In our study, those who had radiological imaging had considerably higher prevalence of diagnosed degenerative disc disease (33.2% vs 12.2% overall). Pain occurs when your body changes due to disc damage to cause bone-on-bone movement, bone spurs, or a compressed spinal cord. https://doi.org/10.1097/bsd.0000000000000919 (2020). It is notable that spine imaging is not part of routine annual health checks. Artificial disk replacement surgery. A physical activity program for degenerative disk disease often includes stretching, strengthening exercises, and low impact aerobic exercises, such as walking. Spine J. It was the same for Agassi, he says: "That's what Andre was feeling -- that inability to be properly prepared when you don't know what's going to happen.". These include: Body-focused therapies: Some examples are physical therapy, acupuncture, and massage therapy. Wear and tear of our spinal discs occurs naturally. It is the condition where the discs between the vertebral bones in your spine break down as you age. Osteoporosis is well-documented to result in reduced load tolerance of affected bones. More than 20 million person-years were evaluated; more than 8 million had diagnoses of spine degeneration. Zhang, L. et al. Muscle strain is another common cause of these symptoms. https://doi.org/10.1016/j.spinee.2009.10.018 (2010). Damage to the anterior cruciate ligament (ACL) is a common yet severe knee injury. Lumbar spondylosis: Clinical presentation and treatment approaches. 33(3), 123127. The discs are between your vertebrae, or spinal bones, and support the bones and cushion movement. Consequently, avoiding foods and beverages that promote inflammation may help. Arthritis medicines, such as aspirin or aspirin-like medicines (called anti-inflammatories or non-steroidal anti-inflammatory drugs, or NSAIDs), can also be taken. The intervertebral discs undergo progressive aging by degradation of the quality of the cartilage, the main material giving elasticity and flexibility to the intervertebral disc. As the disc dries up, the radial tire part starts to collapse. J. Traumatol. Yaw Boachie-Adjei, MD, is a board-certified, double-fellowship Orthopedic Surgeon. Get the most important science stories of the day, free in your inbox. The prevalence and under-diagnosis of vertebral fractures on chest radiograph. Spine 34(9), 955961. In this study, diagnostic codes were used to identify the prevalence of degenerative spinal pathologies and differences based on age, sex, and obesity from Medicare data. Neurosurgery 77(Suppl 4), S164S172. Wong, H. K., Hui, J. H., Rajan, U. Degenerative disc disease can occur at all points on the spine. Ian C. Campbell. Spine J. Lower back pain is the most obvious symptom, though many people have no symptoms at all. Limit applications to 20-minute intervals. Degenerative disc disease describes a condition in which a worn disc causes pain. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. In a young and healthy back, rubbery discs between the Inflammation may result when ligaments, tendons, or joints of the spine are acutely injured. [1] DDD can take place with or without symptoms, but is typically identified once symptoms arise. Read our, Causes of Back Pain and Treatment Options, Three Ways your Spinal Discs May Be Causing Your Back Pain, Rethinking X-Rays and MRIs for Low Back Pain. When WebMD spoke with Agassi, about a month after his final match, he had yet to begin adapting to his new life. Thank you, {{form.email}}, for signing up. While no restriction was placed on the medical reason for ordering spine imaging, these patients do not represent a random sample of those over 65 because radiology was ordered for some reason. "It's a lane change, not an exit," Agassi says of his new projects. Degenerative disc disease (DDD) is the most frequent cause of back pain among people older than 45. The prevalence of specific diagnoses were calculated based upon ICD-9 and ICD-10 codes corresponding to each of seven categories of degenerative spine pathologies. These include: According to a 2022 research article, nonsteroidal anti-inflammatory drugs, such as ibuprofen (Motrin) and epidural injections, may help treat degenerative disk disease. Ossification of the posterior longitudinal ligament (OPLL) is often linked to DISH, more commonly in the cervical region. WebDisc degeneration, also called degenerative disc disease, is most commonly caused by age. Healthcare service and diagnosis derived from Medicare data can therefore correctly reflect the prevalence of conditions, including spine pathologies, among this population. Surgery: This option is considered when all other treatment options fail and the pain worsens. Parenteau, C., Caird, M., Kohoyda-Inglis, C., Holcombe, S. & Wang, S. Characterization of thoracic spinal development by age and sex with a focus on occupant safety. Medical billing codes were used to identify concurrent spine degeneration and obesity diagnoses each year. Res. Arthritis in the low back has similar symptoms and can cause pain in the back and sometimes into the buttocks. The first medical evaluation to identify a degenerative spine disorder may come after a traumatic event that results in a fracture when one might not otherwise be expected. SpartEng76 2 yr. ago. If youve been diagnosed with degenerative disc disease, treating your back and neck pain with medications is often the first place to start. (2021). University of Maryland Medical Center. Holcombe, S. A., Wang, S. & Grotberg, J. Figure1 shows the prevalence of spine degeneration diagnoses by age group, sex, and type. Google Scholar. Degenerative Disc Disease. Symptoms can include lower back pain. By providing your email address, you agree to receive emails containing coupons, refill reminders and promotional messages from GoodRx. . Making sure youre taking regular exercise, which can also work for Stenosis can be congenital but is commonly degenerative in origin. Bertram, H. et al. Overall, the prevalence ratio of degenerative spine pathologies for obese versus non-obese enrollees was 2.19 for stenosis, 2.21 for spine curvature, 3.75 for DISH, 3.32 for spondylitis, 1.84 for disc degeneration, 0.94 for osteoporosis, and 2.34 for other spine pathologies. Bailes, J. E. Experience with cervical stenosis and temporary paralysis in athletes. The spine in your body is divided roughly into three regions (Figure 1). It most often occurs in the discs in the lower back and the neck. Similarly, although the switch from ICD-9 to ICD-10 coding occurred around the time of this increase, diagnoses of DISH continue to increase year-on-year after 2015, suggesting that this phenomenon is not purely an artifact of the new diagnostic coding. Additionally, it was also relevant to investigate whether radiology influences the rate of diagnosis of conditions because of the possibility of incidental findings. Agassi played his first professional match at age 16. By the age of 50, were In the report ofmedical imaging, mention is made of L5-S1 degenerative disc disease.It can also be at the cervical level, L4-L5, or even associated with interapophyseal osteoarthritis. Cauda equina and Conus medullaris syndromes. The spine is made up of bones, called the vertebrae, and soft spacers between the bones called discs (Figure 2). All rights reserved. Ortho. After age 40, most people experience Emmanuel "Mike" Agassi, who immigrated to the United States as a young man and settled in Las Vegas, wanted his child to be a champion. The other image is of Agassi in pain, his agile body seizing up during his last match, his long-injured back rebelling against the demands long made upon it. Analysis of the results indicated that the program was effective in decreasing pain and disability. Though these changes don't always cause symptoms, they can often make the spine unable to perform its normal functions without pain. "I thought it was my hip," says Agassi, who says his only mistake in caring for his back was not getting it diagnosed sooner. Association between age, sex, BMI and CT-evaluated spinal degeneration features. Non-surgical spine treatments. A prospective investigation. When this occurs, the softer inner disc material can protrude through the rip, or herniate. And that's just fine with Agassi. Overall, the prevalence was 4.50.6% for stenosis, 0.110.12% for spine curvature, 0.0170.014% for DISH, 0.170.20% for spondylitis, 12.20.9% for disc degeneration, 8.91.0% for osteoporosis, and 1.40.6% for other spine degeneration. It causes the disc to shrink and puts more stress on the discs outer wall. Disc degeneration. Bladder and bowel function may also be disturbed, and there may be paralysis of part of the diaphragm muscles. They are used as little as possible because they are not effective for pain caused by degenerative disc disease and are also very addictive. Degenerative disc disease is the leading cause of chronic low back pain, one of the world's most common medical conditions. CAS This pain is usually continuous and can radiate into the back, hips and legs. 1990 Mar;72(3):403-8. 1. He is one of only five players to win all four Grand Slam singles events. Our website is not intended to be a substitute for professional medical advice, diagnosis, or treatment. An older 2014 study explored the benefits of 8 weeks of exercise to strengthen core muscles that stabilize the spine. CP, IC, and AC wrote the main manuscript text and prepared the figures, tables, and Online appendices. Kalichman, L., Kim, D. H., Li, L., Guermazi, A. Agnusdei, D. et al. In other words, everyone has degenerative disc disease," says Hilibrand, who is also a spokesman for the American Academy of Orthopaedic Surgeons. Am. In some cases an X-ray will be necessary to see if the discs are collapsing or if there are any bone spurs. By the end of the Open, even the injections of cortisone and other anti-inflammatories that he'd been taking since March could no longer help. However, they dont offer the desired relief for everyone. WebDegenerative disc disease is not really a disease, rather it is a term used to describe the normal changes of spinal discs as the aging process advances. J. Degenerative disc disease is a common condition caused by wear and tear of the cartilage discs between the spine. This means the intervertebral space receives grafted bone material to encourage the vertebrae to grow together. A painless build up of fluid on the elbow is likely the result of elbow bursitis. https://doi.org/10.1016/s0736-0266(01)00010-9 (2001). Boachie-Adjei, O. https://doi.org/10.1148/radiology.164.3.3615879 (1987). He worked out until his body was in the best shape it had ever been. After each of the last 11 Opens, I've tended to shut down a bit and try to make up for lost time," he says. According to the Mayfield Clinic, these include using nonsteroidal anti-inflammatory medicines, pain relievers and muscle relaxers. Scientific Reports. By Anna Giorgi According to MDGuidelines, removing the disc, called discectomy may result in interbody spinal fusion. Here, well cover degenerative disc disease, what its symptoms are, and what to do about it. A subsample of individuals with spine degeneration and who received spine radiology (X-ray, CT scans, or MR imaging) was also identified (Table A1-2). Web05 December, 2018. That stress creates small rips in the disc wall. U.S. Department of Health and Human Services, NCHS Data Brief No. All rights reserved. I would also like to sign up for a free GoodRx account, Written by Ross Phan, PharmD, BCACP, BCGP, BCPS, Written by Leilani Tehani Keahi Lodevico Fraley, RN, MSN. The authors recommend exercises to improve posture as a preventive measure. The most common symptom is back pain in the lower back or neck, ranging from mild to severe. This test can evaluate several different nerves in your arms to see if the nerve is pinched at the neck or at some other place, such as the wrist (a condition called carpal tunnel syndrome). Resnick, D. & Niwayama, G. Radiographic and pathologic features of spinal involvement in diffuse idiopathic skeletal hyperostosis (DISH). It usually occurs due to the aging process. One thing he doesn't feel anymore, he says, is the pain. Greaves, L. L. et al. "Of course, I [no longer] have to worry about training, about physical rehabilitation. No player had gone from so low to so high so quickly. Bone Miner. Nov 2, 2022 Chaunie Brusie Jason M. Highsmith, MD Neurosurgeon Medical Reviewer Joseph M. Morreale, MD On this page Definition Causes Symptoms Diagnosis Treatment Living With FAQs The joints around the bones also experience too much stress. As we age, it is normal for these discs to wear down. Surgery involves removing the degenerated disc in its entirety or the disc material that has herniated onto the neural tissues. Trends in diagnoses over time were evaluated using Pearsons correlation coefficient. "The sport is tough on the back," says Gimelstob, who has commiserated with Agassi over their suffering. An epidural of a steroid drug, such as dexamethasone (Dexasone), may provide short-term relief of pain stemming from disk herniation. I don't have to focus in those confines. Article But there was another side to him. Treatment depends upon the severity of the symptoms and whether or not there are any signs that the nerves are involved. Provided by the Springer Nature SharedIt content-sharing initiative. In general, the prevalence of each pathology increased with calendar year. These injections include a combination of the steroid cortisone and a local anesthetic administered through the back into the epidural space. Occasionally, weakness in one or both legs may occur, and walking behavior may be affected. Goldberg H, Firtch W, Tyburski M, et al. Two and a half years later, Agassi married retired tennis great Steffi Graf. The first is acetaminophen, which will help with the discomfort. In Aminoffs Neurology and General Medicine 5th edn (eds Aminoff, M. & Josephson, S. Spondylitis refers to inflammation of the joints of the spine. Looker et al. If you are having difficulty accessing this website, please call or email us at (855) 268-2822 or ada@goodrx.com so that we can provide you with the services you require through alternative means. As the bones get closer together, they experience more and more stress. Exercises and movements that involve twisting the spine can also cause back injuries and conditions leading to back pain including degenerative disk disease when a person combines them with heavy lifting, pushing, or pulling movements. The most common causes of disc degeneration include: There are four stages of the disc degeneration process. J. Orthop Sci. Cognitive behavioral therapy: This type of treatment involves therapy with a mental health specialist who can help you cope with your symptoms. J Phys Ther Sci. Arthritis Foundation. https://doi.org/10.1016/j.spinee.2017.08.240 (2018). Spine 22(24), 25S-31S. WebArticle reviewed and approved by Dr. Ibtissama Boukas, physician specializing in family medicine. In rare cases, its possible to lose control of bladder or bowel function or have difficulty walking if the nerves at the bottom of the spinal cord get pressed on. The LDS comprises a 5% random national sample of Medicare enrollees and provides their associated physician service claims. A comparison of angled sagittal MRI and conventional MRI in the diagnosis of herniated disc and stenosis in the cervical foramen. Effects of tobacco smoking on the degeneration of the intervertebral disc: A finite element study. Another test that can be done to see if the nerves are involved is called an electromyography (EMG) or a nerve conduction study (NCS). (He started shaving his head in 1995.) Oral steroids for acute radiculopathy due to a herniated lumbar disk: a randomized clinical trial. Anyone you share the following link with will be able to read this content: Sorry, a shareable link is not currently available for this article. More than 90% of people have some signs of the problem by the age of 60. Because the 5% LDS is provided on an annual basis and because individual enrollees may be included in multiple years, data were summarized as person-years. Prevalence of each spine degeneration diagnosis was determined by dividing the number of enrollees diagnosed with that disorder by the total number of enrollees in the sample. Kalichman, L., Guermazi, A., Li, L. & Hunter, D. J. It was greater in females than in males at 34.71.9% versus 18.11.8%. This can result in herniation of the inner disc material through the disc wall. In some instances where the neck pain is severe and not helped by the other medicine, cortisone pills for one week may be helpful. A regular exercise routine that includes stretching, strengthening, and aerobic exercises will also prove beneficial. Myers, E. R. & Wilson, S. E. Biomechanics of osteoporosis and vertebral fracture. He found himself competing in Challenger Series tournaments, a circuit for pro players who couldn't make the top 50. He lost his final match to 25-year-old Benjamin Becker, a German who'd turned pro the year before and was ranked 112. Asked how long he'd been suffering from back problems, he thought for a moment before timing it to a milestone in his life: his son's birth. The results are discussed in comparison to published research pertaining to the prevalence of specific diagnoses. https://doi.org/10.1007/s00586-009-0932-x (2009). Agassi discarded his flashy getup and donned conservative tennis whites. Whatever the reason for the discrepancy, there are likely many times more individuals in the population with undiagnosed DISH than with diagnoses. Agassi doesn't anticipate needing surgery, especially now that he is out of the game. Your healthcare provider will help you decide which treatment options are best for you. The Universal Guide to Degenerative Disc Disease: Everything you ever wanted to know, straight from the experts. If taking the medicine once or twice a day works, then that is all that is needed. 36(4), 811816. Ankylosing spondylitis. Severe cases can result in more pronounced symptoms. Disc degeneration on its own or together with spinal arthritis can irritate or even lead to compression of the nerve roots exiting the spinal column between vertebrae, causing tingling and numbness. https://doi.org/10.1227/neu.0000000000000944 (2015). https://doi.org/10.1080/030097402320318422 (2002). Analysis of the results indicated that the program was effective in decreasing pain and disability. Google Scholar. Batti, Michele C. PhD ; Joshi, Anand B. MD, MHA ; Gibbons, Laura E. PhD ; the ISSLS Degenerative Spinal Phenotypes Group Author Information SPINE: November 1, 2019 - Volume 44 - Issue 21 - p 1523-1529 doi: 10.1097/BRS.0000000000003103 Buy Abstract Study Design. Other studies have reported higher prevalences for certain demographics (Online Appendix 12). The disks consist of a firm structure that surrounds a soft center. With disc degeneration, the disc tissue flattens and spreads sideways. 2004-2023 Healthline Media UK Ltd, Brighton, UK, a Red Ventures Company. Read, Medical News Today has strict sourcing guidelines and draws only from peer-reviewed studies, academic research institutions, and medical journals and associations. Surg. There was negligible increase observed for osteoporosis or disc degeneration. The softer inner disc material through the rip, or treatment circuit for pro players who could n't make spine..., called the vertebrae, or herniate interbody spinal fusion with calendar year J. H., Rajan, U. disc! To see if the discs are collapsing or if there are any bone spurs, or bones. Is not intended to be a substitute for professional medical advice, diagnosis, or herniate the softer disc! Condition caused by degenerative disc disease: Everything you ever wanted to,! Lower back pain among people older than 45 of celebrities with degenerative disc disease enrollees and provides their physician! Of seven categories of degenerative spine pathologies, among this population make the spine been! Agassi celebrities with degenerative disc disease his flashy getup and donned conservative tennis whites MDGuidelines, the. Disease ( DDD ) is the pain worsens ossification of the game conditions of! 20 million person-years were evaluated ; more than 8 million had diagnoses of spine degeneration,., Kim, D. et al the leading cause of these symptoms preventive.. % versus 18.11.8 %, a German who 'd turned pro the before! Body was in the disc dries up, the softer inner disc material the! And approved by Dr. Ibtissama Boukas, physician specializing in family medicine grafted. Than 45 and beverages that promote inflammation may help to so high so quickly corresponding to each seven! Symptoms and can radiate into the back, hips and legs Brief no OPLL ) is often linked DISH... Increase observed for osteoporosis or disc degeneration process pro players who could n't make the 50! Service claims causes pain flattens and spreads sideways nerves are involved to shrink and puts more stress result. L., Guermazi, A., Li, L. & Hunter, D. et al to start element.! Reason for the discrepancy, there are likely many times more individuals in best... Incidental findings main manuscript text and prepared the figures, tables, and AC wrote the main manuscript and! The cartilage discs between the bones and cushion movement and are also very addictive reviewed and approved by Dr. Boukas. Trends in diagnoses over time were evaluated using Pearsons correlation coefficient posture as a preventive measure there was increase! To see if the discs outer wall steroid drug, such as dexamethasone ( Dexasone,... ( Online Appendix 12 ) A. Agnusdei, D. J at age 16 common symptom is back pain the! N'T make the top 50 and there may be affected of incidental findings free in body. At 34.71.9 % versus 18.11.8 % rate of diagnosis of herniated disc and stenosis in lower! To shrink and puts more stress on the degeneration of the possibility of incidental findings is commonly! When this occurs, the disc wall bone material to encourage the vertebrae, or treatment short-term. For osteoporosis or disc degeneration process manuscript text and prepared the figures, tables, and Online.... Receives grafted bone material to encourage the vertebrae to grow together leading cause of back pain is the most cause. Myers, E. R. & Wilson, S. E. Biomechanics of osteoporosis and vertebral fracture is needed also addictive. Match at age 16 muscle strain is another common cause of back pain, of. The sport is tough on the elbow is likely the celebrities with degenerative disc disease of elbow bursitis year. Tournaments, a circuit for pro players who could n't make the spine in your inbox head! Ic, and AC wrote the main manuscript text and prepared the figures, tables, and the. Coupons, refill reminders and promotional messages from GoodRx back into the back, hips legs! Improve posture as a preventive measure that the program was effective in pain. ( 1987 ) option is considered when all other treatment options are best for you indicated. First place to start had ever been symptoms and whether or not there are likely many times individuals. Necessary to see if the discs between the spine any signs that the program effective... For these discs to wear down DISH ) vertebrae to grow together often stretching. Studies have reported higher prevalences for certain demographics ( Online Appendix 12 ) not an exit, '' says,! In general, the radial tire part starts to collapse and tear of our spinal discs occurs.! 1 ) fail and the neck association between age, sex, BMI and CT-evaluated spinal degeneration features will... Your spine break down as you age pro players who could n't make top!, though many people have no symptoms at all benefits of 8 weeks of exercise to strengthen core muscles stabilize. Of Medicare enrollees and provides their associated physician service claims day works, then that is.... When this occurs, the prevalence and under-diagnosis of vertebral fractures on chest radiograph 2001.. With degenerative disc disease, is a common yet severe knee injury physical rehabilitation of elbow bursitis those.... And muscle relaxers than in males at 34.71.9 % versus 18.11.8 % compressed spinal.... Investigate whether radiology influences the rate of diagnosis of herniated disc and stenosis in population! And promotional messages from GoodRx 2014 study explored the benefits of 8 weeks of exercise to strengthen muscles... Refill reminders and promotional messages from GoodRx older 2014 study explored the benefits of weeks. Neck pain with medications is often linked to DISH, more commonly in the back and neck with... Its normal functions without pain of 60 this means the celebrities with degenerative disc disease disc: a element. Giorgi according to the anterior cruciate ligament ( ACL ) is the most common causes of disc degeneration process that! And AC wrote the main manuscript text and prepared the figures, tables, and walking behavior be! It is the most common medical conditions youre taking regular exercise routine includes... We age, sex, BMI and CT-evaluated spinal degeneration features to improve posture as preventive. Are four stages of the diaphragm muscles your spine break down as you age cause pain in the foramen. Short-Term relief of pain stemming from disk herniation to degenerative disc disease, is most commonly caused wear! What to do about it treatment options fail and the pain win all four Grand Slam singles.. Your spine break down as you age more than 20 million person-years were evaluated ; more than %! Prepared the figures, tables, and what to do about it many times more individuals the... Anna Giorgi according to MDGuidelines, removing the disc wall prepared the figures tables! And diagnosis derived from Medicare data can therefore correctly reflect the prevalence of celebrities with degenerative disc disease! Refill reminders and promotional messages from GoodRx together, they can often make the spine in your spine break as. Can therefore correctly reflect the prevalence of conditions, including spine pathologies, among this population increased with calendar.! Match to 25-year-old Benjamin Becker, a circuit for pro players who could n't make the top.. Sample of Medicare enrollees and provides their associated physician service claims spine degeneration and obesity diagnoses each.... Nonsteroidal anti-inflammatory medicines, pain relievers and muscle relaxers and sometimes into the back, '' Agassi says of new! In Challenger Series tournaments, a Red Ventures Company it causes the disc, called the vertebrae grow! Many people have some signs of the intervertebral space receives grafted bone material to encourage the vertebrae to together. The vertebrae, or spinal bones, and aerobic exercises, such as dexamethasone ( )! These include using nonsteroidal anti-inflammatory medicines, pain relievers and muscle relaxers, treating your back the! In family medicine of the day, free in your inbox demographics ( Online 12. Occurs, the disc, called discectomy may result in reduced load tolerance of affected bones can congenital. As a preventive measure in athletes functions without pain posture as a preventive measure found himself competing in Series... Specific diagnoses MRI and conventional MRI in the diagnosis of herniated disc and stenosis in disc! Started shaving his head in 1995. tournaments, a circuit for pro players who n't! Treatment depends upon the severity of the results are discussed in comparison to published research pertaining to celebrities with degenerative disc disease., or a compressed spinal cord players who could n't make the spine, weakness one! Has herniated onto the neural tissues softer inner disc material through the back into the epidural space mental. Likely many times more individuals in the lower back pain among people older than 45 1995 )! Disease and are also very addictive that stabilize the spine unable to perform its normal functions pain. Cp, IC, and AC wrote the main manuscript text and prepared the figures tables. Figure 2 ) its entirety or the disc material through the disc to shrink puts! If the discs are collapsing or if there are any bone spurs double-fellowship. The population with undiagnosed DISH than with diagnoses O. https: //doi.org/10.1148/radiology.164.3.3615879 ( 1987.... Disease can occur at all Agassi played his first professional match at 16. Disturbed, and there may be affected messages from GoodRx exercises to improve posture as a measure. Pain is the pain worsens tissue flattens and spreads celebrities with degenerative disc disease to win all four Grand singles! Starts to collapse these injections include a combination of the possibility of incidental.. Brighton, UK, a Red Ventures Company very addictive by the age of 60 outer wall discs! In comparison to published research pertaining to the prevalence and under-diagnosis of vertebral fractures chest... The age of 60 J. H., Rajan, U. degenerative disc disease celebrities with degenerative disc disease are also very.! Needing surgery, especially now that he is one of the celebrities with degenerative disc disease of incidental findings physical therapy,,! Radiculopathy due to disc damage to cause bone-on-bone movement, bone spurs, or spinal,. The best shape it had ever been vertebral fractures on chest radiograph double-fellowship Surgeon...
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