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Tarlov Cyst, Perineural Cyst & Synovial Cyst Cause & Treatment

A Tarlov cyst is rarely the cause of neck or back pain. Usually, other condition that exists in combination with a Tarlov or perineural cyst cause pain. A synovial cyst on the other hand can be a source of pain by itself. Get treated at our award-winning chiropractic & physiotherapy center today. Our experts help your recovery; contact us now!

What Are The Common Types Of Spinal Or Neural Cysts?

tarlov cyst or perineural cyst

A Tarlov Cyst (TC) or Perineural Cyst is a dilated nerve root sheaths filled with cerebrospinal in the spinal column. Tarlov cysts (Perineural Cysts) are commonly found in the dorsal root ganglion of the spinal column’s sacral region. The most common place for these fluid-filled cerebrospinal fluid sac is in the nerve root sheets of the S2-S3 level of the sacrum, tailbone, or base of the spine. Nevertheless, you can get a Perineural Cyst (Tarlov Cysts or TC) in other areas of the spine. Also, it could be present in multiple areas.

The vast majority of Tarlov cysts diagnosed are not the cause of pain in patients with neck pain, upper back pain, mid back pain, low back pain, upper extremity pain, or lower extremity pain. In 98% of diagnosed cases, the cyst is not the source of pain. However, a small cyst can aggravate an existing disorder. The large cysts can cause symptoms or pain, especially when there are no other clinical findings. If the TC (Tarlov Cyst or Perineural Cyst) is too big, it can pinch and irritate neural structures, causing neurological damage, chronic pain, and sexual dysfunction. A surgeon can remove severely enlarged and symptomatic cysts, and we will discuss this procedure later.

What Is A Cyst?

In the most basic terms, a cyst is a thin sac that is filled with fluids. They can occur in any tissue and vary in size. Regardless of where they are found, these are abnormal sac-like structures that can cause discomfort, chronic pain, and malfunction. However, cysts, in general, do not cause pain. But, it can become painful when enlarged, infected, or irritated. In this article, we will pay attention to the types of cysts in the spine. Now that we have defined what a cyst is let’s see different spinal cysts.

Are There Different Types Of Spinal Cysts?

Yes, there is a variety of cysts found in or around the spinal column. In the spine, there can be small or large cysts. The most common and least understood type is the Tarlov or Perineural cyst, which was first described 70 years ago. They are called perineural cysts (PC) because of their proximity to spinal nerves.

These PC or neural cysts can occur anywhere in the spine but are most common in the tailbone or sacrum’s lowest portions. Researchers have the incidence of 1-2% of the population and more common in males. In this article, we will concentrate on the Tarlov cyst. Still, before getting too in-depth, it might help define other types of cysts such as the Meningeal Cysts, Meningeal Diverticula, and Arachnoid Diverticula.

Is There Any Difference Between Tarlov Cyst & Meningeal Cysts?

The cysts are often multiple, extending around the nerve’s circumference, and can enlarge over time to compress neighboring nerve roots to cause bone erosion.

Having just one TC is rare. Often, multiple TCs extend around the entire circumference of a nerve. Contrary to the common belief, they can enlarge over time, and larger cysts cause symptoms. Larger cysts are known to cause bony erosions. But before we get too in-depth, we must differentiate a TC from other spinal Meningeal Cysts.

We provided the main descriptive criteria for TC and other Meningeal Cysts in the spine to ease understating. Please keep in mind that the topic regarding the differentiation of meningeal cysts form is still relatively new, and as such, remains somewhat controversial. However, both can cause symptoms when enlarged. Nonetheless, let take a closer look at them, starting with the Tarlov first:

What Are The Basic Characteristics Of A Tarlov Cyst (TC)?

  • They have the potential to communicate with spinal subarachnoid space.
  • It is often found beyond the point where the posterior nerve root and dorsal root ganglion lie in the sacral spinal region.
  • The walls of a TC always contain nerve fibers. If you see one, there are more. In other words, there are more than one TC

How Is A TC Differentiated From Other Neural Cysts Such As Meningeal Cysts, Meningeal Diverticula & Arachnoid Diverticula?

  • Meningeal Cysts are the communicating cysts. In other words, they have free access to the spinal subarachnoid space.
  • Meningeal Cysts are typically found proximal to dorsal root ganglion (DRG) throughout the vertebral column (TC was distal or just after the DRG)
  • The Meningeal Cysts walls, Meningeal Diverticula, and Arachnoid Diverticula are all lined by arachnoid mater.
  • , Unlike the TC, there are no neural elements or components. Unlike TC, there can be only one. Multiplicity isn’t documented as it is for TC.

We have spoken quite a bit about cysts (Tarlov) and other meningeal cysts but have not covered other types of cysts found near the spine. We have mentioned numerous times that TCs are often asymptomatic. But, there is a type of cyst, that is. A synovial cyst cause symptoms 100% of the time. Unlike the TCs, they are not classified as neural cysts but rather ones that arise from spinal joints.

What Are Synovial Cysts?

As mentioned earlier, Tarlov cysts are fluid-filled sacs that are not well understood. But, Synovial cysts are the second most common type of spinal cyst. They, too, can be small or large cysts that result from premature wear and tear or degenerative changes in the spine. Synovial cysts are the type of fluid-filled sacs common in patients with spinal instability or congenital malformations such as spondylolisthesis. Spinal instability and conditions such as spondylolisthesis place excessive amounts of stress upon the spinal joint. The cumulative impact of these stresses is said to be the leading cause of synovial cysts. Let’s see how.

In the spinal column, the synovial cysts are located adjacent to the joint or facets. Poor posture, injuries, and spinal instabilities are the leading causative factors. The facet joints or spinal joints bear the weight of the body. When stressed, they get inflamed or swell up. This inflammatory process is initiated to protect the joint but often backfires, causing more significant long-haul issues.

So, increased stresses on your spinal joints can lead to decreased synovial fluid production. Synovial fluids are what the spinal joint needs’ healthy fluids. The increased production of these fluids (synovial fluids) is needed to protect your joint by providing additional lubrication. However, continued stress can lead to an excessive buildup of these fluids. As the fluid levels increase, they can get trapped in the joint lining (synovial lining) and produce sac-like projections of varying sizes.

What Is The Significance Of A Synovial Cyst?

The clinical significance of synovial cysts is that they can compress nerves, cause sexual dysfunction or chronic pain. Nerve compression can occur when the synovial cyst is projected from the facet into the neural foramina. The neural foramina or intervertebral foramina are the openings through which the spinal nerves exit from the spinal canal. Conservative treatment is the best means of approach. Several surgical methods exist, but the long-term outlook of spine surgery for the synovial cyst is not favorable.

Most surgical intervention requires the removal of joints or encapsulating ligaments. These procedures may reduce pain but render the spine unstable. Therefore, if you are diagnosed with Synovial Cysts, the most effective treatment options include targeted research-based chiropractic backed by clinical physiotherapy. In short, you need us for targeted pain management. So, visit one of our centers today.

Chiropractic Specialty Center® has the breakthrough technology, knowledge, and skills needed to target and treat synovial cysts effectively. Integrative solutions and advanced technology are essential to the speedy recovery of patients with cysts in the spine. For our synovial cyst patients, we offer targeted advanced spinal decompression therapy, shockwave therapy, ultrasound therapy, High-Intensity Laser Therapy (HILT), interferential current therapy, along with several other chiropractic combined with physiotherapy procedures and methods that target it comprehensively. Let CSC’s clinical non-surgical spine experts provide you with the care you need today.

How Is Neural Cyst Diagnosed?

The only acceptable means of diagnosing cysts in the spine is through an MRI. As mentioned, cysts are fluid-filled sacs. Synovial cysts contain synovial fluids (joint fluids), while the Tarlov cysts are fluid-filled sacs with cerebral spinal fluid. The most researched and best-proven method of assessing fluid-filled sacs (whether from synovial fluids or cerebral fluids) is through the MRI. CT scans are helpful but rather outdated as they don’t show the fluids and the MRI.

Magnetic Resonance Imaging (MRI) is the gold standard for diagnosing a spine-related condition. And, when it comes to a Tarlov cyst, there is nothing better. The best MRI view of a Tarlov cyst is the T2-weighted MRI images. The T2-weighted images enhance fluid levels as such, making the diagnosis of a Tarlov cyst relatively easy. On a T2-weighted MRI, a Tarlov Cyst will appear to be a white ballooned/dilated area of the sheath covering the exiting sacral nerve roots.

MRI diagnosis of tarlov cyst

As mentioned, dilation of the nerve root sheaths is the source of a perineural cyst. The dilation is the result of excessive accumulation of CSF (cerebrospinal fluid) within the nerve sheath. Now, let’s look into the layers of nerve sheaths where these fluid collections occur. Three meningeal layers cover the brain and the spinal cord; the outermost and the toughest layer would be the dura mater, followed by the arachnoid, and the innermost layer is called the pia mater. Subarachnoid space is the space between the pia and arachnoid mater.

What Are The Signs & Symptoms Of A Neural Cyst (Perineural Or Tarlov)?

The presence of a Perineural Cyst (PC) may or may not accompany neurologic symptoms. However, living with an asymptomatic Tarlov cyst could lead to remodeling and erosions of the sacral bone. This, in turn, may lead to increased spinal fluid pressure causing the cyst to fill up with CSF and cause neurological damage, sexual dysfunction, and chronic pain. The larger cysts can compress nerves and cause symptoms. Patients with large cysts may experience pain in the legs or spine. In short, cysts cause symptoms when they grow. Yes, if you have a PC or TC, it can and will grow over time. Injuries such as falls can dramatically increase the chance for growth, and keep in mind the growing or large cysts cause symptoms.

Traumatic accidents, infections, falls, childbirth, or epidurals can transform asymptomatic Tarlov cysts into symptomatic. Symptoms of an enlarging Tarlov Cyst or Perineural Cyst would be similar to sciatica or slip-disc. Patients would experience either localized or radiating pain, numbness, paresthesia, and tingling. However, a patient with a Perineural Cyst would also complain of pain include soreness or pain in the sacral region. Bowel and bladder changes may also occur. Pain may increase with a cough or sneeze, and they may have headaches or dizziness.

What Are The Links Between Traumatic Events, Childbirth, Epidural Injections & Tarlov Cyst?

If you wonder what caused the TC (Tarlov Cyst), no clinical data definitively report the actual causes. A possible cause or enlargement of a smaller cyst into a large one related to published medical research increases the Cerebral Spinal Fluid (CSF) pressure.

The brain produces CSF (Cerebral Spinal Fluid). CSF’s primary function is to provide nutrients and remove waste products from the brain and spinal cord. Also, it protects the brain and spinal cord by cushioning them from traumatic events.

Increased CSF pressure or blockage of CSF flow is a known causative factor. Furthermore, increased CSF pressure or blocked CSF flow can undoubtedly enlarge a smaller asymptomatic TC into a large symptomatic one. So, it is not unusual for a patient who had an asymptomatic Tarlov Cyst (TC) to become symptomatic following an incident such as sports injuries, car accidents, falls, childbirth, or heavy lifting.

Aside from traumatic events and childbirth, Epidural Injections are known causes or, at least, aggravating factors in TC. An epidural injection is an invasive procedure that delivers steroids to block pain. Epidural anesthesia is injections given during childbirth or surgical interventions from the waist down.

Are There Any Side Effects To Epidural Injections?

Generally speaking, anytime you inject a chemical into the body, there are side effects. The severity of side effects is dependent on the chemical injected and the patient’s tolerances. Although epidural injections are considered minimally invasive procures, they can have severe side effects. One of the known side effects as it pertains to our topic is the increase in CSF pressure. An epidural injected into the spinal column can engorge veins, leading to increased CSF pressure. Epidural are known causes of increased intracranial pressures that result from changes in CSF pressure or flow. As mentioned earlier, a change in CSF pressure is the leading cause of TC.

What Should You Do If You Have A Spinal Cyst?

illustration showing tarlov cyst in tailbone (sacrum)

As mentioned earlier, a Tarlov cyst is often not the cause of pain. Medical research has established that 98% of Perineural Cyst cases are not the source of pain.Most patients diagnosed with a Tarlov cyst suffer from spinal disc disorders such as a herniated disc & slipped disc (slip-disc). Therefore, clinical expertise and judgment are needed to treat patients who present with a Tarlov cyst. In our centers, we have treated thousands of patients with Tarlov cysts. In almost all cases, the pain was not due to their cyst.

Tarlov cysts are often a complicating or aggravating factor. It is much like when you cut your finger while cooking and not feeling the pain until you touch slat or an acidic liquid like lemon juice. Similarly, the Tarlov cyst is an aggravating factor, especially when you have a spinal disc disorder or a joint malfunction. In other words, the spinal disc or spinal joint is the source of pain rather than the cyst. Just like the pain, you feel when your cut finger comes in contact with salt or lemon juice.

Surgical Intervention Through The Two-Needle Fibrin Glue Approach For The Symptomatic Tarlov Cyst

Diagnosis and identification of a perineural or TC start with an MRI, which is more sensitive than CT. In rare instances, radiologists will not write about the cysts in their reports. As mentioned earlier, most are in the sacral area and asymptomatic. Symptomatic Tarlov Cyst is rare. If the cause of neck pain, back pain, or pain in the sacral region is related to a painful Tarlov cyst, surgery is optional. Surgery can provide temporary relief or lasting relief, depending on the procedure. A minimally invasive procedure is better for the symptomatic Tarlov cyst. These procedures are relatively new, and as such long-term impacts are still unknown. As such, proceed with caution.

In one study, Dr. Paulsen’s published study reported immediate symptom relief lasting up to 3 months following single-needle aspiration of symptomatic TC in five individuals. To date, the most promising and least invasive procedure is one that Dr. Zhang published. The fibrin glue injection improved with help from Dr. Murphy and his colleagues. They innovated a new method with a two-needle fibrin glue technique. The good doctors stated that their two-needle method of fibrin glue for the symptomatic Tarlov cyst best minimizes the risks associated with a single needle method. Our advice for TC patients is to obtain multiple surgical consultations from Neurosurgeons when deciding on surgical intervention.

Non-Invasive Therapy & Treatment Options For Cysts At Base Of The Spine

While traditional chiropractic or physiotherapy methods provide temporary relief: our systems of care fix and repair the root causes, the clinical teams of Chiropractic Specialty Center® are experts in the spine and joint conditions. We are not one of those centers that offer temporary relief. Our expertise and successes achieved are the results of the research-based clinical treatment we provide. Our Chiro-zone & physio-zone have the experts you need in identifying the causes of your pain. Too often, patients with a Tarlov Cyst or Synovial Cysts (cysts often found at the base of the spine) receive improper therapeutic procedures. The absence of an accurate diagnosis is the primary factor of ineffective treatment. Diagnosis is the most challenging aspect of your care. As such, our clinical teams will carefully assess you to ensure a speedy recovery.

Our methods of treatment for the spinal column have improved the lives of thousands of our patients. We have helped many that others could not. Our spine and joint care successes are due to our commitment to research and understanding of causes. If you have a Tarlov cyst or a Synovial cyst, your best hope of recovering from pain through a non-invasive manner is us.

CSC’s methods of integrative treatments coupled with advanced spine technology allow us to deliver for you a world-class level of pain management unmatched by others. Visit a CSC chiropractor in Sri Petaling near Taman Desa, CSC’s physiotherapy and chiropractic in Bandar Sri Damansara near Desa ParkCity, or at CSC’s Damansara Heights chiropractor today and discover your non-surgical treatment options for a Tarlov Cyst, Perineural Cyst, and Synovial Cyst.

CSC offers the best Tarlov cyst treatment without injection or surgery. Call us today to learn more about the cause and effects a Tarlov cyst, perineural cyst & synovial cyst has, and what are your best non-invasive therapy options.

This Post Has 12 Comments

  1. Tammy

    What happens if you leave these untreated? I have them in several thoracic areas. What causes them to enlarge? Can cortisone make them smaller?

    1. CSC Clinical Team

      Dear Tammy,

      Tarlov Cyst is a common condition. As mentioned, it is often asymptomatic (painless). If you are experiencing pain, the cause may be related to a co-condition. However, severely larger cysts can become painful. But, I would not recommend steroid injections, even for the large or painful ones. Injecting steroids into cysts can dramatically worsen them! In fact, spinal injections are common causes of Tarlov Cysts in the first place. Besides, there are many side effects associated with spinal injections.

      To date, the only effective treatment is surgical removal. Surgical removal is only recommended for several large and painful cysts. If you want a detailed answer, we will need to assess your spine thoroughly. Please call our main center in Kuala Lumpur at 03 2093 1000 to schedule a one-on-one consultation with one of our experts. You will need to bring in your MRI films or CD for this assessment. After reviewing your MRI, we should be able to offer you better guidance.

      I hope this helped.

      Yours in Health,

      CSC Clinical Team Member

    2. Susanna Leow

      Hi, I have 6 Tarlov cysts in my sacrum, and disc bulges with L5-S1 with nerve root impingements. How would I know if the cysts are the cause of my pain instead of the disc bulges? I have sharp tingling pain in my left butt and down my left leg, mainly behind my knee area, foot, and sometimes in my calf. I have done 8 sessions of acupuncture and haven’t helped at all. I have also done 4 sessions of physiotherapy and stretches to provide little pain relief. Only lying down helps to relieve most of my pain. How much are your services, including consultation, adjustments, decompression, and is it safe to decompression with Tarlov cysts?

      1. CSC Clinical Team

        Dear Susanna,

        Tarlov Cysts are usually not the primary source of pain. However, large cysts can be painful by themselves. Tarlov Cysts that cause pain in the legs are often located at the upper portions of the S-1 segment (first sacral segment). But, in your case, I suspect the leading cause of radicular pain (pain in the buttocks and legs) is related to the L5-S1 disc disorder. Tarlov patients with bulging, herniated, protruded, prolapsed, or extruded disc often experience a higher degree of pain. It is relatively impossible to calculate the degree of pain caused by one or the other when both a cyst and spinal disc are present. Therefore, I recommend NSD Therapy® programs to all Tarlov patients. NSD Therapy® is the best integrative method of spine care. It incorporates Chiropractic, Physiotherapy, Nutrition, Exercise, and spinal decompression therapy through the RxDecom®. NSD Therapy® is not contraindicated in patients with Tarlov Cysts. In other words, it is perfectly safe.

        The goal with NSD Therapy® is to repair and fix the actual cause of your damaged disc. NSD Therapy® is superior to acupuncture, physiotherapy, or chiropractic. Over the years, we have successfully treated hundreds of Tarlov and slipped disc patients. Stretching exercises and the acupuncture you are currently getting are of little help in addressing the actual damage within your spinal disc and spinal joints. The best advice that I can provide is to visit our center to assess your condition thoroughly. We can give you better information once we have assessed your spine. The costs for consultation are RM100. Treatment costs depend on the procedures needed. Each slipped disc patients are unique, and those with Tarlov need additional attention. Our centers provide chiropractic and physiotherapy treatments. You can get more information on costs of care and our pricing when you visit one of the appropriate pages below:

        Our chiropractic treatment prices in KL, Malaysia

        Our physiotherapy treatment prices In KL, Malaysia

        I hope this helped.

  2. Susanna Leow

    Hi, thanks for your reply. Seen another spine specialist, and he said it’s not my disc bulges causing my pain! I have foraminal stenosis caused by spurs and was given 3 options; physiotherapy (not effective), steroid injection, or Transforaminal Interbody Lumbar Fusion surgery. I am mobile and have control of bowel movements, just severe sciatic pain. I don’t understand why I need such a major surgery. Will your treatment help my condition? Thanks, and I hope to hear from you soon.

    1. CSC Clinical Team

      Dear Susanna,
      Thanks for updating us. As we mentioned in our last reply (July 31, 2018), the cause of your pain is not a cyst. I am glad to hear that the surgeons agree with our assessment. However, we disagree with the invasive options. Steroid Injections are short-term at best. Often, they cause more harm than good. The transforaminal Interbody Lumbar Fusion surgery is a more invasive patch. In other words, spine fusions are ineffective in the long term. Besides, spinal fusion success rates performed in the United States are relatively low. Failure rates of spine fusion surgeries are said to be as high as 74%. We have a detailed article published on our site on spine surgery (fusions). Please read it.

      Physiotherapy as a standalone means of care also fails. We have successfully treated thousands of similar cases. Our methods are through integrative solutions enriched with breakthrough spine technology. The care you get is targeted and collaborative through the efforts of our clinical physiotherapists and doctors of chiropractic. I am confident that we can help. Our success rate is higher than 95%. You can read more about our proven methods that repairs damaged ligaments, muscles, joints and spinal discs.

      You don’t have to have surgery. We can help. I invite you to schedule an appointment for a complete assessment. We have several centers throughout the Klang Valley. However, I recommend that you call our main office for the initial assessment at 03 2093 1000. We can help.

  3. Gladys Hong

    May I know who shall I see for Tarlov’s cyst in my sacrum S2?

    1. Dr. Yama Zafer, D.C.

      Dear Gladys,

      Thanks for posting your question, and please forgive us for the delay in getting back to you. A TRarlov’s cyst is an incidental finding on an MRI examination of the spine. They are rarely the cause of pain. Over 99% of them are asymptomatic. On rare occasions, cysts larger than 2cm can cause pain. You should avoid surgery to remove a cyst. A focused and comprehensive non-surgical treatment options are the best initial options.

      Patients with Tarlov’s cyst experiencing back pain always have co-conditions such as disc degenerations, slipped discs (bulging or herniated discs), and spinal joint degenerations (facet syndrome or facet hypertrophy). I encourage you to visit one of our centers for a detailed assessment of your spine, and please do bring with you your MRI.

      I hope this helped.

  4. Mike

    what sources are you citing for your findings that a Tarlov cyst may increase in size due to an increase in pressure?
    I have degenerative changes in my back and would normally try the injection; however, I have a 1.2 mm Tarlov cyst at my s2/3 and 2 smaller ones at s2. Is the increase in pressure and size causing my pain?

    1. Yama Zafer, D.C.

      Dear Mike,

      Thank you for reaching out with your questions about Tarlov cysts and their potential to increase in size due to increased pressure following certain medical procedures.

      In discussing the potential for Tarlov cysts to increase in size due to increased CSF pressure, the information provided is based on general medical understanding about spinal fluid dynamics and the mechanics of CSF pressure. Specifically, procedures like epidural injections, which introduce substances into or around the spinal column, can engorge veins and consequently increase CSF pressure. While this is a recognized mechanism, direct clinical data linking such procedures to an increase in the size of Tarlov cysts is limited and often theoretical, based on isolated case reports rather than extensive clinical trials.

      Regarding your condition, it’s important to consider that degenerative changes in the spine, such as disc degeneration or facet joint issues, are common causes of back pain and may be more directly related to your symptoms than the Tarlov cysts, especially given their small size (1.2 mm at S2/3 and smaller at S2). These cysts are often asymptomatic and may not necessarily cause pain unless they are pressing significantly on nerves, which is less likely with smaller cysts.

      Given the degenerative changes in your back, I recommend prioritizing treatment for these conditions first, as they are more likely to be causing your pain. This can include physiotherapy (physical therapy), chiropractic, rehabilitation combined as these three provided collobratively will have better impact. Treating these primary conditions can often alleviate symptoms without directly addressing the Tarlov cysts.

      If symptoms persist despite treatment and if there is evidence that the Tarlov cysts are contributing to your symptoms, then interventions that directly address the cysts are appropriate. However, any treatment, especially invasive ones like injections, should be approached with caution due to the potential to increase CSF pressure and exacerbate the cysts.

      Always consult closely with your healthcare provider to assess the potential risks and benefits of any treatment. A thorough evaluation, which might include additional imaging or diagnostic tests, is crucial to accurately determining the causes of your symptoms and developing an effective treatment plan.

      Please let me know if there is any further information I can provide or any other way I can assist you by WhatsApp our main center at +(60)17-269-1873

      Best regards,



    1. Yama Zafer, D.C.


      Thank you for reaching out with your concerns about having a Tarlov cyst. It’s important to note that in most cases, Tarlov cysts themselves are not the actual cause of pain; rather, it’s often another underlying issue that needs to be addressed.

      To further assess your condition and determine the appropriate course of treatment, it would be helpful to review your MRI scans. You can send your MRI images in person or through post, as emailed images may not load properly.

      We recommend scheduling an appointment with one of our chiropractors, who can provide a comprehensive evaluation and recommend a conservative course of care that might include evidence-based chiropractic, clinical physiotherapy, and focused rehabilitation. These approaches address the symptoms and any underlying conditions contributing to your discomfort.

      Please contact our office via WhatsApp on +(60)17-269-1873 to arrange for a consultation, or if you need further assistance on how to send your MRI images securely mail currier.

      Best regards,

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