QID: 3648
FIGURES:
1

Initiate high-dose methylprednisolone with a loading dose of 30mg/kg and a drip of 5.4 mg/kg/hr

15%

(366/2386)

2

Initiate high-dose methylprednisolone, without a loading dose, at 5.4 mg/kg/hr

3%

(69/2386)

3

Do not initiate treatment with methylprednisolone

80%

(1900/2386)

4

Initiate high-dose methyprednisolone if his neurologic status does not improve over the next 14 hours

0%

(7/2386)

5

Administer a one-time dose of methylprednisolone at a dose of 30 mg/kg

1%

(34/2386)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(OBQ14.45) A 32-year-old man is brought to the Emergency Department after cervical spine trauma. Physical examination has classified his injury as ASIA B at the C6 level. All of the following exam findings are expected in this patient EXCEPT? Review Topic

QID: 5455
1

Sensation intact in the long finger

14%

(334/2370)

2

Sensation intact over the medial aspect of the forearm

15%

(365/2370)

3

5/5 strength in deltoid function

10%

(242/2370)

4

2/5 strength in triceps function

49%

(1168/2370)

5

0/5 strength in the instrinic hand muscles

10%

(243/2370)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4
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(OBQ09.154) Functional electrical stimulation is used in the rehabilitation of patients with spinal cord injuries. This rehabiliation method has the greatest functional effect on which of the following? Review Topic

QID: 2967
1

Sensory nerves

6%

(100/1730)

2

Motor nerves

13%

(219/1730)

3

Skeletal muscle

77%

(1331/1730)

4

Motor cortex

1%

(25/1730)

5

Dorsal root ganglion

3%

(50/1730)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(OBQ05.12) A 2-year-old child falls down a flight of stairs and is found to have spinal cord injury without radiographic abnormality (SCIWORA). What is the most important predictor of her neurologic outcome? Review Topic

QID: 49
1

Mechanism of injury

1%

(10/894)

2

Severity of initial neurologic injury

79%

(709/894)

3

Injury pattern of fracture or dislocation

2%

(14/894)

4

Location of spinal cord injury

4%

(35/894)

5

Age of patient

14%

(121/894)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2
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(OBQ09.43) All of the following are attributed to the loss of supraspinal control of the sympathetic nervous system that commonly occurs in patients with spinal cord lesions at T-6 or higher EXCEPT Review Topic

QID: 2856
1

Supine hypotension

16%

(263/1696)

2

Orthostatic hypotension

7%

(111/1696)

3

Spasticity

54%

(909/1696)

4

Autonomic dysreflexia

5%

(81/1696)

5

Cardiac arrhythmias

19%

(326/1696)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(OBQ10.35) A 52-year-old male is involved in an altercation where his neck was twisted and extended with force. Upon presentation he complains of neck pain, and loss of ability to stand or ambulate. On physical exam, he has Grade 3 motor strength in the majority of his muscles groups in his upper and lower extremities. His sensory is intact in all four extremities, and his bulbocavernosus reflex is intact. Sagittal and coronal computed tomography are shown in Figure A and B respectively. The patient's neurologic condition is best classified as? Review Topic

QID: 3123
FIGURES:
1

ASIA E

1%

(53/3648)

2

ASIA D

66%

(2404/3648)

3

ASIA C

25%

(897/3648)

4

ASIA B

7%

(260/3648)

5

ASIA A

0%

(16/3648)

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PREFERRED RESPONSE 2

(SBQ12SP.15) An 18-year-old male is evaluated for a suspected spinal cord injury. His neurological exam shows diminished sensation below the T7 level. His bulbocavernosus reflex is intact. Which physical finding of motor function, below the affected neurological level, would classify this injury as an ASIA B according to the American Spinal Injury Association impairment scale? Review Topic

QID: 3713
1

More than half of the major muscles demonstrate palpable or visible muscle contraction

4%

(175/4025)

2

At least half of key muscles have a muscle grade of 5.

3%

(103/4025)

3

More than half of key muscles have a muscle grade less than 3.

19%

(757/4025)

4

At least half of key muscles have a muscle grade of 3 or more.

11%

(458/4025)

5

No motor function preserved below affected neurological level

62%

(2507/4025)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(OBQ10.44) What percentage of patients with a spinal cord injury suffer from Major Depressive Disorder? Review Topic

QID: 3132
1

Less than 5%

1%

(23/2401)

2

5 to 20%

38%

(909/2401)

3

20 to 50%

24%

(572/2401)

4

50 to 75%

22%

(538/2401)

5

Greater than 75%

15%

(354/2401)

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PREFERRED RESPONSE 2

(OBQ12.184) A 36-year-old male involved in a high speed motor vehicle accident is found on exam to have Grade 2 of 5 motor strength in 80% of his key muscle groups in his lower extremity. His perianal sensation and rectal tone are intact. A bulbocavernosus reflex is present. His sensation is decreased from a point at the intersection of the mid-clavicular line and the 4th intercostal space at the level of the nipples distally. Based on the American Spinal Injury Association (ASIA) classification system, what ASIA grade is he? Review Topic

QID: 4544
1

ASIA A

1%

(19/2447)

2

ASIA B

18%

(429/2447)

3

ASIA C

73%

(1782/2447)

4

ASIA D

8%

(192/2447)

5

ASIA E

0%

(11/2447)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(OBQ08.87) Following an acute spinal cord injury a patient presents with systemic hypotension and relative bradycardia. His bulbocavernosus reflex is present. This is characteristic of what type of response in acute spinal cord injuries? Review Topic

QID: 473
1

Spinal shock

9%

(195/2185)

2

Cardiac shock

1%

(18/2185)

3

Neurogenic shock

90%

(1957/2185)

4

Septic shock

0%

(3/2185)

5

Hypovolemic shock

0%

(7/2185)

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PREFERRED RESPONSE 3

(OBQ08.17) A 16-year-old male is involved in a diving accident six months ago that leads to a spinal cord injury. On physical exam he has 5 out of 5 deltoid and biceps strength. He has good brachioradialis muscle tone and 5 out of 5 bilateral wrist extension. He has 0 out of 5 wrist flexion and triceps strength. He has no anal sphincter tone, absent perianal sensation, absent lower extremity sensation, and an intact bulbocavernosus reflex. He has no motor tone in his lower extremities. How would you define this patients neurologic deficit. Review Topic

QID: 403
1

Incomplete C5 spinal cord injury (ASIA A)

1%

(36/2764)

2

Complete C5 spinal cord injury (ASIA E)

2%

(46/2764)

3

Complete C6 spinal cord injury (ASIA A)

69%

(1899/2764)

4

Complete C7 spinal cord injury (ASIA A)

23%

(638/2764)

5

Incomplete C7 spinal cord injury (ASIA B)

5%

(130/2764)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(OBQ09.170) A 30-year-old male is involved in a motor vehicle accident and sustains a fracture-dislocation of the cervical spine. On physical exam he has absent distal motor function, absent sensation, absent rectal tone, and an intact bulbocavernosus reflex. Which term best describes this spinal cord injury pattern? Review Topic

QID: 2983
1

Central cord syndrome

1%

(21/2732)

2

Incomplete spinal cord injury

5%

(138/2732)

3

Complete spinal cord injury

87%

(2381/2732)

4

Neurogenic shock

1%

(32/2732)

5

Spinal shock

6%

(155/2732)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(OBQ08.82) Which of the following best describes a patient's functional level with a complete C5 spinal cord injury? Review Topic

QID: 468
1

Electric wheelchair with only head or chin control

48%

(1001/2083)

2

Electric wheelchair with hand control

45%

(942/2083)

3

Limited use of manual wheelchair, can drive car with manual controls

5%

(100/2083)

4

Long-distance use of a manual wheelchair

1%

(17/2083)

5

Fully independent transfers

1%

(17/2083)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(OBQ11.9) A 23-year-old man falls down a flight of stairs while intoxicated and is brought to the emergency room the following morning. On physical exam he has no motor function in his upper and lower extremities. Sensory exam shows diminished but present sensation in the perianal area and in the lower extremities. Reflex exam shows his bulbocavernosus reflex is intact. The inital CT and MRI are seen in Figures A and B. According to the American Spinal Injury Association (ASIA), how would this injury be classified? Review Topic

QID: 3432
FIGURES:
1

ASIA A

5%

(225/4272)

2

ASIA B

83%

(3554/4272)

3

ASIA C

4%

(184/4272)

4

ASIA D

6%

(241/4272)

5

ASIA E

1%

(53/4272)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2
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