buttock pain after lumbar fusion

Learn what's involved in a total hip arthroplasty, including ideal candidates, procedure, risks, recovery, and more. PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. Advances in Motion-Preserving Surgery for Neck Pain and Cervical Spine Conditions, 3 Options for Your Artificial Disc Replacement, Cortisone Injections for Spinal Conditions, Dr. Schuler Performs First M6-C Artificial Cervical Disc Replacement in DC-Metro, Spine Surgeon Dr. Schuler Becomes a Spine Surgery Patient. A neurosurgeon will advise the patient to avoid lifting objects or repetitive neck movements for the first six to eight weeks after surgery. I have exact same pain as you and I was wondering how you adjusted.. We do not treat disease. Dr. Haines performed the worlds first combined, . Due to the multifactorial nature of hip pain after spinal fusion, youll need to work closely with your healthcare professional to get a proper assessment, especially if the pain does not decrease or actually worsens after recovery from surgery. In fact, as we get older, our spines can create a natural fusion. The sacroiliac (SI) joint is a common but underrecognized source of continuing back pain in patients who have surgical fusions for the treatment of back pain. Pain from a spinal stenosis may be resolved with decompression surgery. Pain for something like this is typically progressive throughout the day as the improper posture starts to wear on the body. Approximately 3 weeks ago I had an anterior fusion at L5 S1 level and a replacement disk in the vertebrae above. If there are issues of continued pain following a fusion surgery, stem cells and PRP treatments may be effective in helping pain if there are issues with ligament and tendon instability causing segment disease above and below the fusion. (2019). Other causes of. The goal of the surgery is to fuse together the vertebrae in the lower back, which will then stop the movement between those vertebrae. Other nerves joining at the same place also send branches down your leg. At least 20 percent of all spinal fusion surgeries fail to relieve lower-back pain, according to Dr. John Sherman, an orthopedic surgeon writing for the website Spine-Health 3. After spinal fusion surgery, youll need time to recover, which likely means youre going to be less active. 2020 Dec;21(1):1-7. If you have a medical emergency, please call 911. Depending on the cause, your hip pain can be temporary as you recover from surgery or last much longer and may require treatment. At our practice we utilize Platelet-Rich Plasma as one of our injection treatments for the patient with chronic low back pain. When conservative treatments such as medication, chiropractic adjustment or physical therapy fail to yield results, some may opt for surgery. He rates his pain as 8 out of 10. It can have associated numbness, tingling and weakness in your leg. Immediately after the spinal fusion surgery, though, you will have to restrict your activities. I have been in all over severe pain because a specialist kept telling me nothing was wrong with me. Commonly hardware is added to enhance the stability while the disc spaces and other areas grow bone. The role of muscle in possibly causing postoperative pain is not simply the effect of sparing of soft tissue. No difference in long-term trunk muscle strength, cross-sectional area, and density in patients with chronic low back pain 7 to 11 years after lumbar fusion versus cognitive intervention and exercises. Like any other joint in the body, the SI joint can degenerate or its supporting ligaments may be injured. During spinal fusion, a surgeon places bone or a bonelike material in the space between two spinal bones. Other potential sources of pain include the muscles, nerves, and blood vessels in the area. Lastly, the surgeon takes two strong rods and attaches them into the vertebrae above and below with big screws. This information is offered for educational purposes only. Find out how beta-blocker eye drops show promising results for acute migraine relief. In addition, the presence of intracranial air can result in cognitive changes. I can't sleep. What is a hip pointer, and how do you heal from one? Firstly, you need to examine the physical causes of the pain. Which after awhile standing causes everything to cramp up in my si joint . Athletes in running and kicking sports often experience muscle strains. I agree about the Miralax, but some of us suffer from IBS. Conventional open surgery produces a greater area of decompression (better surgical result) on follow up MRI than minimally invasive surgery with no statistical significance. I'm a 39 year old female. These blood clots may travel to the lungs or even affect the heart. Pain radiated down both legs into the calves which would be left really aching after long hours standing in my job. I've been seeing him for 5 months and he asked me do I want to get an second opinion and I said yes. It is not intended to be and should not be interpreted as medical advice or a diagnosis of any health or fitness problem, condition or disease; or a recommendation for a specific test, doctor, care provider, procedure, treatment plan, product, or course of action. Mind you when the technician was taking the xrays i was bawling because the pain was so severe. Could it be something you ate? Updated April 9, 2020. Many patients come to us from other physicians with continued pain after spine surgery and have been told that nothing can be done, or that its normal. The average muscle-fat-index (more fat meaning less muscle meaning more degeneration) change at L2-S1 erector spinae muscle was significantly greater in the conventional open surgery group. JBJS Essent Surg Tech. Pirkle S, et al. 6 Cho SM, Kim SH, Ha SK, Kim SD, Lim DJ, Cha J, Kim BJ. Known as failed back surgery syndrome, signs and symptoms of a failed spinal fusion include new or worsened pain, burning, tingling, or weakness in the lower extremities, reduced mobility, headaches or neck pain, or a return of previous symptoms. They told me prior to fusion that a main complaint of women post-fusion is pelvic pain. The gluteus maximus is the largest muscle in the body, and it covers a large portion of the buttock. . I am in the military and I feel i'm getting jerked around by these doctors. so i went in for a spinal fusion in surgury they found that 1 disc was well over sized and flat as a ribbon and around that the spine had started to crumble , i did have complecations i lost blood and developed a blood clot i also lost feeling in my bladder so i had to have emergancy surgury 2 days after ,weeks on i have Numbness in my feet and my left leg drags, for a few weeks ive been getting hip pain and bladder pain witch wakes me up , i also have trouble sitting up and lying on my left side, ive also developed 2 larged lumps on my left leg on below my hip and one just under the top of the leg there hard and painful and burn , do i bother the Dr ? Your doctor may recommend that you only undertake light activities like walking. The pain it can cause shooting down your legs is called sciatica, and this tends to be worse when you're standing up or leaning backwards. Avoid strenuous activities of any kind (golfing, tennis, home improvement tasks, etc.). About 8-10 months after the hip operation I began getting pain in my lower back and groin and sciatic kind of pain radiating into my legs. We explore the types, causes, treatment, and home remedies to help if you have hip pain when youre, The glycemic index (GI) is a value used to measure how much a specific food increases your blood sugar levels. This could be the result of surgical skill, or it could be the patient didnt allow his or herself enough time to recover. Stem cells and PRP may help strengthen the tendon/muscle attachments and help patients who suffer from continued spasms. A Case of Severe Low Back Pain after Spinal Fusion Nov 7, 2013 The patient is a 48-year-old male, with psoriatic arthritis, who underwent L4-S1 spinal fusion in 2000, presents with continuous low back pain and intolerance to sitting. Symptoms of RM after Buttock Pain After Lumbar Fusion may occur as the new bones heal. The pain is caused by damage or injury to the joint between the spine and hip. Glenister R, et al. There are many reasons why someone will have a failed spinal surgery. As weve seen, a fusion is a complex and destructive operation in which lots of things can go wrong. I am much less active therefore I am gaining weight which I know doesnt he4lp the situation. The worst of the pain begins to subside by four weeks after the spinal fusion surgery. The incidence of hardware failure in one study was an alarming 36% (7). I have been given some strengthening exercises for the glute muscle on the left side by my physiotherapist but this seems to be making it sorer at this point. Iron Neck for chronic pain caused by foraminal stenosis? I had had sciatica before my surgery for scoliosis but it was never this bad . Instead, joint pain can be a vague, deep, achy pain, which becomes mixed with other messages in the spinal cord. No minimally invasive procedures were used. Lumbar MRI was performed within 3 months before surgery and 1 year after surgery to compare muscle-fat-index (MFI) change of the paraspinal muscles and the dural sac cross-sectional area (the dural surrounding the spinal cord to assess stenosis compression) change. I went for my mri the other day and they put a towel between my feet and taped them pigeon toed? Any reason why they did this? The first possibility is that the nerves themselves can be damaged. The surgeon puts traction on the nerve so that you can get to the disc itself. Here's the results copied and pasted. The real cause is coming from the failed fusion, but because of somatic referral, the perceived area of pain is much larger. A final cause of numbness after spine surgery could be the result of a failed operation or because spinal hardware is impinging a group of nerves. The sciatic nerve is a large nerve that runs from the lower back through the buttocks and down the leg. Long story so please bear with me..was in a car accident in 2008. To help relieve this pain, your healthcare professional may recommend first-line treatments such as pain medication or physical therapy to restore strength, posture, and stabilize the hips. Its usually done to reduce pain and improve the stability of the spine. Dr. says everything looks good but I dont believe it is or I wouldnt be in so much pain. And then you need to look at an extremely important factor most health professionals ignore: your pain system. Return nerve pain after a microdiscectomy can originate from three issues; nerve inflammation, re-herniation or seroma formation. The most common cause of buttock pain after lumbar fusion is hardware failure, which can occur when the metal screws or rods used to hold the bones in place loosen or break. While its certainly difficult to recover after a failed back surgery, its not impossible. Be sure to take it every night before you go to bed. Did I herniated my disc again by starting to walk and even drive too soon after the surgery -- the next day? Unfortunately, there are instances in which a spinal fusion doesnt take, meaning the bones didnt grow together. Click to read! A 72-year-old male presented with a 2-year history of severe buttock and sole pain in his right lower extremity. If the pain youre experiencing is a deep aching pain, then somatic referral is the more likely cause, and youll need to have the joint more closely examined. Global Spine Journal. Updated April 20, 2020. The causes attributed to this syndrome have been classified as buttock trauma, compression and overuse [ 5 ] that may lead to muscle hyperthrophy, inflammation and irritation. This is why I see a spinal fusion as a last resort, and only to be undertaken when all other paths have been tried. I was diagnosed with a grade 2 spondyliolisthesis and spinal stenosis. I feel like there is no hope left for a normal life. Soft Tissue: A Possible Source of Pain Pre and Post Minimally Invasive Spine Surgery. Its a very difficult thing to fix, especially when you get a pseudoarthrosis. There are significant forces placed on the low back and the hardware. Neither Dr. Darrow, nor any associate, offer medical advice from this transmission. Epub 2011 Aug 3. When these messages reach your brain, your brain interprets them as a mixture of pain that often includes terrible leg and buttock pain with the back pain. However, this statistic also includes patients who may have had preexisting SI pain before surgery. The failure of surgery to relieve pain is most often an indicator that the lesion that was removed during the operation was not actually the cause of the pain in the first place. This method should alleviate the pain. The human spine is designed to be both rigid and flexible, but if we remove portions of the bone, that support system is disrupted. Yoshihara H, et al. (2021). If you have a medical issue, please call our office. Therell be more hardware if youre fusing more levels.). Patients should also continue wearing TED stockings. They found that patients with GCS of five or lower after lumbar fusion were more likely to develop GCS than those with a GCS of nine or higher. I'm 40 years old, and am starting to get extremely depressed and pain meds aren't working Do you a update to your post ? When I was still in pain, he wanted to do another fusion. Stay ahead of the pain. What the surgeons found was Up to 25% of patients report unimproved or worse pain and up to 40% are not happy with the outcome of lumbar fusion.. If the surgery does fail, people often end up with worse pain than before. I found CBD oil. By understanding more about the condition, youll be better equipped to make an informed decision about your treatment options. Here's what to expect. Frequently asked questions about hip pain after spinal fusion, ncbi.nlm.nih.gov/pmc/articles/PMC5106227/, ncbi.nlm.nih.gov/pmc/articles/PMC6787362/, thejns.org/spine/view/journals/j-neurosurg-spine/35/5/article-p564.xml, thejns.org/spine/view/journals/j-neurosurg-spine/31/1/article-p1.xml, arthroscopyjournal.org/article/S0749-8063(22)00281-X/fulltext, ncbi.nlm.nih.gov/pmc/articles/PMC3459112/, What to Expect If You or Your Child Need Periacetabular Osteotomy, Total Hip Arthroplasty: Procedure, Recovery, and More, Hip Fractures Expected to Double by 2050: Here's Why and What You Can Do, What You Need to Know About Postpartum Hip Pain, Daniel Bubnis, M.S., NASM-CPT, NASE Level II-CSS, Identifying and Treating Your Groin and Hip Pain, The Best Sex Positions After a Hip Replacement, Why You May Have Hip Pain When Youre Sitting, Glycemic Index: What It Is and How to Use It, greater load onto the SI joint after spinal fusion, misdiagnosis of back issues instead of hip issues, bone graft harvesting in the iliac joint (which is next to the SI joint), concurrent spine and hip issues (known as hip-spine syndrome). There is typically a specific and correctable reason for pain after spine surgery. i never thought of sciatica again cause I had it beofre my surgery,It was a bad case of it. The most common reason is to treat degenerative disc disease, which is when the discs in the spine start to break down and cause pain. vertebrae below it. Paraspinal muscle changes after single-level posterior lumbar fusion: volumetric analyses and literature review. More so on the right side than the left. Piriformis muscle has been reported in 22% of population and accounts for 5-6% of cases who are referred for back and leg pain . this is suppose to stabilize the SI joints which prevents movement which is causing the pain? In this situation, decompression surgery is necessary to relieve the pressure and pain. After rest the pain goes away. Avoid any activity that is not urgent. The goal was to find answers for failed back surgery syndrome. Statically significant post-operative muscle-fat-index change was only noted in erector spinae muscle at caudal adjacent level and L2-S1 mean global level. Physical therapy and medication are the most common treatment. Thirdly, when the surgeon goes in to destroy the disc, any mistake during this process could damage the nerves. Good Luck! Shaw KA, Griffith MS, Shaw VM, Devine JG, Gloystein DM. It is our goal to provide the highest level of care and service to our patients. The neurosurgeon may also prescribe analgesics for pain control. Heres how it works. A certain proportion of people experience severe leg pain following a spinal fusion operation. I have to sleep on my stomach. 1.1 Recurrent lumbar disc herniation. However, conventional open surgery is associated with more prominent fatty degeneration of the paraspinal muscles. After my first surgery where the doctor screwed up. All rights reserved. Hip pain after spinal fusion is relatively standard. A significant muscle-fat-index change difference between the conventional open surgery and minimally invasive spinal surgery group was also found in the erector spinae muscle at the caudal (lower spine) adjacent level.. The back muscles can also be injured during the procedure itself. Between that & the l5 s1 pain, my butt, hips, legs hurt so much. The problem with a fusion operation is that theres no going back from it. As I recently shared on Instagram, I've started to feel like I've reached a turning point in my spinal fusion recovery/life. Then you end up like this and they cant help youespecially with no medical insurance. By using this Site you agree to the following, By using this Site you agree to the following, severe pain in hip and pelvic region after spinal fusion, 35 Year Old with Left Leg, Buttock, and Lateral Calf Pain when Standing or Walking, I have severe left hip and groin pain after a fusion. The primary form of rehabilitation after spinal fusion is an aggressive walking program. i was so confused and lost about which procedure i should treat my back pain with.Dr.Corenman is just so kind to make time from his schedule to help me :')! Does any body have any idea about this? Finally after three hours I got a nurse to call my doctor to get my drugs changed. They then use special instruments and go into the disc, scrape out all the contents, and then scrape all the way around to remove as much of the disc wall as they can. Lumbar fusion is a type of surgery that is used to treat lower back pain. I often see patients that have had this type of surgery without any sort of bone fusion. I since had 5 surgeries in 5 months and back fussing was the last one. Failed back surgery syndrome: current perspectives. There are many potential causes of hip pain after spinal fusion. The incidence of new onset sacroiliac joint pain following lumbar fusion. The reason behind this may vary, but there are some potential causes. Hip socket pain and buttocks post spinal fusion ALIF surgery. When the messages from your damaged joint join into the trunk line of your spinal cord, the message that reaches your brain is a general one which contains mixed zones. Subscribe to Dr. Darrows newsletter for information on your treatment options and latest health updates. If you follow all your surgeon's instructions, you can expect a smooth spinal fusion recovery that relieves your back pain and any previous numbness or tingling. When I first woke up from Surgery I kept asking for pain meds cause it wasnt doing anything. I am an avid athlete who loves sports and I have not been able to do any type of exercise without being in extreme pain. You may have trouble sitting or standing in one position for very long. This would usually give you pain in your back. Best physical therapy swimming. We offer this Site AS IS and without any warranties. Thank you for choosing Dr. Corenman as your healthcare provider. When lumbar spinal fusion is performed, the most common locations include L4, L5 and S1, essentially enlarging the sacral spine to include the last 1 or 2 vertebral bones in the lumbar region. The pain meds help but on BAD days or weeks I have to stay in bed. (7). This article explains the relationship between the spine and hip, the causes of hip pain after spinal fusion, and your treatment options. Is surgery required for my unstable spondylolisthesis? TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON. as I am 8 months postop and yes, I can walk again( I couldn't walk half a block pre fusion surgery) but, I still have buttock, leg and low back pain. At the end of all this, you have a metal cage packed with bone, two strong metal rods and four large screws. I had xray of my hip area and my neurosurgeon said that everything looked normal. This surgery can treat degenerative disc disease and other vertebral problems. Spinal fusion. I couldnt even move my body either way, I couldnt sit up any higher, and all I could do is move my hands and toes. You must be logged in to reply to this topic. (2016). This is to hold everything in place while the bone grows. Scientific reports. After my 1st of 4 surgeries last year Found out a rod was impingeing on a nerve in my hip: the pain was worse than before my 1st surgery! If the pain is still there after 3 months, it is unlikely to improve on its own. In addition, angiography may be performed to identify blood vessel problems after penetrating head trauma. MRI and CT scans may be performed to determine the extent of brain damage. Vaswani R, et al. Here are 10 ways to stop headaches before they start. The message would certainly have back pain, but due to somatic referral, it may also include buttock pain and leg pain, as all these areas are fed by nerves in the same vertebral segment. I have had chronic pain in my si joint for about 12.5 years since I had my son. Causes of Post-laminectomy Syndrome Recurring pain after spinal surgery may arise from a variety of causes. We treat degenerative joint disease, degenerative disc disease of the spine, and tendon and ligament injury. worse i even had . MedHelp is not a medical or healthcare provider and your use of this Site does not create a doctor / patient relationship. Pain developed 5-6 months after Lumbar Fusion (L5-S1) Krash48. , and Top Doctor recognition in consecutive years. While it can be a helpful. Reston, Virginia 20191, is a board certified spine surgeon and the Director of Research at Virginia Spine Institute. We explain what. Last medically reviewed on November 7, 2022. 2020 Apr;10(2_suppl):137S-42S. Postpartum hip pain is usually caused by pelvic girdle pain. Thank you very much. I had a 2 level fusion of L4-5 L5 S1 and am 7 months post op. The JNDB evaluated 3194 patients who suffered confirmed TBI between 1998 and 2011 and retrospectively studied 888 patients. Never disregard the medical advice of your physician or health professional, or delay in seeking such advice, because of something you read on this Site. The most common is inflammation. Any idea what can be the cause?!?! My first disk slipped at 20, the second at 35, everything caved at 40, preventing me from walking (both were impending on nerves and there was a ton of Arthritis at L4, that was scraped off) total surgery time was 9I was doing ok, the first 5 months PO, (except when there was a cold front or thunderstorm)and then all of the sudden I started experiencing horrific hip pain, in my buttock, and in my right hip, and pain at the site of the surgery. The most common complications from lumbar fusion surgery include: There is also a small risk that the vertebrae will not fuse together correctly and that additional surgeries will be needed. Below are a few reason why leg pain may . I'm not sure if I should get a second opinion from a civilian doctor? We explain the causes, symptoms, diagnosis, and treatment of postpartum hip pain. Dural sac cross-sectional area improvement (meaning less stenosis) was significantly greater in the conventional open surgery group. The relationship was found. The most common symptom is pain, which is often described as diffuse, dull and aching. In our practice, Stem Cell Therapy is a treatment for musculoskeletal disorders. We avoid using tertiary references. Takes care of the constipation and pain! I was put on total disability with restictions and have no medical coverage for six more months. Thank you! Progression of nerve pinching and arthritis. Connecting them prevents movement between them. I hope it's not damaged. PRP treatments involve collecting a small amount of your blood and spinning it in a centrifuge to separate the platelets from the red cells. Pain medication always constipates you. The purpose of this study was to compare the degree of postoperative fatty degeneration in the paraspinal muscles and the spinal decompression between conventional open surgery and Minimally invasive surgery based on MRI. Alternatively the spinal disease may worsen at the level above or below the fusion (that is at L3-4 or L5-S1 level after L4-5 fusion) due to increased strain to the surrounding spine due to the immobile fused segment or just from worsening degenerative spine disease. I am sorry to hear it, it looks same as I had after surgery, but in additional i got foot drop after back surgery.. What's all this mean now? When a patient who has undergone a spinal fusion wakes up from surgery, the spine is not actually fused they're stabilized. My pain is mostly on my right side. Common causes of spinal nerve compression include: Degenerative spinal conditions such as herniated discs I have the same problem ? Dr. Colin Haines is a board certified spine surgeon and the Director of Research at Virginia Spine Institute. I often see patients that have had this type of surgery without any sort of bone fusion. Periacetabular osteotomy is surgery to correct a dislocated hip (hip dysplasia). The nerves from the damaged joint pick up pain messages then join into the spinal cord. What Helps Leg Pain After Back Surgery. A problem following fusion surgery is that not only are the muscles damaged, but the muscle tendons are damaged as well. Patients with GCS scores of three or higher have a significantly increased risk for complication, including mortality. Please, can anyone tell me if they've experienced the same? I was diagnosed as having no cartilage left in that hip. Then 3 more months I was having every scan and test there was. I just had another MRI today and I now have more problems. I go to my post op appointment on Monday but the doctor had to write me a couple more prescriptions (neurontin, & some steriod pack), I believe that's to help with the hip & pelvic pain. First Surgery February 2014 Lumbar Spine Posterior Discectomy Micro-discectomy on L4 & L5. I consulted my neurosurgeon who thought it might be bursitis. I didnt even get to talk to the doctor just some secretary. Thanks. Spine (Phila Pa 1976). He looked at my MRI results from my other doctor and said that he thinks I still have infection in my back and he said that I need to have my hardware taking out of my back and have my back cleaned out and get new hardware. Yoga + Other Exercises after Lumbar Fusion. Spine J. These two are connected through the sacroiliac (SI) joint, which connects each side of the sacrum (the bottom of your spine) to the inner surface of the ilium (the butterfly-shaped hip bone). My spine is unstable AGAIN & I need another fusion. This type of pain is called neurogenic or neuropathic pain. In patients who had continued pain after back surgery, muscle biposies revealed: A team of German and Canadian researchers (2) sought to understand the problem of failed fusion as a result of muscle damage, saying: It is well established that posterior spinal surgery results in damage to the paraspinal musculature. The researchers found that axial (mechanical) compressive forces at the adjacent (fusion) levels increased after surgical muscle damage. But if the bone graft doesnt take, you end up with just the metal cage, the rods and screws holding the vertebrae apart. Following lumbar spinal fusion surgery, a patient must spend a certain amount of time resting so that the bones can heal. The doctor had to catch a plane so he . Flexion, extension or rotation of the lower spine may place undue stress on the growing bones. Does lumbar spine fusion predispose patients to future total hip replacement? It may take 4 to 6 weeks to get back to doing simple activities, such as light housework. Receiving a more thorough examination to determine ALL affected levels, and then revising the original surgery to address all underlying issues. However, if the bone graft doesnt grow after a fusion operation, then the metal spacer starts to force its way into the bone of the vertebrae above and below. In March of 09 I had an L5S1 fusion, In April of 09 6three fusd in my neck and in March of 10 theL5S1 undone and the L4 added to it. If I keep using it then it won't calm down. Following Buttock Pain After Lumbar Fusion, patients are monitored for a number of factors, including neurological status. I had to quit work Dec. 05'. Rest after Spinal Fusion. For 15 years, Charis Grey's award-winning work has appeared in film, television, newspapers, magazines and on the Internet. I was diagnose For almost a year, I've been experiencing pain in my left leg, left buttocks and left side of my left calf when standing or walking for m Hey All. He said there was nothing wrong and I fought him on it cause I knew there was something wrong. Interestingly the researchers also noted: In our study, the association between low back pain and severe multifidus muscle atrophy during the one-year follow-up was unclear. I didnt think it I would have it again and never thought of it. I do not know what to do. Soma is Greek for body. Updated June 2018. A February 2020 paper (6) examined the widely accepted surgical technique, posterior lumbar fusion that had been related to the possibility of paraspinal muscle atrophy after surgery. Someone who needs to return to work as a landscaper will have a different treatment priority than a retired individual with lesser physical demands on his/her back.

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