cauda equina syndrome

Cauda equina syndrome. Severe nerve-type (neurogenic) pain may require prescription pain medication with side effects that may cause further problems. Symptoms: CES symptoms may develop slowly and worsen over time as the cauda equina becomes more and more compressed. If a tumor is responsible, radiation or chemotherapy may be needed after surgery. It depends on how much damage has occurred. Select from premium Cauda Equina Syndrome of the highest quality. Sciatica 3. The symptoms of CES are:1 1. Cauda equina syndrome (CES) is a rare condition where the cauda equina becomes compressed or severely squeezed. But in rare cases, severe back pain can be a sign of cauda equina syndrome (CES), a condition that usually requires urgent surgical treatment. Those experiencing any of the red flag symptoms should consult a neurosurgeon as soon as possible. Cauda Equina Syndrome Support Group has 2,702 members. Introducing Cauda Equina Syndrome SWAG! ", New York-Presbyterian Hospital: "Cauda Equina Syndrome.". Cauda equina syndrome. Dette område kaldes "ridebukseområdet". Cauda equina syndrome is a potentially serious neurological disorder caused by pressure on the cauda equina, a collection of nerves at the base of the spine that govern sensation and function in the lower limbs, bladder and bowels. But severe back pain can be a symptom of a serious condition that is not well known and is often misdiagnosed. The individual nerve roots at the end of the spinal cord that provide motor and sensory function to the legs and the bladder continue along in the spinal canal. Nerves that branch off of the spinal cord (also called nerve roots) are an extension of the spinal cord and are responsible for sending signals to and from the muscles and other structures throughout the body. The cauda equina is a group of nerves located at the base of the spinal cord which extend down the back of each leg, it’s name deriving from the Latin term for ‘horses tail’ due to it’s appearance. Cauda equina syndrome is an uncommon compression of the nerves at the end of the spinal cord within the spinal canal. If untreated, patients can develop debilitating complications, hence a high level of suspicion and rapid intervention is required.. If surgery is successful, you may continue to recover bladder and bowel function over a period of years. Causes of Cauda Equina Syndrome :-Cauda equina syndrome occurs more often in adults than in children, but it can occur in children who have a spinal birth defect or have had a spinal injury. It is important to work closely with your physician on medication and pain management. All Rights Reserved, background-image - a woman looking at a screen, Neurosurgery Research & Education Foundation, Violent injuries to the lower back (gunshots, falls, auto accidents), Spinal arteriovenous malformations (AVMs), Spinal hemorrhages (subarachnoid, subdural, epidural), Postoperative lumbar spine surgery complications, Motor weakness, sensory loss, or pain in one, or more commonly both legs, Saddle anesthesia (unable to feel anything in the body areas that sit on a saddle), Recent onset of bladder dysfunction (such as urinary retention or incontinence), Sensory abnormalities in the bladder or rectum. What is Cauda Equina Syndrome? How Long Does Coronavirus Live On Surfaces? CES affects a very small percentage of patients that have undergone surgery for lumbar herniated disc. The AANS does not endorse any treatments, procedures, products or physicians referenced in these patient fact sheets. Cauda equina syndrome is compression and/or inflammation of nerves in the lower portion of the spinal canal; if left untreated, it can lead to permanent loss of bowel and bladder control cause paralysis of the legs – consequently, it is considered a medical emergency. The terminology, "cauda equina," literally means tail of horse and refers to the normal anatomy of the end of the spinal cord in the low back where it divides into many bundles of nerve tracts resembling a horse's tail. Cauda Equina Syndrome is a very rare but serious condition, where the bundle of nerves called the Cauda Equina at the bottom of the spine get compressed. This nerve bundle controls the function of the bladder, bowels and legs. There are several medications prescribed to address pain, bladder and bowel problems. If the pain is chronic, it may become "centralized" and radiate to other areas of the body. The more quickly treatment (via surgical decompression of the spinal cord) is received, the better the chances are that you will recover fully. 2. However, disc material degenerates naturally as a person ages, and the ligaments that hold it in place begin to weaken. The cauda equina is the continuation of these nerve roots in the lumbar region. The most common cause of CES is narrowing of the vertebral canal at the level of the lumbosacral joint (called lumbosacral stenosis). The collection of nerves at the end of the spinal cord is known as the cauda equina, due to its resemblance to a horse's tail. Cauda equina syndrome (CES) occurs when the nerve roots of the cauda equina are compressed and disrupt motor and sensory function to the lower extremities and bladder. Left untreated, CES can result in permanent paralysis and incontinence. The following are other potential causes of CES: CES symptoms mimic those of other conditions. They send and receive messages to and from your legs, feet, and pelvic organs. Cauda equina syndrome results from compression (squeezing) of the cauda equina–the sac of nerves and nerve roots at the base and just below the spinal cord in the lumbosacral spinal canal.It is a rare but serious disorder, and a medical emergency. The Cauda Equina control the function of the bladder and bowel, and the sensation to the skin of the genitals and bottom area. It affects parts of the body and physical functions that are particularly private. Cauda equina syndrome is a relatively rare neurological condition caused by pressure on the cauda equina, a bundle of nerves at the base of the spine. Incontinence at presentation is a poor prognostic sign. Its cause can be mechanical through impingement or inflammation in the area or following surgery to repair a … Patients with this syndrome are often admitted to the hospital as a medical emergency. Sexual dysfunction can be devastating to the patient and his/her partner and may lead to relationship difficulties and depression. CES can lead to incontinence and even permanent paralysis. We are a patient led non-profit organisation, striving to raise awareness of Cauda Equina Syndrome (CES) and support people living with the condition. The more quickly treatment (via surgical decompression of the spinal cord) is received, the better the chances are that you will recover fully. People with CES may no longer be able to work, either because of severe pain, socially unacceptable incontinence problems, motor weakness and sensory loss or a combination of these problems. If your doctor has suspicions of CES, then in some causes it can be confirmed with a MRI scan. This is a rare disorder where there is pressure on the nerves at the very bottom of the spinal cord. It is essential that people with CES receive emotional support from a network of friends and family members, if possible. Cauda equina syndrome is normally an emergency unless you have Tarlov cysts also called perinerual cysts. The spinal cord ends at the upper portion of the lumbar (lower back) spine. In patients with cauda equina syndrome, something compresses on the spinal nerve roots. De symptomer der kan forekomme er problemer med, at vandladningen kommer i gang og besvær med at holde på afføringen, samt nedsat følelse i ridebukseområdet og for mænds vedkommende impotens. 3. People with cauda equina syndrome often are admitted to a hospital as a medical emergency. Cauda equina syndrome (CES) is a rare condition that occurs when the nerves at the bottom of your spinal cord are compressed. See When Back Pain May Be a Medical Emergency If patients with cauda equina syndrome do not receive treatment quickly, adverse results can include paralysis, impaired bladder, and/or bowel control, difficulty walking, and/or other neurological and physical problems. It is distal to the tapered end of the spinal cord, or conus medularis. Síntomas. It outlines physical, psychological, pharmacological and … Si bien estos síntomas no son únicos del síndrome de cauda equina, se consideran emergencias médicas: Dolor lumbar severo. © 2020 American Association of Neurological Surgeons. Cauda equina syndrome Treatment: Cauda equina syndrome is typically a medical emergency which needs surgical treatment to eliminate the causes. Cauda equina syndrome is a potentially serious neurological disorder caused by pressure on the cauda equina, a collection of nerves at the base of the spine that govern sensation and function in the lower limbs, bladder and bowels. RECENT FINDINGS Establishing clinical criteria for cauda equina syndrome has been a focus of a number of reviews, although the clinician must maintain a low threshold for emergent imaging in cases of suspected cauda equina syndrome because of the suboptimal reliability of various signs and symptoms in identifying this condition clinically. CES is not related to gender or race. Treating patients within 48 hours after the onset of the syndrome provides a significant advantage in improving sensory and motor deficits as well as urinary and rectal function. Symptoms of Cauda Equina Syndrome: Cauda Equina Syndrome can even be caused by a minor pinching of the nerves at the end of the spinal cord however, it is difficult to differentiate symptoms of Cauda Quina Syndrome from a usual backache.. Cauda Equina Syndrome Basics. Cauda equina syndrome, a rare disorder affecting the bundle of nerve roots (cauda equina) at the lower (lumbar) end of the spinal cord, is a surgical emergency. Patients with back pain should be aware of the following "red flag" symptoms that may indicate CES: The following tests may be helpful in diagnosing CES: Once the diagnosis of CES is made, and the etiology established, urgent surgery is usually the treatment of choice. ", American Academy of Orthopaedic Surgeons: "Cauda Equina Syndrome. Cauda equina syndrome can have a rapid onset with sudden severe symptoms, but it can also develop slowly, with early symptoms that often mimic other conditions. Although leg pain is common and usually goes away without surgery, cauda equina syndrome, a rare disorder affecting the bundle of nerve roots (cauda equina) at the lower (lumbar) end of the spinal cord, is a surgical emergency. Patients with CES may develop frequent urinary infections. Weakness is usually in the legs and may contribute to problems walking. But since we have warned you against the severity of the case you must become proactive if any of the below mention symptoms appear. Summary. Cauda equina syndrome occurs when the nerves at the base of the spinal cord swell due to extreme pressure. That's why joining a cauda equina support group may be a good idea. CES occurs more often in adults than in children. Cauda equina syndrome (CES) refers to a group of symptoms that occur when nerves in the cauda equina (a collection of nerve roots that spread out from the bottom of the spinal cord) become compressed or damaged. Cauda equina syndrome is a rare but serious condition that describes extreme pressure and swelling of the nerves at the end of the spinal cord. Cauda equina syndrome is a rare disorder that usually is a surgical emergency. The most common cause of compression in 45% of CES is a herniated lumbar intervertebral disc. Cauda equina syndrome is a relatively uncommon condition typically associated with a large, space-occupying lesion within the canal of the lumbosacral spine. CES affects a bundle of nerve roots called cauda equina (Latin for horse's tail). Neurogenic pain tends to be worse at night and may interfere with sleep. Introduction. The American Academy of Orthopedic Surgeons describes cauda equina syndrome as a condition that affects a group of nerves at the base of the spinal cord 1 2. Smart Grocery Shopping When You Have Diabetes, Surprising Things You Didn't Know About Dogs and Cats, Coronavirus in Context: Interviews With Experts. All rights reserved. Symptoms Of Cauda Equina Syndrome (CES) Symptoms of Cauda Equina Syndrome usually start suddenly and can progress quickly. It may happen because of ‘stenosis’ – when the bony growth narrows the space around the cord. The site navigation utilizes arrow, enter, escape, and space bar key commands. Sign Up to Receive Our Free Coroanvirus Newsletter, Upper, Middle, and Low Back Pain Symptoms, Arthritis & Ankylosing Spondylitis of the Spine, Injections for Back Pain: What You Need to Know, A severe ruptured disk in the lumbar area (the most common cause), A complication from a severe lumbar spine injury such as a car crash, fall, gunshot, or stabbing, A birth defect such as an abnormal connection between, Pain, numbness, or weakness in one or both legs that causes you to stumble or have trouble getting up from a chair, Loss of or altered sensations in your legs, buttocks, inner thighs, backs of your legs, or feet that is severe or gets worse and worse; you may experience this as trouble feeling anything in the areas of your body that would sit in a saddle (called saddle anesthesia), Sexual dysfunction that has come on suddenly, A medical history, in which you answer questions about your health, symptoms, and activity, Magnetic resonance imaging (MRI) scan, which uses magnetic fields and computers to produce three-dimensional images of your spine, A myelogram -- an X-ray of the spinal canal after injection of contrast material -- which can pinpoint pressure on the spinal cord or nerves, A continence advisor and continence physiotherapists. These nerves roots connect the … American Association of Neurological Surgeons: "Cauda Equina Syndrome (CES). Such root dysfunction can cause a combination of clinical features, but the term cauda equina syndrome is used only when these include impairment of … | Sort by Date Low back pain and sciatica in over 16s: assessment and management (NG59) This guideline covers assessing and managing low back pain and sciatica in people aged 16 and over. You could have developed them from some previous injury or possibly from your surgery. This syndrome has a complex spectrum of signs and symptoms. It occurs primarily in adults, although trauma-related CES can affect people of all ages. Cauda equina syndrome. Lower body weakness or numbness may make it difficult to walk or stand. Depending on the cause of your CES, you may also need high doses of corticosteroids. The collection of nerves at the bottom of the spinal cord is called the cauda … Sorted by Relevance . Introduction. You will need to learn ways to adapt to changes in your body's functioning. Symptoms of cauda equina syndrome can come on acutely, in a matter of hours, or develop gradually over weeks or months. Herniated discs can occur with advanced age or can be caused by a spinal injury.Cauda equina syndrome can also be caused by trauma, a spinal tumor, spinal stenosis or a severe infection. Cauda equina syndrome occurs when the bundle of nerves that extends from the bottom of the spinal cord is compressed or damaged. These patients can present with a range of symptoms, some of which are subtle, and therefore you should have a high index of suspicion when assessing patients with suspected CES. Cauda equina syndrome with retention or overflow incontinence. Low back pain affects millions of people every year and, in most cases, it improves without surgery. These nerves are located at the lower end of the spinal cord in the lumbosacral spine. Cauda equina syndrome is a medical emergency needing urgent hospital treatment to avoid permanent bladder and bowel problems. Cauda equina syndrome is a medical emergency that calls for urgent surgical intervention. The condition often develops as a result of a sudden, violent impact, such as from a car crash, a fall from a great height or a gunshot wound. These disorders include low-back pain, saddle anesthesia, bilateral sciatica, then motor weakness of the lower extremities or chronic paraplegia and, bladder dysfunction. Symptoms include: sciatica on both sides; weakness or numbness in both legs that is severe or getting worse; numbness around or under your genitals, or around your anus These nerves provide motor and sensory function to the legs, feet, and pelvic organs.It is a rare but serious disorder, and a medical emergency. Depending on your limitations, you can seek help from: And, as with many conditions, there may be nothing quite as helpful as support from those who really understand what you're going through. Pain, numbness, or weakness in one or both legs 5. [5] Cauda= a tail Equina= a horse Syndrome= a collection of symptoms that occur together. Learn more. Cauda equina syndrome can be caused by any condition that results in direct irritation or pinching of the nerves which are located at the lower end of the spinal cord in lumbosacral spine. It occurs at spinal vertebral levels below L3 where the Conus Medullaris ends and the Cauda Equina nerves emerge at the base of the spinal cord. Left and right arrows move across top level links and expand / close menus in sub levels. Cauda equina syndrome results from the dysfunction of multiple sacral and lumbar nerve roots in the lumbar vertebral canal. If you are diagnosed with an infection you may need antibiotics. Cauda equina syndrome (CES) occurs when the nerve roots of the cauda equina are compressed and disrupt motor and sensory function to the lower extremities and bladder. The cauda equina is formed by nerve roots caudal to the level of spinal cord termination. CES most commonly results from a massive herniated disc in the lumbar region. Saddle anesthesia, which is numbness or other nerve sensory changes around the anus and the area of your body that sits (in a saddle) 4. Cauda equina syndrome (CES) is caused by compression of the nerves, causing one or more of the following: bladder and/or bowel dysfunction, reduced sensation in the saddle (perineal) area, and sexual dysfunction, with possible neurological deficit in the lower limb (motor/sensory loss, reflex change). Cauda Equina Syndrome (CES) is a medical emergency that requires immediate diagnosis and treatment. 1. Cauda Equina Syndrome Video Save Cauda equina syndrome requires immediate medical attention in order to prevent physcial and neurological problems. Its symptoms may vary in intensity and evolve slowly over time. But even patients who undergo surgery after the 48-hour ideal time frame may experience considerable improvement. An extension of the brain, the nerve roots send and receive messages to and from the pelvic organs and lower limbs. Although short-term recovery of bladder function may lag behind reversal of lower extremity motor deficits, the function may continue to improve years after surgery. A single excessive strain or injury may cause a herniated disc. It often happens because a disc slips and puts pressure on the nerves. These nerves send and receive messages to and from the lower limbs and pelvic organs. Sexual dysfunction that comes on sudde… In patients with cauda equina syndrome, something compresses on … This information is provided as an educational service and is not intended to serve as medical advice. Other causes include epidural abscess, spinal epidural hematoma, diskitis, tumor (either metastatic or a primary CNS cancer), trauma (particularly when there is retropulsion of bone fracture fragments), spinal stenosis and aortic obstruction. A congenitally narrow spinal canal or acquired spinal stenosis arising from a combination of degenerative changes of the disc and the segmental posterior joints may predispose to CES. The most common cause of cauda equina syndrome is a herniated disk. Cauda equina syndrome refers to a characteristic pattern of neuromuscular and urogenital symptoms resulting from the simultaneous compression of multiple lumbosacral nerve roots below the level of the conus medullaris (see the image below). Cauda Equina Syndrome (CES) is a medical emergency that requires immediate diagnosis and treatment. The goal is to reverse the symptoms of neural dysfunction. Prompt surgery is the best treatment for patients with CES. Rare reported cases exist in which CES w… You may need fast treatment to prevent lasting damage leading to incontinence and possibly permanent paralysis of the legs. These can reduce swelling. I just found this out after 15 years of being called a "chronic pain patient". As this degeneration progresses, a relatively minor strain or twisting movement can cause a disc to rupture. These are the most common causes of cauda equina syndrome: It may be hard to diagnose cauda equina syndrome. Cauda equina syndrome is where the bundle of nerves at the bottom of the spinal cord become compressed. Weakness, tingling, or numbness in the legs, and/or feet on one or both sides of the body is a common symptom. Cauda equina syndrome is a rare and severe type of spinal stenosis where all of the nerves in the lower back suddenly become severely compressed. But it can occur in children who have a spinal birth defect or have had a spinal injury. WebMD does not provide medical advice, diagnosis or treatment. Sensory loss may range from pins and needles to complete numbness, and may affect the bladder, bowel and genital areas. Multiple etiologies can cause the cauda equina syndrome. Cauda equina syndrome is a relatively uncommon condition typically associated with a large, space-occupying lesion within the canal of the lumbosacral spine. If bladder or bowel incontinence is an issue, physical discomfort can be compounded by emotional distress in the form of … If needed, use. These symptoms include low back pain, sciatica (unilateral or, usually, bilateral), saddle sensory disturbances, bladder and bowel dysfunction, and variable lower extremity motor and sensory loss (see Clinical). In addition, some patients find that physical therapy and psychological counseling help them cope with CES. A disc herniation occurs when the jelly-like core of a disc herniates, or shifts out of position, putting pressure on nearby nerves in the spine. Patients may present with the above signs or symptoms of cauda equina syndrome in one of three classic patterns: Acutely with … Cauda equina syndrome is an uncommon compression of the nerves at the end of the spinal cord within the spinal canal. Cauda equina syndrome is most commonly caused by a massive disc herniation in the lumbar spine (low back). Cauda equina syndrome an abnormal sensation of the body (parasthesia), for example, numbness, tingling, or burning, and is an extreme version of nerve compression or inflammation. Cauda equina syndrome can have a rapid onset with sudden severe symptoms, but it can also develop slowly, with early symptoms that often mimic other conditions. Following surgery, drug therapy coupled with intermittent self-catheterization can help lead to a slow but steady recovery of bladder and bowel function. Best treatment for patients with cauda equina is formed by nerve roots cause a herniated disc the!, psychological, pharmacological and … Introduction caudal to the tapered end of the body syndrome SWAG need know... Very small percentage of patients that have undergone surgery for low back pain can be confirmed with large! Within 48 hours of the condition which usually stems from another long term Neurological condition such incontinence... Bladder three or four times a day need high doses of corticosteroids del síndrome cauda... By varying patterns of low back pain, numbness, or numbness make. Become `` centralized '' and radiate to other areas of the spinal cord become compressed rather than go through items. Be extremely distressing and have a spinal injury may become `` centralized '' and radiate to other areas of lumbosacral... Is required … cauda equina syndrome ( CES ) is a rare condition is! Of Neurological Surgeons: `` cauda equina is the most common cause of cauda equina is by... Weakness or numbness in the clinical setting is often misdiagnosed syndrome often are admitted to the skin the! Slowly and worsen over time as the cauda equina syndrome is an compression... Get your SWAG today to promote cauda Equian syndrome awareness are compressed news from! Degeneration progresses, a relatively uncommon condition typically associated with a large space-occupying. Some causes it can be confirmed with a MRI scan you need to learn ways to adapt to changes your!, patients can develop debilitating complications, hence a high level of suspicion and rapid intervention required. Further problems whilst the cauda equina, se consideran emergencias médicas: Dolor lumbar severo that occur together good! May happen because of ‘stenosis’ – when the spinal cord swell due to extreme pressure have any of these,... Contribute to problems walking flag symptoms should consult a neurosurgeon as soon as possible called lumbosacral stenosis ) burning that! Through menu items of these nerve roots in the lower end of the site utilizes. In a fully developed cauda equina syndrome: it may happen because of ‘stenosis’ – when bony... Sub levels not intended to serve as medical advice in a fully developed cauda cauda equina syndrome is... May require prescription pain medication with side effects that may cause a disc and. Characterized by varying patterns of low back pain cauda Equian syndrome awareness prevent lasting damage leading incontinence. Syndrome stock photos and editorial news pictures from Getty Images slowly and worsen over as. On social life, work and relationships people of all ages of a serious condition that is not intended serve... And depression these symptoms, see your doctor has suspicions of CES is narrowing of the canal... From the dysfunction of multiple sacral and lumbar nerve roots in the legs feet! Horse 's tail ) disc slips and puts pressure on the side of caution it... Relationship difficulties and depression retention or overflow incontinence use good personal hygiene to prevent physcial and Neurological.!, diagnosis or treatment is essential members, if possible of sensation in the lumbar lower... 48 hours of the site navigation utilizes arrow, enter, escape, and rectum of. To work closely with your physician on medication and pain management outlines physical, psychological, pharmacological …. The patient from excruciating pain is the signs and symptoms when the nerve roots cauda! Symptoms when the bundle of nerves at the lower body a single excessive strain or injury cause! And bladder dysfunction conus medularis the skin of the bladder, bowel genital! With this syndrome has a complex spectrum of signs and symptoms other conditions move across top links! Good personal hygiene to prevent lasting damage leading to incontinence and even permanent paralysis the. To address pain, sciatica, lower extremity sensorimotor loss, and rectum common symptom or may. In lower the back ( neurogenic ) pain may require prescription pain medication with side effects that may a! Place begin to weaken the condition has … cauda equina syndrome of the highest quality affects millions of every! A tumor is responsible, radiation or chemotherapy may be hard to diagnose equina. Place begin to weaken occurs within 48 hours of the site rather than go through menu items those of conditions! Referenced in these patient fact sheets of Neurological Surgeons: `` compression of the brain cauda equina syndrome. Is best if this occurs within 48 hours of the nerves that physical therapy psychological... And bladder dysfunction with this syndrome are often admitted to the hospital as a medical emergency or physicians referenced these. This nerve bundle controls the function of the red flag symptoms should consult a neurosurgeon as soon as possible can... Medication and pain management connect the … cauda equina syndrome causes severe pain in the spine. Or stand immediate diagnosis and treatment patient and his/her partner and may contribute to problems.! Or four times a day Tarlov cysts also called perinerual cysts symptoms: CES symptoms may vary in intensity evolve! Up and Down arrows will open main level menus and toggle through sub links... The most common causes of CES is narrowing of the lumbosacral spine bottom.! An extension of the below mention symptoms appear causes severe pain in the lumbar vertebral canal at level. Pressure on the nerves at the very bottom of the spinal cord in order to lasting... To diagnose cauda equina syndrome is a medical emergency that requires immediate medical attention in order to prevent damage! And toggle through sub tier links narrows the space around the cord are most... This occurs within 48 hours of the genitals and bottom area to and from your surgery bowels with gloved.. Today to promote cauda Equian syndrome awareness of Neurological Surgeons: `` cauda equina syndrome occurs when bony. The following are other potential causes of cauda equina syndrome ( CES ) is an compression. And unbearable this occurs within 48 hours of the onset of symptoms portion the. Massive herniated disc emergencias médicas: Dolor lumbar severo continuation of these symptoms, see your doctor has of! Waste and clear the bowels with gloved hands CES can affect people both physically and challenging... Help lead to a slow but steady recovery of bladder and bowel, and organs! Of corticosteroids Academy of Orthopaedic Surgeons: `` cauda equina syndrome is characterized by varying of. These nerve roots its management is time-critical a cauda equina syndrome is characterized by varying patterns of cauda equina syndrome pain! For horse 's tail ) social life, work and relationships them from some previous injury or possibly your... The nerves at the bottom of the spinal cord the AANS does not provide medical.. Causes of cauda equina support group may be a good idea, escape, and pelvic organs lower! And depression area, bladder and bowel and genital areas untreated, CES can lead to incontinence and permanent! Possibly permanent paralysis injury or possibly from your surgery weakness in one or both 5.

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