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Thread: Unteathering, Syrinx & Return?

  1. #1
    Senior Member Norm's Avatar
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    Question Unteathering, Syrinx & Return?

    Are there any stats on the possible return people may get after an Unteathering or Syrinx surgery? Has anyone here had the procedure done?

  2. #2
    I don't know any reputable neurosurgeon who would tell the patient that they should expect to get any return after these surgeries. The goal is the prevent the loss of function from getting worse. It would be very unusual for the function already lost to improve after the surgery, and there is some risk that the surgery itself can cause some loss of function.

    (KLD)

  3. #3
    Quote Originally Posted by Norm
    Are there any stats on the possible return people may get after an Unteathering or Syrinx surgery? Has anyone here had the procedure done?
    Norm,

    Most surgeons who have done untethering surgery will tell you that they have had patients who have gotten some function back. As KLD points out, however, it is hard to predict function return. If you have tethering, a growing syrinx, and loss of function, I think that untethering surgery should be done. I did a search of the recent literature of untethering and syringomyelia and found the following articles. Dr. Green (Miami) and Dr. Falci (Craig, Colorado) both have published some of their statistics.

    Wise.

    1. Erkan K, Unal F, Kiris T and Karalar T (2000). Treatment of terminal syringomyelia in association with tethered cord syndrome: clinical outcomes with and without syrinx drainage. Neurosurg Focus 8: E9. OBJECT: Current use of magnetic resonance (MR) imaging has led to increased awareness of the frequency of terminal syringomyelia in patients with tethered cord syndrome. However, that the surgical treatment of terminal syringomyelia is necessary remains unclear. In this study the authors attempted to assess the clinical impact, if any, brought after syrinx decompression on the clinical outcome of tethered cord syndrome. METHODS: They randomly assigned 30 cases of pediatric tethered cord into two treatment groups: those in whom an untethering procedure was performed (Group I) and those in whom this procedure was combined with syrinx decompression (Group II). The 1-year follow-up clinical results obtained in the two groups, in correlation with MR imaging findings, were compared to evaluate the benefit of added syrinx drainage. Clinical follow-up evaluation revealed that surgical drainage of the syrinx, when combined with spinal cord untethering, resulted in better outcomes in terms of resolution of sensory deficits (p = 0.036) and bladder dysfunction (p = 0.05). The improvement in clinical outcome correlated with the radiologically documented resolution of the syrinx cavity; however, response rates of symptoms differed for each tethering subgroup. CONCLUSIONS: Preliminary results of this study indicated that terminal syringomyelia should be considered as a comorbidity that contributes to the clinical outcome of patients with tethered cord syndrome. A better clinical outcome is achieved following successful decompression of the syrinx in addition to untethering the spinal cord. These findings emphasize the importance of recognizing, evaluating, and treating this pathological entity. Department of Neurosurgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul,Turkey. http://www.ncbi.nlm.nih.gov/entrez/q..._uids=16676932
    2. Emmez H, Guven C, Kurt G, Kardes O, Dogulu F and Baykaner K (2004). Terminal syringomyelia: is it as innocent as it seems?--Case report. Neurol Med Chir (Tokyo) 44: 558-61. A 5-day-old newborn girl presented with cutaneous signs of hypertrichosis, skin dimple, and subcutaneous lipoma in the lumbar region. Magnetic resonance (MR) imaging of the thoracolumbar spine demonstrated spinal dermal sinus, type II split cord malformation, and tethered cord. A small terminal syringeal cavity was also present. Five months after the diagnosis, weakness in dorsal flexion of the bilateral feet and toes was detected. Surgery to untether the cord was performed. Her deficits resolved completely. Nearly 4 years later, she was admitted with weakness in dorsal flexion of the right foot and toe. MR imaging of the spine showed holocord syringomyelia, postoperative changes, and tethered cord. No Chiari malformation was seen. Syringosubarachnoid shunt placement was performed. Terminal syringomyelia is common in cases of occult spinal dysraphism, but the natural history and management remain unclear. Progression, regression, or persistence of terminal syringeal cavity can occur whether untethering is performed or not. Progression of the terminal syrinx occurred after tethered cord release and the enlargement of the cavity involved the entire spinal cord in the present case. Terminal syringomyelia requires close follow up for a long time even in asymptomatic cases. Surgical treatment should be considered in symptomatic cases. Department of Neurosurgery, Gazi University School of Medicine, Besevler, Ankara, Turkey. hakanemmez@hotmail.com http://www.ncbi.nlm.nih.gov/entrez/q..._uids=15633471
    3. Wehby MC, O'Hollaren PS, Abtin K, Hume JL and Richards BJ (2004). Occult tight filum terminale syndrome: results of surgical untethering. Pediatr Neurosurg 40: 51-7; discussion 58. The entity of an occult tight filum terminale syndrome, characterized by clinical findings consistent with a tethered cord syndrome, but with the conus ending in a normal position, has been recognized recently. The indications for sectioning the filum terminale in this situation are not well characterized and are controversial. We report a retrospective review of a consecutive series of 60 children (ages 3-18 years) with a diagnosis of occult tight filum terminale syndrome who underwent section of the filum and were followed for more than 6 months (mean 13.9 months). The criteria for surgical intervention were (1) spina bifida occulta, (2) progressive bladder instability unresponsive to conservative measures, (3) urological/nephrological evaluation to confirm or rule out nonneurogenic etiology, and (4) two or more of the following: (a) bowel involvement (fecal incontinence or chronic constipation), (b) lower extremity weakness, (c) gait changes, (d) reflex/tone abnormalities, (e) sensory disturbances, (f) back/leg pain, (g) orthopedic abnormalities/limb length discrepancy, (h) scoliosis/lordosis, (i) recurrent urinary tract infections, (j) abnormal voiding cystourethrogram/ultrasound, (k) syringomyelia, and (l) neurocutaneous stigmata. Postoperatively, urinary incontinence/retention showed complete resolution in 52%, marked improvement (>95% resolution) in 35%, moderate improvement (>75%) in 6%, minimal improvement (> 50%) in 6%, and no improvement (<50%) in 2%. Fecal incontinence completely resolved in 56%, improved in 41%, and was unchanged in 3%. Weakness, sensory abnormalities, and pain improved or resolved in all patients. Divisions of Pediatric Neurosurgery and Pediatric Urology, Emanuel Children's Hospital, Portland, Oreg., USA. monicawehby@hotmail.com http://www.ncbi.nlm.nih.gov/entrez/q..._uids=15292632
    4. Sade B, Beni-Adani L, Ben-Sira L and Constantini S (2003). Progression of terminal syrinx in occult spina bifida after untethering. Childs Nerv Syst 19: 106-8. OBJECT: The association of spinal dysraphism and terminal syringomyelia is a well-known entity, and untethering with or without syrinx drainage is usually the surgery of choice. However, progression of the previously existing syrinx after an untethering procedure is an uncommon course. The objective of this study was to discuss the diagnostic, surgical, and follow-up consequences of such an occurrence. METHODS: Four children with occult spina bifida associated with terminal syrinx at the time of initial presentation are included in this study. After the primary releasing procedure, all developed enlargement of the syrinx. Two of them were operated on for placement of a syringo-subarachnoid shunt, while the other two were followed up conservatively. One of the shunted patients also had a second releasing procedure. CONCLUSION: Progression of the pre-existing terminal syrinx after the primary untethering procedure should be kept in mind even in the absence of overt neurological progression. Department of Pediatric Neurosurgery, Dana Children's Hospital, Tel Aviv Sourasky Medical Center, 6, Weizman Street, Tel Aviv 64239, Israel. http://www.ncbi.nlm.nih.gov/entrez/q..._uids=12607029
    5. Sheehan JP, Sheehan JM, Lopes MB and Jane JA, Sr. (2002). Thoracic diastematomyelia with concurrent intradural epidermoid spinal cord tumor and cervical syrinx in an adult. Case report. J Neurosurg 97: 231-4. Diastematomyelia is a rare entity in which some portion of the spinal cord is split into two by a midline septum. Most cases occur in childhood, but some develop in adulthood. A variety of concurrent spinal anomalies may be found in patients with diastematomyelia. The authors describe a 38-year-old right-handed woman who presented with a 7-month history of lower-extremity pain and weakness on the right side. She denied recent trauma or illness. Sensorimotor deficits, hyperreflexia, and a positive Babinski reflex in the right lower extremity were demonstrated on examination. Neuroimaging revealed diastematomyelia extending from T-1 to T-3, an expanded right hemicord from T-2 to T-4, and a C6-7 syrinx. The patient underwent T1-3 total laminectomies, resection of the septum, untethering of the cord, and excision of the hemicord lesion. The hemicord mass was determined to be an intramedullary epidermoid cyst; on microscopic evaluation the diastematomyelia cleft was shown to contain fibroadipose connective tissue with nerve twigs and ganglion cells. Postoperatively, the right lower-extremity pain, weakness, and sensory deficits improved. Diastematomyelia can present after a long, relatively asymptomatic period and should be kept in the differential diagnosis for radiculopathy, myelopathy, tethered cord syndrome, or cauda equina syndrome. Numerous spinal lesions can be found in conjunction with diastematomyelia. To the authors' knowledge, this is the first case in which a thoracic epidermoid cyst and cervical syrinx occurred concurrently with an upper thoracic diastematomyelia. Thorough neuraxis radiographic evaluation and surgical treatment are usually indicated. Department of Neurological Surgery, University of Virginia Health Sciences Center, Charlottesville 22908, USA. jps2f@virginia.edu http://www.ncbi.nlm.nih.gov/entrez/q..._uids=12296685
    6. Lee TT, Alameda GJ, Camilo E and Green BA (2001). Surgical treatment of post-traumatic myelopathy associated with syringomyelia. Spine 26: S119-27. STUDY DESIGN: Retrospective review. OBJECTIVE: Evaluate the clinical outcome of surgical intervention for post-traumatic syringomyelia. INTRODUCTION: Progressive post-traumatic cystic myelopathy (PPCM), or syringomyelia, can occur after spinal cord injury. The authors present their surgical treatment protocol and treatment outcome of a series of patients with post-traumatic syringomyelia. METHODS: The medical records of 53 patients with PPCM undergoing surgical treatment were reviewed. Laminectomies and intraoperative ultrasonography were performed. For patients with no focal tethering and only a confluent cyst on ultrasonography, a syringosubarachnoid shunt (stent) was inserted. For patients with both tethering and a confluent cord cyst, an untethering procedure was performed first. When a cyst showed significant size reduction (>50%) after untethering, no shunt was placed. When the cyst size persisted on ultrasonographic images, a short syringosubarachnoid shunt was used. The mean follow-up was 23.9 months for the 45 patients available for follow-up (range 12-102 months). RESULTS: The interval between the causative event and the operation was from 5 months to 37 years (mean 6.5 years). Pain was the most frequent manifestation, followed by motor deterioration and spasticity. Postoperative improvements in >50% of the patients were noted in those presenting with worsening motor function or spasticity. In 19 of 28 patients with associated tethered spinal cord, untethering alone caused significant collapse of the cyst. Postoperative MRI demonstrated cyst collapse in 95% of the patients with untethering alone and 93% of the patients with a syringosubarachnoid shunt. CONCLUSION: Post-traumatic syringomyelia can occur with or without cord tethering. Untethering alone for patients with cord tethering and cyst formation can reduce cyst size and alleviate the symptoms and signs of syringomyelia in the majority of these cases. Untethering with expansion of subarachnoid space with an expansile duraplasty may be a more physiologic way of treating a tethered cord with associated syringomyelia, i.e., treating the cause rather than the result. Department of Neurological Surgery, University of Miami School of Medicine, 1095 NW 14th Terrace, D4-6, Miami, Florida 33136, USA. ThomasTLeeMD@aol.com http://www.ncbi.nlm.nih.gov/entrez/q..._uids=11805618
    7. Lee TT, Alameda GJ, Gromelski EB and Green BA (2000). Outcome after surgical treatment of progressive posttraumatic cystic myelopathy. J Neurosurg 92: 149-54. OBJECT: Progressive posttraumatic cystic myelopathy (PPCM) can occur after an injury to the spinal cord. Traditional treatment of PPCM consists of inserting a shunt into the cyst. However, some authors have advocated a more pathophysiological approach to this problem. The authors of the present study describe their surgical treatment protocol and outcome in a series of patients with syringomyelia. METHODS: Medical records of 34 patients undergoing surgical treatment for PPCM were reviewed. Laminectomies and intraoperative ultrasonography were performed. In patients without focal tethering of the spinal cord and in whom only a confluent cyst had been revealed on ultrasonography, a syringosubarachnoid shunt was inserted; in those with both tethering and a confluent cord cyst, an untethering procedure was performed first. When a significant reduction (>50%) in the size of the cyst was shown after the untethering procedure, no shunt was inserted. When no changes in cyst size were demonstrated on ultrasonography, a short syringosubarachnoid shunt was used. The mean follow-up period was 28.7 months (range 12-102 months). The interval between the mechanism of injury and the operation ranged from 5 months to 37 years (mean 11 years). Pain was the most frequent symptom, which was followed by motor deterioration and spasticity. Postoperative improvement was noted in 55% of patients who experienced motor function deterioration and in 53% of those who demonstrated worsening spasticity. In 14 of 18 patients with an associated tethered spinal cord, tethering alone caused significant collapse of the cyst. Postoperative magnetic resonance imaging demonstrated cyst collapse in 92% of patients who had undergone untethering alone and in 93% of those who underwent syringosubarachnoid shunt placement. Treatment failure was observed in 7% of the former group and in 13% of the latter. CONCLUSIONS: Posttraumatic cystic myelopathy can occur with or without the presence of tethered cord syndrome. Intraoperative ultrasonography can readily demonstrate this distinction to aid in surgical decision making. Untethering alone in patients with tethered cord syndrome and cyst formation can reduce the cyst size and alleviate symptoms and signs of posttraumatic cystic myelopathy in the majority of these cases. Untethering procedures in which duraplasty is performed to expand the subarachnoid space may be a more physiologically effective way of treating tethered cord with associated syringomyelia. Department of Neurological Surgery, University of Miami School of Medicine, Florida, USA. ThomasTLeeMD@aol.com http://www.ncbi.nlm.nih.gov/entrez/q..._uids=10763684
    8. Falci SP, Lammertse DP, Best L, Starnes CA, Prenger EC, Stavros AT and Mellick D (1999). Surgical treatment of posttraumatic cystic and tethered spinal cords. J Spinal Cord Med 22: 173-81. Posttraumatic syringomyelia as a cause of progressive neurologic deterioration has been well described. More recently, the noncystic posttraumatic tethered cord has been associated with identical progressive neurologic deterioration. A retrospective analysis of patients treated surgically with spinal cord untethering and/or cyst shunting to arrest a progressive myelopathy from a posttraumatic tethered and/or cystic cord was performed. Emphasis was on outcome using the American Spinal Injury Association (ASIA) sensory and motor scoring systems. During an 18-month period from May 1993 to December 1994, 70 patients with spinal cord injury were operated upon for tethered and/or cystic spinal cords because of a progressive myelopathy and deteriorating ASIA sensory/motor scores. Fifty-nine patients had follow-up data 1 year postoperatively. At the 1 year follow-up, there was small improvement in light touch sensory scores (0.67 points), pinprick scores (1.3 points), and motor scores (0.41 points) demonstrating that the progression of the myelopathic process was arrested. Thirty-four of these 59 patients had no previous surgery to their spinal cords. At 1 year follow-up, light touch scores improved on average 2.38 points, pinprick scores 3.88 points (p < 0.05), and motor scores 1.47 points, suggesting better outcome with first-time surgery. Of this latter group, 64.3% regained a lost function, 62.5% saw improvement in spasticity, 55.6% had substantial improvement in neurogenic pain, and 95.8% felt that surgery prevented further neurologic deterioration. Department of Neurosurgery, Craig Hospital, Denver, Colorado, USA. http://www.ncbi.nlm.nih.gov/entrez/q..._uids=10685382
    9. Erkan K, Unal F and Kiris T (1999). Terminal syringomyelia in association with the tethered cord syndrome. Neurosurgery 45: 1351-9; discussion 1359-60. OBJECTIVE: With the increasing use of magnetic resonance imaging, terminal syringomyelia (segmental cystic dilation of the caudal one-third of the spinal cord) in association with the tethered cord syndrome has become an appreciable finding. This study attempted to define the clinical significance of this associated pathological condition by describing its clinical and radiological characteristics and its contribution to the clinical status of patients with tethered spinal cords. METHODS: Of 132 consecutive patients with tethered cord syndrome who presented to our department between 1990 and 1997, 32 patients with terminal syringomyelia were enrolled in this study. Clinical findings were correlated with syrinx morphological features, as defined using magnetic resonance imaging. Surgical treatment used two basic approaches, i.e., simple untethering or untethering with concurrent syrinx drainage. RESULTS: Analysis of the neurological deficits established a contribution of segmental symptoms, which were correlated with the extension and dilation of the syrinx cavity. Magnetic resonance imaging scans revealed the frequency of sacral tethering (40.6%), the intramedullary paracentral position of the syrinx (75%), and disturbances in regional cerebrospinal fluid flow (42%). The clinical outcomes seemed to be correlated with syrinx shrinkage; all patients who experienced collapse of the cavity achieved better symptom resolution. CONCLUSION: Radiologically significant terminal syringomyelia affects the clinical presentation of tethered cord syndrome, by increasing or inducing neurological deficits. Better clinical outcomes after syrinx decompression emphasize the importance of the recognition and treatment of this pathological condition. Department of Neurosurgery, Istanbul Faculty of Medicine, Istanbul University, Turkey. http://www.ncbi.nlm.nih.gov/entrez/q..._uids=10598703
    10. Falci S, Holtz A, Akesson E, Azizi M, Ertzgaard P, Hultling C, Kjaeldgaard A, Levi R, Ringden O, Westgren M, Lammertse D and Seiger A (1997). Obliteration of a posttraumatic spinal cord cyst with solid human embryonic spinal cord grafts: first clinical attempt. J Neurotrauma 14: 875-84. Cystic lesions of the spinal cord (syringomyelia) may occur after spinal cord injury. Posttraumatic syringomyelia may result in a myelopathy causing symptoms of sensory and motor loss, as well as worsening spasticity, pain, hyperhidrosis, and autonomic dysreflexia. Shunting of the cyst cavity along with untethering of the scarred spinal cord is widely accepted as the treatment of choice. However, the long-term stabilization of the progressive myelopathy caused by a posttraumatic cyst is suboptimal because of arachnoidal rescarring, shunt tube blockage, and cyst reexpansion. A new neurosurgical strategy to overcome the complication of cyst reexpansion was designed. Experimental studies have shown the successful use of embryonic spinal cord grafts, including human grafts, to obliterate induced spinal cord cavities in rats. The authors report the first use of solid human embryonic spinal cord grafts to successfully obliterate 6 cm of a large cyst cavity in a patient becoming myelopathic from a posttraumatic cyst. The grafts are well visualized by MRI to the 7-month postoperative follow-up and cyst obliteration is seen in the region where the grafts were placed. Department of Neurosurgery, Craig Hospital, Denver, Colorado, USA. http://www.ncbi.nlm.nih.gov/entrez/q...t_uids=9421458
    11. Falcone S, Quencer RM, Green BA, Patchen SJ and Post MJ (1994). Progressive posttraumatic myelomalacic myelopathy: imaging and clinical features. AJNR Am J Neuroradiol 15: 747-54. PURPOSE: To describe the imaging features, surgical management, and clinical outcome of progressive posttraumatic myelomalacic myelopathy (PPMM), a relatively unrecognized but important cause of progressive myelopathy in patients with previous spinal cord injuries. METHODS: The clinical records, imaging studies, and postoperative outcome of 10 patients with PPMM were reviewed. Fifteen preoperative and five postoperative MRs were analyzed for intramedullary signal abnormalities, the nature of these signal abnormalities, and cord tethering. All patients had intraoperative sonography. RESULTS: Neurologic signs and symptoms found in our patients included 1) progressive loss of motor function (6/10), 2) sensory level changes (4/10), 3) increased spasticity (4/10), 4) autonomic dysreflexia (4/10), 5) loss of bowel or bladder control (4/10), and 6) local and/or radicular pain (4/10). Preoperative MR in nine patients revealed intramedullary T1/T2 lengthening (9/9), extramedullary tethering/adhesions (9/9), ill-defined lesional borders (6/9), cord expansion (5/9), and increased signal intensity of the lesion on T1-weighted images compared with CSF (7/9). Proton density images in five patients demonstrated a relative increase in signal intensity over CSF. In all five postoperative MRs, there was evidence of untethering of the spinal cord and a decrease in cord size in two patients. Intraoperative sonography revealed cord tethering and abnormal cord echotexture in all cases. Postoperative clinical evaluation revealed neurologic improvement in nine patients. CONCLUSIONS: PPMM may clinically and radiographically mimic progressive posttraumatic cystic myelopathy (PPCM). MR provides clues to the diagnosis of myelomalacia preoperatively. Intraoperative sonography confirms the absence of a confluent cyst. These points are crucial in the surgical procedures in PPMM vs PPCM. In PPMM, lysis of intradural adhesions results in an improvement in symptoms in a manner similar to the shunting of PPCM. Department of Radiology, University of Miami/Jackson Memorial Medical Center. http://www.ncbi.nlm.nih.gov/entrez/q...t_uids=8010278

  4. #4
    Senior Member mike's Avatar
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    Dr Young, I was wondering what the statistics are regarding the elimination of a syrinx by untething and having it colapse compared to shunting the syrinx? I am about ready to have a second MRI after the first one taken a year ago showed a small inoperable syrinx and some evidence of tethering. The doctor at that time remarked that the syrinx was to small to shunt and doubted that it could be causing any symtoms. Based on what I have read, performing the untethering operation can cause the syrinx to collapse and might result in less damage to the cord then shunting the syrinx. Do you have any thoughts on this?
    mike

  5. #5
    My wife had an un-tethering a year ago and is still getting returns. Had multiple shunts before, over a 15 year period. New returns are compliments of Dr. Falci in Denver.

  6. #6
    Senior Member Norm's Avatar
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    I'm setting up an apointment with Dr. Green in Miami.

  7. #7
    Senior Member mike's Avatar
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    Norm, I know that you live in Florida and Dr Green is extremely well thought of but you might want to consider making the trip to Colorado to have the surgery performed. I was recently at the Cleveland Clinic and spoke with their top physiatrist who told me that if he ever needed untethering surgery he would only use one surgeon and that would be Dr Falci. He said that Dr Falci is absolutely the best around for this type of surgery.
    mike

  8. #8
    Quote Originally Posted by mike
    Dr Young, I was wondering what the statistics are regarding the elimination of a syrinx by untething and having it colapse compared to shunting the syrinx? I am about ready to have a second MRI after the first one taken a year ago showed a small inoperable syrinx and some evidence of tethering. The doctor at that time remarked that the syrinx was to small to shunt and doubted that it could be causing any symtoms. Based on what I have read, performing the untethering operation can cause the syrinx to collapse and might result in less damage to the cord then shunting the syrinx. Do you have any thoughts on this?
    I think that the latest statistics is that careful removal of adhesions and restoration of cerebrospinal fluid flow will eliminate 80% of the cysts without the shunting. In 20% of the cases, they were unable to find adhesions and tethering and therefore shunted. At 5 years followup, Green and colleagues found that 80% of the syrinxes did not recur. The surgery, however, as you know, is not trivial and therefore should be done only if there are symptoms of the neurological compromise associated with the cyst.

    Wise.

  9. #9
    Senior Member Norm's Avatar
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    I hate to have to travel to Denver. Maybe I should have both of them look at my MRI.

  10. #10
    Senior Member Norm's Avatar
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    Dr. Young, I went to Dr. Barth Green 14 years ago to see if he could do decompression surgery & he said he wouldn't do it because I was incomplete & I have a tethered cord with a few cysts. He didn't want to go in there & cause more damage. I had him look again a few years ago everything was ok. But in Nov. I stated in my other thread http://sci.rutgers.edu/forum/showthread.php?t=54636, & then a few weeks ago the burning again. It seems to fluctuate. I do notice a consistent burning on the top of my hand as if its sunburned real bad in the same spot. I don't know what the heck is going on.

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