Lumbar Intervertebral Disc Extrusion at L1–L2

Lumbar intervertebral disc extrusion at L1–L2 occurs when the soft inner core (nucleus pulposus) of the L1–L2 disc pushes through a tear in its outer ring (annulus fibrosus), pressing on surrounding nerves or spinal structures. This condition can cause localized low back pain, radicular symptoms in the lower torso or groin, and, if severe, neurological deficits. Early recognition and a multifaceted treatment plan—combining non-pharmacological therapies, medications, nutritional support, advanced injectable agents, and potentially surgery—can optimize recovery, minimize pain, and restore function.

Lumbar intervertebral disc extrusion at the L1–L2 level is a specific form of herniated disc in which the nucleus pulposus pushes through a tear in the annulus fibrosus and breaches the posterior longitudinal ligament, yet remains partially connected to the disc of origin. Unlike a protrusion, where the disc bulges without rupture, extrusion involves a distinct “neck” between the displaced material and the parent disc, often allowing the extruded fragment to migrate cranially or caudally Verywell HealthRadiopaedia. At the L1–L2 segment, extrusion can compress the conus medullaris or the emerging L1 nerve root, leading to characteristic patterns of low back pain, radiculopathy, and neurogenic claudication Radiopaedia. Understanding the detailed anatomy, pathophysiology, types, causes, symptoms, and diagnostic approaches is essential for evidence-based management and optimal patient outcomes.

Pathophysiology of Disc Extrusion at L1–L2

Disc extrusion involves both mechanical deformation and biochemical processes. Repetitive axial loading and torsional stresses induce microfissures in the annulus fibrosus, leading to annular tears through which nucleus pulposus material can herniate OrthobulletsRadiopaedia. Age-related degeneration decreases proteoglycan content and water-binding capacity, reducing disc height and altering load distribution, further predisposing to extrusion NCBIScienceDirect.

Once extrusion occurs, the extruded fragment can migrate within the spinal canal, causing direct compression of neural elements. At L1–L2, this may impinge upon the conus medullaris or the emerging L1 nerve root, leading to motor deficits (e.g., iliopsoas weakness), sensory changes in the groin or anterior thigh, and disruption of pelvic autonomic pathways in severe cases NCBIRadiopaedia.

Chemical inflammation also plays a crucial role: nucleus pulposus components, especially tumor necrosis factor alpha (TNF-α), evoke an inflammatory response in epidural tissues, contributing to pain and neuritis independent of mechanical compression Wikipedia. Together, mechanical and inflammatory factors explain the variable clinical presentations and underline the importance of targeted diagnostics and treatments.

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Anatomy of the Lumbar Intervertebral Disc

1. Structure
   The intervertebral disc is a fibrocartilaginous joint composed of two main components:

   • Nucleus Pulposus: A gelatinous core rich in proteoglycans and water, providing the disc with its shock-absorbing properties.

   • Annulus Fibrosus: Concentric lamellae of collagen fibers arranged in alternating orientations, offering tensile strength and containing the nucleus pulposus under load WikipediaKenhub.

2. Location
   Intervertebral discs sit between adjacent vertebral bodies, and the L1–L2 disc occupies the space just below the termination of the conus medullaris. This segment is clinically significant because the spinal cord ends at L1–L2, transitioning to the cauda equina below. Disc pathology here can affect both spinal cord structures and exiting nerve roots NCBIRadiology Assistant.

3. Origin and Insertion
   The annulus fibrosus originates from the vertebral endplates—thin layers of hyaline cartilage covering each vertebral body—and inserts into the ring apophyses. The nucleus pulposus is enclosed entirely by the annulus and adheres to the inner surface of both endplates, creating a strong yet flexible connection between vertebrae KenhubWheeless’ Textbook of Orthopaedics.

4. Blood Supply
   Mature intervertebral discs are largely avascular. Blood vessels approach only the outermost fibers of the annulus fibrosus and terminate at the vertebral endplates, supplying nutrients via diffusion. This avascularity renders the disc susceptible to degeneration when diffusion is compromised OrthobulletsNCBI.

5. Nerve Supply
   Innervation is limited to the outer one-third of the annulus fibrosus by sinuvertebral (recurrent meningeal) nerves arising from the dorsal root ganglia. These tiny nerve fibers convey pain signals when the annulus is torn or inflamed. The nucleus pulposus itself is aneural OrthobulletsWikipedia.

6. Functions
   The lumbar intervertebral discs serve six primary roles:

   1. Shock Absorption: Cushioning axial loads through hydrostatic pressure of the nucleus pulposus.

   2. Load Distribution: Evenly transmitting compressive forces across vertebral bodies via the endplates.

   3. Spinal Flexibility: Permitting slight movements in flexion, extension, lateral bending, and rotation.

   4. Spinal Stability: Acting as a ligamentous structure to maintain vertebral alignment.

   5. Height Maintenance: Preserving intervertebral spacing essential for nerve root foraminal patency.

   6. Nutrient Exchange: Facilitating diffusion of glucose and oxygen into the disc and removal of metabolic waste Wikipedia.

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Types of Lumbar Disc Herniation and Extrusion

Intervertebral disc herniations are classified by the extent of nucleus displacement:

• Disc Protrusion: Bulging of nucleus pulposus without annular rupture.

• Disc Extrusion: Rupture of the annulus fibrosus and posterior longitudinal ligament, with a “neck” connection to the parent disc.

• Disc Sequestration: A fragment of nucleus pulposus breaks free, becoming a free fragment within the spinal canal Verywell HealthWikipedia.

Within extrusions, directional subtypes include:

• Posterolateral: The most common, affecting nerve roots in the lateral recess or foramen.

• Centrally Migrated: Can compress the conus medullaris or cause cauda equina syndrome at L1–L2.

• Foraminal/Extraforaminal: Affects exiting nerve roots, leading to radiculopathy in specific dermatomes.

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Causes of Lumbar Disc Extrusion at L1–L2

1. Age-related Degeneration: Proteoglycan loss and annular weakening.

2. Repetitive Load and Microtrauma: Chronic occupational or athletic stress.

3. Acute Traumatic Injury: Falls or motor vehicle collisions causing sudden overload.

4. Genetic Predisposition: Variants affecting collagen and extracellular matrix integrity.

5. Obesity: Increased axial loading accelerates disc wear.

6. Poor Posture: Chronic flexion leading to asymmetric disc stress.

7. Smoking: Impairs disc nutrition and accelerates degeneration.

8. Diabetes Mellitus: Glycation of collagen decreases disc resilience.

9. Occupational Vibration: Prolonged exposure in heavy machinery operators.

10. Sedentary Lifestyle: Reduces disc nutrition via decreased diffusion from movement.

11. Spinal Instability: Spondylolisthesis or facet joint arthropathy altering biomechanics.

12. High-impact Sports: Gymnastics, weightlifting causing repetitive hyperflexion.

13. Connective Tissue Disorders: Ehlers-Danlos syndrome leading to annular fragility.

14. Endplate Injury: Vertebral fractures interrupt nutrient channels.

15. Inflammatory Arthritis: Rheumatoid or ankylosing spondylitis altering adjacent disc environment.

16. Previous Spinal Surgery: Scar tissue and altered biomechanics increase adjacent segment stress.

17. Infection: Discitis weakening annular structure.

18. High-altitude Hypoxia: Chronic low oxygen tensions reduce disc cell viability.

19. Prolonged Valsalva Maneuver: Excessive intra-abdominal pressure transmitted to discs.

20. Hormonal Changes: Menopause-related estrogen decline affecting collagen repair ScienceDirectOrthobullets.

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 Symptoms of L1–L2 Disc Extrusion

1. Acute Low Back Pain: Sudden onset, often unilateral.

2. Anterior Thigh Pain: Radiating along the L1 dermatome.

3. Groin Discomfort: Deep aching sensation.

4. Psoas Muscle Weakness: Difficulty with hip flexion.

5. Diminished Cremasteric Reflex: In males, indicates L1 involvement.

6. Numbness or Paresthesia: In the lower abdomen or anterior thigh.

7. Gait Disturbance: Due to proximal lower limb weakness.

8. Neurogenic Claudication: Leg pain on walking, relieved by bending forward.

9. Autonomic Dysfunction: Rarely, bowel or bladder symptoms if conus is compressed.

10. Hyperlordosis: Protective posturing to reduce nerve stretch.

11. Tender Paraspinal Muscles: Palpable spasm.

12. Positive Straight Leg Raise Test: Radiating pain at low angles.

13. Postural Aggravation: Pain worsens with sitting or flexion.

14. Morning Stiffness: Due to inflammatory component.

15. Night Pain: Deep ache that disturbs sleep.

16. Sensory Loss: Pinprick deficit in L1 distribution.

17. Muscle Atrophy: Chronic cases show thigh muscle wasting.

18. Kemp’s Test Positive: Extension and rotation provoke symptoms.

19. Guarded Movement: Limited trunk flexion/rotation.

20. Referred Hip Pain: Mimicking hip joint pathology OrthobulletsWikipedia.

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Diagnostic Tests

Diagnostic evaluation combines clinical, laboratory, electrodiagnostic, and imaging modalities to confirm L1–L2 disc extrusion and assess severity.

1. Physical Exam

   • Inspection: Observe posture, spinal alignment, and muscle spasm Orthobullets.

   • Palpation: Identify paraspinal tenderness at L1–L2.

   • Range of Motion: Flexion/extension to exacerbate symptoms.

   • Gait Analysis: Look for hip flexor weakness.

   • Reflex Testing: Cremasteric reflex (L1).

   • Sensory Testing: Light touch and pinprick in anterior thigh.

   • Muscle Strength: Hip flexion (iliopsoas) assessment.

   • Straight Leg Raise: Positive at 30–60° suggests nerve root tension.

2. Manual Orthopedic Tests

   • Crossed Straight Leg Raise: Pain on contralateral leg raise.

   • Slump Test: Seated knee extension flexion with neck flexion.

   • Kemp’s Test: Extension/rotation compresses lateral recess.

   • Femoral Nerve Stretch: Supine knee flexion/hip extension.

   • Nachlas Test: Prone heel to buttock stresses L2–L4 roots.

   • Hoover Test: Differentiates true weakness from malingering.

   • Bechterew’s Test: Seated straight leg raise.

3. Laboratory & Pathological Tests

   • ESR & CRP: Rule out discitis or inflammatory arthritis.

   • Complete Blood Count: Assess infection/inflammation.

   • HLA-B27: Screen for ankylosing spondylitis.

   • Rheumatoid Factor: Exclude rheumatoid involvement.

   • Blood Glucose: Diabetes as risk factor.

4. Electrodiagnostic Studies

   • Electromyography (EMG): Detect denervation in L1-innervated muscles.

   • Nerve Conduction Studies: Assess conduction velocity of peripheral nerves.

   • F-wave Studies: Proximal nerve root function.

   • H-reflex: S1 root assessment (ancillary).

   • Somatosensory Evoked Potentials: Central conduction via dorsal columns.

5. Imaging Tests

   • Plain Radiographs: Rule out fractures, spondylolisthesis.

   • Magnetic Resonance Imaging (MRI): Gold standard for disc extrusion visualization.

   • Computed Tomography (CT): Detect calcified fragments or bony pathology.

   • CT Myelogram: Useful when MRI is contraindicated.

   • Discography: Provocative testing to confirm pain source.

Each diagnostic modality contributes unique information, guiding comprehensive management planning.

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Non-Pharmacological Treatments

A. Physiotherapy & Electrotherapy

1. Transcutaneous Electrical Nerve Stimulation (TENS)

   • Description: Low-voltage electrical current via skin electrodes.

   • Purpose: Pain relief by gating pain signals.

   • Mechanism: Activates large nerve fibers to inhibit nociceptive fibers in the spinal cord.

2. Interferential Current Therapy

   • Description: Two medium-frequency currents overlap in tissue.

   • Purpose: Deep pain and inflammation reduction.

   • Mechanism: Beat frequencies stimulate endorphin release and improve circulation.

3. Ultrasound Therapy

   • Description: High-frequency sound waves via a handheld probe.

   • Purpose: Promote tissue healing and reduce inflammation.

   • Mechanism: Mechanical vibration increases local blood flow and cellular metabolism.

4. Cold Laser Therapy

   • Description: Low-level laser applied to the skin.

   • Purpose: Accelerate tissue repair and reduce pain.

   • Mechanism: Photobiomodulation stimulates mitochondrial activity and anti-inflammatory cytokines.

5. Heat Therapy (Hot Packs)

   • Description: Superficial heating of lumbar muscles.

   • Purpose: Muscle relaxation and pain reduction.

   • Mechanism: Increases blood flow, decreases stiffness.

6. Cold Therapy (Cryotherapy)

   • Description: Ice packs applied to the lower back.

   • Purpose: Reduce acute inflammation and numbing pain.

   • Mechanism: Vasoconstriction limits swelling and nerve conduction.

7. Spinal Traction (Mechanical)

   • Description: Axial pulling force on the spine.

   • Purpose: Decompress herniated disc material.

   • Mechanism: Increases intervertebral space, reduces nerve root pressure.

8. Spinal Traction (Manual)

   • Description: Therapist-applied stretching of the lumbar spine.

   • Purpose: Similar to mechanical traction; tailored force.

   • Mechanism: Manual distraction of facet joints and disc.

9. Massage Therapy

   • Description: Soft-tissue mobilization of lumbar muscles.

   • Purpose: Relieve muscle spasm and improve circulation.

   • Mechanism: Mechanical pressure breaks adhesions and stimulates blood flow.

10. Myofascial Release

    • Description: Sustained pressure into fascial restrictions.

    • Purpose: Restore tissue elasticity and relieve pain.

    • Mechanism: Breakdown of fascial cross-links and improved gliding.

11. Dry Needling

    • Description: Insertion of thin needles into trigger points.

    • Purpose: Alleviate muscle tightness and pain.

    • Mechanism: Local twitch response interrupts pain-spasm cycle.

12. Kinesio Taping

    • Description: Elastic therapeutic tape applied to skin.

    • Purpose: Support muscles, reduce swelling.

    • Mechanism: Lifts skin to improve lymphatic drainage and proprioception.

13. Spinal Manipulation

    • Description: High-velocity, low-amplitude thrusts by a trained practitioner.

    • Purpose: Restore joint mobility and reduce pain.

    • Mechanism: Mechanical release of joint restrictions and neurophysiological modulation.

14. Mobilization with Movement (MWM)

    • Description: Therapist applies glide while patient moves.

    • Purpose: Correct movement impairments with immediate pain relief.

    • Mechanism: Passive accessory glide normalizes joint kinematics.

15. Hydrotherapy (Aquatic Therapy)

    • Description: Exercises performed in warm water.

    • Purpose: Gentle resistance and reduced weight-bearing.

    • Mechanism: Buoyancy decreases load on spine, hydrostatic pressure reduces swelling.

B. Exercise Therapies

16. Core Stabilization Exercises

    • Description: Isometric and dynamic strengthening of deep trunk muscles.

    • Purpose: Enhance spinal support and reduce disc stress.

    • Mechanism: Activates transverse abdominis, multifidus for segmental stability.

17. McKenzie Extension Exercises

    • Description: Repeated prone extensions.

    • Purpose: Centralize disc material and relieve leg symptoms.

    • Mechanism: Posterior disc migration reduces nerve impingement.

18. Williams Flexion Exercises

    • Description: Pelvic tilts, knee-to-chest stretches.

    • Purpose: Open posterior disc space to reduce nerve pressure.

    • Mechanism: Flexion pulls nerve roots away from protruding disc.

19. Pelvic Floor Strengthening

    • Description: Kegel exercises targeting pelvic muscles.

    • Purpose: Support lumbar stability and prevent incontinence.

    • Mechanism: Improves core synergy and sacroiliac alignment.

20. Hamstring Stretching

    • Description: Supine or standing hamstring stretches.

    • Purpose: Reduce posterior thigh tension, lower back pull.

    • Mechanism: Lengthens hamstrings to decrease pelvic tilt stress.

21. Piriformis Stretch

    • Description: Figure-4 leg position stretches.

    • Purpose: Relieve sciatica-like symptoms from piriformis compression.

    • Mechanism: Reduces muscle spasm affecting sciatic nerve.

22. Gluteal Strengthening

    • Description: Bridges, clamshells.

    • Purpose: Balance hip extensors, reduce lumbar load.

    • Mechanism: Distributes forces away from lumbar spine.

23. Aerobic Conditioning

    • Description: Low-impact activities (walking, cycling).

    • Purpose: General fitness, weight control, endorphin release.

    • Mechanism: Improves circulation, promotes healing.

C. Mind-Body Therapies

24. Yoga

    • Description: Guided postures, breathing, relaxation.

    • Purpose: Flexibility, core strength, stress reduction.

    • Mechanism: Combines muscle engagement with mindfulness to alleviate tension.

25. Pilates

    • Description: Controlled mat or equipment exercises.

    • Purpose: Core activation, posture correction.

    • Mechanism: Builds deep trunk muscle endurance and alignment.

26. Mindfulness Meditation

    • Description: Focused awareness practices.

    • Purpose: Manage pain perception and stress.

    • Mechanism: Alters nociceptive processing through top-down modulation.

27. Progressive Muscle Relaxation (PMR)

    • Description: Systematic tensing and releasing muscle groups.

    • Purpose: Reduce overall muscle tension.

    • Mechanism: Triggers parasympathetic response, lowering pain sensitivity.

D. Educational Self-Management

28. Back School Programs

    • Description: Structured classes on spine anatomy, lifting techniques.

    • Purpose: Empower patients to protect their backs.

    • Mechanism: Knowledge change encourages safer behaviors.

29. Cognitive-Behavioral Therapy (CBT)

    • Description: Psychological sessions to reframe pain thoughts.

    • Purpose: Decrease fear-avoidance and improve coping.

    • Mechanism: Modifies maladaptive beliefs, reduces pain catastrophizing.

30. Pain Education & Pacing

    • Description: Teaching activity pacing and pain science.

    • Purpose: Prevent overexertion and flare-ups.

    • Mechanism: Balances activity/rest to maintain function.

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Pharmacological Treatments

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Dietary Molecular Supplements

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Advanced Injectable & Regenerative Drugs

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Surgical Options

1. Microdiscectomy

   • Procedure: Small incision, removal of extruded nucleus.

   • Benefits: Immediate nerve decompression, minimal tissue disruption.

2. Open Discectomy

   • Procedure: Larger incision, direct removal of herniated disc material.

   • Benefits: Effective decompression but longer recovery than microdiscectomy.

3. Laminectomy

   • Procedure: Removal of vertebral lamina to expand spinal canal.

   • Benefits: Relieves severe nerve compression.

4. Foraminotomy

   • Procedure: Widening of nerve exit foramen.

   • Benefits: Reduces radicular pain with minimal bone removal.

5. Endoscopic Discectomy

   • Procedure: Tiny endoscopic tools remove disc fragments.

   • Benefits: Less blood loss, quicker recovery.

6. Spinal Fusion

   • Procedure: Joining adjacent vertebrae using bone graft and hardware.

   • Benefits: Stabilizes spine in cases of instability.

7. Artificial Disc Replacement

   • Procedure: Damaged disc removed, prosthetic disc inserted.

   • Benefits: Maintains motion, reduces adjacent-level stress.

8. Interspinous Process Decompression (IPD) Spacer

   • Procedure: Implant between spinous processes.

   • Benefits: Limits extension, relieves neurogenic claudication.

9. Percutaneous Disc Decompression

   • Procedure: Needle-based removal or ablation of disc tissue.

   • Benefits: Outpatient procedure, minimal invasion.

10. Vertebroplasty/Kyphoplasty

    • Procedure: Bone cement injection into vertebral body.

    • Benefits: Stabilizes compression fractures that may accompany extrusion.

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 Lifestyle: What to Do & What to Avoid

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 Preventive Measures

1. Ergonomic Workplace Setup: Adjust desk, chair, and monitor to reduce lumbar strain.

2. Regular Core Strengthening: Maintain trunk muscle balance to support discs.

3. Proper Lifting Techniques: Bend at knees, keep load close to body.

4. Maintain Healthy Body Weight: Reduces axial load on lumbar discs.

5. Quit Smoking: Improves disc nutrition and healing capacity.

6. Stay Hydrated: Disc hydration maintains shock-absorbing properties.

7. Daily Stretching Routine: Prevent muscle tightness around pelvis and back.

8. Balanced Nutrition: Adequate protein, vitamins, and minerals for disc health.

9. Avoid Prolonged Static Postures: Move or change position every 30 minutes.

10. Early Treatment of Back Strains: Address minor injuries before they worsen.

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When to See a Doctor

• Persistent or Worsening Pain: Back or radicular pain lasting > 6 weeks despite home care.

• Neurological Deficits: Numbness, weakness, or tingling in legs or groin area.

• Bladder or Bowel Dysfunction: Loss of control (sign of cauda equina syndrome).

• Severe, Unrelenting Night Pain: Wakes you from sleep or unresponsive to analgesics.

• Constitutional Signs: Fever, unexplained weight loss, or history of cancer.

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Frequently Asked Questions (FAQs)

1. What is a lumbar disc extrusion?
   A lumbar disc extrusion happens when the inner gel (nucleus pulposus) pushes through a tear in the outer ring (annulus fibrosus) of a spine disc, often causing pain and nerve irritation.

2. How is L1–L2 extrusion different from other levels?
   L1–L2 is higher in the lumbar spine—symptoms may include pain in the lower torso or groin rather than the leg.

3. Can I treat disc extrusion without surgery?
   Yes; most patients improve with non-surgical care like physical therapy, exercise, and medications over 6–12 weeks.

4. Is rest good for a herniated disc?
   Short-term rest (1–2 days) may help, but prolonged inactivity can weaken muscles and slow recovery.

5. What exercises help a herniated disc?
   Core stabilization, McKenzie extensions, and gentle stretches reduce pressure on the disc.

6. Will pain go away on its own?
   In many cases, inflammation and disc material retract over months, easing pain.

7. Are opioids necessary for relief?
   Opioids may help short-term for severe pain but carry risks; non-opioid analgesics are preferred first.

8. What is the role of supplements?
   Supplements like glucosamine, curcumin, and omega-3s support joint health and reduce inflammation.

9. When is surgery indicated?
   Surgery is considered for severe neurological deficits, cauda equina syndrome, or unrelenting pain despite 6–12 weeks of conservative care.

10. What is microdiscectomy?
    A minimally invasive surgery to remove extruded disc fragments and relieve nerve pressure.

11. Can I prevent future disc problems?
    Yes; maintain core strength, good posture, healthy weight, and avoid smoking.

12. Is spinal fusion necessary after discectomy?
    Fusion is only required if spinal instability is present.

13. Will an extruded disc heal completely?
    The body can reabsorb disc material over time, though some residue may remain without causing symptoms.

14. How long is recovery after microdiscectomy?
    Most return to light activities in 2–4 weeks and full activity by 6–12 weeks.

15. Can psychological therapies help?
    Yes; CBT and mindfulness reduce pain perception and improve coping strategies.

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 18, 2025.

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