So he got a spinal fusion. Another prominent symptom, herein, is urinary retention occurred 8months after the primary surgery. The site is secure. 2022 Aug 23;14(8):e28293. Signs of spinal infection emergency (Seek care immediately): The biggest challenge is making an early diagnosis before serious morbidity occurs. del Rio J, Beguiristain J, Duart J. Spinal fusion can be thought of like a welding process as it fuses together two or more of these small bones or vertebrae. Previous studies have demonstrated a positive correlation between the length of the fusion and the risk of hardware failure [11, 12]. This seems optimistic because a small amount of metal debris was produced in the short segment applied hardware and only localized in the surrounding area. -, Schuh A, Thomas P, Kachler W, Goske J, Wagner L, Holzwarth U, Forst R. [Allergic potential of titanium implants] Orthopade. By assessing the degree of boney destruction, the amount of spinal instability can be determined and can aid in deciding between non-surgical and surgical treatment options. 2-4 Although rare, serious complications must be considered. doi: 10.7759/cureus.28293. Watts RA, Lane SE, Bentham G, Scott DG. Did you know you can support education and research for conditions like spinal infections while you shop, at no extra cost to you?Register with AmazonSmile to designate the NREF as your charity, and a percentage of your purchase is donated automatically. All rights reserved. In children, there is some controversy as to the origin. Metal hypersensitivity, most documented among total joint arhtroplasty, is one of the rare complications after orthopedic procedures, with small number of cases after spine arthrodesis. Hardware Failure After Spinal Fusion. Temporary nerve injury is much more common, especially in spine surgeries. All authors contributed to the design, conduct of the investigation reported herein. Instrumented spinal fusion is a procedure in which a surgeon uses instruments such as rods, plates, and screws to help bones in the spine fuse, or grow together. Mostly in my hips and shoulder blades. Complete recovery from a spinal fusion surgery usually takes up to 6-9 months, with the fusion process continuing to evolve for 12 to 18 months. I am so, so terrified of having this surgery, but I'm getting desperate. Spinal fusion connects two or more bones in the spine to make it more stable, correct a problem or reduce pain. However, nearly all cases resolve spontaneously within 2 years, thus identifying patients who require more detailed or invasive work-up is a challenging task for clinicians. The extended healing period required after lumbar spinal fusion surgery makes postoperative care especially important. Epub 2023 May 31. Patients generally undergo antimicrobial therapy for a minimum of six to eight weeks. But fusing any level of your spine with hardware can overload other areas of the spine, weakening and damaging those areas as well and causing pain after back fusion. In this situation, decompression surgery is necessary to relieve the pressure and pain. doi: 10.1097/BRS.0000000000000921. Nonsurgical treatment should be considered first when patients have minimal or no neurological deficits and the morbidity and mortality rate of surgical intervention is high. An unusual lymphocytic perivascular infiltration in tissues around contemporary metal-on-metal joint replacements. I cannot say what is fairly typical post. Most. 3month postoperatively, however, the patient represented with low back pain. Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. This leads to spinal instability and compression of the lumbar nerve roots. The pain is usually alleviated by bed rest and immobilization, but increases with movement. Urban RM, Jacobs JJ, Tomlinson MJ, Gavrilovic J, Black J, Peoc'h M. Dissemination of wear particles to the liver, spleen, and abdominal lymph nodes of patients with hip or knee replacement. Metal hypersensitivity after spinal fusion should be considered in patients with representation of postoperative back pain. Shijin Wang, Email: moc.361@aixiefeynaux. The site navigation utilizes arrow, enter, escape, and space bar key commands. The fact that a fusion takes a structure in our body that gives us flexibility in movement and makes a portion of it immovable is a big enough problem, but it gets worse. Sept. 24, 2019. 5, pp. Consequently, the evaluation largely depends on the process of the pain elimination. FOIA Question: Will I Be Able to Feel the Hardware in My Back after My Spinal Fusion? Most authors advocate plate removal and immediate repair of the defect. In general, symptoms are usually nonspecific. The https:// ensures that you are connecting to the Yes, you absolutely can. -, Hallab N, Merritt K, Jacobs JJ. The worst pain is generally over by 4 weeks after surgery. Recent dental procedures increase the risk of spinal infections, as bacteria that may be introduced into the bloodstream during the procedure can travel to the spine. Proper and timely follow-up is necessary to ensure that the spinal infection has been controlled and is responding to the treatment protocol. 2003;417:139147. Some people may refer to the surgery as a posterior spinal decompression. If you have questions or comments about this blog post, please email us at [emailprotected]. Basic physical examination, blood tests including ESR and CRP, radiographs, preoperative and intraoperative biopsy may be helpful to make a definite diagnosis. Metal levels in corrosion of spinal implants. background-image - a woman looking at a screen, Neurosurgery Research & Education Foundation. Hicks DG, Judkins AR, Sickel JZ, Rosier RN, Puzas JE, OKeefe RJ. Intravenous drug abusers are more prone to infections affecting the cervical region. 100, no. Before That being said, it can depend. For example the combination of white cell sulphur colloid scan and Technetium Tc99m bone scan with a high accuracy in diagnosing infection was used in diagnosing metal hypersensitivity related to implants failure has also been reported[19]. sharing sensitive information, make sure youre on a federal http://www.biomedcentral.com/1471-2474/15/314/prepub, Willert HG, Buchhorn GH, Fayyazi A, Flury R, Windler M, Koster G, Lohmann CH. Mayo Clinic has developed new techniques for the diagnosis and treatment of patients with SI joint dysfunction. Rigid, semirigid versus dynamic instrumentation for degenerative lumbar spinal stenosis: a correlative radiological and clinical analysis of short-term results. On some people you can feel the screws - they just feel like little bumps though, nothing too weird or gross. The upshot? Patients usually begin to feel a little stronger each day at this point after lumbar fusion surgery, but need to be aware of infection risks and medication safety issues. This article is published under license to BioMed Central Ltd. Feeling the hardware and noticing weird metal sounds on your back after spinal fusion surgery could be normal except when you feel pain and sensation like metal is protruding underneath the skin of your surgical site. With results this poor and so much research showing reasons not to, why would you want to treat your ASD with another fusion? There was no diagnostic explanation for her pain. Metal hypersensitivity in hip, knee and spine surgery. You might need spinal fusion for a variety of medical conditions, including: Degenerative disc disease; Spinal stenosis; Spondylolisthesis; Scoliosis; Break (fracture) of your spinal column; Infection of your spinal column; Tumor in your spinal column; These conditions might be causing you . doi: 10.1007/s00132-005-0764-2. NOTE: This blog post provides general information to help the reader better understand regenerative medicine, musculoskeletal health, and related subjects. Careers, Unable to load your collection due to an error. The patients diet was advanced to a mechanical soft diet at 2 months postoperatively, which she tolerated well, and the patient self-advanced her diet to a regular diet approximately 6 months postoperatively with some mild episodic dysphagia. 2021 Dec 30;12:635. doi: 10.25259/SNI_1139_2021. Spinal fusion can help correct problems with the way the spine is formed. However, even after a successful arthrodesis, there is continued load sharing between the implants and the fusion mass and this may lead to continued stress within the implants, potentially resulting in fretting corrosion. Seek medical care if symptoms of a spinal infection are present. MRI allows for visualization of the soft tissues that include the nerves, spinal cord, and paraspinal muscles, and adjacent soft tissue around the spinal column. It is common for patients to feel run down when first getting home from the hospital. 24532458, 2002. Musculoskeletal and fixator changes. 2023 Mar;107(1):29-35. doi: 10.1007/s12306-022-00765-8. OOlala Sandal Review: #FeelTheOO with OOFOS, Click here to learn more about Sharon's spinal fusion, Lingering effects of your bodys stress response to surgery and trauma, Continued use and/or cessation of opiate pain medications, Use of other medications that may cause fatigue, Anemia related to blood loss during surgery, Poor physical conditioning prior to surgery because of your back injury. Her postoperative course consisted of no intake by mouth with nutrition through Dobhoff feeding tube. By rejecting non-essential cookies, Reddit may still use certain cookies to ensure the proper functionality of our platform. Guyer RD, Shellock J, MacLennan B, Hanscom D, Knight RQ, McCombe P, Jacobs JJ, Urban RM, Bradford D, Ohnmeiss DD. We are thankful to Bin Wang for editing the manuscript. 17, no. I feel like I may have posted about this before, but I'm honestly to the point where I'm ready to have my hardware removed. S.-H. Ahn, S.-H. Lee, E. S. Kim, and W. Eoh, Successful repair of esophageal perforation after anterior cervical fusion for cervical spine fracture, Journal of Clinical Neuroscience, vol. (0.033 seconds) Spinal cord injury from spinal instrumentation after car accident. Spinal fusion surgery is a major procedure with a lengthy recovery time. Adjacent soft-tissue infections include cervical and thoracic paraspinal lesions and lumbar psoas muscle abscesses. Such cases become rarer and more difficult to diagnose when it comes to lumbar surgery. XS was involved in drafting the manuscript and preparing the figures. The authors performed a clinical and radiographic review of a case of a 47-year-old female who presented with persistent dysphagia 3 years following anterior cervical spine surgery and was found to have an erosive pharyngeal defect with exposed spinal hardware. We present the case of a 52-year-old female patient with reoccured low back pain and sciatica after posterior lumbar decompression and fusion (PLDF) for her lumbar disc herniation. Choices for esophageal repair include primary repair with and without soft tissue reinforcement from an omental free flap or a pectoralis, longus colli, or sternocleidomastoid (SCM) muscle flap. Granular histiocytosis of pelvic lymph nodes following total hip arthroplasty. Sensitivity to implant materials in patients with total knee arthroplasties. 1, pp. 96, no. MyAANS, password-protected resources, and purchases are currently experiencing issues and are unavailable. About 30-70% of patients with vertebral osteomyelitis have no obvious prior infection. 2024, 2008. 8600 Rockville Pike 3, pp. , Spinal Fusion: Frequently Asked Questions. But let me till you this, my grandfather had a spinal fusion years ago, not because of Scoliosis, but because he had worked so hard that his vertebras was completely broken in his lumbar spine. 2009;80(6):646652. D. C. Lu, P. Theodore, W. M. Korn, and D. Chou, Esophageal erosion 9 years after anterior cervical plate implantation, Surgical Neurology, vol. Diagnosis typically takes an average of one month, but can take as long as six months, impeding effective and timely treatment. Accessibility Reddit, Inc. 2023. If a paraspinal abscess is present, the patient may experience flank pain, abdominal pain or a limp. Further imaging and histopathological studies in later period revealed an aseptic loosening of the hardware and an aseptic inflammatory response which . Flexible fiber optic laryngoscopy at 8 months postoperatively demonstrated a well-healed posterior pharyngeal wall all the way to the cricopharyngeus without evidence of exposed cervical spine or cervical spine hardware or any other visual abnormality. The patient initially presented to our institution following a low-energy fall. T. T. Crowder and J. D. Fischgrund, Cervical radiculopathy: anterior surgical approach, in Rothman-Simeone, The Spine, pp. The CT scan above shows vertebral osteomyelitis at L3-L4 resulting in destruction of the L3 and L4 vertebral bodies. However, 5-18% of patients with vertebral osteomyelitis or disc space infection caused by contiguous spread will develop an epidural abscess. i still get confused at what exactly he did but i guess prettr much fried the nerve root by L4 as best as he could. Reconstruction of the pharynx was performed after plate removal by oversewing the defect with imbricating stitches. A nasogastric tube was inserted and attention was turned to the neck dissection. Up and Down arrows will open main level menus and toggle through sub tier links. 2005;34(4):327328. Copyright 2015 Amit Nathani et al. The initial clinical and radiological examinations showed no pathologies. I often see patients that have had this type of surgery without any sort of bone fusion. Unfortunately, we cant reverse the original fusion, but in my experience, the resulting ASD can be treated with advanced Interventional Orthopedics. Metal hypersensitivity as a complication after arthroplasty is rare[4], however, it is likely that cases involving implant-related metal sensitivity have been underreported because of the difficulty of diagnosis[5, 6]. Soft-tissue infections generally affect younger patients and are not seen often in older people. More fusions will simply create more problems and more ASD and more fusionsa never-ending cycle. American Volume, vol. Report of four cases, Journal of Neurosurgery, vol. By about 6 months, most patients receive approval to return to a fully active lifestyle, including bending, lifting, and twisting. Blood cultures, preferably taken during a fever spike, can also help identify the pathogen involved in the spinal infection. There is no equivalent term for post-laminectomy surgery . 251256, 2004. As no other cause for the low back pain (commonly named failed back surgery syndrome) could be identified, a quick decision was made to proceed with removal of the pedicle screw system. Although preoperative history-taking alone appears to be insufficient for identifying patients with metal sensitivity[7], it is still strongly recommended to be taken thoroughly, because this could provide a strong clue towards the delayed postoperative pain in time, and therewith, a timely customized examination and treatment could be conducted to benefit the patient tremendously. 8, pp. The increasingly severly deep aching pain had intensified over the next 5months and ultimately gave rise to trouble walking accompanied by a mild sphincter disturbances before shes review. When recovering from lumbar fusion surgery, the spine should be . doi: 10.2106/JBJS.A.02039pp. The corrosive process accelerated, once the alloy was exposed to the chemical factors from body fluid through the imperfection of the oxidative layer. The pre-publication history for this paper can be accessed here. As a library, NLM provides access to scientific literature. Assessment of hypersensitivity has historically been conducted in vivo by skin patch testing and in vitro by leukocyte migration inhibition testing (LMIT). Imaging studies are necessary to pinpoint the location and extent of a lesion. Received 2014 Apr 21; Accepted 2014 Sep 17. Aoyama R, Anazawa U, Hotta H, Watanabe I, Takahashi Y, Matsumoto S. Cureus. MeSH Their presentation highlights the need for critical evaluation of the patient reporting persistent dysphagia even remotely after anterior cervical surgery, as rare and potentially fatal complications that are correctable could be missed. The AANS does not endorse any treatments, procedures, products or physicians referenced in these patient fact sheets. [Click to read a detailed account of my personal spinal fusion recovery timeline.] Korovessis P, Papazisis Z, Koureas G, Lambiris E. Spine (Phila Pa 1976). Carson Daly Turns 50 After Spinal Fusion Surgery: 'I'm Really on My Bounce Back' (Exclusive) The 'Today' host is feeling great mentally and physically after celebrating his 50th birthday . The late complications reported in the literature typically present with more dramatic clinical deterioration such as recurrent pneumonias, cervical abscesses, sepsis, mediastinitis, meningitis, and unexplained fevers [2, 5, 10]. Even so, prospective studies have shown a higher incidence of metal hypersensitivity in patients with implant failure[7]. Early failure of metal-on-metal artificial disc prostheses associated with lymphocytic reaction: diagnosis and treatment experience in four cases. (A) An immediate postoperative lateral radiograph. It is hypothesized that metal particles are slowly released from the prosthetic bearing surfaces as a by-product of normal wear. Metal sensitivity in patients with Orthopaedic implants. Axial view indicating metallosis in the intervertebral space, the erector spinae with lower attenuation is also identified (C, D). Besides, these tests are unavailable in many hospitals and have not been proven in the clinical setting. 53, no. It may be beneficial to get blood tests for acute-phase proteins, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels. Feb 6, 2008. Bookshelf 1. Log in, The opinions expressed above are 100% my own. Paralysis. A back fusion is a surgery that uses hardware and screws to permanently lock together two or more vertebrae, and the purpose is to indeed make the damaged section of spine immovable. The solution is certainly NOT to get another fusion. Fusion surgeries are lengthy, risky, and painful. While I have seen a few patients who have a severe instability that can only benefit from a fusion, its rare. 2014 Jun;20(6):617-22. doi: 10.3171/2014.2.SPINE13548. This could be attributed to the immunologic effects and /or cell toxicity mediated by exposure to wear debris[810]. Radiol Case Rep. 2022 Mar 7;17(5):1540-1548. doi: 10.1016/j.radcr.2022.01.041. At the time of her presentation, her plain film radiography (Figure 1) and computed tomography (CT) of the cervical spine (Figure 2) revealed nonhealing posterior pseudarthrosis with local kyphosis, screw loosening, plate migration, and air communicating with the plate raising concern for esophageal perforation. eCollection 2021. They kept me in the examination room for over an hour. DK and XJ gave substantial contributions to the interpretation of literature review. 29, no. This site needs JavaScript to work properly. Plain radiograph, lateral view, of the cervical spine demonstrates air that appears to be communicating with plate. Infections within the spinal cord parenchyma (primary tissue) are called intramedullary abscesses. Patients presenting a late-onset postoperative pain with no clinical evidence of infection stand a good chance of metal hypersensitivity and a further evaluation should be performed. Most postoperative infections occur between three days and three months after surgery. Clipboard, Search History, and several other advanced features are temporarily unavailable. Spinal Fusion FAQ: What Was Your Experience with Pain Medication/Management Like After Your Surgery? I now am traveling 4 hrs each way. In total disc replacement cases, Guyer RD et al. . A disc sits between each vertebra, and the vertebrae come together in the back at the facet joint. This is all held together by ligaments and kept stable by a series of muscles called multifidus, and the spinal column has natural opposing curves to distribute our weight and provide stability. . However, nearly all cases resolve spontaneously within 2 years, thus identifying patients who require more detailed or invasive work-up is a challenging task for clinicians. . Infections occur in 1-4% of surgical cases, despite numerous preventative measures that are followed. After PLDF, she did not notice rashes or irritation over the low back area, or any other skin reaction, and other clinical evidence of infection. Patient reviews and testimonials on this site should not be interpreted as a statement on the effectiveness of our treatments for anyone else. Epub 2014 Mar 28. 410415, 1998. This forced lack of movement puts more stress on and overloads the vertebrae above and below the fused levels. 13741380, 2011. Diagnosis is difficult because postoperative dysphagia after anterior cervical spine surgery is common, ranging between 28% and 57%. With corrosion, metal ions are released into the body. Metal hypersensitivity, mostly documented in prosthesis implantation, is a rare complication after arthroplasty. 22, pp. Neither a high skin temperature nor flare was found. And these particles are subject to corrosion resulting in producing high levels of ions potentially causing cell death. The previous left vertical incision was incorporated into the planned surgical incision, as is customary with revision cervical procedures to protect the contralateral recurrent laryngeal nerve, and a standard anterior approach to the cervical spine was undertaken. Studies also give confirmable sensitivities and specificities of various tests to diagnose infection. If imaging results show any loose, broken, or shifted hardware, you must get anoth. Spinal infections can be classified by the anatomical location involved: the vertebral column, intervertebral disc space, the spinal canal and adjacent soft tissues. months and was promoted to Investigator 1 year later. It is common among patients who received spinal fusion to feel the hardware in their backs 1 or 2 weeks after the surgery. I am disclosing this in accordance with the FTCs 16 CFR, Part 255: Guides Concerning the Use of Endorsements and Testimonials in Advertising., Click to share on Facebook (Opens in new window), Click to share on Twitter (Opens in new window), Click to share on Pinterest (Opens in new window), Click to share on LinkedIn (Opens in new window), Click to email a link to a friend (Opens in new window), Click to share on Pocket (Opens in new window), Click to share on Reddit (Opens in new window), Click to share on Tumblr (Opens in new window), OOlala Sandal Review: #FeelTheOO with OOFOS, Spinal Fusion FAQ: What Was Your Experience with Pain Medication/Management Like After Your Surgery? Metal hypersensitivity after spinal fusion should be considered in patients with representation of postoperative back pain. Identification of the organism is essential, and this can be accomplished through computed tomography-guided biopsy sampling of the vertebra or disc space. Metal Hypersensitivity After Spinal Instrumentation: When to Suspect and How to Treat. The cervical plate was found to have eroded through a 2.5cm posterior pharyngeal wall defect that appeared to be chronic. All content provided in this blog, website, or any linked materials, including text, graphics, images, patient profiles, outcomes, and information, are not intended and should not be considered or used as a substitute for medical advice, diagnosis, or treatment. Esophageal injuries are a rare complication of anterior cervical spine surgery [13]. I see you are located in England. As we know, all metals which are in contact with biologic systems are subject to corrosion. Metal degradation products: a cause for concern in metal-metal bearings? Fusion surgeries are lengthy, risky, and painful. CT and x-ray studies will allow the surgeon to assess the integrity of the boney structures of the spine and ensure that spinal instrumentation has not failed. Tao Y, Wu J, Ma H, Zhang L, Shao S, Si Z, Gao B, Ji Y, Li H, Tao F. Spine (Phila Pa 1976). Aug 13, 2009 . The vast majority of those perforations occur acutely during the index operation due to retraction or sharp instrumentation, with very few cases in the literature occurring as a late complication. A pharyngeal defect with exposure of the spinal hardware was noted in the posterior pharynx in the midline (Figure 3). Most cultures and biopsies in children are negative, leading experts to believe that childhood discitis may not be an infectious condition, but caused by partial dislocation of the epiphysis (the growth area near the end of a bone), as a result of a flexion injury. Even in cases of subtle symptomatology, persistent dysphagia 2-3 years following ACDF should prompt a more thorough work-up, as these symptoms may be an indication of underlying esophageal/pharyngeal pathology, which, if missed, can lead to significant morbidity and mortality. Coronal, Computed tomography (CT) showing loosening of the pedicle screws and the osteolysis (A, B). Flexible fiber optic laryngoscopy at those time intervals also demonstrated an upper airway in continuity without evidence of erosion or abnormalities. The authors declare that there is no conflict of interests regarding the publication of this paper. Thomas P, Summer B, Sander CA, Przybilla B, Thomas M, Naumann T. Intolerance of osteosynthesis material: evidence of dichromate contact allergy with concomitant oligoclonal T-cell infiltrate and TH1-type cytokine expression in the peri-implantar tissue. Spangehl MJ, Masri BA, O'Connell JX, Duncan CP. R. Bazaz, M. J. Lee, and J. U. Yoo, Incidence of dysphagia after anterior cervical spine surgery: a prospective study, Spine, vol. Correctly identifying the underlying etiology of dysphagia may lead to improved revision of ACDF outcomes. All rights reserved. To our knowledge, few allergic cases in the matter of spinal fusion were reported so far. 2001;83-A(3):428436. Soft tissue injuries are a well-recognized complication of the anterior approach to the cervical spine. But a small granulation tissue was identified around the pedicle scerw in the L4/5 level and sent to biopsy along with a piece of bone from the L5/S1 intervertebral space. Acta Orthop. It keeps your bones intact as it heals. We still offered a postoperative treatment toward infection, including intravenous antibiotics application for 3weeks and continuous antibiotic lavage and drainage for 25days. Neurological emergency from rare spinal metalloma: Case report and literature review. However after removal of the hardware, the pain alleviated greatly when stay in bed, not that much when she got out of bed. Immobilization may be recommended when there is significant pain or the potential for spine instability. Further imaging and histopathological studies in later period revealed an aseptic loosening of the hardware and an aseptic inflammatory response which was diagnosed to be metal hypersensitivity. 2, pp. See this image and copyright information in PMC. The .gov means its official. Before 1, pp. N. P. Patel, W. P. Wolcott, J. P. Johnson et al., Esophageal injury associated with anterior cervical spine surgery, Surgical Neurology, vol. R. R. Reid, J. Dutra, D. B. Conley, S. L. Ondra, and G. A. Dumanian, Improved repair of cervical esophageal fistula complicating anterior spinal fusion: free omental flap compared with pectoralis major flap. Hypersensitivity reactions to metals in spine surgery. The Cervical Spine Research Society described hardware failure as the third most common cause of esophageal perforation after esophageal retraction and esophageal manipulation intraoperatively [9]. -, Thyssen JP, Jakobsen SS, Engkilde K, Johansen JD, Soballe K, Menne T. The association between metal allergy, total hip arthroplasty, and revision. Specific laboratory tests can be useful in helping to diagnose a spinal infection. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Broken instrumentation: Instrumentation can break when. Infection is another common cause. Serial blood analysis showed erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and complete blood count with differential (CBC w/ diff) were within normal limits. A back fusion is a surgery that uses hardware and screws to permanently "lock" together two or more vertebrae, and the purpose is to indeed make the damaged section of spine immovable. 86, no. The patient had sustained pain relief but persistent dysphagia for approximately 3 years without any additional work-up. Careers. Kwon YM, Thomas P, Summer B, Pandit H, Taylor A, Beard D, Murray DW, Gill HS. In our case, cervical stability following plate removal and defect repair was compromised and local kyphotic deformity and pseudarthrosis prompted staged PSF.
Neck Pain When Looking Down And Left,
Syracuse Bus Schedule,
What Agreement Did Hercules And King Augeas Come To?,
Articles F