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 Table of Contents  
Year : 2021  |  Volume : 4  |  Issue : 1  |  Page : 18-28

Current concepts in the treatment of degenerative spondylolisthesis

Department of Spine Surgery, Christian Medical College, Vellore, Tamil Nadu, India

Date of Submission02-Aug-2020
Date of Decision11-Sep-2020
Date of Acceptance01-Dec-2020
Date of Web Publication28-Jan-2021

Correspondence Address:
Dr. Kenny Samuel David
Dept of Spine Surgery, Christian Medical College, Vellore 632004, Tamil Nadu.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ISJ.ISJ_63_20

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Degenerative spondylolisthesis is one of the commonest spinal pathologies encountered in the aging population. The clinical presentation of degenerative spondylolisthesis can be highly variable, and a large proportion of patients can be managed non-operatively. Operative treatment is reserved for patients with activity limiting disability. Decompression alone can be offered to patients with no radiological or clinical evidence of segmental instability. Fusion procedures have shown high rates of clinical success, although long-term effects such as adjacent segment degeneration have spurred the evolution of non-fusion technologies. These newer options have shown evidence of motion preservation, although long-term clinical benefits have yet to be confirmed.

Keywords: Degenerative, spondylolisthesis, treatment

How to cite this article:
David KS, Ghimire N, Krishnan V, Amritanand R, Arockiaraj J. Current concepts in the treatment of degenerative spondylolisthesis. Indian Spine J 2021;4:18-28

How to cite this URL:
David KS, Ghimire N, Krishnan V, Amritanand R, Arockiaraj J. Current concepts in the treatment of degenerative spondylolisthesis. Indian Spine J [serial online] 2021 [cited 2021 Apr 18];4:18-28. Available from: https://www.isjonline.com/text.asp?2021/4/1/18/308203

  Introduction Top

Degenerative spondylolisthesis (DS) is a commonly encountered pathology in the elderly population, although the clinical presentation can have significant variations. It is essential to have a broad understanding of the disease processes at work as well as management options in order to develop an evidence-based treatment algorithm for each patient. The current article aims to review the current state of knowledge and practice regarding the treatment of DS.

  Materials and Methods Top

An extensive literature search was done through the PubMed database using the search terms [“Spondylolisthesis”[Mesh] AND Degenerative [All Fields]], and articles published during the last 25 years were collected. Meta-analysis and systematic reviews (including Cochrane database reviews) were also included; however, information from them was parsed to get data directly from the original research articles where needed. Where available, Level 1 studies were given weightage over other descriptive studies/narrative reviews. Similarly, more recent studies (2015 and later) were given weightage over older studies.

Definition, incidence, natural history

DS is defined as “an acquired anterior displacement of one vertebra over the subjacent vertebra, associated with degenerative changes, without an associated disruption or defect in the vertebral ring.”[1] The incidence of DS has been reported to vary between 2.7 and 8.4% in patients >60 years of age, with a higher prevalence in women.[2] The pathological processes seen in DS include disc degeneration, facet arthropathy, and ligamentum flavum thickening. These changes lead to facetal subluxation and anterolisthesis, causing a variable amount of central canal, lateral recess, and foraminal stenosis. Although there is universal agreement that degeneration is the driving force for the development of DS, there is some evidence that joint laxity may be a predisposing factor.[3],[4]

A large proportion of asymptomatic or minimally symptomatic patients with DS may report stable symptoms for long periods of time. Matsunaga et al. reported 76% (84/110) of patients of DS without deficits continued to be without deficits at 10 years of follow up and 77% (85/110) reported improvement in the symptoms of back and leg pain over time.[4] However, 83% (29/35) of the patients who presented with deficits and who refused surgery experienced neurological deterioration over time. Radiological progression of the slip (>5%) may occur in up to 30% of patients over 5 years, and it has been noted that loss of disc height may offer a protection against further slip as well as an improvement in back pain.[3],[4]

DS has been reported in up to 55% of patients with degenerative scoliosis.[5] The presence of a coexistent sagittal and coronal plane deformity may significantly impact spinopelvic parameters and therefore potentially influence treatment considerations, as discussed later.

Clinical features and radiological characteristics

Most patients with DS present with back pain of a mechanical nature, often exacerbated with movements that require spinal extension, such as overhead activities and prolonged standing accompanied by leg pain, often with sensory disturbances in the posterior thighs and calves. The classical neurogenic claudication syndrome may be seen in 42–82% of patients, with bladder and bowel symptoms on presentation being seen only in 3% of patients.[3]

An important differential diagnosis to be considered is vascular claudication, and the pattern of pain (distal to proximal, fixed walking distance, no relief with forward bending) and the history of smoking should alert the clinician to this possibility. Clinical examination should routinely include confirmation of distal arterial pulsations in both feet. When in doubt, abnormal ankle-brachial and toe-brachial pressure index measurements may be used to evaluate arterial insufficiency in the lower limb.[6] Co-existent vascular compromise has been reported in up to 26% of patients presenting with neurogenic claudication and magnetic resonance imaging (MRI) evidence of spinal stenosis.[6]

The lateral standing radiograph is the commonest imaging study done for detecting DS.[1] Rosenberg et al. reported a mean slippage of 14 percent and a maximum slippage of 30 percent in patients with DS in their study.[7] Dynamic (flexion/extension) radiographs may reveal an angular or and increasing translational deformity [Figure 1]A and B that may influence the plan for management, as discussed later. In advanced cases, antero-posterior radiographs may show asymmetric disc space collapse with degenerative scoliosis [Figure 2]A and B. The most appropriate, non-invasive test for imaging the stenosis accompanying DS is MRI.[1] Apart from facetal arthritis and hypertrophy, evidence of facet joint effusion >1.5 mm on supine MRI may be suggestive of the presence of DS.[1] Other MRI findings include central and foraminal stenosis, and occasionally there may be intrathecal clumping of nerve roots proximal to the stenosis [Figure 3]A and B. CT-myelography imaging is reserved for situations where an MRI may be contra-indicated, such as a cardiac pacemaker, ocular implants, or previous spinal surgery with implants where imaging artefacts are likely to obscure the area of interest.
Figure 1: (A) and (B) A 52-year-old lady with degenerative spondylolisthesis at L4-5, showing significant angular instability on supine lateral flexion-extension radiographs

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Figure 2: (A) and (B) A 66-year-old male with L4-5 degenerative spondylolisthesis with significant coronal plane deformity due to asymmetric disc space collapse and lateral translation

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Figure 3: T2 weighted sagittal (A) and axial (B) MR images of a 52-year-old lady with L4-5 degenerative spondylolisthesis, showing bilateral facetal arthropathy, increase in the L4-5 facetal fluid, severe central canal stenosis, as well intrathecal root clumping proximal to the stenosis

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  Non-operative Treatment Top

Although there is not much data available to recommend an optimal non-operative treatment protocol in DS specifically, it is well accepted that all patients should undergo a trial of non-operative care before being offered surgery.[1],[8] Much of the information currently available is sourced from the spinal stenosis literature, and suggests that brace wearing, NSAID’s, physical therapy, and exercises can all play a role in the non-operative treatment options. It has been logically suggested that when radicular/claudication leg symptoms predominate, the treatment of DS should be along the lines of that for degenerative lumbar spinal stenosis.[1] Some of the non-operative treatment options commonly employed are discussed in more detail in the following sections.

The roles of bracing, exercises, manipulation

All patients should begin with a trial of non-operative therapy, which includes some combination of physical therapy, home-based exercises, modification of ADL, and medications.[4] While there is no data available to specifically evaluate brace treatment for symptoms associated with DS;[8] the use of a lumbosacral corset can offer symptomatic relief, improve walking distance, and decrease pain scores in patients with symptomatic degenerative lumbar stenosis.[9] Although muscle deconditioning has been a concern with long-term use of spinal braces,[10] the use of braces in combination with spinal exercises appears to maintain trunk muscle strength.[11]

Spinal exercises often constitute one of the earliest recommended interventions in patients with DS. An understanding of the pathophysiology of DS, particularly the contributory role of the posterior-based facet joints to the symptomatology should guide the exercise recommendations. Targeted (specific) exercises have been shown to yield superior results when compared with generic treatment.[12]

The benefits of a “flexion” over “extension” exercise program have been conclusively demonstrated in the literature, with reported overall improvement rates of 62% for flexion and 0% for extension exercises at three-year follow up.[13] Flexion exercises have also been shown to reduce the likelihood of using back supports, requiring job modification or painful limitation of activities.[14] Findings of paraspinal muscle denervation and trunk extensor muscle dysfunction in the spinal stenosis population[15],[16] have led some to recommend spinal extensor-strengthening exercises; however, most authors currently advise against any activity or exercise program that favors spinal extension over flexion.

The role of spinal manipulation therapy in DS is unknown. The limited information available in the literature on this matter suggests that the results of manipulative treatment are not significantly different in patients with or without DS.[17]

The role of epidural steroid injections

Steroids (glucocorticoids) are thought to exert their beneficial effects by inhibiting the formation and release of inflammatory mediators, and thereby reduce local inflammation in the region of the nerve root. In general, epidural steroid injections (ESI’s) may be preferable to systemic medications such as NSAIDS, as they avoid the associated gastrointestinal and cardiac side effects of the latter.

Most of the information on lumbar ESI’s is from studies in the spinal stenosis population, and the effect on patients with DS may need to be extrapolated from there. The available data on the efficacy of ESI’s shows mixed results. Although several studies[18],[19],[20] on patients with spinal stenosis have reported improvement in symptoms ranging from 6 weeks to 2 years, longer term (4-year) follow-up data from the SPORT trial showed no beneficial effects on symptoms.[21]

The potential complications of ESI’s also need to be kept in mind—adverse event rates of 9–20% were reported in a large series of 1295 patients who underwent lumbar transforaminal ESI’s.[22] The risk of hematoma formation makes this procedure contraindicated in patients on anticoagulation therapy. There is also some evidence that patients who receive ESI’s have a statistically higher rate of postop infection if they progress to surgical treatment within 3 months of the ESI.[23],[24] However, keeping in mind its limitations and potential complications, ESI can be considered as a viable and (relatively) non-invasive alternative to provide short to medium term relief in patients who may not be suitable for, or keen to defer surgery. Facet joint injections have been used for relief of back as well as leg pain, with contrast studies showing epidural spread of dye in up to 83% of patients after a facet joint injection.[25]

  Surgical Treatment Top

Surgical treatment can be offered to patients who report persistent disability in walking/standing in spite of an 8–12-week course of structured non-operative treatment. For the unusual situation where a patient may present with recent onset motor deficits, surgery can be considered earlier.[26] Most long-term outcomes of surgical treatment for spinal stenosis with DS have shown sustained improvement in quality of life outcome measures. The Maine Lumbar Spine Study reported on the outcomes of a mixed cohort of spinal stenosis patients with and without DS, and found that the initial benefits of surgery during the 4-year follow-up narrowed by 10 years.[27] However, the more recent Spine Patient Outcomes Research Trial (SPORT) reported a persistent advantage for surgery over non-surgical treatment in all outcome measures after an 8-year follow-up period in the DS population.[28]

The role of decompression without fusion

Not all patients with DS will require fusion, and this has led to several studies exploring the role of decompression without fusion. Multiple large studies have reported satisfactory outcomes in 69–82% of patients with DS where there was no dynamic instability on lateral radiographs, and where back pain was not a dominant preoperative symptom.[29],[30],[31],[32] Rampersaud et al. reported comparable outcomes at 2 years among 179 patients who underwent either MIS decompression or decompression with instrumented fusion for DS, where patients had leg dominant symptoms, no (or tolerable) mechanical back pain, and a “favorable” facet anatomy;[33] others have reported similar results on follow-up of years.[34] Conversely, patients with back-dominant pain have shown superior results when fusion has been added to decompression.[35],[36] Therefore, while the cost-utility benefits of decompression without fusion may be attractive,[37] this option should be considered in carefully selected patients, especially as there are reports of a higher rate of postoperative back and leg pain when decompression is performed without fusion for DS.[38]

The role of fusion in DS

Biomechanics of fusion in DS

Several authors have shown that spinopelvic parameters impact HRQOL in the adult deformity population. A positive SVA (ventral shift of the C7 plumb line) as well as loss of lumbar lordosis has been shown to negatively affect pain and function scores.[39],[40] As the maximum contribution to lumbar lordosis (approximately 66%) comes from the L4-5 and L5-S1 motion segments,[41] it is, therefore, important to achieve adequate lordosis in a lumbar fusion to restore a physiological sagittal profile. A failure to regain lordosis between L4 and S1 can trigger compensatory mechanisms such as hyperextension in the motion segments immediately above the fusion, along with retroversion of the pelvis (increasing pelvic tilt). The pelvic tilt (PT) is a positional parameter and its restoration has been found to correlated with improved clinical outcomes after fusion for DS.[42]

Sagittal profile may also impact surgical planning—some authors have suggested that when DS is accompanied by loss of lumbar lordosis (>10degrees), increased PT (>25degrees), and global sagittal imbalance (sagittal vertical axis > 4 cm), patients may benefit from longer fusion constructs.[43]

The role of decompression with non-instrumented fusion

In a landmark prospective surgical trial in 1991, Herkowitz et al. demonstrated for the first time that the addition of a posterolateral fusion with iliac crest autograft to a laminectomy reduced postoperative back and leg pain significantly compared with patients who underwent laminectomy alone, and that even a pseudarthrosis rate of 36% did not seem to impact the clinical outcome.[38] Pooled data from other studies have similarly confirmed the beneficial results of non-instrumented fusions.[44] Notwithstanding such results, current practice invariably incorporates the use of instrumentation with resultant higher fusion rates, although that may not necessarily reflect improved clinical outcomes.[45]

Role of decompression with instrumented fusion

Although the addition of fusion to decompression invariably increases the operative time, blood loss, length of hospital stay, this option is usually considered the procedure of choice in patients with more disabling back pain, and/or evidence of radiological instability. The use of pedicle screws-based systems has gained immense popularity in the past two decades, which has rendered the non-instrumented fusion option almost obsolete. The beneficial effects of adding instrumentation to the fusion procedure were clearly demonstrated by Bridwell et al., who followed 44 patients who underwent either decompression alone, decompression with uninstrumented intertransverse fusion or decompression with instrumented intertransverse fusion.[46] They noted postoperative progression of the slip in “decompression alone” group (4/9 patients) and uninstrumented fusion group (7/10 patients), whereas there was slip progression in only 1/24 patients in the instrumented fusion group, and that was a patient with a malpositioned pedicle screw. They also noted worse functional outcomes in patients who had post-surgery progression of translation. Fischgrund et al. performed a randomized study in 67 patients comparing single level intertransverse fusion with and without pedicle screw instrumentation, and reported higher fusion rate (82 vs. 45%) in the pedicle screw group, although the outcomes with respect to back and leg pain were similar in both groups.[45]

Posterolateral vs. interbody fusion for DS

Although posterolateral (intertransverse) lumbar fusion (PLF) was considered the gold standard for many years, it remained by definition an “extra-articular” fusion where the fusion mass was of doubtful strength, and its location away from the instantaneous axis of rotation (IAR) of the lumbar spine suggested that it may be less suitable to bear loads required of a fusion mass. Improvements in our understanding of lumbar spine biomechanics and the development of newer instrumentation systems opened up the possibility of performing an intra-articular (interbody) fusion (IBF), which has several theoretical advantages including larger surface area for union, placement of graft in compression, restoration of intervertebral height, and lordotic alignment in the lumbar spine, apart from the fusion mass being more co-axial with the IAR. Whether such benefits translate into improved functional outcomes and whether the added cost, operative time, and possibly increased complication rate of an interbody procedure outweigh the benefits is not clear.

The subgroup analysis of Spine Patient Outcomes Research Trial (SPORT) revealed that the functional outcomes (SF-36 and ODI) were similar at 4 years for instrumented PLF group and 360degree fusion group with added IBF.[47] Similarly, a 2017 meta-analysis which included six studies with pool of 721 patients also failed to demonstrate any difference in clinical and functional outcomes between PLF and IBF for DS, with comparable fusion rates and complication rates in both groups.[48]

PLIF vs. TLIF for DS

The original posterior lumbar interbody fusion (PLIF) popularized by Cloward in 1953 preceded the modern era of pedicle screw instrumentation.[49] Although the addition of instrumentation significantly added to the stability of the motion segment and allowed a wider decompression, there were concerns about root handling with potential neural injury, which became more evident in revision cases as well as when operating at higher lumbar levels.[50] The development of the transforaminal lumbar interbody fusion (TLIF) technique involved unilateral facetectomy to gain a more lateral trajectory with lesser traction on the roots and thecal sac and therefore a safer access corridor to the intervertebral disc.[51]

Clinical series comparing TLIF and PLIF techniques in DS have reported comparable clinical outcomes with a more favorable (lower) rate of complications with TLIF with regard to intraoperative blood loss, reoperation rates, dural and root injuries, and operative time.[51],[52],[53] In addition to the above, radiological outcomes such as reduction rate, loss of reduction, restoration of disc and foraminal height, and loss of disc and foraminal height at 2 years have been reported to be similar in both techniques.[54][Figure 4] shows 7 year followup image of a patient who underwent PLIF for degenerative spondylolisthesis with solid interbody fusion.
Figure 4: (A) Preoperative lateral radiograph of a 64-year-old male who underwent L4-5 PLIF for L4-5 Degenerative Spondylolisthesis in sacralised L5. (B) Immediate postoperative lateral xray of the same patient. (C) 7-year postoperative lateral x-ray of the same patient. Note solid bony fusion mass anterior to the cage in 4C

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Minimally invasive options for DS

Minimally invasive TLIF options have been described since 2005, and include variations such as “minimal access,”[55] “mini-open,”[56] and “microendoscopic” TLIF.[57] Common to all such procedures is a percutaneous technique to insert pedicle screws, and tubular dilators to access the area where decompression and fusion is performed. As the decompression is invariably performed from one side, preservation of the midline tension band, as well as the preservation of the soft tissue and bony anatomy on the opposite side have been shown to result in a reduction of approach-related morbidity including intraoperative blood loss, duration of hospital stay, and postoperative narcotic requirements.[56],[58],[59]

However, the above benefits of MIS fusion techniques have not always been correspondingly accompanied by superior patient-related outcomes when compared with conventional “open” lumbar fusion procedures. A multi-center database registry review of 11 centers comparing 254 open fusions with 91 MIS fusions for DS found no difference between patient reported outcomes at 1 year among patients who underwent single-level fusions. Among two-level fusions, the MIS group had significantly superior leg pain relief, but all other outcome variables were comparable. In addition, the authors reported that the MIS group had significantly lower intraoperative blood loss, although the operative time was higher.[60] Other studies have concurred that patient-reported back and leg pain scores are comparable in both techniques, while MIS patients had a lesser intraoperative blood loss and a shorter hospital stay.[56],[58],[59]

The XLIF (extreme lateral interbody fusion) variation utilizes the trans-psoas approach to the intervertebral disc, which allows for a more thorough discectomy without the need for a formal anterior approach which may require the services of an access surgeon. The XLIF anterior fusion is usually accompanied by insertion of percutaneous pedicle screws. Comparison of XLIF and the posterior-based MIS TLIF procedures have shown similar improvements in back and leg pain, comparable ODI improvement, although with a lower incidence of subsidence and better foraminal height restoration in the XLIF group.[61],[62]

The oblique lumbar interbody fusion (OLIF), also known as the “anterior to psoas” approach, is performed in the lateral position. Advantages include high fusion rates due to the ability to perform aggressive disc space clearance, as well as superior restoration of lordosis. However, sympathetic nerve injury and vascular injury are potential complications related to access.[63] There is insufficient data to assess the results of OLIF in DS.

Non-fusion/motion-sparing technologies in DS

Long-term follow up of patients with lumbar fusions have revealed an 18.5% incidence of symptomatic adjacent segment degeneration (ASD).[64] This has spurred the development and evolution of multiple non-fusion techniques with the aim of providing controlled motion and thereby minimizing ASD. Non-fusion techniques use implants that can either function as an elastic tether which allows controlled motion, or as a rigid interspinous/interlaminar device that limits spinal extension, and, therefore, prevents central canal and foraminal narrowing.[65] Examples of the former are Dynesys (Zimmer Spine, Minneapolis, MN, USA) and the Graf ligament (Neoligaments, Leeds, UK), whereas Coflex (Paradigm Spine, New York, NY, USA), X-STOP (Medtronic, Memphis, TN, USA), and DIAM (Device for Intervertebral Assisted Motion) (Medtronic, Memphis, TN, USA) are examples of extension-limiting devices. The lumbar total disc replacement (TDR) and total facet joint replacement (TFR) also serve as an example of a motion-preserving procedure that may offset the negative effects of a fusion on adjacent segments.

The theoretical advantages of motion sparing devices have not always been borne out in their clinical results. Schaeren et al. reported clinical relief of preoperative back and leg pain at an average of 4 years postoperatively, although there was a 47% incidence of radiographic ASD.[66] The comparative benefit of non-fusion techniques over other conventional methods is also not clear. A comparison of the Dynesys system with MIS-TLIF showed comparable clinical results as well as similar complication rates (including ASD) at 2 years, with a longer operative time and higher blood loss in the Dynesys group.[67] Hoppe et al. showed an 86–89% improvement in back and leg pain at 7.2 years follow up, but also had a 21% re-operation rate for symptomatic ASD.[68]

The Graf ligament system has similarly shown good early clinical results, including preservation of segmental motion in up to 80% of patients,[69] reduced postoperative back pain compared with patients who undergo decompression alone.[70] However, it has failed to demonstrate an effective reduction in the incidence of ASD[69],[70],[71] in addition to a 27% incidence of progressive instability at the index level.[72]

Interspinous devices such as the Coflex, X-STOP, and DIAM are other examples of fusionless techniques developed within the past 10–15 years. Clinical results have confirmed efficacy rates superior to non-operative treatment,[73] and comparable to fusion.[74] Of concern, however, has been reoperation rates of up to 58% that have been reported by several authors[74],[75] as well as spinous process fractures caused by interspinous devices.[76] Additionally, it has been noted that information available to patients from the internet about these devices is often insufficent to make an intelligent decision, and may in fact be biased towards industry.[77]

The role of TDR in DS has not been adequately explored in the literature, as anterolisthesis and facetal arthropathy have been considered to be contraindications for TDR.[78] Hahnle et al. reported “excellent/good” outcomes at a mean of 23 months in six out of seven patients who underwent TDR for DS, including adjacent segment degeneration.[79] However, the authors acknowledged the potential of access-related complications in revision procedures, due to the anterior vascular anatomy at L4-5, and concluded that the encouraging early results need to be interpreted with caution, and that the use of TDR in DS should be considered “off-label.”

The total facet joint replacement (TFR) is a novel concept using titanium pedicle screws that are connected horizontally at the same level (unlike the vertical rod connections used in conventional pedicle screw constructs) and a posterior polycarbonate urethane articulating core. Currently available data from small series (10 and 29 patients) indicates sustained ODI and SF-36 improvements up to 11 years follow up, with no reports of implant failure.[80],[81],[82] However, there are no larger data series available yet on the beneficial effects of TFR vis-à-vis ASD. A prospective FDA trial is currently underway comparing TFR (using the Premia TOPS system) with TLIF.[83]

  Summary Top

Formulating an appropriate management plan for a patient with DS requires a sound understanding of the underlying pathophysiological processes and awareness of the available management options. The various treatment modalities for the management of DS have been summarised in [Table 1]. A significant number of these patients can be effectively treated using non-operative means, while those with persistent and disabling symptoms can be offered surgical treatment. Minimally invasive procedures have increasingly gained popularity, although their superiority vis-à-vis functional outcomes over other conventional surgical interventions is less clear. The majority of patients undergoing fusion procedures can be expected to gain significant relief of leg symptoms, along with a variable degree of relief from back pain. The role of motion-sparing procedures is not yet well established. Newer technologies such as the total facet replacement appear promising, though long-term clinical results are still awaited.
Table 1: Summary and key studies of various treatment modalities in DS

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Conflicts of interest

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

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