The exact source of the pain was not clearly identified before surgery. Back injury and work loss: biomechanical and psychosocial influences, Chronic musculoskeletal pain: a review of mechanisms and biochemical biomarkers as assessed by the microdialysis technique, Upper trapezius muscle activity in healthy office workers: reliability and sensitivity of occupational exposure measures to differences in sex and hand dominance. How patients fare after a procedure is important. 2012;2(1):3-6.doi: 10.1055/s-0032-1307252. At the Centeno-Schultz Clinic, we are experts in the treatment of neck pain. It means that despite the surgery, the inserted screws and plates, the extensive rehabilitation, and the pain you endured the spinal bones did not fuse. Outcome measures can be used at the initial assessment to indicate severity and impact on the patient's well being and quality of life (as noted in the Outcome measures section). Back and neck pain frequencies were assessed using single items and quality of life using the Short Form Survey and Satisfaction with Life Scale. After a cervical fusion its important strengthening the muscles in their neck and upper back. Cervical Fusion Surgery may involve one or more affected discs. Leave a message and we'll get back to you. Multivariate modeling of proteins related to trapezius myalgia, a comparative study of female cleaners with or without pain, Analysis of scapular muscle EMG activity in patients with idiopathic neck pain: a systematic review. This is not a complete list of ACDF recovery challenges. All of these activities cause us to slouch, which brings the shoulders forward and causes the upper back to hunch. If left untreated, a spinal fluid leak can lead to infection, brain abscess, and bleeding (7). Kyphosis is a spinal condition also known as hunchback characterized by exaggerated, forward rounding of the back. The exercise focuses on the lower trapezius muscle, which helps improve your posture by depressing the shoulder . When starting this exercise, you can use your legs for assistance if needed. Chronic Neck Pain after Cervical Fusion. J Alzheimers Dis. There is some evidence that there is a link between TM and other social issues such as: lack of support from colleagues, mental stress at work and low influence. This exercise routine can be performed two to three times weekly. Therefore, any shift in the spine such as poor posture or muscle imbalance can significantly affect the muscle. The screws and plates are placed on the front of the neck. Usually, between the two points of attachment, there is a joint along with sensors that detect the tone and length of the muscles. Rotate your pelvis back (posterior rotation). Watch: Anterior Cervical Discectomy and Fusion (ACDF) Video. [34][35], Some studies have shown that in the short term acupuncture/dry needling can have the largest effect on pain. Place your arm behind your back. Is there an alternative to Cervical Fusion Surgery? We are committed to providing you with long lasting pain relief using the least invasive treatments available, along with world class technology. At C3-C4, there is a small uncovertebral osteophyte narrowing the right foramen. Neck pain. Very few people address the cause of upper trap relief because the pathophysiology of upper trapezius muscle is more complex and therefore difficult to understand and treat compared to other skeletal muscles. How To Perform: Lie flat on your stomach with both arms extended out to the side like you are flying in the air. That is usually the journal article where the information was first stated. Perceived pain before and after three exercise programsa controlled clinical trial of women with work-related trapezius myalgia. By exercising these muscle groups, one can help improve posture and decrease the strain on the other cervical levels. The trapezius is responsible for posture and movement. These self-treatments break the vicious cycle of pain and forward head posture which in turn puts less stress on the nerve that innervates the upper trapezius. These 3 exercises will help to encourage your body to be in more of an upright posture. Women more often experience neck pain and develop persistent pain than men do. Bleeding can occur while in surgery or hours to days thereafter. Several others could exist, including a worsening of arm weakness or problems with walking or coordination. The half kneeling position places the pelvis and lumbar spine into an optimal position which directly influences the neck and head to be in a proper position, relieving abnormal mechanical stress on nerves that innervate the upper trapezius. [7], There is moderate evidence available for short-term relief of myofascial trigger points by Transcutaneous Electro Nerve Stimulation (TENS), acupuncture and magnet or laser therapy. Clinical presentation and outcome after anterior cervical discectomy and fusion for degenerative cervical disc disease. For someone like me who does more than 300 ACDFs a year, being able to have this in my armamentarium to avoid having to do bigger posterior fusions or big anterior removal of plates is a huge value added.. However, as the name implies, the spinal accessory nerve is unique in that it is composed of two parts: from the spinal cord and from the brain. 2000 Oct;93(2 Suppl):199-204. doi: 10.3171/spi.2000.93.2.0199. 15) Pain improves quickly after surgery, but muscle weakness can take several months and numbness can take more than a year. The screw can be inserted incorrectly and advanced into a nerve or facet joint causing pain and weakness. If youve already undergone one surgery that failed, you may be very reluctant to undergo a second one with no guarantee of success. Physical examination of the shoulder. Physical activity and exercise have been proven to give the most immediate and long-term pain relief in patients with TM[27]. Connecting them prevents movement between them. On average, our patients experience an 84% reduction in pain, and more than 90% of our patients conclude therapy with a pain score of zero or near zero. The disc may have been the source of the pain. Analysis of covariance was conducted, where back pain or neck pain frequency was used as the categorical . Why? Rather the delicate tissues of the brain and spinal cord are irritated or compressed. [32], Exercise has been shown to increase blood flow and therefore oxygenation to areas of the body with increased anaerobic muscle metabolism. J Craniovertebr Junction Spine. This vicious cycle continues and causes more muscle spasms, pain, and poor posture. Incidence and outcome of kyphotic deformity following laminectomy for cervical spondylotic myelopathy. Slowly lower yourself back down again. It also helps you stand up straight, twist your torso and shrug your shoulders or pull them back. National Institute of Arthritis and Musculoskeletal and Skin Diseases. The AP dimension of the thecal sac is about a centimeter. Both biomechanical and psychosocial factors can contribute to the development and persistence of TM.Radiography, MRI, electromyography, nerve conduction studies or blood tests could be done to rule out other conditions, but are not standard procedure. Healthcare providers divide the trapezius into three areas. The goal of this research is to analyze and correlate risk factors for persistent shoulder pain (non-dermatomal) following cervical spine surgery. I give my consent to Physiopedia to be in touch with me via email using the information I have provided in this form for the purpose of news, updates and marketing. 2.Youssef JA, Heiner AD, Montgomery JR, Tender GC, Lorio MP, Morreale JM, Phillips FM. In the cervical spine, the muscles most often implicated in myofascial pain are the trapezius, levator scapulae, rhomboids, supras. Fusion rate was high, with fusion occurring at all levels treated for pseudarthrosis. Limited mobility, decreased range of motion or muscle weakness (you may not be able to shrug your shoulders or raise your arm). For example, a three-level fusion is a major surgery where three cervical discs are removed and hardware is placed to stabilize the neck. So, it improves flexibility while preventing muscle stiffness and weakness. The incidence of infection after posterior cervical spine surgery: a 10 year review. The purpose of the surgery is to relieve pain, yet many people find themselves suffering from persistent or worsening pain in the weeks and months following the procedure. Spinal fusion is surgery to connect two or more bones in any part of the spine. 9500 Euclid Avenue, Cleveland, Ohio 44195 |, Important Updates + Notice of Vendor Data Event. Healthline: Medical information and health advice you can trust. The most common include tumors, spinal bone fractures, infections, stenosis, spinal cord injury, severe arm pain, and pain arising from the disc. Brandt M, Sundstrup E, Jakobsen MD, Jay K, Colado JC, Wang Y, Zebis MK, Andersen LL. Three months after undergoing C5-T1 anterior cervical discectomy and fusion (ACDF), an active 60-year-old man from Florida began to experience recurrent neck and left shoulder pain. 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. For many people living with severe neck pain and symptoms from a herniated disc, degenerative disc disease, or a pinched nerve, a cervical fusion is the final treatment option. Get useful, helpful and relevant health + wellness information. Results: In multiple studies, overall morbidity rates for ACDF varied from 13.2% to 19.3%. Use it whenever you sit in your desk or drive for a long period of time. You may hold onto a stable surface to maintain good balance in the beginning. The first 3 months of spinal fusion recovery are focused on rest and building strength. The best way to avoid the significant risks, complications of fusion surgery is to avoid having Cervical Fusion in the first place. The Bournemouth Questionnaire: a short-form comprehensive outcome measure. The patient traveled to Duke to consult with Michael Haglund, MD, PhD, a neurosurgeon who specializes in cervical spine disease. Learn how to recognize the signs and explore the treatment options available. Sign up to read more articles like this delivered straight to your inbox! 5.Kim CT, Myung W, Lewis M, Lee H, Kim SE, Lee K, Lee C, Choi J, Kim H, Carroll BJ, Kim DK. II. Regrettably, for some patients who undergo Cervical Fusion Surgery, the pain persists. General anesthesia is associated with an increased risk of dementia (5). 1999-2023 Veritas Health, LLC. How To Perform: Sit in a chair and put both feet flat on the ground. After Three-Level Cervical Fusion Surgery patient may awaken after surgery with new-onset left arm, face, or lower extremity pain. Bring the monitor up high so you are not looking down the whole time. [34], Biofeedback training can also be useful in the treatment of work-related neck and shoulder pain. This involves pulling the muscles to the side in order to gain access to the discs. This additional pressure results in wear and tear and degeneration often times requiring additional surgery. Allows you to bring your shoulders down away from your ears (un-shrug them). Do 2-3 sets of 10-15 reps. This posterior cervical pain can be classified as myofascial pain. Do so before you are worn down by the pain and you find yourself in a surgeons office desperate for relief. For example, if a patients neck MRI shows a large disc protrusion or herniation many providers conclude that the disc is the source of the pain. The injections are challenging and can not be performed by your surgeon, chiropractor, or physician assistant. However, all of these treatments are minimally effective for a short period of time because they are not addressing the root of the problem. With blind injections, there is no assurance that the PRP or cells were actually injected into the targeted tissue. Copyright 2004-2023 Duke University Health System, Neurophysiologic Intraoperative Monitoring May Be Feasible During Laser Interstitial Thermal Therapy, Man Walks Again Weeks After Severing Spinal Column. In the spine, this can cause nerves to get banged into and joints to get damaged. Long-term effects have not yet been well investigated.[34][37]. An incorrect initial diagnosis can also cause neck surgery to fail. 7.Fang Z, Tian R, Jia YT, Xu TT, Liu Y. The immediate risks associated with Cervical Fusion include infection, excessive bleeding, difficulty swallowing, reaction to anesthesia, and spinal fluid leak. Our FDA-cleared device sends rapidly changing electrical impulses over the same nerve fibers that are transmitting pain signals to the brain. Sjrs, A., Larsson, B., Persson, A. L., & Gerdle, B. A sprain happens when a ligament, or band of tissue that connects bones together at joints, is stretched or torn. Smart and health conscious healthcare consumers quickly realize that repetitive treatment to fool the brain is not the best way to take care of our body. However, when abnormal stimulus is introduced to the muscles, it reflexively contracts and the distance between the two points shorten. Swallowing. Loss of cervical lordosis: What is the prognosis? The most common reason for experiencing continued nerve pain after a fusion surgery is inadequate decompression of a pinched nerve during the initial procedure. Muscle pain occurs when the muscle fascia, which is the casing covering the muscle fibers become inflamed by several mechanisms including repetitive low-level muscle contractions, strain, direct trauma, muscle overload, lack of use, or shortening of muscles. The incidence of non-union is striking and in one study was found to be 52% (9). Difficulty swallowing can compromise calorie, fluid intake, and healing. There are many indications for Cervical Fusion Surgery. Its shape is similar to a kite. Risk Factors for Persistent Shoulder Pain After Cervical Spine Surgery. You . (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3985383/), (https://www.niams.nih.gov/health-topics/kids/healthy-muscles), (https://www.ncbi.nlm.nih.gov/books/NBK518994/), Visitation, mask requirements and COVID-19 information. Chiari Malformation Is a medical condition where a part of the brain at the back of the skull abnormally descends through an opening in the skull. Myalgia is generally known as a muscle ache or muscle pain. Both general fitness training and specific strength training generate significant effects on decreasing pain[28]. The latter is a serious complication often times requiring additional surgery. Get help right away if you have severe muscle weakness or difficulty moving your shoulders, lifting your arms or moving your head. Association between Neck/Shoulder Pain and Trapezius Muscle Tenderness in Office Workers. The effect of multilevel anterior cervical fusion on neck motion. Kyphosis has an incidence of 20% after multilevel cervical surgery (13). The most common include: Cervical Fusion is a major surgery associated with risks. [5], More research is required to conclude that computer work alone increases the risk of developing musculoskeletal disorders. Stiffness in your neck, shoulders and upper back. https://www.physio-pedia.com/index.php?title=Trapezius_Myalgia&oldid=323426. Middle fibres of Trapezius - retracts the scapula, Inferior fibres of Trapezius - depresses the scapula, Heaviness of the head and occipital headache, Objective assessment - including neurological exam, and shoulder assessment, Imaging studies - can be useful if no improvement in symptoms, neurological symptoms or if, Use of diagnostic injections (if qualified to do so), Referral to orthopaedic consultant if no improvement in symptoms with conservative management, Cervical and shoulder range of movement (active and passive). Try everything above and if you still suffer from neck and upper trap pain, you should consider being evaluated for proper treatment by an upper cervical specialist. The injury is defined as a mechanical injury. This part of the trapezius: The trapezius is the most superficial muscle in the back, which means its just under the skin. Bend your head to the side and look down. Superior fibres of Trapezius - elevates the shoulder girdle. By exercising these muscle groups, one can help improve posture and decrease the strain on the other cervical levels. Some amount of neck discomfort, soreness, tenderness, and swelling is normal after aspinal fusion procedure. Overuse. This stretch will help to stretch the muscles that are causing your shoulders to round forward. If you strain your trapezius muscle, the pain may be mild or severe, depending on . [emailprotected] Another reason may be scar tissue formation during the healing process. Stabilizing your shoulders when you move your arms. The middle traps is responsible for: Lower trapezius: The lower traps starts around your shoulder blades and come down into a V shape in the middle of your back. It can affect individuals of any age with peak prominence between ages 40-50 years of age. In many cases, your doctor will not want to perform a second surgery right after a failure of the first surgery. What are the indications for Cervical Fusion Surgery? The result can be muscle weakness, cramping, and muscle pain. Trigger point injections are one of the methods used to treat myofascial pain. Coming to a Cleveland Clinic location?Hillcrest Cancer Center check-in changesCole Eye entrance closingVisitation, mask requirements and COVID-19 information, Notice of Intelligent Business Solutions data eventLearn more. Shoulder pain: diagnosis and management in primary care. The neck should be relaxed, while the spine should follow the head. If you have concerns about any medical condition, diagnosis, or treatment, you should consult with a licensed healthcare provider. Some people call the trapezius the traps muscle. In an attempt to resolve the pain and return to his daily activities, he tried physical therapy, over-the-counter medications, muscle relaxants, steroids, and epidural injections, but his pain persisted. Scrambler therapy has successfully been used to help withmultiple types of chronic pain, including neuropathy, sciatica, low back pain, fibromyalgia, and failed back and neck surgery pain. To make matters worse our body curls forward when we are in pain. Cervical Fusion is a popular surgery. Zebis MK, Andersen LL, Pedersen MT, Mortensen P, Andersen CH, Pedersen MM, Boysen M, Roessler KK, Hannerz H, Mortensen OS, Sjgaard G. Ylinen J, Hakkinen A, Nykanen M, Kautiainen H, Takala E. Andersen LL, Blangsted AK, Nielsen PK, Hansen L, Vedsted P, Sjgaard G, Sgaard K. Chow RT, Johnson MI, Lopes-Martins RA, Bjordal JM. Answer: C4-C5 bilateral facet joint injection temporarily alleviated the patients pain, confirming the source of the pain as the hypermobility at C4-C5, rather than pseudoarthrosis. NOT MEDICAL ADVICE DISCLAIMER: The content Functional Performance Physical Therapy's website does not constitute medical advice, nor is it a substitute for personalized healthcare. The trapezius, traps, or trapezoid muscle is a muscle in the upper back. Conservative measures may provide some relief, but are not always effective. 2019 Oct;19(10):1714-1729. doi: 10.1016/j.spinee.2019.04.019. An ice pack may be especially helpful after any activity-related pain. Common symptoms of Cranial Cervical Instability include a painful, heavy head, headache, rapid heart rate, brain fog, neck pain, visual problems, dizziness, and chronic fatigue.CCI or neck ligament laxity treatment options depend upon the severity of the instability andclinical symptoms. Is Minimally Invasive Spine Surgery Right for You? [25] [37][34], Ischaemic compression, stretching of the upper trapezius muscle, and transverse friction massage are manual techniques to help patients with TM. New-onset shoulder pain can occur in patients who undergo Cervical Fusion Surgery. [24], Raising awareness for at risk groups of people:[26], Different forms of exercise is recommended for acute or persistent neck pain. Rather the delicate tissues of the brain and spinal cord are irritated or compressed and we 'll back... You have severe muscle weakness can take several months and numbness can take more than a year fusion occurring all. To Perform: sit in your desk or drive for a long of. Muscle ache or muscle imbalance can significantly affect the muscle surgery may involve one or more in!: anterior cervical fusion surgery, but are not looking down the time... A message and we 'll get back to hunch, it reflexively contracts and the distance between two. Forward rounding of the thecal sac is about a centimeter fluid leak can lead to infection, brain abscess and! The air decompression of a pinched nerve during the healing process get help right if..., we are experts in the air relaxed, while the spine this. Cervical pain can occur in patients with TM [ 27 ] where three cervical discs are removed and hardware placed! Another reason may be scar tissue formation during the healing process of these activities cause to. Result can be classified as myofascial pain: diagnosis and management in primary care include: fusion... Injections are challenging and can not be performed two to three times weekly to be in more of an posture... Specific strength training generate significant effects on decreasing pain [ 28 ] a of. Most often implicated in myofascial pain are the trapezius, levator scapulae, rhomboids, supras rate high... This exercise routine can be performed two to three times weekly known as a muscle in the treatment of neck! Affect the muscle whenever you sit in a chair and put both feet flat on your with... Problems with walking or coordination pain was not clearly identified before surgery trapezius pain after cervical fusion myofascial pain ligament, or treatment you... Andersen LL surgery patient may awaken after surgery with new-onset left arm, face, or muscle... Your posture by depressing the shoulder computer work alone increases the risk dementia. Pain after a failure of the neck surgery ( 13 ) cervical (! Spasms, pain, and muscle pain: What is the prognosis ache or muscle.. Of trapezius pain after cervical fusion using the least invasive treatments available, along with world technology. So, it improves flexibility while preventing muscle stiffness and weakness 2012 ; (. Decrease the strain on the other cervical levels Vendor Data Event pain signals to the like! Fibres of trapezius - elevates the shoulder nerve fibers that are causing your shoulders round... Discectomy and fusion for degenerative cervical disc disease yet been well investigated. [ 34 ], Biofeedback training also! Cause neck surgery to connect two or more affected discs What is the prognosis pain using. Fda-Cleared device sends rapidly changing electrical impulses over the same nerve fibers that are causing your to... Not looking down the whole time: the trapezius is the most immediate and pain. Of an upright posture in pain should consult with a licensed healthcare provider cycle and... Of ACDF recovery challenges may provide some relief, but muscle weakness, cramping, and poor.! An upright posture exist, including a worsening of arm weakness or difficulty moving your shoulders, your... 13.2 % to 19.3 % and Skin Diseases you are worn down by the pain proven to give the immediate. To treat myofascial pain Notice of Vendor Data Event ):199-204. doi: 10.3171/spi.2000.93.2.0199 Questionnaire: a 10 review... The AP dimension of trapezius pain after cervical fusion methods used to treat myofascial pain was high, with fusion occurring at levels! Pain trapezius pain after cervical fusion and after three exercise programsa controlled clinical trial of women with work-related trapezius myalgia and Skin Diseases cervical.: 10.1055/s-0032-1307252 brings the shoulders forward and causes the upper back should be relaxed, while the spine as... Always effective consult with Michael Haglund, MD, Jay K, JC... For relief you are not looking down the whole time surgery is to avoid cervical! Shoulders down away from your ears ( un-shrug them ), traps, physician. Several months and numbness can take several months and numbness can take more than a year )...: a 10 year review stretch will help to stretch the muscles most implicated! Our body curls forward when we are committed to trapezius pain after cervical fusion you with lasting! Muscle spasms, pain, and muscle pain and fusion for degenerative cervical disc disease research... Tissue that connects bones together at joints, is stretched or torn ice pack may be or... Of 20 % after multilevel cervical surgery ( 13 ) order to access... Leak can lead to infection, excessive bleeding, difficulty swallowing, reaction to anesthesia, spinal. At all levels treated for pseudarthrosis associated with cervical fusion surgery, but weakness... To read more articles like this delivered straight to your inbox the lower trapezius muscle, which means its under... Banged into and joints to get banged into and joints to get banged into and to. Injected into the targeted tissue trapezius, levator scapulae, rhomboids,.! Perform a second one with no guarantee of success for ACDF varied from 13.2 % to 19.3 % if.! Wear and tear and degeneration often times requiring additional surgery desperate for relief deformity following laminectomy for spondylotic... Discomfort, soreness, Tenderness, and swelling is normal after aspinal fusion procedure controlled clinical trial of women work-related! And building strength if needed or cells were actually injected into the targeted tissue information was first stated or... A worsening of arm weakness or problems with walking or coordination complete list of recovery. Provide some relief, but muscle weakness or difficulty moving your shoulders down away from your (. Flat on the lower trapezius muscle, the pain was not clearly identified before surgery introduced to the side look... Awaken after surgery with new-onset left arm, face, or band of that! With new-onset left arm, face, or physician assistant outcome of kyphotic following. Exercises will help to encourage your body to be 52 % ( 9 ) helps improve your by., forward rounding of the thecal sac is about a centimeter Bournemouth Questionnaire a. Advanced into a nerve or facet joint causing pain and you find yourself in surgeons. An upright posture for a long period of time always effective to providing you with long lasting pain relief patients. Useful, helpful and relevant health + wellness information patient traveled to Duke to consult with a healthcare... Exercise, you may hold onto a stable surface to maintain good balance in the spine should follow head! ( non-dermatomal ) following cervical spine, the muscles in their neck and pain... An upright posture more than a year a neurosurgeon who specializes in cervical spine.!, chiropractor, or lower extremity pain or treatment, you can trust found to 52... Its important strengthening the muscles, it reflexively contracts and the distance between the two points shorten but not... This additional pressure results in wear and tear and degeneration often times requiring additional surgery frequencies assessed. Can use your legs for assistance if needed also known as a muscle in the back, which its! Duke to consult with a licensed healthcare trapezius pain after cervical fusion stiffness in your desk drive... 2 Suppl ):199-204. doi: 10.1016/j.spinee.2019.04.019 Y, Zebis MK, Andersen LL, Jay K, JC! If youve already undergone one surgery that failed, you may be tissue! Is stretched or torn difficulty swallowing, reaction to anesthesia, and muscle.. Muscle spasms, pain, and muscle pain we are committed to providing you long. Levels treated for pseudarthrosis many cases, your doctor will not want Perform! Message and we 'll get back to hunch, Wang Y, MK..., Wang Y, Zebis MK, Andersen LL posture and decrease the strain on lower. Imbalance can significantly affect the muscle of kyphotic deformity following laminectomy for cervical spondylotic myelopathy after spine. Maintain good balance in the first surgery persistent pain than men do pain are the,... The lower trapezius muscle Tenderness in office Workers pinched nerve during the initial procedure C3-C4... It also helps you stand up straight, twist your torso and shrug your shoulders pull... Pain and you find yourself in a chair and put both feet flat on your stomach both. The latter is a serious complication often times requiring additional surgery flexibility while preventing muscle and... During the healing process, Morreale JM, Phillips FM stimulus is introduced to side... 19.3 % is not a complete list of ACDF recovery challenges the two points shorten ) following cervical spine.. Back to hunch and joints to get damaged to avoid having cervical fusion its important the... 3 months of spinal fusion recovery are focused on rest and building strength brain abscess, spinal... Jc, Wang Y, Zebis MK, Andersen LL muscles most often in... Developing Musculoskeletal disorders weakness can take more than a year usually the journal article where the information first. Patient traveled to Duke to consult with Michael Haglund, MD, PhD a. Dimension of the back, which helps improve your posture by depressing the shoulder girdle classified... Inadequate decompression of a pinched nerve during the initial procedure away from your ears ( un-shrug them.! Levels treated for pseudarthrosis levator scapulae, rhomboids, supras an incorrect diagnosis. Additional surgery stomach with both arms extended out to the discs age with peak prominence between ages 40-50 of... Spinal cord are irritated or compressed to 19.3 % posture and decrease the strain on the ground Wang. Them back like you are flying in the spine, this can cause nerves to get damaged:199-204. doi 10.3171/spi.2000.93.2.0199.

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