spinaltraume (LH Indholdsside)

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      <HtmlField Name="PageContent"><![CDATA[<h2>Basisoplysninger<a href=" " data-type="journal-reference" data-value="Maschmann C, Jeppesen E, Rubin MA, Barfod C, New clinical guidelines on the spinal stabilisation of adult trauma patients - consensus and evidence based. Scand J Trauma Resusc Emerg Med 2019;27: 77" data-value-piped="Maschmann C, Jeppesen E, Rubin MA, Barfod C|New clinical guidelines on the spinal stabilisation of adult trauma patients - consensus and evidence based.|Scand J Trauma Resusc Emerg Med|2019|27|77|31426850" data-url="reference-link" data-pubmedid="31426850" title="Maschmann C, Jeppesen E, Rubin MA, Barfod C, New clinical guidelines on the spinal stabilisation of adult trauma patients - consensus and evidence based. Scand J Trauma Resusc Emerg Med 2019;27: 77">1</a></h2>
<h3>Definition</h3>
<ul>
    <li>Spinaltraumer omfatter
    <ul>
        <li>columnafrakturer evt. med diskusruptur</li>
        <li>rygmarvsskader</li>
        <li>cauda equina skade og rodl&aelig;sioner </li>
    </ul>
    </li>
    <li>Inddeling af spinaltraumer
    <ul>
        <li>Lukkede vs &aring;bne (inklusive penetrerende skader) </li>
        <li>Fraktur med eller uden neurologiske udfaldssymptomer </li>
        <li>Niveau i rygs&oslash;jlen </li>
        <li>Stabile vs ustabile frakturer </li>
        <li>H&oslash;j- vs lavenergitraumer</li>
    </ul>
    </li>
    <li>Se procedure om h&aring;ndtering af patient med <a href="~/link.aspx?_id=1979DCA745134F90983732BF48BE176C&amp;_z=z">mist&aelig;nkt brud i nakken</a></li>
</ul>
<h3>Forekomst</h3>
<ul>
    <li>Columnafrakturer
    <ul>
        <li>&Aring;rlig incidens er ca. 500 pr. million indbyggere </li>
        <li>Frakturerne er oftest lokaliseret i 1./2. eller 5./6. cervikalhvirvel, i nedre thorakalcolumna eller &oslash;vre lumbalcolumna </li>
        <li>Cervikale skader er oftere forbundet med rygmarvsskader</li>
    </ul>
    </li>
    <li>Traumatiske skader af rygmarv og cauda equina
    <ul>
        <li>I Danmark forekommer cirka 60 nye tilf&aelig;lde af traumatiske rygmarvsskader om &aring;ret, som har behov for omfattende rehabilitering </li>
        <li>Klinisk skadeniveau er cervikalt hos 50 %, thorakalt 33 %, lumbalt 18 % </li>
        <li>Trafikulykker og fald udg&oslash;r tilsammen 90 % af skaderne</li>
    </ul>
    </li>
</ul>
<h3>Diagnostisk tankegang</h3>
<ul>
    <li>Smerter i ryggen efter ad&aelig;kvat traume giver mistanke om brud i columna og skal behandles som dette, indtil tilstanden er afklaret </li>
    <li>Alle med alvorligt kranietraume som medf&oslash;rer s&aring; sv&aelig;r bevidsthedsp&aring;virkning, at smerter ikke kan angives, skal udredes for columnafraktur </li>
    <li>Skademekanismen kan give v&aelig;rdifuld information om skadens art og omfang</li>
</ul>
<h4>Skadesmekanismer</h4>
<ul>
    <li>Skader i nakkehvirvler
    <ul>
        <li>C0/1-fraktur (fraktur af kraniets occipitale kondyler) </li>
        <li>Jeffersons fraktur<a href="%20" title="Driscoll P, Skinner D, Earlam R. ABC of Major Trauma. London: BMJ Books; 2000" data-url="reference-link" data-value-piped="Driscoll P, Skinner D, Earlam R|ABC of Major Trauma|London|BMJ Books|2000" data-type="book-reference" data-value="Driscoll P, Skinner D, Earlam R. ABC of Major Trauma. London: BMJ Books; 2000">2</a>
        <ul>
            <li>Den klassiske version har bilateral fraktur af atlasbuerne som f&oslash;lge af aksialt traume </li>
            <li>Unilateral fraktur af atlasbuen er n&aelig;sten lige s&aring; hyppig som klassisk Jefferson fraktur </li>
        </ul>
        </li>
        <li>Fraktur af dens axis<a href="%20" title="Peitzman AB, Rhodes M, Schwab CW, Yealy DM, Fabian TC. The Trauma Manual. Lippincott : Williams and Wilkin; 2002" data-url="reference-link" data-value-piped="Peitzman AB, Rhodes M, Schwab CW, Yealy DM, Fabian TC|The Trauma Manual|Lippincott |Williams and Wilkin|2002" data-type="book-reference" data-value="Peitzman AB, Rhodes M, Schwab CW, Yealy DM, Fabian TC. The Trauma Manual. Lippincott : Williams and Wilkin; 2002">3</a><sup>,</sup><a href="%20" title="Tintinalli JE, Ruiz E, Krome RL. Emergency Medicine - A comprehensive study guide. : McGraw-Hill; 1996" data-url="reference-link" data-value-piped="Tintinalli JE, Ruiz E, Krome RL|Emergency Medicine - A comprehensive study guide||McGraw-Hill|1996" data-type="book-reference" data-value="Tintinalli JE, Ruiz E, Krome RL. Emergency Medicine - A comprehensive study guide. : McGraw-Hill; 1996">4</a>
        <ul>
            <li>Er ustabil </li>
            <li>Rygmarvsskade p&aring; dette niveau er ofte d&oslash;delig, fordi skaden sidder over afgangen af nerverne til diafragma. Er ustabil</li>
        </ul>
        </li>
        <li>Hangman fraktur (h&aelig;ngningsbrud)
        <ul>
            <li>Brud af buerne p&aring; C2 med dislokation af C2 i forhold til C3 </li>
            <li>Er ustabil</li>
        </ul>
        </li>
        <li>Fleksions/ekstensions- og/eller rotationsskade
        <ul>
            <li>Er den hyppigste skadesmekanisme </li>
            <li>C5/C6 er den hyppigste lokalisation
            <ul>
                <li>Skaden kan medf&oslash;re en subluksation eller luksation af C5 i forhold til C6</li>
            </ul>
            </li>
        </ul>
        </li>
        <li>Kompressionsskade
        <ul>
            <li>H&oslash;jden p&aring; en eller flere hvirvler kan v&aelig;re reduceret, evt. spr&aelig;ngt med skade p&aring; rygmarv og nerver&oslash;dder</li>
        </ul>
        </li>
        <li>Hyperekstensionsskade
        <ul>
            <li>Optr&aelig;der hyppigere blandt &aelig;ldre </li>
            <li>Brud i knogler ses sj&aelig;ldent ved denne skadesmekanisme </li>
            <li>Kan give anledning til central medull&aelig;r skade med uforholdsvis mere lammelse i arme i forhold til ben</li>
        </ul>
        </li>
        <li>Diskusruptur er hyppigst p&aring; de nedre cervicale niveauer, ofte kombineret med corpusfraktur og/eller fraktur/luksation i facetleddene
        <ul>
            <li>B&oslash;r opfattes som ustabil</li>
        </ul>
        </li>
    </ul>
    </li>
    <li>Skader p&aring; torakolumbal columna
    <ul>
        <li>Fleksions- og/eller rotationsskade er den hyppigste skadesmekanisme
        <ul>
            <li>Hyppigste lokalisering er Th12/L1 </li>
            <li>Der opst&aring;r en overrivning af de bagre ligamenter og en dislokation af Th12 forover p&aring; L1 </li>
            <li>Kompressionsbrud af corpus er ofte til stede samtidigt </li>
            <li>Er ustabil og kan give neurologiske udfald</li>
        </ul>
        </li>
        <li>Kompressionsfrakturer
        <ul>
            <li>Sammenklemning af &eacute;n eller flere hvirvler </li>
            <li>Ses hyppigst i den torakolumbale overgang og kan skade conus og cauda equina </li>
            <li>Skaderne er almindeligvis stabile, sj&aelig;ldnere forbundet med neurologisk skade </li>
            <li>Kan give perifere udfald med slappe pareser med oph&aelig;vede dybe reflekser, ridebuksean&aelig;stesi og sfinkterparese</li>
        </ul>
        </li>
    </ul>
    </li>
</ul>
<h3>Diagnostiske faldgruber</h3>
<p>Columna inddeles stabilitetsm&aelig;ssigt i tre s&oslash;jler: forreste, midterste og bagerste s&oslash;jle.</p>
<p><img alt="Tegning af columnainddeling." src="5963603E7F0B4A89A0D955EBA620F08A-240-188" style="height: 188px; width: 240px;" title="Tegning af columnainddeling." height="188" width="240"></p>
<ul>
    <li>Ustabile columnaskader
    <ul>
        <li>Brud som omfatter 2 eller 3 s&oslash;jler opfattes almindeligvis som ustabile </li>
        <li>Columnaskade kompliceret med skade af nervev&aelig;v
        <ul>
            <li>Fleksionsskader med reduktion af forreste corpuskant med 50 % eller mere </li>
            <li>Aksial kompression med &oslash;gning af pedikelafstanden og samtidig forsn&aelig;vring af spinalkanalen </li>
        </ul>
        </li>
    </ul>
    </li>
    <li>L&aelig;sioner i C1-C2
    <ul>
        <li>Medull&aelig;r kompression giver akut respirationsstop</li>
    </ul>
    </li>
</ul>
<h3>ICPC-2</h3>
<p>[ICPC]</p>
<h3>ICD-10/SKS-koder</h3>
<p>[ICD10]</p>
<h2>Differentialdiagnoser</h2>
<h3>
<a href="~/link.aspx?_id=F69469A4F6B44C6AAF4A998FFBE0CB82&amp;_z=z">Columnafraktur</a> </h3>
<ul>
    <li>Kompressions- eller hvirvelendepladebrud pga. pludselig aksial belastning
    <ul>
        <li>hyppigst ved halisterese </li>
        <li>Er ofte stabile frakturer</li>
    </ul>
    </li>
    <li>Brud p&aring; processus transversus hvor m. psoas har sit udspring
    <ul>
        <li>Skyldes som regel kraftige muskelkontraktioner eller direkte traumer </li>
        <li>Selv om de virker uskyldige, kan disse brud for&aring;rsage st&oslash;rre bl&oslash;dninger ind i det retroperitoneale rum og give akut an&aelig;mi og ileus</li>
    </ul>
    </li>
    <li>Brud p&aring; proc. spinosi
    <ul>
        <li>Som f&oslash;lge af direkte traume mod ryggen eller som et resultat af kraftig fleksion og rotation </li>
        <li>Giver almindeligvis ikke neurologiske udfald</li>
    </ul>
    </li>
    <li>Pars interartikularis fraktur som f&oslash;lge af hyperekstension
    <ul>
        <li>Akut traumatisk spondylolistese</li>
    </ul>
    </li>
</ul>
<h3>
<a href="~/link.aspx?_id=F7A70DADAF934F349F87E1560E8EAD20&amp;_z=z">Rygmarvsskade</a> </h3>
<ul>
    <li>Opst&aring;r som regel som komplikation til columnafraktur </li>
    <li>Komplet tv&aelig;rsnitsl&aelig;sion; alle op- og nedadstigende nervebaner forbi skadestedet er &oslash;delagt
    <ul>
        <li>Resultatet bliver paralyse, an&aelig;stesi og autonom dysfunktion distalt for skadestedet </li>
        <li>Tv&aelig;rsnitsl&aelig;sion ovenfor C3/C4 medf&oslash;rer respirationsstop</li>
    </ul>
    </li>
    <li>Inkomplet tv&aelig;rsnitsl&aelig;sion - enkelte op- eller nedadstigende nervefibre er intakte
    <ul>
        <li>Delvis intakt motorisk eller sensorisk funktion nedenfor skadestedet</li>
    </ul>
    </li>
    <li>Spinalt shock
    <ul>
        <li>Forbig&aring;ende slappe pareser distalt for skadestedet efter en st&oslash;rre spinal skade </li>
        <li>Tilstanden varer fra f&aring; dage til et par m&aring;neder </li>
        <li>Ses som regel ved tv&aelig;rsnitsl&aelig;sion</li>
    </ul>
    </li>
    <li>Spastisk parese
    <ul>
        <li>Udvikler sig efter ca. 2 uger, n&aring;r det spinale shock aftager </li>
        <li>Giver spasticitet og livlige til kloniske dybe reflekser samt ekstensive plantarreflekser</li>
    </ul>
    </li>
    <li>Brown-S&egrave;quard syndrom
    <ul>
        <li>Skyldes halvsidig medull&aelig;r skade, hvor de neurologiske udfald prim&aelig;rt skyldes l&aelig;sion af bagstrengen, corticospinale baner og spinothalamiske baner ensidigt </li>
        <li>Ipsilateral parese (pyramidebane) og tab af vibrationsans og proprioception (bagstrengsbanerne)&nbsp;distalt for skaden og kontralateralt tab af smerte- og temperatursans (sidestrengsbanerene) </li>
        <li>Skyldes ofte penetration af skarp genstand (fx kniv)</li>
    </ul>
    </li>
    <li>Anterior medull&aelig;r skade
    <ul>
        <li>Forreste 2/3 af medulla er skadet </li>
        <li>Skyldes som regel vaskul&aelig;r skade p&aring; a. spinalis anterior </li>
        <li>Giver bilaterale pareser (pyramidebane) og nedsat smerte- og temperatursans (sidestreng) </li>
        <li>Positions- og vibrationssans er intakt (bagstreng)</li>
    </ul>
    </li>
    <li>Central medull&aelig;r skade
    <ul>
        <li>Skyldes almindeligvis hyperekstenssionsskade i nakken </li>
        <li>Giver kraftneds&aelig;ttelse mest udtalt i overekstremiteterne og evt. i mindre grad i underekstremiteterne. Typisk er lammelsen mest udtalt i fingrene </li>
        <li>S&aelig;dvanligvis&nbsp;kun minimale til lette sensoriske udfald (smerte og temperatur)</li>
    </ul>
    </li>
    <li>Commotio medulla
    <ul>
        <li>Rygmarven er midlertidig sat ud af funktion som f&oslash;lge af acceleration/decellerationsskade (jfr. cerebral commotio) </li>
        <li>Funktionen genvindes s&aelig;dvanligvis i l&oslash;bet af de f&oslash;rste&nbsp;timer efter skaden</li>
    </ul>
    </li>
</ul>
<h2>Sygehistorie</h2>
<h3>Centrale elementer</h3>
<h4>Vurdering af sv&aelig;rhedsgrad</h4>
<ul>
    <li>Skademekanisme; fald, slag, stik, skud, osv. </li>
    <li>Opstod skaden ved aksialt, fleksions-, rotations- eller ekstensions-traume? </li>
    <li>Traumets st&oslash;rrelse, h&oslash;j- eller lavenergetisk? </li>
    <li>Andre kropsdele som er skadet? </li>
    <li>Tidspunktet for traumet? </li>
    <li>Eventuel alvorlig forgiftning eller selvp&aring;f&oslash;rt rus som kan g&oslash;re diagnostik og behandling vanskelig? </li>
    <li>Eventuel akut sygdom/skade som f&oslash;rte til ulykken</li>
</ul>
<h4>Ang&aring;ende patienten</h4>
<ul>
    <li>Symptomudvikling efter traumet? Har tilstanden &aelig;ndret sig? </li>
    <li>Er patienten ved bevidsthed? </li>
    <li>Har patienten st&aelig;rke smerter? Hvor? </li>
    <li>Synlige s&aring;r eller bl&oslash;dninger? </li>
    <li>Har patienten kendt sygdom? </li>
    <li>Indtag af rusmidler/medikamenter?</li>
</ul>
<h2>P&aring; skadestedet</h2>
<h3>Unders&oslash;gelser</h3>
<h4>Mistanke om brud</h4>
<ul>
    <li>Smerter i ryggen efter ad&aelig;kvat traume giver mistanke om brud i columna og skal behandles som dette, indtil tilstanden er afklaret</li>
    <li>Udvis den st&oslash;rste forsigtighed for at undg&aring;, at skaden forv&aelig;rres - udf&oslash;r korrekt l&oslash;ftning, lejring og stabilisering af columna</li>
    <li>Pr&aelig;hospitalt skal der ved oss&oslash;s palpations&oslash;mhed over columna og/eller neurologiske udfald lejres p&aring; vakuummadras (p&aring; hospital polstret backboard). Asymptomatiske (eller hvis oss&oslash;s palpations&oslash;mhed over rygs&oslash;jlen er eneste symptom) m&aring; forflytte sig selv. Ellers assisteret under hensyntagen til akseforholdene i ryggen</li>
    <li> Alvorlige columnaskader er specielt ustabile for fleksion
    <ul>
        <li> Undg&aring; eller indskr&aelig;nk man&oslash;vrer, som kan forandre akseforholdene p&aring; skadestedet i ryggen </li>
        <li>S&oslash;rg altid for bedst mulig stabilitet i forbindelse med l&oslash;ft og flytning af den skadede</li>
        <li> Stiv halskrave og spineboard skal alene anvendes efter n&oslash;je overvejelse, idet der ikke er dokumenteret gavnlig effekt, og der er mulige skadevirkninger</li>
        <li>For detaljer henvises i &oslash;vrigt til&nbsp;<a rel="noopener noreferrer" href="https://app.magicapp.org/app#/guideline/2840" target="_blank">NKR for spinal stabilisering af voksne traumepatienter i Danmark</a></li>
    </ul>
    </li>
</ul>
<h4>ABC: A (airway), B (breathing), C (circulation)</h4>
<ul>
    <li>Luftveje
    <ul>
        <li>Er luftvejene blokeret som f&oslash;lge af opkast, tilbagefald af tungen eller fremmedlegeme?</li>
    </ul>
    </li>
    <li>&Aring;ndedr&aelig;t - overv&aring;g og assister ved behov
    <ul>
        <li>Se, f&oslash;l og lyt om patienten har normal vejrtr&aelig;kning </li>
        <li>Dyspnoe, stridor, h&aelig;shed</li>
    </ul>
    </li>
    <li>Cirkulation
    <ul>
        <li>Vurd&eacute;r puls og BT (blodtryk i begge overekstremiteter) </li>
        <li>Cyanose</li>
    </ul>
    </li>
</ul>
<h4>Andre unders&oslash;gelser</h4>
<ul>
    <li>Enkel neurologisk unders&oslash;gelse
    <ul>
        <li>Pupiller
        <ul>
            <li>Vurder st&oslash;rrelse, symmetri og lysreaktion</li>
        </ul>
        </li>
        <li>Ekstremiteter
        <ul>
            <li>Kontroller stilling, bev&aelig;gelse, muskeltonus og smerterespons </li>
            <li>Str&aring;lende smerter, begyndende nedsat kraft, forstyrrelser af autonome nervefunktioner, hudtemperatur, sensibilitetsudfald?</li>
        </ul>
        </li>
        <li>Vurdering af bevidstheden (<a href="~/link.aspx?_id=BCA876249EC5496A870DCDBA17899CC5&amp;_z=z">Glascow Coma Scale)</a> </li>
        <li>Bl&aelig;reparese?&nbsp;</li>
    </ul>
    </li>
    <li>Led efter alvorlige skader i andre organer; thorax, abdomen, CNS, b&aelig;kken, ekstremiteter?
    <ul>
        <li>Alvorlige thoraxskader har altid h&oslash;jeste prioritet! </li>
        <li>Frakturer p&aring; columna er ofte multiple og kan samtidig findes s&aring;vel cervikalt som thorakalt og lumbalt</li>
    </ul>
    </li>
</ul>
<h3>Tiltag</h3>
<ul>
    <li>Rygs&oslash;jlen skal stabiliseres under unders&oslash;gelse og transport </li>
    <li>Sikre ventilation og cirkulation </li>
    <li>Ved bl&aelig;reparese b&oslash;r kateter anl&aelig;gges </li>
    <li>Patienten b&oslash;r v&aelig;re fastende </li>
    <li>Smertebehandling </li>
    <li>Monitorer blodtryk og oxygenm&aelig;tning </li>
    <li>Hurtig transport til sygehus ved mistanke om alvorlige skader </li>
</ul>
<h2>P&aring; sygehus</h2>
<h3>Unders&oslash;gelser</h3>
<h4>Neurologisk unders&oslash;gelse</h4>
<ul>
    <li>Efter at patienten er stabiliseret cirkulatorisk, udf&oslash;res en mere grundig neurologisk unders&oslash;gelse </li>
    <li>Mental status og hjernenerver </li>
    <li>Columna inspiceres og palperes
    <ul>
        <li>Se efter hudforandringer efter skade, sk&aelig;vheder i columna, palper for at lokalisere evt. skader</li>
    </ul>
    </li>
    <li>Kortl&aelig;g motorik og sensibilitet
    <ul>
        <li>F.eks. er senereflekserne lokaliseret til f&oslash;lgende niveau: Biceps (C5), brachioradialis (C6), triceps (C7), patellar (L4), achilles (S1) </li>
        <li>Maksimal kraft b&oslash;r ikke testes, fordi det kan forskyde en ustabil columna
        <ul>
            <li>God og hurtig bev&aelig;gelse i fingre og t&aelig;er er et lige s&aring; godt tegn som stor styrke i store muskelgrupper - tjek derfor tempo</li>
        </ul>
        </li>
    </ul>
    </li>
    <li>Sakralrodsfunktioner
    <ul>
        <li>Anal sfinktertonus, perianal sensibilitet, bulbocavernosus refleks </li>
        <li>Bevarede sakrale funktioner indikerer inkomplet rygmarvsskade </li>
        <li>Sakralreflekser, som genopst&aring;r, indikerer at spinalshocket er p&aring; retur</li>
    </ul>
    </li>
    <li>Vurder, om der er central eller perifer skade </li>
    <li>Hudtemperatur - svedgr&aelig;nse? </li>
    <li>Paralytisk ileus eller urinretention?</li>
</ul>
<h4>Billeddiagnostik<a href="%20" title="Paulson OB, Gjerris F, Sørensen PS, Juhler M. Klinisk neurologi og neurokirurgi. København: Foreningen af Danske Lægestuderendes Forlag, 1999; 1999" data-url="reference-link" data-value-piped="Paulson OB, Gjerris F, Sørensen PS, Juhler M|Klinisk neurologi og neurokirurgi|København|Foreningen af Danske Lægestuderendes Forlag, 1999|1999" data-type="book-reference" data-value="Paulson OB, Gjerris F, Sørensen PS, Juhler M. Klinisk neurologi og neurokirurgi. København: Foreningen af Danske Lægestuderendes Forlag, 1999; 1999">5</a></h4>
<ul>
    <li>R&oslash;ntgen
    <ul>
        <li>Almindelig r&oslash;ntgenunders&oslash;gelse anvendes ikke l&aelig;ngere </li>
        <li>CT, s&aring;kaldt traumescanning, er en helkropsunders&oslash;gelse med kontrast og 3-D rekonstruktion, er rutineunders&oslash;gelse ved alle landets traumecentre </li>
        <li>MR er meget anvendelig til diagnosticering af diskusruptur, bl&oslash;dninger i spinalkanalen, rodl&aelig;sion og l&aelig;sion af medulla samt l&aelig;sion af ligamenter og ledb&aring;nd&nbsp; </li>
        <li>EMG og urodynamiske studier anvendes ikke i den akutte fase</li>
    </ul>
    </li>
</ul>
<h4>Klassificeringer</h4>
<ul>
    <li>ASIA-funktionsvurdering - vurdering af grad af nedsat funktion og klinisk syndrom </li>
    <li>
    <a href="~/link.aspx?_id=3E73B97BBFC04D43AA893AB486D82770&amp;_z=z">ASIA-klassifikation</a> - standard neurologisk klassifikation af rygmarvsskade</li>
</ul>
<h4>Andre unders&oslash;gelser</h4>
<ul>
    <li>Monitorer cirkulation og ventilation
    <ul>
        <li>Hypotension kan opst&aring; ved rygmarvsskade (neurogent shock)
        <ul>
            <li>Ved hypotension skal muligheden for alvorlige abdominalbl&oslash;dninger, skader af aorta eller hjerte vurderes</li>
        </ul>
        </li>
        <li>Ved skader af dens axis kan der opst&aring; akut respirationsstop pga. l&aelig;sion af rygmarven over afgangen af nervus phrenicus (innerverer diafragma)</li>
    </ul>
    </li>
    <li>Vanlige blodpr&oslash;ver</li>
</ul>
<h3>Tiltag</h3>
<h4>I akutfasen p&aring; sygehuset</h4>
<ul>
    <li>Klassific&eacute;r patienten lige efter skaden og foretag j&aelig;vnlige nye vurderinger af status </li>
    <li>Kraniestr&aelig;k anvendes sj&aelig;ldent&nbsp;
    <ul>
        <li>Ustabile nakkeskader kan stabiliseres med kraniestr&aelig;k i nakkens l&aelig;ngderetning </li>
        <li>Gardner-Wells str&aelig;k er enkelt og kan skrues direkte ind i huden efter <a href="http://pro.medicin.dk/Laegemiddelgrupper/Grupper/225030">lokalan&aelig;stesi</a></li>
    </ul>
    </li>
    <li>Bradykardi og hypotension
    <ul>
        <li>Kr&aelig;ver n&oslash;je overv&aring;gning og volumenterapi</li>
    </ul>
    </li>
    <li>Smertestillende
    <ul>
        <li><a href="http://pro.medicin.dk/Laegemiddelgrupper/Grupper/315123">Opioidanalgetika</a></li>
    </ul>
    </li>
    <li>Methylprednisolon
    <ul>
        <li>Anses som virkningsl&oslash;s og har ikke l&aelig;ngere plads i behandling af rygmarvsskader</li>
    </ul>
    </li>
    <li>Ventrikelretention og paralytisk ileus
    <ul>
        <li>Behandles med faste og ventrikelsonde</li>
    </ul>
    </li>
    <li>Urinretention
    <ul>
        <li>Behandles initialt med permanent kateter og senere intermitterende kateterisering </li>
        <li>Antibiotikaprofylakse benyttes ofte</li>
    </ul>
    </li>
    <li>Dyb venetrombose forekommer hyppigt
    <ul>
        <li><a href="http://pro.medicin.dk/Laegemiddelgrupper/Grupper/62900">Tromboseprofylakse</a></li>
    </ul>
    </li>
    <li>Stressulcusprofylakse
    </li>
    <li>Ligges&aring;r kan let opst&aring;
    <ul>
        <li>Forebyggende tiltag med specielle liggeunderlag og beskyttelse af knoglefremspring</li>
    </ul>
    </li>
    <li>Vurd&eacute;r om videre behandling skal v&aelig;re konservativ eller operativ
    <ul>
        <li>Stabile skader behandles konservativt, mens ustabile oftest kr&aelig;ver operation </li>
    </ul>
    </li>
</ul>
<h4>Konservativ behandling</h4>
<ul>
    <li>De lette skader behandles kun med <a href="https://pro.medicin.dk/Laegemiddelgrupper/Grupper/226500">smertestillende medicin</a></li>
    <li>Sengeleje de f&oslash;rste dage hvis n&oslash;dvendigt, derefter optr&aelig;ning af ryg og abdominalmuskulatur, samt instruktion i "rigtig brug af ryg" </li>
    <li>Sygemelding efter individuel vurdering </li>
    <li>Hvis skaderne vurderes som mere alvorlige, og smerterne synes at v&aelig;re langvarige, kan det komme p&aring; tale at bruge halskrave og/eller korset </li>
    <li>I udvalgte tilf&aelig;lde kan Halo-vest anvendes ved skader p&aring; cervikaldelen, men metoden er n&aelig;sten helt erstattet af operativ stabilisering
    <ul>
        <li>Dette b&oslash;r kombineres med daglig tr&aelig;ning </li>
    </ul>
    </li>
    <li>Kontroller individualiseres </li>
</ul>
<h4>Operativ behandling</h4>
<ul>
    <li>Ustabile skader b&oslash;r oftest opereres </li>
    <li>Kontakt rygcenter som h&aring;ndterer columnafrakturer </li>
    <li>Metode
    <ul>
        <li>Den hyppigste m&aring;de at stabilisere columnafrakturer p&aring; er med transpedicul&aelig;r skruefiksation i segmenterne over og under frakturniveau </li>
        <li>Hvis der foreligger neurologiske symptomer eller v&aelig;sentlig forsn&aelig;vring af spinalkanalen, laves en bagre dekompression (laminectomi) </li>
        <li>I en del tilf&aelig;lde skal der ogs&aring; laves reponering eller fjernelse af knoglefragmenter, som er disloceret ind i spinalkanalen </li>
        <li>I cervikaldelen&nbsp;anvendes ofte&nbsp;anterior stabilisering evt. kombineret med posterior </li>
    </ul>
    </li>
</ul>
<h4>Videre behandling og tiltag</h4>
<ul>
    <li>&Oslash;vrig behandling og rehabilitering omtales n&oslash;je i dokumentet <a href="~/link.aspx?_id=F7A70DADAF934F349F87E1560E8EAD20&amp;_z=z">Rygmarvsskader</a></li>
</ul>
<h2>Illustrationer</h2>
<h3>Billeder</h3>
<ul>
    <li>
    <a href="~/link.aspx?_id=DB3EA36C44614B1E805FEB8B052CA73F&amp;_z=z">Cervikalcolumna, side, normal</a> </li>
    <li>
    <a href="~/link.aspx?_id=49C9BF3CC610447B992DFBB64738C594&amp;_z=z">Cervikalcolumna, front, normal</a> </li>
    <li>
    <a href="~/link.aspx?_id=AC5BCF6303794118ABD9C0878BED9E9A&amp;_z=z">Torakalcolumna, front, normal</a> </li>
    <li>
    <a href="~/link.aspx?_id=7F255A026B874B04BC43459D50AC15AB&amp;_z=z">Lumbalcolumna, side, normal</a> </li>
    <li>
    <a href="~/link.aspx?_id=7F6583DF875C42BB8E161B7252A6217F&amp;_z=z">Lumbosakralcolumna, side, normal</a> </li>
    <li><a href="~/link.aspx?_id=2D2D1046C2CF47B29034FED58ECCA693&amp;_z=z">Columnafraktur, side</a></li>
</ul>
<h3>Plancher eller tegninger</h3>
<ul>
    <li>
    <a href="~/link.aspx?_id=3E73B97BBFC04D43AA893AB486D82770&amp;_z=z">ASIA-klassifikation</a> - standard neurologisk klassifikation af rygmarvsskade </li>
    <li><a href="~/link.aspx?_id=8B9A9FC3676147678140DE932FBFC73E&amp;_z=z">Kolumnakompression</a> </li>
    <li>
    <a href="~/link.aspx?_id=E558DC9C307F4DD6A7E8A0E5AB009B69&amp;_z=z">Rygmarv, l&aelig;ngdesnit</a> </li>
    <li>
    <a href="~/link.aspx?_id=44EFCDBD78AF46F39D15C98A7981DB6C&amp;_z=z">Rygmarv, tv&aelig;rsnit</a> </li>
</ul>
<h2>Patientinformation</h2>
<h3>Hvad findes af skriftlig patientinformation</h3>
<ul>
    <li>
    <a href="~/link.aspx?_id=86B9F62962654579805C574A6901A4F5&amp;_z=z">Brud i ryggen</a> </li>
    <li>
    <a href="~/link.aspx?_id=31699134CD6341438675BCA7D906B9EE&amp;_z=z">Information om rygmarvsskade</a> </li>
    <li>
    <a href="~/link.aspx?_id=687BE6DF559340648E7BF622CB79B780&amp;_z=z">Akutbehandling af rygmarvsskade</a> </li>
    <li>
    <a href="~/link.aspx?_id=C390F4D3401748E3A20FBDC0ABAC0C16&amp;_z=z">Rehabilitering efter rygmarvsskade</a> </li>
    <li>
    <a href="~/link.aspx?_id=504DDB3114204433820CD8F0275FA5E5&amp;_z=z">Udskrivning fra sygehus efter rygmarvsskade</a> </li>
    <li>
    <a href="~/link.aspx?_id=759B0003F86545109F5AB6CB198E9FB2&amp;_z=z">Opf&oslash;lgning af rygmarvsskade</a></li>
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8CoAu7fjp4et/7anle9ijHmTWjtFMdvUgovP/fBzUfh/wCMXiPxP8VdLtLa7a20W7liRrEwxNtPljeA+3cRvDEHPQ9ulfRNfMLaXBo/7UEdnbIEi/tFJVVRgDzIxIQPbLGgD6K8ReILDwvoN1rGpSFLa3XJC8sxPAVR3JOBXhMPjP4rfEq5mm8LW/8AZ2lo5UNHsVR7GVxlm9dvr0rX/aV1CWLRtB05WIiuJ5ZnHqY1UD/0YawdA/aBt/D2gWGkWvhACG0hWIEahjcQOWI8rqTkn3NAE134i+MPw5KX+uj+0dLDASGTZKnPq6/MnsTxn1r23wf4s0/xp4dg1jTiQjkpLE33opB1U/mPqCDXiuoftGQanp1zYXXg0SW9zE0UinUc5Vhg/wDLL3p/7NN/KLvX9OLEwmOKcDsrAsp/MEfkKAJvG3xZ8R+E/i5qOnpc/aNItkUR2Pkx/M72wK5bbvx5jAnnpxVzQbb41P4h0u/1K6aOwu7hPtMTeURDETk5T+Hj05BxnFc34mtI779qaOCUAob6zcg9DthjbH6V9L0AeHeO/ij4mvPGr+DfAsAN3G5iknCKzvIBlgu75VVeQSfQ9Mc41/B8cvDNlJq82oSXEEKmSZFeKbao5JKEdP8Ad6Vn+N9H8U/DT4m3vjDSLZprK5nkuFuPLMkY8wkvHIB93kn04wQc9Ok0X9pCwuAIfEGhSwhhtaW0cSKc+qNggfiaAO2+FPxGPxA0W4N3BHBqdkyrcJFnY4bO11B5GcEEc4x714R8XP8AhO/7RtP+Ex/49fNuP7N/1H3Mru/1fPTy/vf419DeAZfAt5Zy3fgyHT0BAWfyItkq+gcEbvXGeD2rzD9pr/mVv+3v/wBo0AdR8Kf+Fmf2iv8Awlv/ACAv7P8A9E/49vv5TZ/q/m+5u6/jziqfxD+LupWfiE+E/Bdp9r1cN5cswj8zY/dEXoSO5PA54649MsLn7H4NtrrGfJ09JMeuIwf6V8p/D74jJ4J1vUdYutH/ALVvrxcCVrnyjHlizn7jZ3HHp096APQTpHx6WL7f/aDmX732fz4Cf++cbPwrovht8WL3WNbbwv4qthZa2pKRv5ZjErDko6n7r9xjg+xxnA/4aa/6lH/ypf8A2qvOvGPxEXxR4007xPaaT/Zd3aeWW23HmeYyNuVs7V57d+AKAPsIPzhhg0+kIBGCKbhk+7yPQ0AeM/En4pa9b+LU8G+DIFfUsqkk+wO3mMMhUB+UYBySc9+mM1g3Nh8dtHtH1Nr+WcRrveFJYZWAHX5MYP0GaqfEvQPEvgz4mP450S3klt3fzxMsfmCFiu10kA6AjPPAw2M5FbGh/tJwOVj1/Qnj/vTWMm4f98NjH/fRoA6/4R/E6Tx7Z3VpqUMUOq2YVnMXCTIeNwHYg8EdORjrgdZ4y8Xaf4K8OTaxqGXCkJFCpw00h6KPyJJ7AE1j+AbvwBqZnv8AwfBp8d0VxceXD5c6gnOGBG7BIHtkV5j+0tfSG78P6eGIiVJZ2HYsSqj8sH8zQBUsfE/xe+JM0t5oLfYNNRyqmLZFGD6b2+Zz6449hVXWPiD8UPh+8ml+IXt5prmBjbzS+W7oOm9Sh5wf7wPSvcbq+0n4afD+J7jEdpp1ssSRrgNK+OFHqzHJ/Ek968fXwXe+MfBXij4geKw3266spJ9OgyQIIoxvUgehC4HsSed1AHqfwlsvsnw50yT+1pdTa6U3DTPIWCM3VFzyApyD75PfFcTqfj3xNb/tBp4Xi1LboxuIENt5EZ4aFWI3bd3Uk9an/Zxv5Z/BmpWTsWS2vcx5PQMgJA/EE/jXKaz/AMnXx/8AX3bf+kyUAegfH7/kl8//AF9w/wAzVv4MH/i0Ogj/AK+P/SiSqnx+/wCSXz/9fcP8zVX4d3sul/s9xajFnfa2V9Oh91kmYfyoAyPGnxa1qfxK/hbwFafab9GMUl0IxId4+8EU8YHdm469uazH0r49WcX28X8ksg+YwCaBz/3yRtP0FcF8N/iRD8PpdQuDog1G7u9q+cbnyyijJK/cbOSQT9BXoI/aaPfwjn/uJf8A2qgDqvhf8WJfFN/J4e8Q2y2evQ7tuFKCbb94FTyrjBJHsemMV6tXyFfeO18RfFvSPFFnpn9mS/aLcSxrP5nmENgknavVcLjHavr2gAooooAKKKKAK8n3zU0f3BUDfeP1qwv3B9KBC0UUUDCiiigCGbqKdD0NMlPz1JEPk/GgB9FFFABRRRQBU1WwTVdJu9PkdkS5iaJmXqARjIrN8KeGIPCely2FvcSTpJMZi0gAIJVRjj/drdopcqvc1VeoqbpJ+69bBRRRTMiCUYf61JEcpj0pJhwDTYT8xHrQB8ueHrCHVP2jtT0+5XdBdX+qQyD1Vo5wf0NdX8A7+bQ/FHiLwbetiWN2kRTwPMjbY+PqNp+i1z3g3/k6G5/7Cupf+gzVreP/APig/j7pXiRf3dnfFJZmHQA/upR/3z831NAH0Fe3cOn2Fxe3L7ILeJpZG9FUZJ/IV8r+HrSbxFofxE8aXq5drd0jz0DyuGbH+6oA+jV7H8dPEH9jfDe4to3xPqci2q4POz7zn6bVx/wKufstBHh/9mS9jdQtxeWbXkvqTIQV/wDHAg/CgCt+zj/yL2t/9faf+gVN4t8e+JdJ+NmkeHrLUvK0q4uLNJYPIjbcruAw3FSwyD2NQ/s4/wDIv63/ANfSf+gVhePxj9pDw/n/AJ+9P/8ARi0Ae8+KvEtj4R8OXetagSYYF+VF+9I54VR7k/l17V4RY+J/i58S7ie88Pt9g02Nyq+UUjjU/wB3e3zOfXHHsM1t/tLX8sekeH9PUnyp55pmHqUVQP8A0Ya9X8FaZDo/gjRLGBAqRWcWcd2Kgs34sSfxoA+fPGPjHxtpvhXVPBvjmzZ5rxI3tLzC5OyVGPzL8rDCn3Bxnrx2vwuXWT8Crk+HhnVjLN9l+59/cP7/AMv51u/HzSoL74Y3N66AzWE8UsbdxucRkfQ7/wBBSfAH/kl8H/X3N/MUAeD3Y8dD4rKLn/kcvNj2/wCo+/5a7On7v7m3+vNfSnw/n8W2vhW8uPiBIsd7FcO4djCAtuEU5Ji+XAO/rz+leR6z/wAnXx/9fdt/6TJXpvxu1CXT/hXqYhYq1y0duWHZWcbvzAI/GgDgNS+Kfjfx5rs+l/DyyeKziODceWpdl/vMz/LGD2HX37CG7Hxy8KQNqc1y9/bRDfMgMc4Cjrlcbse6/nXPeAPjLb+A/DK6TD4YF1KZWlmuftvlmVieOPLOMKAOvaup/wCGmv8AqUf/ACpf/aqAPR/hp8R7T4gaRIxiW21O1wLm3ByOejp6qcfUHj0J5L4yeP8AX/BvibQ4dL1A29lNGZLmNYI3LgOAcFlJHGehFcB8I9eW5+OP2iytfsVtqv2kG1V9wjUq0u3OBkAoMcCtX9pT/kYdD/69H/8AQ6ALTan8Z/FcTeJ9FD2mmyEvaWaNECY88EK3L/U9ewxiun+J3xP1bweumeHdKSK68RXMCNPP5e4KT8o2J3ZmBwD0GODmvVLG1Wy0+2srdQsNvEsSewUAD+VeG/Gzwbr8Pimx8Z6DBNceQsZkMKb3gkjbKvt7r07HG0560AVzpHx5Nub86hL5mN/2fz4N3/fGNv4V0vwl+KuoeJdVn8NeI4Ej1WFGaOVU8syFTh1dezDrxjoeBjnm9D/aRnj2xeINCVyOGmspNp/74bv/AMCFeheC9c+HPijW5NU0K3sk11i0snmwBLkEjDEZ68E5Kk9eaAPOfjr/AMJ35+pef/yJvmweR/qPv7Fz0/eff3df5Yo+D/8AwszyNA+y/wDIm+a+f+Pb7m99/X959/d/Tiu4+P3/ACS+f/r7h/ma0Pgl/wAkh0L/ALeP/SiSgCt8UvipH4GSHTdOgS71u5XckbZKRKTgMwHJJPRR/wDr4OGw+O+tRDUDeSWgcbkgeSKE49NgHH/Aua5DW/GSaP8AHXVvEN9pw1L7DfSxRQNL5YBjzGhztbptz0612n/DTX/Uo/8AlS/+1UAWPDPxb8S+G/Esfhz4jWpiMhCreNGqNHngMdvyunbcOnPWveK+R/iV8UoPiJYWUJ8PiwuLSUstx9r80lCMFcbF6kKevavpP4e38up/DzQLudi0r2UYdj1YqNuT9cZoA6WiiigArL8RaJF4i0O40uaZ4Y5ipLoASNrBu/0rUopNXVmXTnKnNTi7Naoy/DuiReHdDt9LhmeaOEsQ7gAncxbt9a1KKKErKyCpOVSbnJ3b1YUUUUyAr5e8bSJF+07DJI6oiappzMzHAACQ5JNfUNfKXxM0xNa/aEuNKkkaNL28srZnUZKh4olJH0zQB9O/29o//QWsf/AhP8adHrWlSyLHHqdm7uQqqs6kknoAM147/wAM16P/ANDBff8AflKvaL+z7pWi67p+qx65eSPZXMdyqNEoDFGDAH64oA9irwLxT8YfEfiHxK/hz4eWxcqxQXSRiR5SOrLu+VU/2j9civWPiHfS6b8O9fuoWKyrZSKjDqpYbc/hnNeafs26TAnh7V9Y2KbmW6FrvI5CIitgfUv+g9KAMW9i+Ofhm1bVpryW6hiG+WNXin2r3ymM4/3elejfC34oQeP7OW2uoUtdYtVDSxIfkkTpvTPIGcAjnGRzzXolfNVhbp4V/agazsVEdvLdFTGvC7Zot+MegLjA9hQB2vx08beIvB39g/2BqH2P7V9o879zHJu2+Xt++pxjc3T1rnJtb+Lnjgz+I/DIksdGV2+x26tGrSKpxnDcueOc8Z4FP/aa/wCZW/7e/wD2jXtHhO0jsPB+i2kQASKxhQY9kHNAHmnxU8XeLvB3gnw3PBqSwatPhL6RbeNgz+WCQAykDnPTFc4niD4s/EGNtW8Ll7PSrcCOL5o4zcOo+Y/N94k9vujp1BrW/aU/5F7Q/wDr7f8A9Ar0j4cWkdl8NvDkUQAVtPhlOPV1Dn9WNAGXeeM7jwP8MrHV/FrmfWHhUNAiqjSzMCQmBwMDqQMcH2FeY2et/GX4hKdR0g/2dpjE+UU2QofozZd/r0+lQ/tHakzeLtE06UM9tBafaDGGxuLyFTz24jHNXYP2k4rW3jt4PBqxwxKERF1HAVQMAAeV0xQBC3jr4ofDW+tz4vtjqGlyvt3uEbPrtlTo3s3p0717xo+uafruhW+s2M4eyni81XPGB3B9CCCD7g188eK/jzB4r8L6holx4TCLdRFVkN/u8t+qtjyhnBAPUdK639nuZtT8AaxpNwzGFLllXnlVkQZA/EE/jQBhXXxI8f8AxF8RXWneBIvsthBz5ihA5TOAzu/3c9gMH64NV9U1r4yfDuNNT1e5F5p+8K5k2TR5PQMRhlz68fWufsbzxl8DfEV6jWCyWlwQjPLGTBcqpO1lcdDgnjPGeRXf2Xx78KeI7F9M8VaLNbQTgLKP+PiEgHPOAG6gHgGgDv8ARfFlz41+GdxrWgR+TqslpMkMOVPl3SqQoy3ykbtpGeMEZr5q8Q/8J3/wsqw/tr/kavNt/s3+o+/uHlfd/d9cdfxr6s8KL4b/ALDSXwqliumSsXBslCqWwASQP4uADnnivCviH/ycnoH/AF96f/6MWgD1f4bt45TTL9vHrBbhZAYCTAAI9vP+q46+teea78WfFni/xFLofw5s2MUZIN2I1Z5AON2X+VE9CeenI6V6T8WdQl0v4Wa/cwsVcwCHI7CR1jP6Ma8B+HPxbt/h9oc9hH4bF7PPMZZbn7Z5ZYYAVceWeBz37mgDq7i0+O3h+E6ibuS9RBukhR4pzjv8mMn/AIDzXofwu+J8Hj6zltrqFLXWbVd00KZ2yLnG9M84zwQemRzzXBf8NNf9Sj/5Uv8A7VXJeBfE66l8e7TWbKy+wQ6lcOslqsm8DehDc4Gct83SgD6tooooAKKKKAOXufBNrc+NIvErXcyzxlSIQo2nC7evWuooopKKWxrVr1Kqipu/KrL0CiiimZBRRRQAUUUUAFFFFABRRRQAUUUUAFFFFABRRRQBzPjPxcvhCytrhrI3XnyFNol2YwM56Gt6wuvt2nW13s2efEku3Odu4A4z+NQ6no2nazEkWo2cVykbblWQZwfWrcMUcEMcMShI41Coo6AAYAqUnd9jonKi6MYxj7+t337D6KKKo5wooooAKKKKACiiigAooooAKKKKACiiigAooooAK8v+P3/JL5/+vuH+Zr1CuX8f+D/+E58Lvov2/wCxbpUk87yfMxtPTbuH86AOX+AP/JL4P+vub+Yr02WaOCNpJpEjjUZLOwAH4mvAv+GZf+pu/wDKb/8Abaen7MyBwZPFrMvcLp+D+fmGgDl/jNrlr44+IWn6Z4fZb1oY1tVkhO5ZZWbopHUDIGfXNemfHCe80T4SW9layvtkngtLh14JjCMT+BKKPxxW54J+EnhzwTci+t1mvNRAIF1ckEpng7FAAXPryfeur1/QtP8AEuiXOkanD5tpcLtYA4IPUMD2IIBFAHlnwe8B+C9Q8D2WqzWFpqmoSlvtLXKiQROGPybDwMDHbJznpirXxi1zw74W8B32g2MVlBqGoIsSWttGqlU3AlmC9BgEDPUn645uT9nbU7K8dtH8WeTA/domRwPQlWwf0rqfDHwH8PaPHPLrE8ms3s8bRmSVdiJuBBKrk/Nz1JPqMUAYn7NTg6DrqfxC5jJ/FT/hXKeC7+H4VfGfU9M1hvs9hcb7cTNwqozB4pD7YAB9Nxz0r1n4a/DGX4d3Wosmu/b7e9VAYjaeWVZScHO89mI6enpVHxBp/wAPvi9etpsep51qyVwJYEZJUVWwwIdcMoJ6e/BGTQB6Bfa9pOm6U2qXmo20ViF3eeZBtYex7/Qda+X9B8QDxT+0JZ60issd1qIMQbqEC7Vz77QK7yy/ZqsIr1XvvElxcWwOTFFaiJiPTcWb+VcvpumadH+0xbafocCRWNncKiJGchfKgAfJ9dytknqc0Adv+0XoU9/4U07V4ULjTp2WXA+6kgA3fTcqj8a6j4T+NtP8VeD7C3W5QapZQJBc27Nh8qAocDuCADn1OK7m5toLy1ltrmJJoJUKSRuuVZSMEEdxXimu/s62kt+154b1qXTvm3LBMhcIf9lwQwH1yfegD1jxP4m0zwnok+qanOkccakpGWAaVuyKO5P/ANfpXP8Aw3+Ib/EKyvbtdGl0+G2dY97TCRZGIyQDtHQYz/vCvPbL9nW5ur1ZvEPiiS5jXqsMZLsPTe5OPyNe1aJomneHdIg0vS7Zbe0gGERefqSepJ7k0AfP+s/8nXx/9fdt/wCkyV9IV5ve/Cj7X8V18c/21s2yxyfYvsufuRqmN+/vtz93vXpFAHlGmfGUSfEm58K63psGlxRyyW6XDzlt0gPy5yAAGHT6iuq174beDNejkk1DQ7NHIJa4gHkuPcsuM/jmsj4g/CHR/HdwNQFw+n6oFCG4jQOsgHTeuRkjpkEHHrgY4Ff2ededRaTeMF+xDjYI3YAf7hYD9aAML4UwJpnx3lsdAu3utJQ3MbTZyJIQp2kkcEbwnPfr3roP2mgceFzjj/S//aNen+A/hxovgG0lWw8ye8nAE93NjewH8IA4Vc9vzJwKb8Rvh7afEHRobSW6a0urZzJb3ATeFyMEFcjIOB3HQfSgDc0eOK+8IWERIeGewjUlT1VowP5Gvnf4S67H8OPiHq3h/wAQSC1iuD9neV+FSVGOxieykM3PTkHpzXo/w3+FOs+CPEH2+68QJd2ot3gW2RXx8xByMnA5Udq3PHvwq0Px4VuZ2ey1NF2rdwgEsOwdT94D8D70Adyro8YkVlZCMhgcgj1zXmOrfGjT7XxzB4Y0jTW1iSSRIWuLe4AUSscFR8pBA4yc8c+lcZ/wzxrqIbRPF6CyJ+55TgEf7m7H616H4B+EmieBZjfJJJf6oVKi6mUKEB67FGdufXJPvQB6BRRRQB5PP8YhYfE+TwprWmQ6fZpOYftrzk8EZjcjAADZX6Z68V1ut/D3wl4hVpNQ0OylZxkzxL5Uh996YJ/Gs74g/CvR/H3l3M0r2WpRLsS7iUNuXsrqcbgMnHIPvXnK/s868E+yf8JggsjwUEcmMf7m7H60Ac34NsrfRP2hINP8MXkl1p8dw8fmbt26LyyXBI4IByM99oNdd+0lok8tno2txIWigZ7acgfd3YKH6cMPxFd/4C+Fui+A45JbZ5LvUZV2SXcoAIX+6qj7o/Mn1pnxQ8OeI/FWg22i6LPbxWlzcKNQeQ4cRAgjaO4BGSOpwB60Aed+H3vfjh4ns7nU4zD4a0SOMyWxb/j4uCozn1BIP0UY4LGuz+M/jDT/AA74GvdISaP+0dQh+zxWyEZWNuGYjsu3IHuR71y2o/s8iG78/wAN+Jbiy4wY7hSWHrh0I49sfjVnw7+zxZW2oLfeJNXk1Mhtxt40KK5/22JLMPYY+tAGt+z9oc2l/D9724Qo2o3LTRgjB8sAKp/Ehj9CK4bWf+Tr4/8Ar7tv/SZK+jYoo4IUhhjWOKNQqIgwFA4AA7CvnLWDn9q6PHP+l23T/r3SgD0D4/f8kvn/AOvuH+Zp/wAK9OXV/gJZaYzBVvLa8tyT2Dyyr/Wul8f+D/8AhOfC76L9v+xbpUk87yfMxtPTbuH86seCfDH/AAh3hCx0D7Z9s+y+Z+/8ry926Rn+7k4xux17UAeEfBLxNb+D/E2reGfEDCyNzIEVpjtWOdCVKk9s569MqPWvpFkRUL7wEAyWJ4x65rgvHvwg0PxxcG/8x9P1QgKbmFQwkA6b043Y9QQffpXn4/Z411kFo/i9PsIP3PKcgD/c3Y/WgDrv+FxWV18QIfC2j6Y+prJKsP22GcbM/wAZA28qoySc84OPf0wEjocVyHgL4W6J4CDz2zSXepSLse8mABC/3VUfdH5n3rtyoPUUARxuzHBqWmqgXOKdQAUUUh6GgCsetWh0qrT/ADW9aYieiofOb0FL53+zSGS0E4Gai84f3aY0hbjoKAEJ3MT61YUYUCoo0ycnoKmoAKKKKACiioXdgxANAEGr6gNJ0a81AxeaLaFpdm7G7aM4z2rL8HeKB4t0iW/W0NqI5zDsMm/OFU5zgf3v0ralgivbOS3uY1lhlUpIjdGB6g1FpulWGj2zW+nWsdtCzlykYwC2AM/kB+VS0+byOiM6PsHFx9++j8i5RRRVHONcZQ1ApwwNWarFTuIANAHzP4OYD9p+5bt/aupf+gzV6F+0Dov9qeBotUjTMumThye/lvhW/XYfwq3o3webSvibJ4y/tvzN91cXP2T7Jtx5ocY37z039cc47V6DrOiwa3od9pdy37q7geFiBnbuGMj3HX8KAPl/UdduPijrHgfw/udvIgS3uT337sSP/wB8Rq3517z8TY1j+FuvRxqFRLMqqgcAAjisP4f/AAUg8D+JhrUus/2i6QvHFH9k8rYzYBbO9s8bhj3rvvFWhf8ACTeF9Q0X7T9m+2RGPztm/Zz125GfzoA8m/ZsQNoGtk9rpP8A0CsD4h/8nJ6B/wBfen/+jFr1j4a/Dz/hXmnX1p/an9ofapVk3fZ/K24GMY3Nms/xD8KP7e+JVh4w/tryPsktvJ9k+y7t/lMGxv3jGcenHvQBhftF6FNf+EtP1eFC/wDZ1wwlwPuxyADd/wB9Kg/Guu+Ffi2x8U+CNOEU6G+s4Et7uHd86so27iPRsZB98dQa7G6tYL60mtbqFJreZCkkcgyrqRggj0rxHWP2dwmptd+GfEElgjEkQzKxMeeyupBI9iM+5oA0P2gfFdlZ+Ef+EbjnR7++lRpIlOTHEp3Zb0ywXHrz6VqfAH/kl8H/AF9zfzFY9l+z3Yx+HtSt7vWXn1i9VFF80G5YAJFc7ULZJO3BYt0P1z6B4A8H/wDCDeF00X7f9t2yvJ53k+Xncem3cf50AeLa4yx/tWxM5Cg3dqATxkm3QD9eK9b+LehT+IfhrqtpaoZLmJVuIkAyWKMGIA7kqGA96wPiR8GYvGutLrVhqYsL8oqSh496SbeFbIIKkDjv0HSug+G/g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