Lumbar Disc Proximal Extraforaminal Displacement

Proximal extraforaminal displacement of a lumbar intervertebral disc refers to the focal displacement of nucleus pulposus material beyond its normal confines, occurring lateral to the neural foramen and just proximal to the exit zone of the spinal nerve root. In this location, the displaced material can directly impinge on the dorsal root ganglion and exiting nerve root, often leading to intense radicular pain and sensory disturbances along the affected dermatome. Although most lumbar disc herniations occur in the central or posterolateral areas, extraforaminal herniations account for approximately 7 – 12 % of cases and are distinguished by their unique anatomical relationship outside the neural foramen Radiology AssistantScienceDirect.

Proximal extraforaminal displacement—also called far-lateral disc herniation—occurs when nucleus pulposus material extrudes lateral to the exit foramen, compressing the exiting nerve root outside the spinal canal. This variant accounts for roughly 7–12 % of lumbar herniations and often produces severe radicular pain, sensory changes, and sometimes motor weakness in a dermatomal distribution. Its unique location challenges both diagnosis and treatment planning due to atypical imaging appearances and the need to avoid undue facet or nerve root retraction during surgery Surgery Referencejss.amegroups.org.

Types

Bulging Disc

A bulging disc involves circumferential extension of disc tissue beyond the margins of the vertebral endplates, without focal rupture of the annulus fibrosus. In extraforaminal bulge, the disc may bow laterally under pressure but remains continuous with the annulus, often causing mild compression of adjacent soft tissues without significant nerve impingement Radiology AssistantSurgery Reference.

Protrusion

In a protrusion, disc material extends beyond the disc space in a focal manner, but the width of the displaced material is less than the width of its base. When protrusions occur extraforaminally, the annular fibers remain intact, yet the localized bulge can press on the proximal exiting nerve root, producing radicular symptoms Radiology AssistantSurgery Reference.

Extrusion

Extrusion is characterized by disc material that extends beyond the disc space with a span greater than the base and with disruption of annular fibers. Extraforaminal extrusions are often uncontained, allowing fragments to migrate into the lateral recess, where they may compress the dorsal root ganglion and cause severe sciatica Radiology AssistantSurgery Reference.

Sequestration

Sequestration denotes free disc fragments that have lost continuity with the parent disc. In proximal extraforaminal sequestration, these fragments can lodge in the lateral extraforaminal space or neural foramen, frequently eliciting intense radicular pain and, at times, inflammatory reactions around the nerve root Radiology AssistantSurgery Reference.

Causes

A range of degenerative, mechanical, genetic, and lifestyle factors contribute to the development of proximal extraforaminal disc displacement. Age-related disc dehydration and annular weakening set the stage for herniation; occupational strain, improper lifting, and repetitive movements further accelerate annular fissuring. Additional risk factors include excess body weight, smoking, genetic predisposition, poor posture, and systemic inflammatory conditions Spine-healthMayo Clinic.

1. Age-Related Disc Degeneration
   With aging, water content in the nucleus pulposus decreases and annular fibers develop fissures, predisposing to lateral tears and herniation WikipediaWikipedia.

2. Occupational Lumbar Loading
   Jobs involving heavy lifting or prolonged bending increase cumulative lumbar stress, accelerating annular damage and far-lateral herniation risk SpringerLink.

3. Tobacco Smoking
   Smoking impairs disc nutrition via vasoconstriction, promoting degeneration and predisposing to annular disruption and extraforaminal displacement PMCSAGE Journals.

4. Obesity and High BMI
   Excess body weight increases axial spinal load, hastening disc degeneration and lateral herniation; weight loss is advised to reduce recurrence SpringerLinkWiley Online Library.

5. Genetic Predisposition
   Polymorphisms in collagen, aggrecan, MMPs, and interleukin genes have been linked to weaker annular structures and higher herniation rates Wikipedia.

6. Repetitive Microtrauma
   Sports or activities with frequent twisting and axial loading can cumulatively injure the annulus, leading to far-lateral tears Wikipedia.

7. Vibration Exposure
   Operators of heavy machinery or frequent drivers experience spinal vibration that can accelerate annular fissuring and lateral displacement Wikipedia.

8. Sedentary Lifestyle
   Prolonged sitting with deconditioned paraspinal muscles fails to off-load the disc, promoting degeneration and tear formation Wikipedia.

9. Poor Posture
   Chronic slumping or non‐ergonomic workstations unevenly stress one side of the disc, favoring lateral annular failure Wikipedia.

10. Pregnancy
    Hormonal changes and added lumbar lordosis increase disc load, sometimes precipitating extraforaminal herniation Wikipedia.

11. Acute Trauma
    Falls or motor-vehicle collisions can impart sudden axial or torsional forces, tearing the annulus and forcing disc material laterally Wikipedia.

12. Diabetes Mellitus
    Glycation of disc proteins reduces elasticity, increasing susceptibility to fissures and herniation ScienceDirect.

13. Dyslipidemia
    Serum lipid abnormalities correlate with poorer disc nutrition and faster degeneration ScienceDirect.

14. Cardiovascular Comorbidities
    Atherosclerosis of disc‐supplying vessels may hasten degeneration and predispose to lateral tears ScienceDirect.

15. Psychological Stress
    Chronic stress alters muscle activation patterns and spinal loading, indirectly contributing to annular injury SpringerLink.

16. Connective Tissue Disorders
    Conditions like Ehlers-Danlos weaken collagenous tissues, including the annulus fibrosus Wikipedia.

17. Facet Arthrosis and Instability
    Degeneration of facet joints shifts load onto the disc peripherally, encouraging far-lateral fissuring Radiology Assistant.

18. Spondylolisthesis
    Vertebral slippage can distort disc geometry, promoting lateral displacement under stress Radiopaedia.

19. Inflammatory Arthritides
    Ankylosing spondylitis and related conditions can erode spinal structures, altering load and precipitating tears Wikipedia.

20. Endplate Modic Changes
    Subchondral bone marrow changes reflect inflammation that may weaken the disc interface, allowing lateral extrusion Wikipedia.

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Symptoms

1. Severe Far-Lateral Radicular Pain
   Sharp, shooting pain radiates along the exiting nerve’s dermatome, often more intense than central herniations PMC.

2. Unilateral Leg Pain (Sciatica)
   Pain may extend into the anterior thigh (L2–L4 roots) or dorsum of foot (L5) depending on the level Hospital for Special Surgery.

3. Paresthesia
   Tingling or “pins and needles” occur in the affected dermatome PMC.

4. Numbness
   Sensory deficits in the lateral thigh or calf correspond to the compressed root Hospital for Special Surgery.

5. Muscle Weakness
   Weakness of muscle groups innervated by the compressed root (e.g., foot dorsiflexors in L5) may be evident PMC.

6. Reflex Changes
   Hypoactive knee or ankle reflexes signal nerve root involvement PMC.

7. Positive Straight-Leg Raise
   Pain reproduced between 30°–70° of elevation indicates nerve root tension Nature.

8. Positive Crossed Straight-Leg Raise
   Contralateral leg elevation eliciting ipsilateral pain is highly specific for herniation Nature.

9. Positive Femoral Nerve Stretch (Reverse Laségue)
   Pain in the anterior thigh upon hip extension implicates an upper lumbar root Nature.

10. Pain on Lateral Bending
    Ipsilateral lateral flexion narrows the lateral gutter, exacerbating pain PMC.

11. Valsalva-Related Pain
    Coughing or straining increases intradiscal pressure, worsening symptoms Wikipedia.

12. Antalgic Lean
    Patients may lean away from the pain side to decompress the affected foramen PMC.

13. Gait Disturbance (Foot Drop)
    Severe L5 root compression can impair dorsiflexion, causing foot drag PMC.

14. Muscle Atrophy
    Chronic denervation leads to wasting of affected muscle groups PMC.

15. Allodynia/Hyperesthesia
    Light touch provoking pain indicates sensitization of the dorsal root PMC.

16. Localized Paraspinal Tenderness
    Tenderness at the lateral gutter region may be elicited on palpation NCBI.

17. Difficulty with Heel- or Toe-Walking
    Tests specific myotomes (L5 for heel-walk, S1 for toe-walk) and can reveal weakness PMC.

18. Neurogenic Claudication-Like Leg Pain
    In some cases, exertion-induced leg fatigue mimics vascular claudication NCBI.

19. Sleep Disruption
    Nocturnal radicular pain often awakens patients, impairing rest PMC.

20. Cauda Equina Warning Signs (Rare)
    Saddle anesthesia or bowel/bladder dysfunction may occur if multiple roots are compressed Hospital for Special Surgery.

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Diagnostic Tests

Physical Examination

1. Postural Assessment
   Observation of spinal alignment and antalgic postures can localize lateral compression PMC.

2. Paraspinal Palpation
   Tenderness over the extraforaminal gutter suggests local inflammation NCBI.

3. Range of Motion Testing
   Flexion, extension, lateral bending and rotation reproduce pain patterns Wikipedia.

4. Gait Analysis
   Evaluating heel- and toe-walking can reveal root-specific weaknesses PMC.

Manual Tests

• Straight Leg Raise (SLR) Test reproducing sciatic pain when the leg is raised

• Crossed SLR Test, where raising the contralateral leg elicits pain on the symptomatic side

• Slump Test combining neck flexion with SLR to tension the neural axis

• Femoral Nerve Stretch Test for upper lumbar root (L2 – L4) irritation

• Kemp’s Test (extension–rotation) to localize facet versus discogenic pain

• Bowstring Test applying pressure on the popliteal fossa during SLR to accentuate radicular pain

• Valsalva Maneuver (bearing down) to increase intraspinal pressure and reproduce pain

• Well Leg Raise (WLR) Test raising the unaffected leg to provoke contralateral radicular pain

• Reverse SLR Test (femoral nerve traction) for anterior thigh pain

Lab and Pathological Tests

• Complete Blood Count (CBC) and Differential to rule out infection or inflammatory markers

• Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP) for inflammatory or infectious etiologies

• HLA-B27 testing when ankylosing spondylitis or spondyloarthropathy is suspected

• Blood cultures if discitis or spinal infection is a concern

• Provocative Discography under fluoroscopic guidance to confirm symptomatic disc levels

Electrodiagnostic Tests

• Nerve Conduction Studies (NCS) to assess peripheral nerve function and conduction velocity

• Electromyography (EMG) for denervation potentials in muscles supplied by the affected nerve root

• Somatosensory Evoked Potentials (SSEPs) evaluating dorsal column and peripheral nerve integrity

• F-Wave Studies examining proximal nerve segment conduction

• Motor Evoked Potentials (MEPs) when central motor pathways need evaluation

Imaging Tests

• Plain Radiography (X-rays): AP, lateral, and oblique views to exclude fractures, spondylolisthesis, or disc space narrowing

• Magnetic Resonance Imaging (MRI): the gold standard for visualizing disc displacement, neural compression, and soft-tissue changes

• Computed Tomography (CT): for detailed bony anatomy assessment and surgical planning

• CT Myelography: when MRI is contraindicated or for dynamic evaluation of nerve root impingement

• Discography: delineating tear morphology and correlation with patient symptoms under contrast injection

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Non-Pharmacological Treatments

Evidence-based management begins with non-drug options, grouped into four categories: physiotherapy and electrotherapy (15 modalities), exercise therapies, mind-body therapies, and educational self-management. Early use of these interventions can reduce pain, improve function, and often obviate the need for surgery NICEPhysiopedia.

Physiotherapy & Electrotherapy

1. Spinal mobilisation – gentle manual gliding of facet joints to restore mobility and decrease pain by stimulating mechanoreceptors NICE.

2. Soft-tissue massage – kneading and stretching paraspinal muscles to reduce spasm and improve circulation NICE.

3. Myofascial release – sustained pressure on fascia to alleviate trigger points and improve tissue glide Physiopedia.

4. Muscle energy technique – active patient-initiated muscle contractions against resistance to lengthen tight muscles Physiopedia.

5. Maitland mobilisation – graded oscillatory mobilisations targeting hypomobile spinal segments Physiopedia.

6. Mulligan mobilisation – mobilisation with movement applied to spinal joints to correct positional faults Physiopedia.

7. McKenzie extension exercises – repeated lumbar extensions to centralize pain and improve disc hydration Wikipedia.

8. Mechanical traction – axial stretch of the lumbar spine to unload nerve roots and reduce disc bulge Wikipedia.

9. TENS – transcutaneous electrical currents to block nociceptive transmission via gate control PubMed.

10. Interferential therapy – medium-frequency currents to target deeper tissues, modulating pain and edema Frontiers.

11. Ultrasound therapy – high-frequency sound waves producing thermal and non-thermal effects to enhance tissue repair and reduce spasm BioMed Central.

12. Extracorporeal shockwave therapy – focused acoustic pulses to disrupt nociceptors and stimulate neovascularization PMC.

13. Laser therapy – low-level light to modulate inflammation and promote cellular healing Wikipedia.

14. Pulsed electromagnetic field therapy – magnetic fields to influence cellular signaling and reduce inflammation medisij.com.

15. Neuromuscular electrical stimulation – electrical pulses to evoke muscle contraction, improving strength and spinal stability Frontiers.

Exercise Therapies

1. Core stabilization – targeted activation of transverse abdominis and multifidus to support spinal segments and reduce micro-motion Wikipedia.

2. Pilates – controlled mat or reformer exercises to improve trunk control, flexibility, and posture Wikipedia.

3. Structured walking programmes – graded aerobic activity to boost circulation, endorphins, and functional capacity Lippincott Journals.

4. Aquatic therapy – buoyancy-assisted movements to reduce spinal load while strengthening musculature Wikipedia.

5. Extension-flexion routines (McKenzie) – repeated movements designed to centralize radicular pain and improve mobility Wikipedia.

Mind-Body Therapies

1. Cognitive behavioural therapy (CBT) – addresses maladaptive thoughts and behaviors to reduce pain catastrophizing and improve coping ICERICER.

2. Mindfulness-based stress reduction (MBSR) – meditation and body-scan practices to decrease stress and pain perception ICER.

3. Yoga – integrated postures and breathing to enhance flexibility, strength, and mental focus Lippincott Journals.

4. Tai chi – slow, rhythmic movements to improve balance, core strength, and mind-body awareness ICER.

5. Biofeedback – real-time feedback of muscle activity or heart rate variability to teach relaxation and reduce muscle tension ICER.

 Educational Self-Management

– Pain neuroscience education – teaching the biology of pain to reduce fear and empower active management.
– Ergonomics training – optimizing workstation and movement patterns to prevent strain.
– Graded activity and pacing – setting achievable goals to avoid flare-ups and maintain progress.
– Risk stratification (STarT Back Tool) – tailoring intensity of interventions based on psychosocial risk NICE.
– Return-to-work planning – structured advice to resume duties safely and avoid deconditioning NICE.

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Pharmacological Treatments

First-line analgesics are non-steroidal anti-inflammatory drugs (NSAIDs):

• Ibuprofen 400–800 mg every 6–8 hours (max 2400 mg/day); GI upset, renal risk.

• Naproxen 250–500 mg twice daily; may raise cardiovascular risk.

• Diclofenac 50 mg three times daily; monitor liver function.

• Celecoxib 200 mg once daily; COX-2 selective, lower GI risk but CV caution.

• Etoricoxib 90 mg once daily; similar profile.

• Indomethacin 25–50 mg two to three times daily; CNS side effects.

• Piroxicam 20 mg daily; long half-life increases bleed risk.

• Meloxicam 7.5–15 mg daily; intermediate COX-2 selectivity.

• Ketoprofen 50 mg every 6 hours; photosensitivity possible.

• Nabumetone 1000 mg once daily; prodrug with less GI toxicity.
  These reduce prostaglandin synthesis to relieve pain but require gastroprotection and monitoring BMJDerbyshire Medicines Management.

Adjuvant Analgesics & Muscle Relaxants

• Paracetamol 500–1000 mg every 4–6 hours; minimal anti-inflammatory effect.

• Tramadol 50–100 mg every 4–6 hours; seizure risk, serotonin syndrome.

• Codeine 30–60 mg every 4–6 hours; constipation, sedation.

• Gabapentin 300 mg at bedtime, titrate to 900–3600 mg/day; dizziness.

• Pregabalin 75 mg twice daily; edema, weight gain.

• Duloxetine 30–60 mg once daily; nausea, sleep disturbance.

• Amitriptyline 10–25 mg at bedtime; anticholinergic effects.

• Baclofen 5–10 mg three times daily; drowsiness.

• Cyclobenzaprine 5–10 mg three times daily; dry mouth.

• Tizanidine 2–4 mg every 6–8 hours; hypotension.
  Used judiciously for neuropathic or muscle-spasm components, though evidence in sciatica is limited NCBIBMJ.

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Dietary Molecular Supplements

Commonly recommended supplements—often with mixed evidence—for supporting disc health and reducing inflammation include:

1. Glucosamine sulfate 1500 mg/day; supports proteoglycan synthesis in cartilage PMCArthritis Foundation.

2. Chondroitin sulfate 1200 mg/day; inhibits breakdown of extracellular matrix PMCArthritis Foundation.

3. Hyaluronic acid 100 mg/day; enhances synovial fluid viscosity and disc hydration Verywell Health.

4. Boron (calcium fructoborate) 3 mg/day; modulates inflammatory mediators.

5. MSM 1000 mg/day; supplies sulfur for collagen synthesis and anti-inflammatory action Verywell Health.

6. Vitamin D₃ 1000–2000 IU/day; regulates calcium homeostasis and muscle function Achieve Health and Wellness –.

7. Turmeric (curcumin) 500–1000 mg/day; inhibits COX-2 and NF-κB to reduce neuroinflammation PMC.

8. Krill oil (omega-3) 1000 mg/day; anti-inflammatory via eicosanoid modulation Achieve Health and Wellness –.

9. Astaxanthin 4–8 mg/day; antioxidant that may protect disc cells.

10. Type II collagen 40 mg/day; provides building blocks for disc matrix Verywell Health.

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Advanced Therapeutic Agents

Emerging and specialized agents include:

1. Bisphosphonates (Alendronate 70 mg weekly; Risedronate 35 mg weekly; Zoledronic acid 5 mg IV yearly; Ibandronate 150 mg monthly; Clodronate 1600 mg daily) – inhibit osteoclasts to preserve endplate integrity and slow disc degeneration PubMedWikipedia.
2. Recombinant BMP-2 (1.5 mg/ml on collagen sponge) – osteoinductive for fusion and experimental disc repair via TGF-β signaling PubMedWikipedia.
3. Recombinant BMP-7 (OP-1, 3.5 mg) – similar regenerative intent.
4. Platelet-Rich Plasma (PRP) (3–5 ml intradiscal) – delivers autologous growth factors to modulate inflammation and matrix synthesis PubMedWiley Online Library.
5. Mesenchymal Stem Cells (MSCs) (5–20 × 10⁶ cells intradiscal) – regenerate nucleus pulposus cells and secrete anti-inflammatory cytokines BioMed CentralMDPI.
6. Exosome preparations – cell-free MSC derivatives under investigation for anti-inflammatory and regenerative effects.

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Surgical Options

When conservative care fails, ten surgical approaches for far-lateral herniations include:

1. Open extraforaminal discectomy – direct exposure with muscle dissection; reliable nerve decompression jss.amegroups.org.

2. Microsurgical extraforaminal discectomy – magnified view, less tissue trauma jss.amegroups.org.

3. Paramedian mini-open discectomy – muscle-splitting corridor to reduce postoperative pain.

4. Transforaminal endoscopic discectomy (TELD) – percutaneous via Kambin’s triangle under local anesthesia; minimal blood loss Surgery Reference.

5. Extraforaminal endoscopic lumbar discectomy (EELD) – targeted resection of SAP facet to access fragment Surgery Reference.

6. Biportal endoscopic extraforaminal approach – two portals for endoscope and instruments; preserves stability PubMed.

7. Microendoscopic discectomy (MED) – tubular retractor system with endoscope SpringerLink.

8. TESSYS method – stepwise foramenotomy with endoscope; day-surgery under sedation Wikipedia.

9. Foraminoplasty with tubular retractor – partial SAP removal to widen exit zone.

10. Combined laminectomy and facetectomy – reserved for large fragments, with instrumented fusion for stability.

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Prevention Strategies

1. Maintain neutral spine posture when sitting or lifting.

2. Use ergonomic workstations with lumbar support.

3. Practice core strengthening exercises regularly.

4. Avoid prolonged static positions; take micro-breaks.

5. Lift with legs, not back—keep loads close to the body.

6. Maintain a healthy weight to reduce spinal load.

7. Quit smoking, which impairs disc nutrition and healing.

8. Ensure adequate calcium and vitamin D intake for endplate health.

9. Wear supportive footwear to optimize spinal alignment.

10. Engage in regular low-impact aerobic activity (walking, swimming) WikipediaNICE.

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When to See a Doctor

Seek prompt evaluation if you experience any red flags:

• Severe or progressive neurological deficits (weakness, numbness, incontinence) Avella Injury & Pain ManagementMayo Clinic.

• Trauma (fall, accident) causing back pain.

• Unexplained weight loss, fever, or history of cancer.

• Pain not improving after 4 weeks despite home care H2 Health.

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“Do’s” and “Don’ts”

Do:

• Keep active with gentle stretching.

• Use heat/cold packs for symptomatic relief.

• Practice proper lifting mechanics.

• Follow a graded exercise plan.

• Use a lumbar brace intermittently if advised.

Don’t:

• Bed-rest for more than 1–2 days.

• Heavy lifting during acute flare-ups.

• Bending and twisting simultaneously under load.

• Sitting in a slumped posture for prolonged periods.

• Ignoring worsening or new neurologic symptoms nhs.ukNICE.

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Frequently Asked Questions (FAQs)

1. What is far-lateral disc herniation? See definition above.

2. What symptoms should I expect? Severe leg pain, numbness, possible muscle weakness.

3. How is it diagnosed? MRI with axial and sagittal cuts, clinical exam.

4. Can it heal without surgery? Many cases improve with conservative care over 6–12 weeks.

5. Which non-drug therapy works best? Core stabilization and manual therapy often help most.

6. Are NSAIDs safe long-term? Use lowest effective dose briefly; watch GI and renal function.

7. Do supplements really help? Evidence is mixed; glucosamine, curcumin, and omega-3 have modest effects.

8. When is surgery indicated? Persistent pain > 6 months, motor deficit, or intractable radiculopathy.

9. Is endoscopic surgery better? It’s less invasive, but patient-specific factors guide choice.

10. How long is recovery? Return to light activities in 2–4 weeks; full recovery 3–6 months.

11. Can I drive after surgery? Usually after 1–2 weeks if pain is controlled.

12. Is flying safe? Yes, once comfortable, typically after 1 month.

13. What sleeping positions help? On side with pillow between knees or back with pillow under knees.

14. Can I return to work? Sedentary jobs in 2–4 weeks; heavy labor in 2–3 months.

15. How do I prevent recurrence? Maintain core strength, practice ergonomics, and avoid smoking.

Disclaimer: Each person’s journey is unique, treatment plan, life style, food habit, hormonal condition, immune system, chronic disease condition, geological location, weather and previous medical  history is also unique. So always seek the best advice from a qualified medical professional or health care provider before trying any treatments to ensure to find out the best plan for you. This guide is for general information and educational purposes only. Regular check-ups and awareness can help to manage and prevent complications associated with these diseases conditions. If you or someone are suffering from this disease condition bookmark this website or share with someone who might find it useful! Boost your knowledge and stay ahead in your health journey. We always try to ensure that the content is regularly updated to reflect the latest medical research and treatment options. Thank you for giving your valuable time to read the article.

The article is written by Team Rxharun and reviewed by the Rx Editorial Board Members

Last Updated: May 24, 2025.

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