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Institute of Oncology in MediterraneanI.O.M. M. -- Catania a -- ITALY

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Pfirrmann CW, Metzdorf A, Zanetti M et-al. Magnetic resonance classification of lumbar intervertebral disc degeneration. Spine. 2001;26 (17): 1873-8

Magnetic resonance classificHappily Instable

• Shock Absorber• Glue

Creating a miracle:Stability + Mobility

Even if the majority of a healthy adult disc is avascular….it’s ALIVE

THE NORMAL ADULT INTERVERTEBRAL DISC

ty of a healthy adult disc is thy adult disc is avascularavascular….itit ss ALALhe majoritty of a

• Discogenic Pain Syndrome.• Facet Joint Syndrome.• Instability Syndrome.

Specific structural alterations Discogenic Pain SyLOW BACK PAIN

• Intervertebral disc degeneration first appears in the second decade.

• The speed and extent of the degenerative changes appear to be impacted by Genetic Factors as well as specific and continuous Traumatic Events that occur along patient’s life.

This is Normal Anatomy too

Minimalall Invasive Spine e Therapyy Deptpt ––– IOM M M –– Catania, ITALYM

DEGENERATIVE CHANGES

Degenerative changes are very common in the asymptomaticpopulation. Most individuals can anticipate pathological changeson MRI, CT scan or radiographs, even in the absence ofsymptoms.

The incidence of MRI patologycal findings in the normal population

DEGENERATIVE CHANGES should be considered “Normal Anatomy” when no symptoms occurs

Minimalal Invasive Spine e Therapyy Deptpt ––– IOM M –– Catania, ITALYM

The ImagingTODAY

What to look for?How to look for?

1. Disc height loss

2. Disc signal changesProgressive loss of hydration best seen on MRI

3. Endplate signal changes

Modic/Ross changes of the endplateWater: low on T1WI, high on T2WI

Fat: high on T1WI, T2WIBone: Low or no signal T1WI, T2WI


Disc degeneration is characterized by:

- Progressive fibrous change in the nucleus.

- Loss of distinction from the anulus.

- Loss of organization of the anular lamellae.

- Progressive damage of end plate cartilage

Early signs of age-related alterations could already be observed in the second decade of life

DISC DEGENERATION

ANATOMYTHOMPSON’S GRADING SYSTEM

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Yuvalaal Noahh Harariaari. Homo Deus, s, 2017

27 yo m• Active sport• LBP for years• No sciatica• Chronic pain• He did a lot of Physio

• He came with a 2yo MRI scan

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DO NOT TRUST ON OLD STUDIES

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AAA.GoGoGoGGoGoGGooooGooGGoGooooooooodooooodooooooodooooodooGGGG.GoGoGoGoGoGoGoGoGoGoGoGoGoGoGoGoGoGoGoGGoGoGoGoGoGGoGoGoGooGoGGooGoooGooodododoodododododododododododoododododododoododooodoodoodddoGGGGGGGGGGGGYlmazdddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddenneeeennnnnnnnnnnnnnnnnnnnnnenennnnnnnnnnnnnnnnnnnnnnnnnnnnnnneeeeneeeeneeeneeneennnateeeeeeeeeeeeeeeeeeeeeeeeeeeeeeateeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeaeeeeeeeeeeeeeeeeeeee:wswssswsswwwwwwwwwwww:wwwwwwwww“Physiological movement and a balanced load distribution arenecessary for disc regeneration. We conclude that DSS may decelerate thedegeneration process and appears to facilitate regeneration”. Asian Spine J 2017

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We need more than physical images…we need Chemical Images

In-Vivo MR Spectroscopy (MRS) To identify Painful versus Non-Painful Lumbar Discs

*Freemont, A. J., (2009) Rheumatology; 48:5–10.


IIn- iViVivo MMRR SSpectroscopy (((MRMR )S)S)

Voxel Prescription

SagittalCoronal Axial

• Painful (P) discs are distinguished from Non-Painful (NP) discs by hypoxia, inflammation, neovascularization & neoinnervation

• Chemical changes in painful discs = “disc pain biomarkers”

• Not detected by standard MRI or discogram, but detectable and objectively quantifiable via non-invasive MRS

BackgroundIdentify Disc Pain Biomarkers asMR Spectroscopy (MRS) targets


Background: Ex Vivo Disc MRS, 11T100% accurate P vs. NP discs (18/18 discs, PG-ProteoGlycan/Lactate ratio)

PG

Lactate

col

Non-Painful Disc

PG

Lactate

Col

Painful Disc

14Keshari, Spine 2008. 33(3): p. 312-317

Courtesy of S. BeckerCourtesy of S. Becker

Lactate=

hypoxia

PGProteoGlycans

=Fiber distruction

Guest which one isThe painful disc…

CourC tesy fffof

Discal Pain

Discal Pain

L5/S1…for sure!L5

L4/L5…minimal, almost normal (?)L4/L5…painful too..

Guest which one isThe painful disc… Courtesy of S. Becker

Antagonist co-contraction (flexors)reduces the risk

ooof

low back injuriesoooos by

increasingss

spinalstabilityKP Granata & co. Spine 2000

Neural Control Unit

BONY COLUMNIntrinsic stability

transducerinfo load – position - motion

MUSCOLAR COLUMNDynamic stability

actuatorsmuscle attivation pattern

Neural Control Unit DisfunctionINSTABILITY

Suboptimalalal Neuromuscolarr ControlpMM

ppMM Punjabibibi,ii,i JJJ Electromyoyoyo. and d d Kineseses., 2003

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electrically stimulation of the outer annulus activate multifidus at multiple levelsA Indahl, Spine 1995

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MUSCLES COUNTS: LOOK AT THEMSteps

MUSCLEs Theory

CLEryry:

S COUNTS:ESLE:: Disfunction

TS:nn,

OOK AT TL:, Instability

T Ttyty,

EMHT, StabilizationSt

KirkaldyStydy-

epss TheTteStyy-Willis WH,

eorryhe,, Farfan

Dy::n HF.

sfunctioDisD. Instability

on,,,tioyy of the

nstabnIne lumbar

bilittyabr spine.

Sy,,. Clin

tabiliztSn Orthop

zationizpp 1982; 1100-0-23

Age predominance of instability > 46 y.oADisc degeneration & Muscolar atrophy

BAD MUSCLES – BAD BONE-JOINTS

Stability: disc degeneration but muscolar protection

GOOD MUSCLES – BAD BONE-JOINTS

INSTABILITY: THE E AGEE-E-DISTRIBUTION

DEMONSTRATING MUSCOLAR COLUMN ROLEATINGT

G MUSTINGT T Iguchi

SCOLAR COMUShihi, Spine 2003

20 4545-55-5525252 -5--40

Angulation > 100°

Translation > 3mm

NNormalal position slip > 3mm

Hypermobilee segmentss withoutt disc c degenerationypermobilee segmentssWEAK MUSCLES

ntssS S –

without discd c dewws–– GOOD BONE

deEE-

enerationgeegdeEEE--JOINTS

HYPERMOBILITY Y IS NOTT INSTABILITY

edemarupture

diffuse atrophy

diffuse atrophydiffusno deeper

se atrophyffusr paraspinal

yphyal muscles

focal atrophy

Imagingg the e Muscles

30000.0 0000 spinee fusionn // yearr inn USA30+

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00 lumbarssarsarsar

rr fusion/yearr inn EuropeMccc Cormickkk PCCC.CC. Clinnn Neurosurggg 2015

Neuroimagingg ofof thee Instabilityty...Flying

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ggttt the

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nn patients”ppNachemsonn eteet al

pala .

appl. Lippincott,,t, 1999


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R. . Cartolariri et al. Riv. R..Ita

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et al.eri elll 2001

Blankenbakerr DG et al. BlankeAJR

enbaknkeR R 2006

TORSOR

Rotational Instability Axial Instability

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before load after load

++++ anterolisthesisbulging gg ligggigig.gg. flavum

We need dd Physiological alal Examination Of Of the Spiney

Courtesyy of A. A. Splendiani

neutral Seated-flexion

UPP-P-RIGHT MRI SCANNER

Occult Foraminal Stenosis

Pre-load

After-load

Cadaver studies before and after axial load (1996) Radiol Med. 2014 Mar;119(3):164-74., Occult neural foraminal stenosis caused by

association between disc degeneration and facet joint osteoarthritis: demonstration withdedicated upright MRI system., Splendiani A et al

Pre-load After-load

Courtesyy of A. A. Splendiani

Dynamic MR

Supine Upright

Physiologic disc thickness: 13mm in supine / 11.2mm upright

Significative differences among sex - disc thickness is << in females

U. Tarantino; E. Fanucci; R. Iundusi; et al. Lumbar spine MRI in upright position for diagnosing acute and chronic low back pain - J Orthopaed Traumatol (2013) 14:15–22

Dynamic MRI Changes: Physiological

Male, 30 yrs, back painIncrease of disc protrusion in extension

Flexion Extension

Dynamic MRI Changes: Pathological

Courtesy of M. Muto

Male, 56 yrs, back pain.anulus lesion and hypermobility in extension

Seated - flexion Seated - extension

F. Alyas, D. Connell, A. Saifuddin.Upright positional MRI of the lumbarspine. Clinical Radiology (2008) 63,1035e1048


Proposed risk factors for osteoarthritis of the facet joints include anatomical abnormalities such as an increased facet angle and tropism (congenital predisposition)

Anatomy of the Facet Joints & InstabilityThe Most common cause of LBP

After load

MICROINSTABILITYPainful Facet Joint Syndrome (FJS)

Small Things cause Great Pain…

Be gentle….

Y

Instrumentation &“solution”?

Anatomy: relevant nerves

L4

DORSAL RAMUS OF SPINAL NERVE

MEDIAL BRANCH

INFERIOR ARTICOLAR BRANCH

LATERAL BRANCH

L5

L3

SUPERIOR ARTICOLAR BRANCH

Each facet joint receives dual innervation from medial branches arising from posterior primary rami at the same level and one level above the z-joint

DORSSPINA

AR BRANCH

Stepp n. 11: RFRF-F-ablationporpp nn. 1 R: R: RFF blationabapporoor Crioablationoor CrioablationC

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MUSCLESDILATORS

CT-GuidedTFF SCREW

Step. 2

MUSCLESDILATORS

CTCT-TT GGuidid dedTFF SCREWMUSCLESMUSCLES

Step. 2

Large Gantry diameterCT scan duringthe procedure

Combined vision

X-ray + CT

Precise Position

Proving Mechanical Efficacy of MicroFixation with FU MRIMicroFixation with FU MRI

Hypermobility = InstabilityModic I: painful edemaainful edemaModic I: paainfu

6 months FU: STABILITYModic II: painless fatty degeneration

Facet Joint SyndromeFacet Joint SyndromeThe Occult Syndromes

Dynamic MRI & Dynamic MRI & Functional Data

Upright

Dynamic MR & Starting InstabilityIncreasing intrarticular fluid

in Supine position

Supine


Dynamic MR, patient standing seated or upright with trunk extension, improves the synovial cyst detection

F. Alyasa, D. Connella, A. Saifuddina. Upright positional MRI of the lumbar spine. Clinical Radiology (2008) 63, 1035-1048.Niggemann P1, Kuchta J, Hoeffer J, Grosskurth D, Beyer HK, Delank KS. Juxtafacet cysts of the lumbar spine: a positional MRI study. Skeletal Radiol. 2012 Mar;41(3):313-20.

Facetsdegeneration Intrarticular fluid

Dynamic MR and synovial cyst

+

Synovial cyst

Radicularpain

y y y

Flexion

Extension


The Pedicle: When the Scotty Dog is beheaded…

The Painful Spondylolysis Treat IN TIME (before Spondylolisthesis comes)

Treatinggg Spondylolysis

Minimalal Invasive e painful Spondylolysiss treatment

The Buck’s technique

The Yellow Ligaments: enfolding the dural sac & nervesg g

LF

ISL

SSL

Dural sacdiameter

N.V. 13,1 mm(13,2 ± 1,9 mm)

Interspinousdistance

N.V. 14,6 mm(15 ± 2,9 mm)

Gradingg the Gradinggbulging

he g hthgg of bulgingg of o

ligaments

Stenosis: a dynamic concept…

Old Style Myelograms EXTENSIONEnlarge ligaments

Reduce Spinal Canal

FLEXIONFlat ligaments

Increase Spinal Canal

Minimalalal Invasive Spine e e Therapyyyy Deptppt ––– IOM M –– Catania, ITALYMM

It’s a Mechanical problemm………let’ss go to o BiomechanicsInterspinous Spacersrs: how do they work

EBMEVIDENCEBASED MEDICINE

IBMINTELLIGENCE BASED MEDICINE

PATIENT SELECTIONBe a Physician before beeing a NRadiologistClinical symptoms count!

Be a NRadiologist before beeing a Surgeon

Hi-Res CT – Full spine MRI

NO “SPACE FOR SPACER” IF:Ligament calcificationDegenerative arthropathyOther neurodisease (Parkinson, Altzh)

Multilevel SCS-Hyperkyphosis !!!

LumbarStenosis

Meningioma

CervicalMielopathy

EEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEBBBBBBBBCCCCCCCCCC

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EEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEBBBBBBBBBBBB SSSSSSSSSSSSSSEEEEEEEEEEEEEEEEEEEEEEEEVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVIIIIIIIIIIIIIIIIDDDDDDDDDDDDDDDDDDDDDDDDDDDDDEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVIIIIDDDDDDDDDDDDDDDDDDDDDDDDDDDEEEEEEEEEEEEEEEEEEEEE

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EEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEiiiii iiiieeeeeeeeeeeeeeeee inininnininininininiinininininininningngngngnngngngngngngngngngngngnngngnnnnnnnggioioiioioiooooooooioiooooiooooioiioooiooooioomamamamammamammmmamamamamamamamammmmm

mmbmbmbmbmbmbmbmbmbmbmbmbmbmbmbmmmbmmmbmbmbmmmbmmm aararararararararararararaaaraaaenenenenenenenenenenennnnnenenennnnnnennnenenennnosososososososososososososososososossoooosssssisisisisisisisisisssssississisisisiisisssis

B

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Schizas classification of LSCS

Sturesson B et al. A radiostereometric analysis of the movements of the sacroiliac joints in the reciprocal straddle position. Spine 2000Sturesson B et al A radiostereometric analysis of the movements ofB

SACROt lt

O-A di t mlt

O-ILIAC JOINT: a tri-planar shock absorber

Finite ElementsSIJ POWER

The largest (17.5cmm2m2)

The strongest hT(Raise up 4800NNN)

Small rotation (<4°)Small translation movement (1.6mm app.)

SACROILIAC JOINT INSTABILITY C JOINT I(SIJI)

Frequentnt &..FrequeFrequently

nnt &..&ueyy unknownwnw …

SIJ J Instability55-5-25525%

SIJJ %% of ALL

tabilnstInL L Low

itybilww Back k k Painn!!!

Polly, Sembrano Spine 2008Cohen, SA Anesthesia and analgesia 2005

• Afterr DeliveryAftPost

teAftss -

er DeDteAftstst-Partum

eliveryelimm syndrome

• Afterr PIF F Posteriorr Fusion75

A75755%

er PIFPAfteA%%%% patients

ostePoFFsss have

eriorsteee SIJI775%

afteratientspa%%% p

ererr PIF in 5 avee SSss hah

5 55 yearsHA Young , Spine 2008Ivanov Spine 2009

INNERVATION: a a NightmareINNEA

ERVATIONNEAAnterior

: aa ightmareNPosterior

LAAntLL2

tertnt22 to

riorero ooo S

rorSS2

Po L

osPoLL4

steos44 to

erioeo ooo S

orrioSS4

PPoPPoCCCo

Symptoms No use…

Physicalal MMManouvreses.Physicaysicaalal MMMMMM nouvnanansuggestive

vrevrees.nouvnouvonlygggggggggggggggggeeeeseseseseeeeeeeeeeeeeeeee tiveggessssesssssesssseeseeesti eveveevessssssssstiiiititititttitititttttititit vvvvssssssssssssss eeeeeeeee ynnnnnnnnnnlyynlyyonononooooononooooooonnnonooooooooooooooooo

Lidocaine e Blockk TEST

SPECT T -- CT

5-7 14G needles, Generally bilateral5 7 14G needles Generally bilaateral

Option. n. 11::: destroyy the e nerves

7 1

OptiCT

4

OptiTT-

dl

onn. 1io

4G

OptiTT--guided

G

estroyde:: ddddd Radio

royioio-oyoo--/

ll bil t l

hee ervesne

ll

hth

l

tyy--// Crioablation

ProblemsFAILURE 5-21%

So many needles/cannulas

Option. 2: CTCT-T-TT guidedd Endoscopicc RadioablationOption. 2: CCTT uidedgug d EndoE oscopicc RadioablationRoscopicc R

The Final Option: SIJ JJ FIXATION

SIJ Sagittal global displacementssimulations at 1000 N

uninstrumented one screw

80% sacral nutation mov. reduced

Finite Element Analysis of Sacroiliac Joint Fixation under Compression Loads Claire Bruna-Rosso et al. IJSS AUG.2016l OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOThTTTTTTThTTThTTTTTTTTThThThThTTTThThTThTThTTThTTThThhThTTTThThTTTThThTTTTTThTThTTThhThTTTTThTThThTTThTTThhThThhThhThTTTThTThTThThThThThThhhThTTThThTTTTTThThhThhhhhTTThThTTTTTTTTThhhThThTTTTTTTTTTTTTThhhhhTTTTTTTTTTThThThhThTTTTTTTTTThhThThTTTTTTTTTTThhhThTTTTTTTTTTTThhhThTTThThTTTTTTThhhhTThTThTTTTTTTThhTTTTTTTTTTTThhhTThTTTTTTTTThThTTTTTTTThTTTTTTThhTTTTTTTThhhhTThTTTTTTTTTThhTTTTTTTThhTTTTTThhhTTTTTTTTTTTTTTTThhhhhTTTTTTTThhTTTTTTTTThTTTTThTThhhTThhhThhheeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeee iiiiiiiiiiinannannnnnanananannnanannnnnnnnaannnannnnnnnnnnnnanaaaaaananannnnnnaaaaaannnnaaaannnnnaaaannnaanaaaaanannaaaaannnaaaaaaaaaaaFFFFFFFFiFFFFFFFFFFFFFFFFFFFFFFFFFFFiiFFFFFiFFFFFFFFiFFFFFFFiFFFFFFFFiiFFFF aaaaaaaalllllllllltetteeeeeeeFinFiFinFFF nnnnnnnFFFFFF itititteeeeeeeeeeeeeee iiiiiiiiiiiinnnnnnnnnnnnnniiiiiiiiiinnnnnnFFFFFFFFiFiFFFFFFFFiFFFFFFFFiFFFiFFFFFFFFiFFFFFFFFFFFFFFiFFFFFFFFiiFFFFFFFFFFFFFFFFFFFFFFFFiFiFFFFFFFiFFFFFFFiFFFiFFFFFFiFFFFFFFFFiFFFFFFFFiiFFFFFFFFFF meeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeemmmmmmmmmmmmmmmmmmmmmll OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOEEEEEEEEEEEEEaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaElellellleaaaaalllllllllllllll ossissssssississssssssissssssssssssssssssssssssssssssssssssssssssssssssssssssssll OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOmmmmmmmmmmmmmmmmmmmmmppreprppprrrrrreeeeeppppppprerrprrrreeeepppppprrrrrrrrreeepppppprrrrprrpreppprprrprepprepreprepComComCoComCCCCComCooCoooCCComCooCoCoComCooCoCCComCCoComCooCCCCCComomoooommmmmmComCCCoooooommCoCCComComCoCoCoomooComommeeeeeeeeeeeeeeeeeee eeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeee iiinaaaaanananaaaaaanaaaaaanaanaaanaaaaannnnnanaaanaaaannannnnnnannnnaannnannnnnaaaaannnnnnaaaaaaaannnnnnnaaaaaannnnnaaaaaaaannnnnnnaaaaaaaiinannanaannnnaannnnnnaaaannnnnaaaaaaaannnnnnaaaaannnnaaaaaaanaaaaFFFFFFFFiFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFiFFFFFFiFFFFFFiFFFFFFFFFFFFFFFFFFFFFFFFFFFi eeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeessssssssssaaaaalllllllllllllaaaalllllll XAXXXXAXXXXAXXXAXAXXXAAAXXXXAXAAXAAAAXAXAXXAXAXXXXXXAXXAAXXXAXXXXXXXAAXAAXXAXAXXAAAAAXXXXAXAAAXAAXAXXXXXXXXXXXXXXAXXXAXXXXAXAXXXAAAAXAAAAAAXXXAAAAAAAAAXXXAAAAXAAAAXAAAAAAATITTTTTTTIITITTTITITTTTTTTTTIITTTTTT ONONOOOOOONOONOOOONOONOOOOOONOOOOOOONOONOOOOOOONOOOOONOOONOOONONOOOOOONNNOOOOOOOONOOONOOOOONOOOOOOONNOOOOOONOOONOOOOOOOONONNOOOOOOOOOOONNNNNOOOOONNONOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOONOONNOOOOOOOOcroiliacXAXXXXXAXXXXXXXXXXAXAAAXAAXAAAAXAXXXXAAAXAAAAAXXXXAXAAAAXAAAXXXXXXXXXXAAAAAAAXXAXAXXXXXXAAAAAXXXXXXXXXXXXAAAAAXXXXXXXAAAAAAAXXXAXXXXXXXAAAATITTTTTTTTTTTITTTTTTTITTITTTITTTTTTTITITTTTTITTTTXAXXXXAXXXXXXAAAAAAAXAXXAAAAXAAXAAXXXXXAAAAXAAXXXAAAAAXXXXXXAAAAAXXXXXAAAAAAXAATITTTTTTTTTTTITTTTTITTITTITTTTTTITTTTTTITT Joint tttttttttttttttttttttttttttttttONONOOOOOONONONNNONNNNNNNNONNNONOOOONONONNNNNNONOOOOOONNNNNONNOOOOOOOONONONNNNONONONNNNNNNONOOONOOOOONNNNONONNNNNNNNOONOOOOOOONNNONONNNNNOOOONONNNNNNNNOOOONNNNNOOOOOOOONNNNONNNNNNNNONNNONNONONNNONOOOONNNNONOOOOOONNNNNOONONNNONOOONOOOONNNONONNNNNOOOOOOOONONONOOONNNOOOOOOOO xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxatiattiattitiaaaaaaatiatttttatiatiatiaataaatiaatiattatatiiaatataatitttatatiiataaatattatttiatiataaatittttiaaaaaaatttiaataaaattttiaaatttttiiaaattttt onoooooooonnnnnnnnnooonooooonnononononoonoonnnooonooooononnnnoonooooonnnnnnnonnoooooonnnnnnnnnnoooooonnnnnnnoononoooonnnoononnooFixFFFixiiFFFFFFFFFFixixFFFFFFFFFixiFixFFFFiFFFFFFiixxFFFFiiixFFFFFiiFFFFFFi u

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