Diaphragmatic reinnervation in ventilator-dependent patients with cervical spinal cord injury and concomitant phrenic nerve lesions using simultaneous nerve transfers and implantable neurostimulators. The incidence of transient phrenic nerve palsy is virtually 100% after landmark- and paresthesia-guided interscalene block techniques that use a large-volume injection of 20 ml or greater.13,14. There is little crossover innervation of the right and left hemidiaphragms, and each can contract independently of the other in the event of unilateral phrenic nerve palsy. Copyright 2017, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved. Phrenic Nerve Repair Reconstructive Services Our team is made up of experts and leaders in the art and science of plastic surgery. All the terminal nerves supplying the shoulder arise distal to the origin of the superior trunk and hence analgesic efficacy is not compromised. Long-Term Follow-Up after Phrenic Nerve Reconstruction for Diaphragmatic Paralysis: A Review of 180 Patients. A paralyzed diaphragm can be either unilateral (on one side of the muscle) or bilateral (on both sides of the muscle). As with any surgically implanted device, there are risks related to the implant procedure which may include, but are not limited to, pain, swelling and infection. In: Kaufman MR, Elkwood AI, Aboharb F, et al. Renes et al.15 showed that ultrasound-guided injection of 10 ml ropivacaine 0.75%, around the C7 nerve root resulted in similar analgesia, but only a 13% incidence of phrenic nerve palsy compared with 93% with a neurostimulation-guided interscalene block using the same dose of local anesthetic. You may stay in the hospital overnight, which will depend on your health, how well you tolerate the procedure and how fast you recover. After then, even if the injured nerve is reconstructed, it wont be able to tell the muscle to contract. Effect of unilateral phrenic nerve section on lung function. However, phrenic nerve palsy is a significant complication that potentially limits the use of regional anesthesia, particularly in high-risk patients. Visualization on the left often is technically more challenging due to the smaller acoustic window of the spleen and the presence of the air-filled stomach. This nerve wrap acts to promote regrowth and to prevent recurrence of scar tissue and adhesions. The phrenic nerve controls your diaphragm (the large dome-shaped muscle between your abdominal and chest cavities). Call (212) 305-3408 for existing patients, (212) 304-7535 for new patients to make an appointment with an expert from the Diaphragm Center at Columbia. However, just as phrenic nerve palsy does not always result in dyspnea, dyspnea may also be experienced in the absence of phrenic nerve palsy.3138 Although up to 40% of patients complain of dyspnea after interscalene block or supraclavicular block,14,17,39 only one third40 to three quarters41 of these patients have objective evidence of phrenic nerve palsy. The Remede System is an implantable device that stimulates the phrenic nerve to stimulate breathing. To learn more about our services, call 310-825-5510. This video demonstrates surgical repair of the phrenic nerve in a patient diagnosed with right diaphragm paralysis resulting from a prior neck surgery. The conventional ultrasound-guided interscalene block is a direct carryover from the landmark-guided approach, which relied on the interscalene groove and the anterior tubercle of the C6 transverse process as key landmarks, and thus necessitated a needle approach to the brachial plexus at the root level. High volume and low concentration of anaesthetic solution in the perivascular interscalene sheath determines quality of block and incidence of complications. The rest is a long story you can check my history. Prolonged diaphragm dysfunction after interscalene brachial plexus block and shoulder surgery: A prospective observational pilot study. The pleural line (yellow circle) can be seen progressively descending with inspiration. The remed System is an implantable system that stimulates a nerve in the chest (phrenic nerve) to send signals to the large muscle that controls breathing (the diaphragm). [1] Mechanical Ventilation or Phrenic Nerve Stimulation for Treatment of Spinal Cord Injury-Induced Respiratory Insufficiency Spinal Cord. Activities the person formerly enjoyed are basically out of the question due to inherent difficulty with simple breathing. Patients endured chronic shortness of breath, sleep disturbances, and lower energy levels. Learn more about the Avery Diaphragm Pacing System System, Published Article: Diaphragm Pacing Using the Minimally Invasive Cervical Approach. Diaphragm muscle replacement surgeryFor some patients, phrenic nerve surgery and diaphragm pacemakers are not the right solutions, especially when the condition has been present for many years, or if the individual has previously undergone diaphragm plication. Persistent phrenic nerve palsy after interscalene block is a complication that has recently gained wider recognition, and its incidence has been estimated from case series data to range from 1 in 2,00018 up to 1 in 100.19 There are several potential causes of persistent phrenic nerve palsy that have been put forth in the literature. Be sure to talk with your doctor so that you thoroughly understand all of the risks and benefits associated with the implantation of theremed System. The most common causes of phrenic nerve injury are surgical complications and trauma. Patients usually stay awake, but are drowsy during the procedure. It makes eating and drinking easier. The incidence of respiratory compromise was not reported in this study, so it is unclear whether there are further reductions in the incidence of phrenic nerve palsy at volumes less than 5 ml. It is indicated for patients with diaphragmatic dysfunction owing to a C3 or higher spinal cord injury (such that the lower motor neuron formed from the C3-C5 nerve roots is uninjured), polio, amyotrophic lateral sclerosis, central sleep apnea . For further information, please visit remede.zoll.com, call+1-952-540-4470 or email info@remede.zoll.com. Address correspondence to Dr. El-Boghdadly: Department of Anaesthesia, Guys and St. Thomas National Health Service Foundation Trust, Great Maze Pond, SE1 9RT, London, United Kingdom. A nerve wrap is then applied around both the phrenic nerve proper and the sural nerve interposition graft. In arthroscopic shoulder surgery, suprascapular nerve block alone or combined with an axillary nerve block has been shown to provide superior analgesia compared with placebo or subacromial local anesthetic infiltration7981 but is less effective compared with interscalene block.78,79 Because this peripheral nerve block technique primarily targets the capsular innervation of the shoulder, it also may be less useful in open or extensive shoulder surgery.82 Nevertheless, this technique has a good safety record in chronic pain practice83 and has not been associated with any reported episodes of phrenic nerve palsy to date. Read full indications for use. The technical storage or access that is used exclusively for statistical purposes. Several studies have shown that reducing local anesthetic concentration independent of volume, thus reducing the dose of drug delivered, also produces a significant decrease in the incidence of phrenic nerve palsy and an improvement in pulmonary function after landmark- or ultrasound-guided interscalene block.36,43,44 With a nerve stimulator-guided interscalene block, halving the concentration of a 30-ml mixture of 0.5% bupivacaine and 2% lidocaine but doubling the volume led to a reduction in phrenic nerve palsy from 27% to 0%.55 Halving the concentration of bupivacaine from 0.5% to 0.25% reduced the incidence of phrenic nerve palsy from 100% to 17% when 10 ml was administered via a landmark approach36 and from 78% to 21% when 20 ml was administered with nerve-stimulator localization.44 Similarly, the incidence of phrenic nerve palsy was reduced from 71% to 42% by halving the concentration of 20 ml ropivacaine from 0.2% to 0.1% in an ultrasound-guided interscalene block.43 Unfortunately, this reduction in phrenic nerve palsy generally appears to come at the expense of reduced analgesic efficacy. A comprehensive microscopic neurolysis of the phrenic nerve and upper cervical roots is performed. Phrenic nerve injury that results in diaphragm paralysis can significantly decrease quality of life. Contraction of the diaphragm muscle permits expansion of the chest cavity and inhalation of air into the lungs. 46, No. Even if it doesnt come to that, patients with phrenic nerve injury or paralysis endure chronic shortness of breath, sleep difficulty, and fatigue. Analgesic effectiveness of ropivacaine 0.2% vs 0.4% via an ultrasound-guided C5-6 root/superior trunk perineural ambulatory catheter. According to a study published in the journal Spinal Cord [1], diaphragm pacing costs about 90% less than the comparable costs for keeping a patient on a positive-pressure ventilator (PPV). The techniques used are derived from the procedures commonly used to treat arm or leg paralysis, which have allowed surgeons to restore function to previously paralyzed muscle groups. Comparison between ultrasound-guided supraclavicular and interscalene brachial plexus blocks in patients undergoing arthroscopic shoulder surgery: A prospective, randomized, parallel study. Chest fluoroscopy is an even more detailed X-ray and can show the right and left side of the diaphragm in motion as the patient breathes in and out. Cost of Neuropathy Treatment - 2023 Healthcare Costs - CostHelper Long-term follow-up after phrenic nerve reconstruction for diaphragmatic paralysis: a review of 180 patients [published correction appears in. Less disposable equipment A patient utilizing the Avery Diaphragm Pacing System with a plugged or omitted tracheostoma does not need respiratory tubes, filters, or suction catheters. Aggressive Treatment of Acquired Phrenic Nerve Paralysis in Infants and This may include one or more of the following: 1) removing scar tissue from around the nerve to allow the electrical signals to travel more easily across the nerve (nerve decompression/neurolysis); 2) cutting out the scar tissue that is filling the nerve gap and bridging it with a sensory nerve (nerve graft); 3) selecting a motor nerve from a healthy but less important muscle group (spinal accessory nerve or intercostal nerves) and transferring it to the injured phrenic nerve (nerve transfer). Diaphragm paralysis caused by transverse cervical artery compression of the phrenic nerve: the Red Cross syndrome. Inflammatory scarring causing nerve entrapment has been reported with both landmark-guided and ultrasound-guided interscalene block, and although it has been suggested that this scarring may be related to local anesthetic myotoxicity,24,25 these are postulated mechanisms without direct supporting evidence at present. Transvenous Phrenic Nerve Stimulation for Treatment of Central Sleep Apnea: Five-Year Safety and Efficacy Outcomes. The technical storage or access that is used exclusively for anonymous statistical purposes. This traditionally has been achieved by performing an interscalene block, which targets the C5 and C6 roots of the brachial plexus in the interscalene region. Cervical spondylosis as a possible hidden reason beyond delayed phrenic Cadaveric (left) and corresponding sonographic images (right) demonstrating the course of the right phrenic nerve as it emerges beneath the lateral margin of the sternocleidomastoid muscle (SCM), between the middle scalene muscle (MSM) and the anterior scalene muscle (ASM). Learn More Share With Friends Request Information The reduction in local anesthetic concentration and dose decreased duration of sensory blockade by 34% and increased postoperative opioid requirements by up to 50%.43,44 Zhai et al.56 demonstrated that there is no significant difference in the incidence of phrenic nerve palsy with a fixed 50-mg dose of ropivacaine for ultrasound-guided interscalene block using concentrations of 0.25, 0.5, or 0.75%, with minimal effect on analgesic outcomes. The sural nerve is then sewn into the phrenic nerve, proximal and distal to the visualized defect. That's a savings of up to $20,000 per year. Dr. Kaufman is the only known expert in the world to perform phrenic nerve reconstruction surgery. Without a subpoena, voluntary compliance on the part of your Internet Service Provider, or additional records from a third party, information stored or retrieved for this purpose alone cannot usually be used to identify you. In 3-4 years the diaphragm pacing system can pay for itself with the cost savings! In this article, we aim to describe the anatomical, physiologic, and clinical principles governing phrenic nerve palsy in the context of regional anesthesia for shoulder surgery. The phrenic nerve provides both sensory and motor nerves to the diaphragm, and sensory fibers to parts of the pleura and peritoneum. It tells the diaphragm when to contract, allowing the chest cavity to expand and triggering the inhalation of air into the lungs. These nerves supply the diaphragm muscle. Hiccups, Cough, Neck Pain, and Vagus and Phrenic Nerve Injury The Institute for Advanced Reconstruction is one of the only practices in the world to offer several groundbreaking procedures to treat diaphragm paralysis caused by phrenic nerve damage. Functional Electrical Stimulation and Neuromuscular Electrical - Aetna Quantified sonography of the diaphragm is more sensitive to changes in unilateral diaphragmatic dysfunction than pulmonary function tests and oxygen saturation because the latter two variables assess bilateral pulmonary function simultaneously, including the use of accessory muscles and contralateral diaphragmatic activity. (C) The osteotomal supply of the shoulder. Asymptomatic profound oxyhemoglobin desaturation following interscalene block in a geriatric patient. Phrenic nerve paralysis leads to a poor quality of life, as the person is plagued by chronic fatigue and shortness of breath. Consequently, there is reduced lung ventilation on the affected side, particularly of the lower lobe.28,30 In healthy individuals, however, tidal volumes remain unchanged due to a greater contribution from the rib cage.11,28 In higher-risk patient groups, hypoxia and dyspnea may ensue and require treatment by sitting the patient upright and administering supplemental oxygen therapy or, in severe cases, instituting noninvasive or invasive ventilatory support to augment tidal volumes. Board certified thoracic surgeons evaluate and treat diaphragm conditions in conjunction with pulmonologists at the Brigham and Women's Hospital Lung Center. Hemidiaphragmatic paralysis following ultrasound-guided supraclavicular. Plastic & Reconstructive Surgery Clinic Fort Smith AR | Mercy Shoulder pain: Diagnosis and management in primary care. In 1948, Lurje 3 suggested that the phrenic nerve may be used as a source of motor axons, but it is not recorded whether he ever used it clinically. The impact of phrenic nerve palsy on respiratory function may be quantified by several bedside methods, including pulse oximetry, pulmonary function tests, and sonographic evaluation of the diaphragm. Key landmarks to identify proximity to the phrenic nerve include the posterior border of the sternocleidomastoid muscle medially, the brachial plexus laterally, and the anterior scalene muscle, upon which the phrenic nerve courses. For additional information on Phrenic Nerve Paralysis and Paralyzed Diaphragm treatment in Los Angeles, CA, call our office at (310) 423-2129 to schedule a consultation today! So that is one of the paths of the right and left-sided pairs of the phrenic nerve. Kaufman MR, Elkwood AI, Brown D, et al. In addition, its system of using small implanted radiofrequency receivers rather than electrode wires that pass directly through the skin may decrease a patients risk of infection and ongoing wound care management issues. Hemidiaphragmatic paresis during interscalene brachial plexus block: Effects on pulmonary function and chest wall mechanics. Diaphragmatic motion studied by m-mode ultrasonography: Methods, reproducibility, and normal values. Ultrasound reduces the minimum effective local anaesthetic volume compared with peripheral nerve stimulation for interscalene block. 1). Eric Vallieres. Our doctors are at the forefront of research and innovation in the field. Sensory contributions to the muscles of the shoulder comprise the following: the ventral rami of the third and fourth cervical nerves to the trapezius muscle, the pectoral nerves (C5C7) to the pectoral muscles, the dorsal scapular nerve (C5) to the levator scapulae and rhomboid muscles, and the axillary nerve (C5C6) to the deltoid muscle. These include the intercostal nerves, 4,5 the spinal accessory nerve, 2 and the motor branches of the cervical plexus. Peripheral Nerve Surgery for Chronic Pain | Michigan Medicine - U of M Care How can I keep my diaphragm healthy? https://www.uptodate.com/contents/surgical-treatment-of-phrenic-nerve-injury. We report a case report that describes this complication and how it can be resolved. Clonidine as an adjuvant to local anesthetics for peripheral nerve and plexus blocks: A meta-analysis of randomized trials. See a direct comparison between the Avery Diaphragm Pacemaker and the leading competitors diaphragm pacing system. The latest advancement in remed System technology is now FDA approved. 105 The nerve then passes from the neck posterior to the subclavian vein to enter the thorax, innervate the ipsilateral diaphragm . The. Phrenic nerve stimulation, a rare complication of : Medicine A recent study compared the effect of performing an ultrasound-guided intraplexus injection on the anterior versus posterior aspect of the C5C6 nerve roots with 15 ml ropivacaine 1%.35 There was a similar reduction of 12 to 28% in all pulmonary function parameters in both groups. Led by the renowned Dr. Matthew Kaufman, our surgical team provides world-class treatment for phrenic nerve injury in order to reverse diaphragm paralysis. Update of phrenic nerve injury due to heart ablation. In the past, treatment options for phrenic nerve injury were limited to either nonsurgical therapy or diaphragm plication, neither of which attempts to restore normal function to the paralyzed diaphragm. SURGERY for shoulder pathology is increasingly common,1,2 with regional anesthesia playing an important role in multimodal analgesia for these painful procedures.3 Interscalene brachial plexus block is the most common regional anesthetic technique; however, phrenic nerve palsy and hemidiaphragmatic paresis have traditionally been inevitable consequences, which limit its utility in the population of patients at high risk of respiratory complications. With any surgery there are risks, but the alternative of not having your nerve damage addressed has far more downsides. Injection with 20 to 30 ml local anesthetic is associated with a 25 to 51% incidence of phrenic nerve palsy in both landmark- and ultrasound-guided studies.11,40,41,59 Nonetheless, inferior sensory block and greater analgesic requirements in shoulder surgery have been reported with supraclavicular brachial plexus block compared with interscalene block.37,59 This may reflect incomplete blockade of the suprascapular nerve, which has left the brachial plexus at this point. You will not be able to have an MRI or diathermy (special heat therapies) if you have the remed system implanted. Patient-controlled interscalene analgesia with ropivacaine 0.2%. Dr. Matthew Kaufman is an award-winning cosmetic and reconstructive plastic surgeon, board certified in both Plastic Surgery and Otolaryngology-Head and Neck Surgery, and he is a Fellow of the American College of Surgeons (FACS). A range of modifications and alternatives to interscalene block have been proposed to minimize the respiratory impact of phrenic nerve palsy, but to date there has been no thorough assessment of the clinical value offered by each of these strategies. The loss of functionality occurs when patients use ventilators for breathing. Injuries to the phrenic nerve can occur in a variety of ways, including injections of medicine in the neck prior to shoulder surgery or to treat pain, chiropractic adjustments of the neck, or neck, chest or vascular surgery. The phrenic nerve controls function of the diaphragm muscle - the primary muscle involved in breathing. Paralyzed diaphragm caused by neurological disorders, spinal cord disorders and trauma to the phrenic nerve from surgery, radiation or a tumor. A number of nerves have been used for neurotization after brachial plexus injuries with nerve root avulsions. A standard X-ray can provide a snapshot of the diaphragm and its location. Palhais et al.17 recently reported that an ultrasound-guided extrafascial (periplexus) injection of 20 ml bupivacaine 0.5%, performed 4 mm lateral to the brachial plexus sheath not only provided similar analgesia compared with an intraplexus injection between the C5 and C6 roots but also reduced the incidence of diaphragmatic paresis from 90% to 21%. Recently, the concept of ultrasound-guided periplexus (between the interscalene muscles and brachial plexus nerve sheath) injection of local anesthetic has been introduced for interscalene block. Find a provider Our locations Innovative new surgery repairs phrenic nerve injury, restores breathing function The remed system may not work for everyone. Neurostimulation of the phrenic nerve is a new technology that has demonstrated improvement. It therefore falls to the individual anesthesiologist to assess the likely impact of phrenic nerve palsy in any given patient undergoing shoulder surgery and to select the appropriate regional anesthetic technique accordingly. Regional and total lung function studies in patients with hemidiaphragmatic paralysis. On breathing out, the diaphragm rises to push air out. Intact phrenic nerves are required for successful stimulation. What side(s) of your diaphragm is paralyzed? Your doctor will need to determine the type and severity of sleep apnea based on your sleep study. (surgery, post-surgical recovery and phrenic conditioning) typically takes 12 weeks. Dr. Chan receives honoraria from SonoSite, Inc. (Bothell, Washington) and is on the medical advisory board of Smiths Medical (Ashford, United Kingdom) and Aspen Pharmacare (Durban, South Africa). MT = middle trunk; ST = superior trunk. Answer a few short questions to see if you may be a candidate. Ultrasound-guided block of the axillary nerve: A volunteer study of a new method. 6) in a two-dimensional B-mode. Anatomical, Physiologic, and Clinical Considerations, A Tool to Screen Patients for Obstructive Sleep Apnea, ACE (Anesthesiology Continuing Education), https://doi.org/10.1097/ALN.0000000000001668, 2023 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting: Carbohydrate-containing Clear Liquids with or without Protein, Chewing Gum, and Pediatric Fasting DurationA Modular Update of the 2017 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting, 2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade: A Report by the American Society of Anesthesiologists Task Force on Neuromuscular Blockade, 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway, Subomohyoid Anterior Suprascapular Block versus Interscalene Block for Arthroscopic Shoulder Surgery: A Multicenter Randomized Trial, Suprascapular and Interscalene Nerve Block for Shoulder Surgery: A Systematic Review and Meta-analysis, Comparison of Anterior Suprascapular, Supraclavicular, and Interscalene Nerve Block Approaches for Major Outpatient Arthroscopic Shoulder Surgery: A Randomized, Double-blind, Noninferiority Trial, Superior Trunk Block: A Phrenic-sparing Alternative to the Interscalene Block: A Randomized Controlled Trial, Superior Trunk Block Provides Noninferior Analgesia Compared with Interscalene Brachial Plexus Block in Arthroscopic Shoulder Surgery, Copyright 2023 American Society of Anesthesiologists. Prior tests can be particularly helpful, such as EMG/NCV, diagnostic nerve blocks, and 3T MRIs. The remed System model 1001 has received CE Mark approval. My invasive tumor was involved with both phrenic nerves, and as my surgeon tried to free the right nerve it was damaged; he opted to not attempt to disentangle the left phrenic nerve to avoid putting me on a ventilator for life. Phrenic Nerve Paralysis can involve injury of the right, left, or both phrenic nerves. Complete phrenic nerve palsy may be diagnosed by paradoxical cephalad movement of the diaphragm61,62 or a 75% or greater reduction in diaphragmatic movement.15,41 Diaphragmatic ultrasound has been shown to have high sensitivity (93%) and specificity (100%) in diagnosing phrenic nerve dysfunction.63. The double crush in nerve entrapment syndromes. Phrenic nerve function after interscalene block revisited: Now, the long view. It winds through C3-C5 and makes its way down towards the diaphragm. Your doctor will need to evaluate your condition to determine if the remed system is right for you. Among the three TOS subtypes neurogenic, venous and arterial neurogenic accounts for about 96 percent . Furthermore, one anatomical study indicate, that the phrenic nerve on the right side supply the liver capsule with thin sensory nerves. Patients are often misdiagnosed because the . The phrenic nerve is a mixed motor/sensory nerve that originates from the C3-C5 spinal nerves in the neck. Theremed System cannot be used with Magnetic Resonance Imaging (MRI). If you and your doctor decide to remove the system, another surgery will be required. Persistent phrenic nerve paresis after interscalene block: A triple crush hypothesis of nerve injury. About KOL ; Learn more about our technology and how more and more universities, research organizations, and companies in all industries are using our data to lower their costs. Comparison of tissue distribution, phrenic nerve involvement, and epidural spread in standard- vs low-volume ultrasound-guided interscalene plexus block using contrast magnetic resonance imaging: A randomized, controlled trial. Image adapted with permission from Danilo Jankovic and reproduced with permission from Ultrasound for Regional Anesthesia (USRA; http://www.usra.ca). Pain relief after arthroscopic shoulder surgery: A comparison of intraarticular analgesia, suprascapular nerve block, and interscalene brachial plexus block. Your Mayo Clinic care team may include doctors trained in diagnosing and treating nervous system disorders (neurologists and neurosurgeons); repairing damaged bones, muscles and . Some of the known causes and risk factors include: Sometimes, we are unable to pinpoint a direct cause for a phrenic nerve injury that results in diaphragm paralysis. The effect of continuous interscalene brachial plexus block with 0.125% bupivacaine vs 0.2% ropivacaine on pain relief, diaphragmatic motility, and ventilatory function. The condition is often mis-diagnosed or viewed as insufficiently severe enough to require corrective surgery. The diaphragm muscle turns off and the patient may have difficulty breathing. It has been almost 6 months since my ablation and still having to sleep on the recliner due to doctor injuring my phrenic nerve during surgery. Introduction: Phrenic nerve lesion is a known complication of thoracic surgical intervention, but it is rarely described following thymectomy and lung surgery. The superior trunk also can be targeted at the supraclavicular brachial plexus level. When was your most recent Pulmonary Function Test completed? Now, Dr. Kaufman and his team have found a way to offer it to both children and adults who experience diaphragm paralysis. Regardless of the specific type of diaphragm paralysis, the symptoms are generally the same, including: Causes of phrenic nerve injury can vary from accidents and trauma to infections and diseases. Anterior (left) and posterior (right) innervation of the shoulder. This video demonstrates surgical repair of the phrenic nerve in a patient diagnosed with right diaphragm paralysis resulting from a prior neck surgery. Ultrasound imaging of the axillary nerve and its role in the diagnosis of traumatic impairment.
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