Having reduced bone density means your bones don’t have as much mineral content as they should. Medical Therapy: Many patients recover very well with medical therapy that consists of: Reduced activity and progressive ambulation; Non-steroidal medications to manage pain (although these medications do nothing to heal the fracture. Deformity. " Pain can be disabling, and take weeks to months to go away. Humerus (upper arm). The treatment of thoracolumbar fractures can be either conservative or surgical. It can progress to osteoporosis. Injection. They’re usually caused by landing on your bone at an angle after a fall, or when your bone is hit suddenly from an angle (like in a car accident). doctors in 147 specialties are here to answer your questions or offer you advice, prescriptions, and more. Step It Up. L3 spinal nerves affect sensation at the front portion of the lower thighs and knees, as well as the ability to straighten the knees (knee extension) and rotate the hip outward (external rotation). You can feel the spinous process, a projection from this arch, when Aug 21, 2022 · 1. Generally, bones break as a result of force and/or trauma like a car crash. Methods. Treatment is usually observation and pain management. (See also Overview of Fractures. Conditions affecting the L5-S1 spinal motion segment are usually treated with nonsurgical methods. Women over the age of 50 are the most likely to experience osteoporosis and compression fractures. The patient subsequently underwent a posterior arthrodesis with iliac crest bone graft and transpedicular screw placement. In addition to spinal compression fractures, his specialties include scoliosis, spinal tumors, trauma, degenerative disease, radiculopathy, herniated discs, and spinal stenosis. In general, a Dr. In more than two-thirds of these cases, the thoracolumbar junction, i. Dr. the thoracic vertebral bodies T11/T12 or the lumbar vertebral bodies L1/L2 are affected (). This injury can take anywhere from 2-6 weeks to fully heal, and it generally heals fully without the need for surgery. Vertebroplasty is typically used to treat compression fractures, which can cause your vertebrae to collapse. each year. 1 Risk factors for these fractures are well established and include, elderly females, osteoporosis, and corticosteroid therapy. This is the most common type of compression fracture. In a multicenter study, the incidence of neurological deficit ranged from 22% to 51% depending on the fracture type (22% in type A, 28% in type B and 51% in type C fractures, according to the AO classification). , 2 Riggs, B. In recent years, the use of percutaneous vertebroplasty for the treatment of vertebral fractures has become very common. Apr 25, 2024 · Osteoporotic Vertebral Compression Fractures are very common fragility fractures of the spine that affect up to 50% of people over 80 years old. Postmenopausal women and patients taking long-term corticosteroid therapy are most Dec 7, 2021 · Oblique fractures occur when your bone is broken at an angle. Osteoporotic fracture is an important risk factor for subsequent fracture. Oct 15, 2015 · However, there are few reports on using intraoperative, full rotation, three dimensional image (O-arm)-based navigation, transpedicular wedge osteotomy for the correction of kyphotic deformity in old thoracolumbar fracture. But you also want to lower your odds of getting more broken In 1963, Holdsworth described burst fractures. Spinal compression fractures that occur as a result of osteoporosis are actually quite common, occurring in approximately 700,000 people in the U. Clavicle (collarbone). The most common cause of these fractures is the thinning and weakening of bones (osteoporosis) or a spinal injury. 8. Ligamentum taxis then was applied by distracting the pedicle screws. May 21, 2021 · How serious is a fractured L1? Lumbar (L1-L5) Spinal Cord Injuries. Luiz Vialle. Most are isolated fractures of the anterior spinal column related to low bone mineral density. 4 The incidence of burst fractures is maximum at the thoracolumbar junction and occurs frequently in high-energy traumas which are most commonly associated with falls and traffic accidents. Each vertebral body is separated from the other with a disc. Spiral fractures happen when a fracture winds around the Spinal Fractures are Common. Mar 26, 2019 · Vertebral Compression Fracture Treatment. The scapula (shoulder blade) is a bone, shaped somewhat like a triangle, that is protected by a complex system of surrounding muscles. This can make them weaker and increase your risk of bone fractures (broken bones). The condition is sometimes also called by the shortened names, “pars defect” or "pars fracture. Type 2 Spinal Fracture – The chip fracture is displaced to the point where it causes lesions on neighboring tissues. 1,2,9,10. ) Prescription medications for pain (opioids) Bracing to stabilize the spine and reduce pain Oct 29, 2022 · Therefore, our study was performed, and trying to clarify the relationship between new fractures after PKP treatment and L1-HU value, we established the age-, sex-, first fracture vertebrae-, surgical segment-, and comorbidity-matched control group and found out that the patients in the study group had much lower L1-HU value than the control group. Apr 6, 2024 · They often occur at the midthoracic (T7-T8) spine and the thoracolumbar junction (T12-L1). Osteoporosis is the most common cause of compression fractures. ”. L. Methods: The established L1 fracture was fixed with 10 different depths of screw insertion: 10-100% screw-path length (SPL). In the burst fracture with no neurological deficient and without any injury to posterior longitudinal ligament conservative treatment should be the first choice. It is situated in between the thoracic and the sacral part of the spine and is characterised by lordosis. Diagnosis is confirmed using plain radiographs, while computed tomography and Mar 30, 2018 · The goals of treatment in thoracolumbar fractures is to achieve a painless, stable spine with normal neurology and maximum mobility, which is well balanced in the sagittal plane in order to have an ergonomic stance. The bones of the spine have two main sections. Materials and Methods: Patients (231) with isolated L1 fractures were included and Overview. Jun 9, 2022 · They often occur at the midthoracic (T7-T8) spine and the thoracolumbar junction (T12-L1). Individuals with a lumbar spinal cord injury at this level will therefore have more hip and knee movement, but may lack Aug 2, 2023 · They often occur at the midthoracic (T7-T8) spine and the thoracolumbar junction (T12-L1). Treatment for a fracture of the thoracic or lumbar spine will depend on: Other injuries and their treatment; The particular fracture pattern; Whether there is neurological injury; Once the trauma team has stabilized all other life-threatening injuries, the doctor will evaluate the spinal fracture pattern and decide whether spine surgery is needed. S. A compression fracture is a type of fracture or break in your vertebrae (the bones that make up your spine). Posterior intermediate screw fixation techniques in treating T12 vertebral fracture models were simulated and compared using Nov 30, 2021 · Patients with ankylosing spondylitis (AS) are especially prone to sustaining spinal fractures. A stable burst fracture may be treated without surgery. 2 The prevalence of this condition increases with age, reaching 40% by age 80. Diagnosis can be made with lateral radiographs. Regular follow-up visits during this time allow your doctor to evaluate the fractured Symptoms. Vertebroplasty is used most often to treat a type of injury called a compression fracture. You might need surgery to repair your bone. 1 Other etiologies of VCF include infections and neoplasms. If a vertebra is crushed in all directions, the condition is called a burst fracture. J. Loading on the T12 endplate was simulated. Options include: Slowly marching your feet. Some people only need a splint or cast for the bone to heal. Or you may not be able to control when you pass a stool. 1. is important to the prognosis. These injuries are usually caused by osteoporosis, a condition that weakens bone. The main symptoms of multiple compression fractures include height loss, kyphosis, and a bulging stomach. The Screws inserted to 60% depth or more can achieve effective strength to withstand the postoperative height correction loss of the L1 vertebrae fracture, however, continuous prolonged depth of screw insertion did not significantly increase the effective strength of the screw against injured vertebrates and maximum equivalent stress of screws. The classification system described here exists in order to provide surgeons from different institutions with a common language to discuss various injuries. For example, you may have a difficult time passing stools. Usually the trauma necessary to break the bones of the spine is quite substantial. Alex Vaccaro, Frank Kandziora, Michael Fehlings, Rajasekaran Shanmughanathan. Sacral insufficiency fractures after lumbosacral fusion are a rare complication after surgery and can be misdiagnosed and underreported due to inconclusivity of plain radiographs. Trouble bending or twisting your body. During the healing process, spinal bones The effect of the extent and location of fixation on short- or long-segment pedicle screw fixation through intermediate screw fixation at the fracture level in the treatment of thoracolumbar burst fractures is discussed. Fractures can also be caused by less traumatic but repeated force. Other causes include injuries to the spine and tumors. Thoracolumbar Burst Fractures are a common high-energy traumatic vertebral fractures caused by flexion of the spine that leads to a compression force through the anterior and middle column of the vertebrae leading to retropulsion of bone into the spinal canal and compression of the neural elements. Mar 19, 2024 · Osteopenia is a loss of bone density. Raising one or both arms overhead. Diagnosis is made with radiographs of Dec 12, 2022 · Vertebroplasty is a procedure that involves injecting cement into vertebrae, the bones that make up your spine. This can cause severe back pain. 2 VCFs mostly affect the thoracolumbar spine (most common at T12–L2) due to mechanical forces related to the transition from the relatively A spinal vertebral compression fracture causes low back pain and weakness. Treatment for pedicle fractures varies and may include bracing, rest, pain medications, and surgery. Preventing and treating osteoporosis is the best way to decrease your risk for compression fractures. 1 "Advances in Osteoporosis Prevention, Diagnosis and Treatment Presented at 7th," National Osteoporosis Foundation, Accessed April 10, 2013. Transverse fractures are almost always caused by traumas like falls or car accidents. Radius and ulna (forearm). A 45-year-old woman with L1 old fracture, presented to us with a Cobb angle of 45 degrees. Many spine compression fractures heal in two or three months. A retropulsed fragment is any vertebral fracture fragment that is displaced into the spinal canal, thereby potentially causing spinal cord injury. A vertebral compression fracture occurs when the block-like part of an individual bone of the spine (vertebra) become compressed due to trauma. It implies that the vertebral body has suffered a crush or wedging injury. The goals of vertebroplasty are to reduce pain while also stabilizing and strengthening the fractured vertebra. Stable spinal fractures involve the Dec 28, 2022 · A compression fracture is a bone break to the spine’s vertebrae. Chiropractic manipulation. 13 It is important to image the entire 90,000 U. He manually realigns the bone or applies a traction device. " The spinal cord is protected by rings of bone that make up the middle and posterior (rear) portion Feb 27, 2024 · infection rates of open fracture depend on zone of injury, periosteal stripping and delay in treatment. Normal treatment routines involve rest and pain medications, and a back brace is sometimes used to stabilize Jan 23, 2023 · According to this study, an operative treatment with SI in a patient with thoracolumbar burst fracture whose McCormack score is <7 would result in a stable fixation with a good spinal range of motion and low correction loss and failure rates. Lumbar spine fractures, as the name suggests, are always located in the lumbar spine. Jul 1, 2016 · Vertebral compression fractures (VCFs) are the most common complication of osteoporosis, affecting more than 700,000 Americans annually. Osteoporotic spinal compression fractures are associated with significant performance impairments in physical, functional, and psychosocial domains. Apr 1, 2023 · Background and Objectives: The adequate therapy of thoracolumbar fractures in the elderly population is still controversially discussed. Both surgical and nonsurgical options are available to treat this painful injury. Spinal bones are called vertebrae. Spinal fractures can be stable or unstable. The bones spread out in all directions and may damage the spinal cord. There are three main treatment options: n Conservative management. Sliding your heel along the ground to straighten and bend one leg at a time. The patient underwent a left L1 laminotomy for nerve root compression with placement of pedicle screws above and below the fracture (T12 and L2). , Melton L. Spine service consultation is common for further evaluation and management. If you have osteopenia, your bone density is lower than average. The AOSpine thoracolumbar fracture Treatment Options. 6% of men older than 65 years. Is kyphoplasty a major surgery? A burst fracture is a type of traumatic spinal injury in which a vertebra breaks from a high-energy axial load (e. (See Presentation . We Mar 25, 2017 · Fractures of the thoracolumbar junction can produce a mixture of cord and root syndromes caused by lesions of the spinal cord, conus medullaris, or thoracic and lumbar nerve roots. Doctors diagnose spinal compression fractures using x-rays or computed tomography. Nov 30, 2023 · Kyphoplasty treats vertebral compression fractures. Mar 4, 2016 · Burst Fractures: Treatment and Recovery. For any fracture that causes spinal cord compression, spinal fracture symptoms can also include muscle spasms, numbness, weakness, tingling sensation, and paralysis. The process of passing a stool through and out of your body is known as a “bowel movement. There are several studies that demonstrate no difference in clinical outcome with or without spine service intervention. What is the recovery time for compression fracture of L1? Aug 22, 2023 · A vertebral wedge fracture is when one side of your vertebra collapses, usually the front side. Keywords: Thoracolumbar spine, Compression fracture, Burst fracture, Neurological deficit A compression fracture is a condition in which a vertebra is crushed only in the front part of the spine, causing a wedge shape. Our experts offer nonsurgical care to help you build bone strength, maintain stability in the spine, and walk without pain. You may also hear this called a vertebral or compression fracture. Endplate and IVD injuries are usually found in association with vertebral fractures (VFs); however, little is known about their relevance to the healing of osteoporotic VFs May 27, 2023 · In the short term, treatments like pain medicines, physical therapy, and bracing might help ease your pain and get you moving again. In certain circumstances, such as in elderly Nov 17, 2015 · Compression-type vertebral fractures with kyphosis less than 30 are stable and good candidate for conservative treatment. Several studies have documented the effectiveness of vertebroplasty in alleviating the pain associated with acute or subacute compression fractures. The vertebral body is the block of bone that makes up the spinal column. 1 Approximately 25% of all postmenopausal women in the US get a compression fracture during their lifetime. Although it is less than two centimeters from the main 2. 5 million VCFs annually in the general US population. Conservative treatment is recommended for stable fractures without neurological compromise and less than 35° of kyphosis. He places a cast or brace to prevent movement of the fracture while it heals. This means allowing the bone to heal naturally and therefore without a specific brace or the need for The provider treats a fracture or dislocation of the vertebral body, the main part of a vertebra, one of the interlocking bones of the spine, in a closed procedure. Feb 28, 2023 · The leading cause of osteoporosis is lack of hormones. Preliminary remarks. When an external force is applied to the spine, such as from a fall or carrying Symptoms. Vertebral compression fractures (VCFs) of the thoracolumbar spine are common in the elderly, with approximately 1. Nov 7, 2021 · SUMMARY. 3 Symptoms are often Even though it’s classified as a fracture, a transverse process spinal fracture is more similar to a muscle sprain. Feb 27, 2024 · infection rates of open fracture depend on zone of injury, periosteal stripping and delay in treatment. Burst fractures are much more severe than compression fractures. 1–3 Although benign osteoporosis is the most common cause of compression fractures, multiple myeloma is another common Introduction. Jun 30, 2011 · Treatment options range from external orthoses to traction, halo vest placement, or surgical management. Nov 12, 2023 · A compression fracture of the L1, or the first lumbar vertebra, can be treated in various ways depending on the severity and underlying cause. Bringing one knee to your chest at a time. Long-term radiological and clinical outcome retrospective study of surgical treatment for T12 and L1 burst fractures in perspective of sagittal balance measures. A corpectomy was performed, with a vertebral reconstruction with Harms cages and a screw to stabilize the cage. Key Highlights. Additional reduction of the fracture was carried out with a bone tamp. Clinically Relevant Anatomy. Dec 19, 2019 · Selected Treatment. Estrogen for women and androgen for men. Diagnosis of bony Chance fractures is made with radiographs or a CT scan. This is called “constipation. , traffic collisions or falls from a great height or high speed, and some kinds of seizures), with shards of vertebra penetrating surrounding tissues and sometimes the spinal canal. Oct 29, 2022 · Therefore, our study was performed, and trying to clarify the relationship between new fractures after PKP treatment and L1-HU value, we established the age-, sex-, first fracture vertebrae-, surgical segment-, and comorbidity-matched control group and found out that the patients in the study group had much lower L1-HU value than the control group. Lack of movement. First, the study design was a descriptive study. Rest and immobilization can help the bone heal without the need for surgery. mutlidisciplinary training of open fracture management has been associated with decreased timing to antibiotic administration. Here is a listing of the common types that may happen: Greenstick. If the lower back and/or leg symptoms worsen or do not improve despite these treatments, or in case of certain medical emergencies, such as tumors or cauda equina syndrome, surgery may be recommended. May 14, 2020 · Vertebral compression fractures (VCFs) are predominantly due to osteoporosis, which afflicts 25% of women and 5. Treatment of A1 Wedge-compression fractures. Stable fracture patterns are amenable to a more conservative approach, such as mobilization in a cervical collar or a clamshell thoracolumbosacral orthosis (TLSO) [8, 9, 27]. However, no study to our knowledge provides an additional cost analysis. The pain is most commonly felt in the middle or lower spine. 5 The treatment of thoracolumbar and lumbar burst fractures has remained controversial due to many different May 16, 2022 · L3 Spinal Cord Injury. n Surgery. Fractures may result in significant back pain, limited physical functioning and activities of daily living, and can lead to loss of independence, depression, and chronic pain. The pain is often sharp and "knife-like. In most people, compression fractures due to osteoporosis do not cause any symptoms, but when pain occurs, walking, standing, or sitting for a long time worsens the pain. Compression fractures can occur suddenly. The condition weakens a person’s bones to the extent that they Type 1 Spinal Fracture – The fragmented chip is only minimally displaced from the main bone. ) Skin overlying the fracture should be inspected for abrasions or contusions. The fracture is a straight line that’s angled across the width of your bone. Dec 1, 2023 · A pedicle fracture is a type of spinal fracture that involves a break or fracture in one or more of the vertebral pedicles. High-energy, blunt trauma injuries, such as those experienced in a motor vehicle collision or after falling from a significant height, can cause a scapula fracture. A burst fracture is an injury in which the vertebra, the primary bone of the spine, breaks in multiple directions. He subsequently presented with a newly diagnosed acute chalkstick fracture of L1 which was treated without surgery. Again, it is imperative to be mindful of any preexisting kyphosis May 5, 2022 · Tibia (shin). AO Spine thoracolumbar injury classification system. This procedure can also treat pathologic fractures (a broken bone caused by an underlying condition) related to spinal tumors or multiple myeloma. n A spinal brace. The majority of mild to moderate compression fractures are treated with immobilization in a brace or corset for a period of six to twelve weeks. Jul 19, 2019 · Background The endplate-intervertebral disc (IVD) complex is closely interrelated with the vertebral body (VB) in the structural integrity of the anterior spinal column, including biomechanical and biological functions. They usually arise from the vertebral body with or without a portion of the pedicle, and are displaced posteriorly, hence the prefix 'retro'. Vertebral compression fractures typically present with abrupt-onset low back pain with or without a history of trauma, although more than two-thirds are detected incidentally. Pain that gets worse when you stand or walk. treatment and prognosis of a non paralyzing burst fracture of l1 and t11?: Vertebral Fractures: If you have a burst fx of T11 and L1 then i woul. May 17, 2023 · If there are no neurologic malfunctions, the best way to treat a stable L1 burst fracture is by wearing an orthopedic brace to support your spine. The injury may also appear crooked and out of place. A compression fracture is usually defined as a vertebral bone in the spine that has decreased at least 15 percent to 20 percent in height due to fracture. Patients with age of 16-60 years, complete radiographs, early surgical treatment surgery, and follow-up (F/U) > 18 months were included and strict exclusion criteria applied. Gumley et al. Typically, individuals suffering from a stable T12 burst fracture have to Jan 10, 2024 · Chance Fractures are traumatic fractures of the thoracic and lumbar spine that occur by a flexion-distraction injury mechanism and are associated with high rates of mechanical instability and gastrointestinal injuries. Wearing such back braces can help prevent your spine from going out more and can help get it on the right track to recovery. Pedicles are small, triangular-shaped bone protrusions that help form the vertebral arch and stabilize the spine. A curved L5-S1 Treatment. Compression fractures can often be treated . The bone is broken, but the skin is intact. Injuries to the thoracolumbar spine are usually the result of high-energy blunt trauma. In the early stages, when symptoms may not be present, treatment options may include conservative measures such as medication, rest, wearing a back brace, or engaging in physical therapy. Loss of height. Jun 18, 2024 · Bruising. ) Vertebral compression fractures due to osteoporosis are common in the thoracic spine (usually below T6) and lumbar spine, particularly near the T12-L1 junction Aug 23, 2020 · The most common symptom of any spinal fracture is pain, which typically gets worse with movement. It provides consistency in injury diagnosis and treatment. Conservative treatment The majority of vertebral fractures are treated conservatively. A 72-year-old male with AS had a previous T10/11 chalkstick fracture requiring a T8-L1 fusion 1 year ago. Fibula (calf). A spinal fracture takes between six and 12 weeks to heal. incidence of fracture-related infection range from <1% in type I open fractures to 30% in type III fractures. Injuries to the lumbar spine are severe but not life-threatening. 3rd, "The worldwide problem of Compression fractures typically occur in the thoracic region of the spine, which includes the T1 through T12 vertebrae, but may also occur in the lumbar spine, or L1 through L5. Oct 19, 2018 · Every year, an estimated 8000 severe fractures of the thoracic and the lumbar spine occur in Germany (). Chiropractic adjustment of the lumbar spine may help relieve pain stemming from the L3-L4 motion segment. It can also be felt on the sides or in the front of the spine. e. Fracture risk increases with age, with four in 10 white Physical therapy is usually performed under the guidance of a physical therapist and may include exercises, stretches, manual therapy, massage, and/or other treatments. An MRI may be required to identify a ligamentous Nov 2, 2022 · But over time, symptoms of a spinal fracture may include: Sudden, severe back pain. Michael Virk is a widely published neurosurgeon with specialty training in minimally invasive and complex surgery for a wide variety of spine conditions. Sep 29, 2021 · A compound fracture is a break or crack in your bone that is visible through your skin. Closed fracture (also called simple fracture). Lower lumbar fractures may cause solitary or multiple root deficits. Fractures have a variety of names. 3 Population studies have Jul 5, 2023 · Transverse process fractures (TPF) of the thoracic and lumbar spine have become increasingly identified due to CT imaging. Open fracture (also called compound fracture): The bone pokes through the skin and can be seen, or a deep wound exposes the bone through the skin. Early treatment is important to the prognosis. Challenge your core strength further by adding arm and leg movements to your basic pelvic tilt. Mar 25, 2017 · A 37-year-old man who underwent an anterior approach for an unstable L1 burst fracture. There are three types of compression fractures: Wedge fracture — This fracture usually occurs in the front of the vertebra, collapsing the bone in the front of the spine and Most vertebral compression fractures are a consequence of osteoporosis, are asymptomatic or minimally symptomatic, and occur with no or minimal trauma. If you have a spinal cord injury, this process may be tough for you. Generally, there is pain around the injury, and you may be unable to move the affected area. As women begin to enter menopause they also type of fracture you have and the options for treating it. g. The lumbar spine is the part of the spine located in the lower back and is a common painful area in physiotherapy. Nonetheless, there were some limitations to this study. The goals of kyphoplasty are to reduce pain from the fracture, stabilize the vertebra, and restore the vertebra back to its normal height. Introduction. Jan 1, 2004 · Compression fractures can occur anywhere from the occiput to the sacrum, although they usually occur at the lumbodorsal junction, namely T8-T12, L1, and L4. Jun 28, 2016 · Burst fractures of the thoracolumbar junction is a very common condition, treatment of each patient must be individualized. This injury causes severe pain, spine instability, and sometimes nerve compression, making daily activities difficult. For example, if a soldier frequently marches with a heavy pack on their back, the repeated force on their leg could 5 days ago · Citation, DOI, disclosures and article data. Determining the acuity of a fracture requires an MRI or bones scan. If you have osteoporosis, a full recovery may take as long as a year. OBJECTIVE To evaluate the biomechanical effects of Most compression fractures result from slight or no force in older people with osteoporosis. [1] The burst fracture is categorized by the Nov 15, 2022 · Vertebroplasty is a treatment that injects cement into a cracked or broken spinal bone to help relieve pain. Compression fractures typically occur in the thoracic region of the spine, which includes the T1 through T12 vertebrae, but may also occur in the lumbar spine, or L1 through L5. It's not the same as a broken back, and it won't cause you to become paralysed. A spinal fracture is when a bone in your spine becomes compressed or squashed after losing strength. Mar 17, 2022 · Vertebral compression fractures are the most common complication of osteoporosis, with 700,000 cases reported every year in the United States. Other major injuries often accompany scapular Spondylolysis is a spinal defect or fracture of a bone structure called the pars interarticularis, which connects the facet joints of the spine. Sixty-five percent of thoracolumbar Share. Objective: To evaluate the biomechanical effects of internal fixation with different screw insertion depths on vertebrae stiffness and screw stress for L1 fracture. A compression fracture is a common fracture of the spine. The aim of this study was to evaluate and compare the results of conservatively and surgically treated younger (≤60a) and elderly patients (>60a) with fractures of L1. The vertebral arch is a ring-shaped section that forms the roof of the spinal canal and protects the spinal cord. 35: 10 subjects with fracture between T12–L3. If the skin is broken over the injury, the fracture may be an open fracture, which carries a greater risk of infection. xn pk za xw ni an jo xv wk cz