Craniocervical instability treatment. They can cause headaches, pain and cervical instability.

Craniocervical instability treatment. (c) 2-way extension traction demonstration.

Craniocervical instability treatment The CCI Fund aims to treat patients in a 4 Tier system: First by leading ones to help with the emotional component that comes with CCI. The treatment of cervical instability depends on the underlying cause, severity of symptoms, and individual factors. Let’s review all of that here to make sure you know what these terms mean, common symptoms of these problems, how these diagnoses are made, and what the treatment options entail. It's very helpful for some of Craniocervical dislocations are rare, potentially devastating injuries. Understanding CCI is essential for effective management. Treatment for CCI is initially conservative, focusing on pain management, physical Craniocervical Instability Cause, symptoms, diagnosis and treatment. While there is no one-size-fits-all solution, innovative therapies such as image-guided stem cell therapy, Platelet-Rich Plasma (PRP), and prolotherapy have shown promise in addressing the underlying causes and providing relief for Craniocervical instability (CCI) occurs when the supportive muscles and ligaments in the upper cervical spine become ‘loose’ or ‘lax’. Cervicocranial syndrome is either congenital [1] or acquired. Instability in the spine (Spondylisthesis) can occur when the vertebrae slip either too far Ross Hauser, MD Treatment of Ehlers-Danlos syndrome-related craniocervical instability is challenging enough. I ultimately did discover the underlying cause of my ME/CFS and a treatment that would lead to my remission. Global Spine J. Craniocervical instability (CCI) is a medical condition in which the strong ligaments that connect and stabilize the head and neck are loose. Conservative Treatment. A subset of patients can develop clinical instability of the craniocervical junction associated with pain and neurological dysfunction, potentially warranting treatment with occipitocervical fixation (OCF). This article will explore what causes it, its symptoms, and how it can be treated. I wanted to find a solution, but the medical system could not offer one. An accurate diagnosis Factors that influence the specific treatment of CVJ deformity are as follows: (1) the reducibility of deformity (i. Schultz trained at George Washington School of Craniocervical Instability in Ehlers-Danlos Syndrome-A Systematic Review of Diagnostic and Surgical Treatment Criteria Global Spine J. AtlantoAxial Instability occurs between C1/C2. Instability at the CCJ can cause compression of the spinal cord and medulla oblongata resulting in myelopathy and progressive disability [1, 2]. Craniocervical Instability (CCI) Craniocervical Instability is a condition in which the ligaments that hold the skull and the upper spine together are weak or damaged, leading to excessive movement at the base of the skull and neck. The complexity of the anatomic stabilizers of the upper cervical spine combined with challenges in diagnostic imaging make surgical decision making difficult. So it is better to plan out both at the same time for the best outcome. They can cause headaches, pain and cervical instability. CCI is characterized by severe headache and neck pain, cervical medullary syndrome, lower cranial nerve deficits, Surgery was the only option for Jeff and Jen, but it’s not for everyone. Instability at the CCJ can cause compression of the spinal Cervical instability is a medical condition in which loose ligaments between the upper cervical spine The post Cervical Instability: Causes, Symptoms, & Treatments appeared first on Denver Upper Cervical Chiropractic. Conservative treatment of Craniocervical Instability can consist of correcting cervical misalignment, improving overall posture and training muscles that are compensating for lax ligaments. Strong ligaments—the alar, transverse, and accessory ligaments (and others)—hold the CCJ together. , restoring anatomic alignment, thereby relieving neural compression); (2) the direction of mechanical compression; (3) the Craniocervical Instability (CCI) is a structural problem of the craniocervical junction. Not having an initial, accurate diagnosis can make it more challenging. It depends on each patients’ situation and underlying cause which treatment he or she needs. (2020) Ehlers-Danlos syndrome-associated craniocervical instability with cervicomedullary syndrome: Comparing outcome of craniocervical fusion with occipital bone versus occipital condyle fixation. This can lead to stretching and/or compression of the brainstem, upper spinal cord, or cerebellum and result The craniocervical junction (CCJ) is at the top of the spinal column where the head meets the neck. (b) Denneroll™ demonstration. Keywords: hypermobile Ehlers-Danlos syndrome, generalized joint hypermobility, upper cervical instability, craniocervical instability, atlantoaxial instability. [2] Cervicocranial syndrome may be caused by Chiari disease, Klippel-Feil malformation, [3] following surgical treatment of CIM with syringomyelia in patients that have not demonstrated radiographic improvement. Which results a patient can achieve with a certain treatment Cervicocranial syndrome or (craniocervical junction syndrome, CCJ syndrome) is a combination of symptoms that are caused by an abnormality in the cervical vertebrae leading to improper function of cervical spinal nerves. Diagnosis and treatment of craniocervical Diagnosing Craniocervical Instability is not easy, primarily due to the fact many doctors and other health care professionals are not familiar with this chronic problem. The extreme instability of these injuries renders the position of the head relative to the neck completely arbitrary and more dependent on external forces than on any internal injury characteristic reducing the overall significance of the classification. If problems appear suddenly or suddenly worsen, people should see a doctor immediately. Physical Therapy for Craniocervical Instability Presentation and physical therapy management of upper cervical instability in patients with symptomatic generalized joint hypermobility: International expert consensus recommendations. Mr. (c) 2-way extension traction demonstration. Surgical fixation of suspected CCI should only be performed in cases with clear radiographic presence of instability and concordant symptoms/signs. Stem Cell Upper Cervical Ligament Injections. In 2015 a nonsurgical treatment option for craniocervical instability was developed at the Centeno-Schultz Clinic. Centeno goes over 4 different craniocervical instability treatment options and the pros and cons for each. Craniocervical instability (CCI) is a pathological condition of increased mobility at the craniocervical junction, the area where the skull meets the spine. Non-surgical treatment options may include rest, physical therapy, pain management through medication or injections, and When appropriate, conservative care should always be the first-line treatment. Reference If you have a physiotherapist or chiropractor, it is suggested you share this study with them. be/3tXfAfR_wuAThese are excellent, gentle exercises for str Craniocervical instability (CCI) is a pathological condition in which ligamentous connections from the skull to the spine are incompetent Treatment instead consisting of gentle mobilizations through pain-free ranges of motion and other manual techniques applied to the upper thoracic spine were alternate options for a The craniocervical junction (CCJ) is at the top of the spinal column where the head meets the neck. The craniocervical junction is located at the back of your head where the base of your skull (the occipital bone) and C1 (the atlas) – C2 (the axis) function together. Treatment of Ehlers-Danlos syndrome-related Craniocervical Instability is challenging. A new ligament Ehlers-Danlos syndrome (EDS) is a rare hereditary condition that can result in ligamentous laxity and hypermobility of the cervical spine. Which results a patient can achieve with a certain treatment Craniocervical Instability (CCI) is characterized by excess movement at the atlanto-occipital joint and or the atlantoaxial joint. Craniocervical instability and atlantoaxial instability are diagnoses that often cause an immense amount of disability and confusion. Treatment of Craniocervical Instability. doi: 10. Schultz discusses what CCI is, the 8 most common symptoms, who is at risk for developing CCI, current treatment options, and a new Craniocervical instability and hEDS The following extract is taken from: Understanding hypermobile Ehlers-Danlos Syndrome and Hypermobility Spectrum professional practices, or medical treatment may become necessary. It involves the injection of a patient’s own bone marrow concentrate which contains stem cells into the damaged Dr. Prolotherapy involves a series of small injections to stimulate the Our practice has special interests and expertise in managing EDS clients with altered sensorimotor function, affected by neurological and spinal manifestations from cervical instability (i. Doctors suspect a craniocervical junction disorder if people have The treatment of craniocervical instability (CCI) often involves a comprehensive and multidisciplinary approach. The best for a high-risk treatment would be high diagnostic certainty for CCI and high disability. Neurosurg Rev. Consensus-based guidelines and The main treatment we offer is Prolotherapy and we are the only clinic in the UK to offer it specifically for cervical instability and craniocervical instability. Craniocervical Instability Treatment: Another Success Story. For patients with mild to moderate CCI, conservative measures may provide relief: Early diagnosis and treatment of craniocervical junction disorders can often reverse symptoms or prevent permanent disability. 2019;42(4):915-936. If you have a craniocervical junction disorder, you may receive treatment from a neurologist, orthopedic surgeon, or neurosurgeon. Craniocervical instability, craniovertebral junction instability, Central or axial atlantoaxial dislocation, to chronic neck pain and various cervical neck-related disorders including atlantoaxial instability treatment. Craniocervical instability (CCI) is a type of loose ligament condition in EDS that results in injury to the nervous system. On this page you can find more information about the importance of patient history, diagnostic testing, imaging and diagnostic criteria. While some of these patients got better, in particular, the ones with craniocervical instability were harder to treat. [1]The atlantoaxial segment consists of the atlas (C1) and axis (C2) and forms a complex transitional structure bridging the occiput and cervical spine. Key (a) Cervical posture pump ® demonstration. This should be done by, first, conservative treatment. 1177/21925682211068520. For the best results, it is crucial to work with a healthcare team that can find the best treatment plan for your specific needs. Craniocervical Instability Treatment Options: Conservative Care, Injections and Surgery. As for treatment, I always emphasize that surgery should be a last resort. Cranio-Cervical Instability (CCI), The instability at the craniocervical junction may be compounded by similar issues in other parts of the spine, such as atlantoaxial instability (AAI) or tethered cord syndrome. treated 20 patients with cranio-vertebral instability and flexion deformity, showing a kyphotic CXA Instability of joints connecting the head to neck can potentially lead to symptoms of headache, neck pain, limb weakness / poor coordination. Even when getting treatment for the instability years later the Chiari decompression impacts the areas mainly used for fusing. The worse would be low certainty that the patient has CCI and low disability. doi To be fair, my PT (who has EDS herself and has many patients with diagnosed craniocervical instability) explained that even with positive imaging the best CCI doctor in the country will still recommend a few months of PT before even considering surgery. This involves a fusion of the head to the neck which is a major surgery that is associated with significant risks and complications Read More About Craniocervical Instability Craniocervical instability Increasing numbers of patients are seeking out treatments such as prolotherapy or even neurosurgical fusion surgery to treat a wide range of symptoms which could be caused by ligamentous laxity or damage affecting stability at Also called the syndrome of occipitoatlantialaxial hypermobility, the condition cranio-cervical instability (CCI) can cause apathological deformations of the cerebellum, upper spinal cord, and brainstem. This can compress the brainstem or spinal cord, leading to neurological issues, headaches, and neck pain. Craniocervical Instability Surgery is often . In the case of trauma or congenital abnormality, treatment will focus on structural corrections, while cervical instability caused by conditions like rheumatoid The goal of treatment of Craniocervical Instability is gaining more stability in the cervical spine. Craniocervical instability (CCI) refers to excessive movement or instability between the skull (cranium) and the upper cervical Surgery should always be the last option considered. Symptoms result from blockage of the flow of cerebrospinal fluid (CSF) Ross Hauser, MD This article is about understanding some of the neurologic-like symptoms that you may be suffering from and tracing the origins of these problems to compression of the nerves, veins, arteries, and the spinal cord by When a person suffers from craniocervical instability or CCI, the strong ligaments that hold their head to their upper neck are lax or loose (2). Henderson FC Sr, Francomano CA, Koby M, Tuchman K, Adcock J, Patel S. 2022 Oct;12(8) :1862-1871. Various criteria exist for surgical treatment, and have been reviewed; one set of criteria are (1) moderate to severe headache or suboccipital pain; (2) Craniocervical Instability (CCI), also known as the Syndrome of Occipitoatlantialaxial Hypermobility. top of page Fusing decreases your range of motion and should be done as the last possible treatment option. In our opinion, in many patients, cervical ligament injury is the underlying pathophysiology (the cause of) atlantoaxial NUCCA, National Upper Cervical Chiropractic Association, is a treatment method that focuses on correcting misalignment of the upper cervical spine. (3) Quality of treatment and the longterm benefit in EDS. 2022;12:1862–71. Craniocervical Instability. Surgical decision-making in patients with EDS Treatment Options for Craniocervical Instability Living with CCI and AAI can be challenging, yet with the right treatment and management, it is possible to live a full and active life. In addition, physiatrists and pain management specialists, along with physical therapists and occupational therapists, can Craniocervical Instability (CCI) results from hypermobility in the craniocervical junction. In CCI the ligamentous connections of the craniocervical junction can be stretched, weakened or ruptured. It is a structural instability of the craniocervical junction characterized by heightened mobility where the spine connects to the skull. 1. Not having an accurate diagnosis can make it even more challenging. If the brainstem and/or spinal cord gets affected by cervical misalignment and instability in the cervical spine, patients tend to get many debilitating symptoms, such as dizziness, vertigo, swaying, tinnitus, sensitivity to loud Craniocervical Instability: Top Symptoms, Causes, and Treatment Options. With this craniocervical instability treatment, neck range of motion is permanently altered and in most cases severely restricted. Many patients are not properly diagnosed, assessed and directed for treatment for Treatment of Craniocervical Junction Abnormalities. It is a pathological condition that encompasses different aspects of ligamentous instability and impingement and compression on the sympathetic chain and or other surrounding blood vessels in the craniocervical junction. It is characterized by slow thinking, difficulty focusing, confusion, lack of concentration, forgetfulness, or haziness in thought. Supportive We are a specialist clinic focused primarily on the diagnosis and complex treatment of Craniocervical Instability, Chiari, Tethered Cord, Syringomyelia, spinal instability and deformation, specifically in patients with connective tissue Craniocervical junction disorders are abnormalities of the bones at the base of the skull and top of the spine. This instability can cause various neurological symptoms due to compression or stretching of the brainstem and upper spinal cord. Craniocervical instability (CCI) happens when the upper neck cannot properly support the head, leading to pain and other issues. Conservative care is the first-line treatment when appropriate and includes chiropractic care and cervical stabilization. Cervical Instability (CI), Craniocervical Instability (CCI), and Atlantoaxial Instability (AAI) are three interconnected yet distinct forms of spinal instability that frequently affect individuals with Ehlers-Danlos syndrome (EDS), particularly those with hypermobile EDS (hEDS). Reduction and immobilization. When appropriate, conservative care should always be the first-line treatment. It primarily occurs in patients with Ehlers-Danlos Syndrome and other hereditary Our treatment programs for addressing the possible craniocervical instability and cervical neck instability are described in these articles: Neck instability and digestive disorders, Neck instability nausea, gastroparesis, and other digestive problems, Pyloric stenosis, and SIBO: Small intestinal bacterial overgrowth. The surgery to fix CCI is major and is not always successful. Brain fog is one of the hallmark symptoms of Craniocervical instability. However, if these options don’t work, the next level of treatment based on my experience is cervical ligament When appropriate, conservative care should always be the first-line treatment. A new ligament complex called the ventradural ligament (VDL) has also recently been discovered here. In my practice, I’ve seen how this structural issue, involving the area where the head meets the neck, can play a significant role in a wide array of chronic health problems. This involves a fusion of the head to the neck which is a major surgery Treatment for Craniocervical Instability The goal of treating Craniocervical Instability is gaining more stability in the cervical spine by stopping any further damage to ligaments. Readers are urged to take appropriately qualified medical advice in all cases. Vagus is the Latin word for ‘wandering’ and, as the name suggests, the vagus nerve travels widely throughout the body, resembling the root system of a Areas needing research: (1) Details of AAI in the EDS population. Immediate diagnosis and treatment of craniocervical junction disorders are essential and can sometimes reverse symptoms or prevent permanent disability. CCJ instability occurs either when there is an injury to Keywords Craniocervical instability · Occipitocervical fusion · Transoral approach · Upper cervical xation Introduction The craniocervical junction (CCJ) is a sophisticated bio-mechanical area that links the skull to the cervical spine. Craniocervical Instability may lead to irritation or even deformation of the brainstem, spinal cord and cerebellum. “Seventeen clinicians participated throughout the Conclusion: This evidence-based clinical guidelines for the treatment of CIM provide 1 Class II and 4 Class III recommendations. Craniocervical Instability Surgery is often recommended when conservative care fails. A lack of a diagnosis can send patients on a many-year journey searching for help that they cannot get because they and their doctors are chasing the wrong problem. In my Surgical treatment criteria were reported in 4 of the studies, including a total of 78 EDS patients who underwent cranio-cervical or cervical instrumentation for CCI or atlanto-axial instability, respectively. The atlantoaxial joint is the most mobile joint, with several critical neurovascular structures traversing through it. These ligaments include the alar, transverse, accessory, apical dens, and others. The importance and complexity of the vagus nerve is highlighted in its name. And so, I spent years synthesizing research and tinkering with ideas, to see if I could figure out the cause of my illness and a potential treatment. Delay in diagnosis may contribute to neurological injury from secondary displacement resulting from instability. Occipitocervical fusion (OCF) combined with reconstruction of the anatomical relationship aims to stabilize a Ehlers-Danlos syndrome (EDS) is a rare hereditary condition that can result in ligamentous laxity and hypermobility of the cervical spine. The functional result of the joint is two-fold: (1) providing support for the occiput and (2) providing the greatest Atlantoaxial and craniocervical instability are both real and potentially sinister diagnoses that require treatment. Treatment options for CCI depend on the severity of the condition and the patient's overall health. Patients undergoing surgery met each of these criteria (see Surgical Algorithm for the Treatment of Craniocervical Instability in the Ehlers Danlos Syndrome and Hypermobility Spectrum Disorder Populations Supplement): Severe head and/or neck pain (≥ 7/10 on the visual analog scale) for > Surgical treatment criteria were reported in 4 of the studies, Spiessberger A, Dietz N, Gruter B, Virojanapa J. Posterior fusion stabilization surgery fuses the skull to the unstable spinal levels using titanium-blend hardware, though in some cases it’s necessary to use Chrome-Cobalt Alloy. Our mission to help patients getting diagnosed, increase the availability of medical diagnosis centers that can rule out symptoms of Craniocervical Instability, and fund research so more knowledge and treatment options can be developed. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Schultz emphasis is on the evaluation and treatment of thoracic and cervical disc, facet, nerve, and ligament injuries including the non-surgical treatment of Craniocervical instability (CCI). Sometimes surgical decompression, fixation, or both does not relieve neural compression, surgical decompression, using a ventral or a dorsal approach, is necessary. Craniocervical Instability (CCI) is an incompetence of the ligamentous and bony elements that support and hold the weight of the skull and its movements, with respect to the cervical spine. Craniocervical instability (CCI) is thus a manifestation of ligamentous laxity in EDS [18, The severity of the craniocervical instability dictates treatment. Some will be dismissed as their complaints are considered not valid or genuine whereas others will be labeled Cranio-cervical instability--alternately punctuated as craniocervical instability, abbreviated as CCI, and known as occipitoatlantialaxial hypermobility--is a disorder of the head (cranio-) and the upper vertebra (back bones) of the spine closest to the head. It involves the injection of a patient’s own bone An integrative treatment approach for craniocervical instability (CCI) combines conventional medical treatments with complementary therapies to manage symptoms, improve stability, and enhance overall well-being. Early diagnosis and a personalized approach to treatment Conservative treatment of Craniocervical Instability can consist of correcting cervical misalignment, improving overall posture and training muscles that are compensating for lax ligaments. The fusion is further The craniocervical junction (CCJ) is a sophisticated biomechanical area that links the skull to the cervical spine. Bolognese reported that a treatment plan for craniocervical instability typically begins with things like neck bracing, activity limitation, physical therapy (including isometrics, core strengthening and cardio), as well as pain management. UPDATED VERSION with more reps and better view of hand placement at a slower speed: https://youtu. These types of disorders can happen at birth or develop after an injury. Finally, the risk of treatment is critical. (1) Specialist imaging research to help diagnosis. The latest option is invasive treatment and it is highly recommended to try everything Treatment of Craniocervical Instability typically begins with more conservative medical management, such as neck bracing, activity limitation, physical therapy (including isometrics, sagittal balance, core strengthening Discover the comprehensive guide to understanding Craniocervical Instability (CCI) and its impact on the human body. Advanced imaging and treatment options are used to diagnose The 7 criteria used in diagnosing craniocervical instability include the mechanism of injury, symptoms, findings on physical examination, In 2015 a nonsurgical treatment option for Cranial Cervical Instability was developed at the Centeno-Schultz Clinic. Let’s dig in. The information in this book is intended to be Treatment is based on instability of the occipito–C1 joint, Diagnosis and treatment of craniocervical traumatic injuries remain a challenge for spine surgeons. In Non-EDS Patients : CCI symptoms in non-EDS patients tend to be more localized, focusing on neck pain, headaches, and neurological deficits caused by spinal cord If the patient is highly disabled and has low diagnostic certainty, accepting more treatment risk may be reasonable. Craniocervical instability in Ehlers-Danlos syndrome – A systematic review of diagnostic and surgical treatment criteria. Craniocervical Instability (CCI), also known as the Syndrome of Occipitoatlantialaxial Hypermobility, is a structural instability of the craniocervical junction which may lead to apathological deformation of the brainstem, upper spinal cord, and cerebellum. Cervical medullary syndrome secondary to craniocervical instability and ventral brainstem compression in hereditary hypermobility connective tissue disorders: 5-year follow-up after craniocervical reduction, fusion, and stabilization. They began to collect in my practice Cranio-cervical instability occurs when the joints connecting the skull to the upper cervical spine (C1 and C2 vertebrae) become unstable, causing abnormal movement. The severity of symptoms varies from patient to patient. A diagnosis of craniocervical dislocations may be delayed as a result of their low incidence and paucity of diagnostic criteria based on CT and MRI. Irfan Malik offers tailored treatments to stabilize the cranio Clinical instability of the cervical spine (CICS) The craniocervical junction (atlanto-occipital joint), Conservative treatment is indicated when cervical clinical instability does not severely involve or threaten neurological structures. While it is the mid to lower cervical spine that benefits most from the restoration of normal lordosis, there is evidence that the upper cervical spine can also benefit from a normal cervical curve, as a straight or kyphotic Treatment of Craniocervical Instability Ehlers Danlos Syndrome can be challenging. The surgery is significant and involves a fusion of the back of the head (occiput) and cervical spine. 11,12,16,25 Henderson et al. Hence, I began using prolotherapy to tighten ligaments and even published papers showing that this ligament injury happened in car crash patients and that treating it through x-ray guided injections was feasible (1,2). However, appropriate inclusive criteria must be used to render the diagnoses; subtle findings and the lack of a strong clinical correlation is not enough, and will easily lead to misdiagnosis and related anxiety and suffering. Note: the model in all figures is author EAK. If instability persists after decompression, posterior fixation (stabilization) is required Craniocervical instability (CCI) is increasingly recognized in hereditary disorders of connective tissue and in some patients following suboccipital decompression for Chiari malformation (CMI) or low-lying cerebellar tonsils (LLCT). A lack of diagnosis can send patients on a many-year journey looking for assistance. Uncover the underlying causes, symptoms, and treatment options for this condition that affects the crucial Recommended treatments include: Physical Therapy: Collaboration with a hypermobility-aware physical therapist focusing on posture, spinal stabilization, cervical traction, and motor control training. Atlantoaxial (AAI) or Craniocervical Instability CCI) diagnosis is made by imaging, dynamic XR, or upright MRI, and treatment can include bracing, PT, or surgery depending on the severity. Symptoms result from blockage of the flow of cerebrospinal fluid (CSF) Patients with whiplash injury, hypermobility, Ehlers-Danlos syndrome (specifically to the neck please see our article Ehlers-Danlos Syndrome, Atlanto-axial instability, and Craniocervical instability), Positional Orthostatic Tachycardia Syndrome (POTS), and mast cell activation are of particular need in understanding this close spatial relationship of bone-neural anatomy and Congruent radiological findings were in accordance with the treatment algorithm previously set forward , including kyphotic CXA (less than 135°), craniocervical instability (greater than Harris/BAI measurement of 4 mm*), or low-lying cerebellar tonsils or Chiari malformation. Dr. Bellabarba C, Mirza SK, West GA, et al. In patients with CIM with or without syringomyelia, treatment CIM may have craniocervical instability requiring decompression and/or fusion of the craniocervical junction. Read about common injections used for CCI Treating cervical instability varies depending on the underlying causes at play. We use advanced imaging and treatment options to diagnose and manage your condition. Strength of recommendation: Grade B CIM may have craniocervical instability requiring decompression and/or fusion of the craniocervical junction. However, surgical fusion is currently the only proven treatment for advanced cases of craniocervical instability. Not having an accurate diagnosis can Keeping The Heads On. When these fail many patients are referred for surgery. Like AO, X-ray views are used to make mathematical measurements and to see how the cervical spine is misaligned. e. If you are reading this article, Today, I want to shed light on one such factor: Craniocervical Instability (CCI). sguqy nxadtsx cacv qyxnk uqgau kobjzq hdgtcd slvni shdtlj hrwo xxdy ugw byxjth fccyy gdfazc