Objective To biomechanically compare the stress distribution of established posterior cervical fixation techniques—conventional pedicle screw (PS), Abumi technique, unicortical lateral mass screw (LMS), and bicortical LMS—with a novel PS method, the Lee point technique, using finite element modeling (FEM).
Methods A patient-specific FEM of C5–6 was developed using high-resolution computed tomography scan data of a degenerative cervical spine. Five fixation models were constructed: Lee point, Abumi, conventional PS, unicortical LMS, and bicortical LMS. Screw dimensions were ø3.5×28 mm for PS and ø3.5×14/18 mm for LMS. A pure moment of 1.0 N·m was applied in flexion, extension, axial rotation, and lateral bending, and the peak von Mises stress (PVMS) of both the vertebrae and implants was recorded for each loading condition.
Results Abumi technique showed the highest PVMS at C5–6 (23.09–43.22 MPa and 24.96–39.91 MPa), with stress concentrated at the pedicle entry and medial wall. Lee point and conventional PS demonstrated more evenly distributed stress across the pedicle and near cortex of the lateral mass. Unicortical and bicortical LMS showed stress mainly at the entry point, with overall lower and more uniform magnitudes. Implant stress was greatest in Abumi construct (up to 295 MPa), moderate in Lee and conventional PS, and lowest in LMS models.
Conclusion Abumi technique showed higher localized stress concentrations that may warrant careful patient selection, particularly in those with compromised bone quality. Lee point technique achieved a balanced stress profile comparable to conventional PS, suggesting a favorable biomechanical profile for posterior cervical fixation.
Paulina Cewe, Victor E. Staartjes, Victor Gabriel El-Hajj, Ihab Ahmad Al-Rikabi, Basel Musmar, Joana M Roy, Dennis Troung, Mats Beckman, Marcus Ohlsson, Pascal Jabbour, Adrian Elmi-Terander, Erik Edström
Neurospine 2025;22(4):905-915. Published online December 31, 2025
Objective Traumatic vertebral artery injuries (tVAIs) are uncommon but potentially devastating if missed. While computed tomography angiography (CTA) is routinely used for diagnosis, data on the number needed to image (NNI) remain limited. We hence analyzed tVAI epidemiology and imaging practices at a major Scandinavian level 1 trauma center.
Methods A retrospective study (2013–2020) was performed based on a single-center trauma registry. Patients were grouped based on CTA imaging protocol used; selective screening (2013–2017) and universal screening (2018–2020). Imaging protocols, treatment strategies, and outcomes were analyzed.
Results Among 2,843 patients admitted with level 1 trauma and receiving CTA imaging, 62 had a tVAI (2.2%) yielding a NNI of 46 patients to diagnose 1 tVAI. Twenty-five of these patients (40.3%) were found to have a posterior circulation stroke, resulting in an incidence of 0.9%, and a NNI of 114 to diagnose 1 stroke on CTA. NNIs for both tVAI and stroke detection increased with adoption of universal screening (tVAI: 35→65; stroke: 90→149). However, the detection rate of tVAI during the universal screening period was not significantly higher than during the selective screening period (p=0.261).
Conclusion In our level 1 trauma cohort, the incidence of tVAI was 2.2% and stroke rate 0.9%. The NNI rose with universal screening, yet detection rates did not improve. These findings suggest that selective screening based on risk factors may be more efficient than a universal approach. Further research is needed to balance diagnostic accuracy with resource use in trauma care.
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Optimizing Diagnostic Yield: Evidence Against Universal Computed Tomography Angiography for Traumatic Vertebral Artery Injury Screening – A Commentary on “Epidemiology and Screening of Traumatic Vertebral Artery Injuries at a Large Scandinavian Level 1 Tr Jae Taek Hong Neurospine.2025; 22(4): 916. CrossRef
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Objective This study aims to investigate the anatomical relationship among the nerve roots, intervertebral space, pedicles, and intradural rootlets of the cervical spine for improving operative outcomes and exploring neuroventral decompression approach in posterior endoscopic cervical discectomy (PECD).
Methods Cervical computed tomography myelography imaging data from January 2021 to May 2023 were collected, and the RadiAnt DICOM Viewer Software was employed to conduct multiplane reconstruction. The following parameters were recorded: width of nerve root (WN), nerve root-superior pedicle distance (NSPD), nerve root-inferior pedicle distance (NIPD), and the relationship between the intervertebral space and the nerve root (shoulder, anterior, and axillary). Additionally, the descending angles between the spinal cord and the ventral (VRA) and dorsal (DRA) rootlets were measured.
Results The WN showed a gradual increase from C4 to C7, with measurements notably larger in men compared to women. The NSPD decreased gradually from the C2–3 to the C5–6 levels. However, the NIPD showed an opposite level-related change, notably larger than the NSPD at the C4–5, C5–6, and C7–T1 levels. Furthermore, significant differences in NIPD were observed between different age groups and genders. The incidence of the anterior type exhibited a gradual decrease from the C2–3 to the C5–6 levels. Conversely, the axillary type exhibited an opposite level-related change. Additionally, the VRA and DRA decreased as the level descended, with measurements significantly larger in females.
Conclusion A prediction of the positional relationship between the intervertebral space and the nerve root is essential for the direct neuroventral decompression in PECD to avoid damaging the neural structures. The axillary route of the nerve root offers a safer and more effective pathway for performing direct neuroventral decompression compared to the shoulder approach.
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Objective To identify factors associated with the absence of cervical spine instability in patients with rheumatoid arthritis (RA).
Methods Cervical spine instability was defined as the presence of at least one of the following: atlantoaxial subluxation, vertical subluxation of the axis, or subaxial subluxation. In 2001–2002, 634 enrolled outpatients with “classical” or “definite” RA underwent a radiographic cervical spine checkup. In 2012–2013, 233 (36.8%) prospectively underwent routine clinical follow-ups with a >10-year radiographic evaluation. The prevalence and independent predictive factors for no instability were analyzed by multivariable logistic regression. Next, 85 of 292 outpatients (29.1%) without baseline cervical spine instability completed consecutive >5-year and >10-year radiographic examinations. The incidence and predictors for no new development of instability were assessed similarly.
Results Among 233 patients, those without cervical spine instability decreased from 114 (48.9%) to 47 (20.2%) during >10 years. Steinbrocker peripheral joint destruction stages I–II (odds ratio [OR], 3.797; p=0.001), no corticosteroid administration (OR, 2.700; p=0.007), and no previous joint surgery (OR, 2.480; p=0.020) were predictors for no instability. Then, 33 of 85 (38.8%) consecutively followed patients without baseline cervical spine lesions did not develop instability throughout. Steinbrocker stages I–II (OR, 5.355; p=0.005) and no corticosteroid therapy (OR, 3.868; p=0.010) were predictors for no new onset of instability. C-reactive protein (CRP) level≤1.0 mg/dL was marginal in both models (n=233 [OR, 2.013; p=0.057], n=85 [OR, 2.453; p=0.075]).
Conclusion Steinbrocker stages I–II, no corticosteroids, no previous joint surgery, and possibly CRP ≤1.0 mg/dL are factors associated with >10-year absence of cervical spine instability in RA.
Objective To develop and evaluate a technique using convolutional neural networks (CNNs) for the computer-assisted diagnosis of cervical spine fractures from radiographic x-ray images. By leveraging deep learning techniques, the study might potentially lead to improved patient outcomes and clinical decision-making.
Methods This study obtained 500 lateral radiographic cervical spine x-ray images from standard open-source dataset repositories to develop a classification model using CNNs. All the images contained diagnostic information, including normal cervical radiographic images (n=250) and fracture images of the cervical spine fracture (n=250). The model would classify whether the patient had a cervical spine fracture or not. Seventy percent of the images were training data sets used for model training, and 30% were for testing. Konstanz Information Miner (KNIME)’s graphic user interface-based programming enabled class label annotation, data preprocessing, CNNs model training, and performance evaluation.
Results The performance evaluation of a model for detecting cervical spine fractures presents compelling results across various metrics. This model exhibits high sensitivity (recall) values of 0.886 for fractures and 0.957 for normal cases, indicating its proficiency in identifying true positives. Precision values of 0.954 for fractures and 0.893 for normal cases highlight the model’s ability to minimize false positives. With specificity values of 0.957 for fractures and 0.886 for normal cases, the model effectively identifies true negatives. The overall accuracy of 92.14% highlights its reliability in correctly classifying cases by the area under the receiver operating characteristic curve.
Conclusion We successfully used deep learning models for computer-assisted diagnosis of cervical spine fractures from radiographic x-ray images. This approach can assist the radiologist in screening, detecting, and diagnosing cervical spine fractures.
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Objective Chordoma, a rare malignant tumor originating from embryonal notochord remnants, exhibits high resistance to conventional treatments, making surgical resection imperative. However, the factors influencing prognosis specifically for cervical spine chordoma have not been clearly identified. We investigate the prognosis of cervical spine chordoma with factors influential in a nationwide multicenter retrospective study.
Methods This study included all patients diagnosed with cervical spine chordoma at 7 tertiary referral centers from January 1998 to March 2023, excluding those with clivus and thoracic spine chordomas extending into the cervical spine. Local recurrence (LR) was identified through follow-up magnetic resonance imaging, either as reappearance in completely resected tumors or regrowth in residual tumors. The study assessed LR and overall survival, analyzing factors influencing LR and death.
Results Forty-five patients with cervical spine chordoma had a mean age of 46.4 years. Over a median follow-up of 52 months, LR and distant metastasis were observed in 21 (46.7%) and 4 patients (8.9%), respectively, and 16 patients (36%) were confirmed dead. The 5-year and 10-year cumulative LR rates were 51.3% and 60%, respectively, while the 5-year and 10-year survival rates were 82% and 53%. Age was the only significant factor affecting mortality (hazard ratio, 1.04; 95% confidence interval, 1.04–1.07; p=0.015). Notably, the degree of resection and adjuvant therapy did not statistically significantly impact local tumor control and mortality.
Conclusion This study, the largest multicenter retrospective analysis of cervical spine chordoma in Korea, identified age as the only factor significantly affecting patient survival.
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Objective This study aimed to investigate the correlation between ossification of the posterior longitudinal ligament (OPLL) size and multifidus fatty degeneration (MFD), hypothesizing that larger OPLL sizes are associated with worse MFD.
Methods One hundred four patients with cervical OPLL who underwent surgery were screened. OPLL occupying diameter and area ratios, the severity of MFD using the Goutallier classification, and range of motion (ROM) of cervical flexion-extension (ΔCobb) were measured. Correlation analyses between OPLL size, MFD severity, and ΔCobb were conducted. MFD severity was compared for each OPLL type using one-way analysis of variance.
Results The final clinical data from 100 patients were analyzed. The average Goutallier grade of C2–7 significantly correlated with the average OPLL diameter and area occupying ratios, and OPLL involved vertebral level (r = 0.58, p < 0.01; r = 0.40, p < 0.01; r = 0.47, p < 0.01, respectively). The OPLL size at each cervical level significantly correlated with MFD of the same or 1–3 adjacent levels. ΔCobb angle was negatively correlated with the average Goutallier grade (r = -0.31, p < 0.01) and average OPLL occupying diameter and area ratios (r = -0.31, p < 0.01; r = -0.35, p < 0.01, respectively). Patients with continuous OPLL exhibited worse MFD than those with segmental OPLL (p < 0.01).
Conclusion OPLL size is clinically correlated with MFD and cervical ROM. OPLL at one spinal level affects MFD at the same and 1–3 adjacent spinal levels. The worsening severity of MFD is associated with the longitudinal continuity of OPLL.
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Objective To evaluate the biomechanical stability of anterior transarticular crossing screw (ATCS) and compare it with anterior transarticular screw (ATS) which may provide basic evidence for clinical application.
Methods Eight human fresh cadaveric specimens (occiput-C4) were tested with 5 conditions including the intact status, the injury status (type II odontoid fracture), the injury+ATS fixation status (traditional bilateral ATS fixation); the injury+unilateral ATCS fixation status; and the injury+bilateral ATCS fixation status. Specimens were applied to a pure moment of 1.5 Nm in flexion-extension, lateral bending, and axial rotation, respectively. The range of motions (ROMs) and the neutral zones (NZs) of C1 to C2 segment were calculated and compared between 5 status.
Results ATS and ATCS fixations significantly reduced the motions in all directions when compared with the intact and injury statues (p < 0.05). In flexion-extension, the ROMs of ATS, unilateral ATCS, and bilateral ATCS were 4.7° ± 2.5°, 4.1° ± 1.9°, and 3.2° ± 1.2°, respectively. Bilateral ATCS resulted in a significant decrease in ROM in flexion-extension when compared with ATS and unilateral ATCS (p = 0.035 and p = 0.023). In lateral bending and axial rotation, there was no significant difference in ROM between the 3 fixations (p > 0.05). Three fixations resulted in similar NZs in all directions (p > 0.05).
Conclusion ATCS is a biomechanically effective alternative or supplemental method for atlantoaxial instability.
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Objective The surgical treatment of lower cervical facet dislocation is controversial. Great advancements on reduction techniques for lower cervical facet dislocation have been made in the past decades. However, there is no article reviewing all the reduction techniques yet. The aim is to review the evolution and advancements of the reduction techniques for lower cervical facet dislocation.
Methods The application of all reduction techniques for lower cervical facet dislocation, including closed reduction, anterior-only, posterior-only, and combined approach reduction, is reviewed and discussed. Recent advancements on the novel techniques of reduction are also described. The principles of various techniques for reduction of cervical facet dislocation are described in detail.
Results All reduction techniques are useful. The anterior-only surgical approach appears to be the most popular approach. Moreover, many novel or modified reduction and fixation methods have been introduced in recent years.
Conclusion The selection of surgical approach depends on a combination of factors, including surgeon preference, patient factors, injury morphology, and inherent advantages and disadvantages of any given approach.
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Over the last few decades, the importance of the sagittal plane and its contour has gained significant recognition. Through full-body stereoradiography, the understanding of compensatory mechanisms, and the concept of global balance and reciprocal change has expanded. There have been a few reports describing how cervical realignment surgery affects global spinal alignment (GSA) and global balance. Despite the research efforts, the concept of reciprocal change and global balance is still perplexing. Understanding the compensatory status and main drivers of deformity in a patient is vital because the compensatory mechanisms may resolve reciprocally following cervical realignment surgery. A meticulous preoperative evaluation of the whole-body alignment, including the pelvis and lower extremities, is paramount to appreciate optimal GSA in the correction of spinal malalignment. This study aims to summarize relevant literature on the reciprocal changes in the whole body caused by cervical realignment surgery and review recent perspectives regarding cervical compensatory mechanisms.
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Odontoid parameters in subjects with and without degenerative cervical spondylosis Tao Kang, Weiyou Chen, Longao Huang, Hongyuan Xu, Hua Jiang BMC Musculoskeletal Disorders.2025;[Epub] CrossRef
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Cervical spine deformities (CSD) are complex surgical issues with currently heterogenous management strategies. The classification of CSD is still an evolving field. Rudimentary classification schemas were initially proposed in the late 20th century but were largely informal and based on the underlying etiology (i.e. , postsurgical, traumatic, or inflammatory). The first formal classification schema was proposed by Ames et al. in 2015 who established a standard nomenclature for describing these deformities. This classification system established 5 deformity descriptors based on curve apex location (cervical, cervicothoracic, thoracic, craniovertebral junctional, and coronal deformities) and 5 deformity modifiers which helped surgeons utilize a standard language when discussing CSD patients. Koller et al. in 2019 subsequently established a classification system for patients with rigid cervical kyphosis based on regional and global sagittal alignment. Most recently, Kim et al. in 2020 proposed an updated classification system utilizing dynamic cervical spine imaging to guide surgical treatment of CSD patients. It identified 4 major groups of deformities – (1) those with “flat-neck” deformities caused by cervical lordosis T1 slope mismatch; (2) those with focal kyphotic deformities between 2 cervical vertebrae; (3) those with cervicothoracic deformities caused by large T1 slope; and (4) those with coronal deformities. Group 2 deformities most often required combined anterior-posterior approaches with short constructs, and group 3 deformities most often required posterior-only approaches with 3-column osteotomies.
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Objective It remains unclear whether cervical sagittal deformity (CSD) should be defined by radiographic parameters alone versus both clinical and radiographic factors, and whether radiographic malalignment by itself warrants a CSD corrective surgery in patients who present primarily with neurologic symptoms.
Methods We administered a survey to a group of expert surgeons to evaluate whether radiographic parameters alone were sufficient to diagnose CSD, and in which scenarios surgeons recommend a CSD realignment procedure versus addressing the neurologic symptoms alone.
Results No single radiographic criteria reached a 50% threshold as being sufficient to establish the diagnosis of CSD. When asymptomatic radiographic malalignment was present, a sagittal deformity correction was more likely to be recommended in patients with myelopathy versus those with radiculopathy alone. The majority of surgeons recommended deformity correction when symptoms of cervical deformity were present in addition to radiographic malalignment (85% with deformity symptoms and radiculopathy, 93% with deformity symptoms and myelopathy).
Conclusion There is no consensus on which radiographic and/or clinical criteria are necessary to define the presence of CSD. We recommend that symptoms of cervical deformity, in addition to radiographic parameters, be considered when deciding whether to perform deformity correction in patients who present primarily with myelopathy or radiculopathy.
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Current Concepts of Sagittal Alignment in Adult Cervical Deformity Zeeshan M. Sardar, Justin L. Reyes, Josephine R. Coury, K. Daniel Riew Journal of the American Academy of Orthopaedic Surgeons.2026; 34(2): e176. CrossRef
C2–C7 sagittal alignment on lateral cervical X-rays and its correlation with neck pain, disability, and neurological symptoms Hoon Sub Han, Won Kyu Kim, Yong Seok Nam Journal of Back and Musculoskeletal Rehabilitation.2026;[Epub] CrossRef
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Risk factors associated with distal junctional kyphosis and failure after surgical management of adult cervical deformity: a systematic review Davin C. Gong, Anthony N. Baumann, Zhaorui Wang, Omkar S. Anaspure, Muhammad Waheed, Evan J. Beck, Rakesh D. Patel, Ilyas S. Aleem European Spine Journal.2025; 34(8): 3430. CrossRef
Reducing Chronic Spine Pain in an Adult Male by Decreasing Lumbar Scoliosis and Increasing Cervical Lordosis Using Chiropractic BioPhysics® Protocols: A 26-Month Follow-Up Case Report Jason W Haas, Miles O Fortner, Thomas J Woodham, Deed E Harrison Cureus.2024;[Epub] CrossRef
From the Spinopelvic Parameters to Global Alignment and Proportion Scores in Adult Spinal Deformity Yongjae Cho, Dae Jean Jo, Seung-Jae Hyun, Jin Hoon Park, Na Rae Yang Neurospine.2023; 20(2): 467. CrossRef
Development and Validation of an Online Calculator to Predict Proximal Junctional Kyphosis After Adult Spinal Deformity Surgery Using Machine Learning Chang-Hyun Lee, Dae-Jean Jo, Jae Keun Oh, Seung-Jae Hyun, Jin Hoon Park, Kyung Hyun Kim, Jun Seok Bae, Bong Ju Moon, Chang-Kyu Lee, Myoung Hoon Shin, Hyun Jun Jang, Moon-Soo Han, Chi Heon Kim, Chun Kee Chung, Seung-Myung Moon Neurospine.2023; 20(4): 1272. CrossRef
Objective By using angulation of the axis itself, this study aims to define and analyze odontoid incidence (OI) and odontoid tilt (OT) as novel cervical alignment parameters and investigate their correlations with cervical alignment.
Methods Novel and existing parameters were measured with whole-spine lateral plain radiographs and EOS images of 42 adults without cervical symptoms. The correlations of OI, OT, C2 slope (C2S), and T1 slope (T1S) were calculated.
Results The OI, OT, and C2S showed significant correlations with C2–7 angle (r = 0.43, r = -0.42, r = 0.62, respectively) and C0–2 angle (r = -0.33, r = 0.48, r = -0.61, respectively). OI, OT, T1S were independent predictors of the C2–7 angle in univariate regression analysis (adjusted-R2 = 0.17, R2 = 0.15, R2 = 0.28, respectively). OI, OT, and T1S were independent predictors in the multivariable regression analysis with estimated standardized coefficients of 0.36, -0.67, -0.69, respectively (adjusted- R2 = 0.80, p < 0.001). Regarding the C0–2 angle, OI and OT were independent predictors in the univariate regression analysis (adjusted-R2 = 0.08, R2 = 0.21, respectively).
Conclusion OI, OT, and C2S had significant correlations with cervical alignment. As the pelvic incidence, the OI is the only anatomical and constant parameter that could be used as a reference point related to the cervical spine from the rostral end. The study results may serve as baseline data for further studies on the alignment and balance of the cervical spine.
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The effect of cervical spine flexion-extension motion on odontoid parameters Longao Huang, Dun Liu, Hongyuan Xu, Junfei Feng, Tao Kang, Shengwang Wei, Hua Jiang Journal of Orthopaedic Surgery and Research.2025;[Epub] CrossRef
Odontoid parameters in subjects with and without degenerative cervical spondylosis Tao Kang, Weiyou Chen, Longao Huang, Hongyuan Xu, Hua Jiang BMC Musculoskeletal Disorders.2025;[Epub] CrossRef
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The Significance of Odontoid Incidence in Patients With Cervical Spondylotic Myelopathy Hongyu Qin, Weiyou Chen, Longao Huang, Xin Xiao, Qinghua Yang, Hua Jiang Global Spine Journal.2024; 14(8): 2374. CrossRef
Variation of Odontoid Incidence According to Age in Asymptomatic Children Yuwang Du, Weiyou Chen, Hongyuan Xu, Xiao Liang, Chongyang Wang, Hongyu Qin, Hua Jiang World Neurosurgery.2024; 190: e496. CrossRef
Odontoid incidence: a constant cervical anatomical feature evident in standing plain radiographs and supine magnetic resonance images Longao Huang, Weiyou Chen, Hongyuan Xu, Hongyu Qin, Hua Jiang Journal of Orthopaedic Surgery and Research.2024;[Epub] CrossRef
Atlantoaxial Instability in the Course of Rheumatoid Arthritis in Relation to Selected Parameters of Sagittal Balance Robert Wróblewski, Małgorzata Mańczak, Robert Gasik Journal of Clinical Medicine.2024; 13(15): 4441. CrossRef
Analysis of odontoid parameters in adolescent idiopathic scoliosis patients with different curve types Kelin Li, Longao Huang, Qiongrun Xiao, Weiyou Chen, Yuwang Du, Hua Jiang Frontiers in Pediatrics.2024;[Epub] CrossRef
Surgical and Clinical Outcomes Associated With the Use of Barbed Sutures and Self-Adhering Mesh System and Polymeric Glue for Wound Closure in Multilevel or Revision Spinal Surgery: A Matched Cohort Comparative Study With Conventional Wound Closure Proced Junho Mun, Seung-Jae Hyun, Jae-Koo Lee, Sungjae An, Ki-Jeong Kim Neurospine.2023; 20(3): 981. CrossRef
Reciprocal Changes Following Cervical Realignment Surgery Jae-Koo Lee, Seung-Jae Hyun, Seung Heon Yang, Ki-Jeong Kim Neurospine.2022; 19(4): 853. CrossRef
Commentary on “Clinical Impact and Correlations of Odontoid Parameters Following Multilevel Posterior Cervical Fusion Surgery” Sang Hun Lee Neurospine.2022; 19(4): 921. CrossRef
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