International Journal of Current Research and Review
ISSN: 2231-2196 (Print)ISSN: 0975-5241 (Online)
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IJCRR - 7(22), November, 2015

Pages: 52-56

Date of Publication: 21-Nov-2015


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STUDY ON ANALYSIS OF FUNCTIONAL OUTCOME OF FENESTRATION TECHNIQUE IN SINGLE LEVEL LUMBAR INTERVERTEBRAL DISC PROLAPSE

Author: Imran B.M., Pisudde P.M., Aravind Kumar

Category: Healthcare

Abstract:Objective: Aim of this study was to assess functional and neurological outcome by fenestration technique, since standard laminectomy and discectomy carries a risk of spine instability, it is preferable to perform discectomy through fenestration. Methods: Out of the 51 patients who were operated for single level lumbar disc herniation by fenestration discectomy between 2009 to April 2011, only 48 patients were available for follow up. Patients were followed up for a period of 1 year. The post operative outcome was analysed using the JOA score. The outcome was analysed with motor deficit, sensory deficit and bladder function as variables. Results: Back pain improved immediately in almost all 48(100%) patients. The outcome was excellent in 35.4%% patients good in 56.3% and fair in 8.3%. Conclusion: Fenestration technique with minimal disc removal is an effective technique for treating properly selected patients.

Keywords: Laminectomy, Discectomy, Herniation, Fenestration technique

Full Text:

INTRODUCTION
Disc prolapse is most common cause of the Low Backache. Disc prolapse commonly occurs in males with a male to female ratio of 2:1, highest prevalence is found to be in the age group of 30- 50 years.1 In India Prasad et al found that in their hospital 65.6% were male and 34.4% were female most common age of presentation was 31-40 years, they also found that disc prolapse is more common in moderate workers (59.4%) in rural India population2 . It is the responsibility of the orthopaedic surgeon to diagnose and treat this disease, since disc prolapse is the most common cause of low back pain. Disc prolapse is more common at the L4-L5 and L5-S1 levels followed by L3-L4 and L3-L2 levels.3 Lumbar discectomy is very commonly performed to treat disc prolapse if conservative management fails. Pain is the common indication to do fenestration, but neurological status is also to be taken inconsideration, other factors are far less of functional importance because they appear to be more of objective than pain related signs.4 Even with the advent of newer techniques like percutaneous endoscopic lumbar discectomy and use of Nd: YAG Laser, fenestration and microdiscectomy, technique still remains a good tool for treating patients of Low back pain with disc related pain.5,6Fenestration though relieves pain in almost all patients, it is important to select the patients carefully to get a good result. Fenestration is less time consuming, with lower blood loss and lesser postoperative complications and maintains the stability of the spine better than procedures like laminectomy and discectomy.3, 7 To assess objectively, the results of lumbar disc surgery, there are no specific criteria. Interestingly, the results of lumbar disc disease present a challenge to surgeons. Dissimilarity among the population undergoing surgery compared the problems of wide variability in analyzing results. This subjective and objective obser vation and purposed implication from data assembled tends to confuse rather than illuminate. Clearly there is a need for simple systematic protocol for analyzing results of lumbar disc disease. There are very few literatures which emphasize on improvement about the various parameters after different disc surgery and also fenestration surgery. So the present study was undertaken to analyze the improvement of various parameters after fenestration for example gait, activities of daily living etc. Aim of this study was to access functional and neurological outcome by fenestration technique, since standard laminectomy and discectomy carries a risk of spine instability, it is preferable to perform discectomy through fenestration.

MATERIALS AND METHODS

Present cross sectional study which was prospective in nature was carried out between the period of February 2011 to April 2013. Patients visiting to orthopaedics Out Patient Department(OPD) in hospital were included in study. A detailed history and thorough clinical examination was done in all patients. Magnetic Resonance Imaging(MRI) was done followed by routine pre op investigations. All details were recorded in a proforma. The study subjects having Single level disc disease, low back pain and radicular pain, sensory, motor deficit and bladder symptoms were included in study. Study subjects showing significant evidence of disc prolapse in MRI were carefully selected and included in study. Study subjects those who were excluded were those who underwent surgical treatment for disc prolapse, suffering from other associated disease of spine, not undergone conservative management and suffering from only back pain and no associated signs or symptoms. Pre op and post op assessment was done using the Japanese Orthopaedic Association scoring (JOA score)system.8 For uniformity all surgeries were done by single surgeon, all patients underwent fenestration and intra-op complications were noted. Follow up was done at 14 days, 1 month, 3 months and 6 months and 1 year was done. Neurological status and signs for radicular pain and LBA were checked.Operative technique of fenestration: Patient is positioned in the prone knee-chest position, care being taken to see the abdomen is free so as to prevent undue engorgement of the epidural veins and thus decrease the extent of intra operative blood loss. A vertical mid-line incision is made after localizing the level of the disc. The para-spinal muscles are retracted and the interlaminar space is exposed. Only the ligementum flavum is excised removing only small part of the lamina. The thecal sac is retracted the disc herniation identified and discectomy carried out using disc removing forceps. The disc at that level is removed partially. The thecal sac and the roots are confirmed to be decompressed and lying freely in their respective canals. The wound is closed in layers and dressing done. After treatment: IV Antibiotics were given routinely for 2 days; the suction drain was removed within 48 hrs and the patient was mobilized with a lumbo sacral corsette on the second post operative day. Suture removal done on 10th post operative day. Patient was explained the different methods of taking care of the back and advised against doing any strenous activity for the first six weeks after which patient was gradually encouraged to get back to his previous level of activity. It is proved that limited disc excision is sufficient, rather than entire disc removal which can cause collapse of disc space and degeneration of apophyseal joints at a later date. 9, 10,11

RESULTS

A total number of 53 patients were selected for fenestration and operated during the period of February 2011 to April 2013. 48 patients were available for follow up of one year. Most of them had central paracentral PIVD more commonly and less commonly lateral and far lateral PIVD. Distribution of the study subjects were as follows mentioned in table 1

Above table 1 shows that majority of study subjects were males (56.3%) and female (43.7%). Table also shows that males were more in age group of 31-40 years and females were more in 41-50 years. Majority of the study subject were indulge in doing light work 56.3% followed by 43.8% performing heavy work. Majority of study subject had gradual onset of the symptoms ie 89.6% and only 10.4% had sudden onset of symptoms.75% of study subjects witnessed dull aching pain followed by catching pain in 22.9% study subject and 2.1% witnessed severe type of pain.

Above table 2 shows that there is improvement in all the parameters after fenestration operation majorly in low back pain with 66.7%, motor disturbances (65), followed by leg pain (63.3), and followed by gait (60%). Activity of daily living improved by 43.6% followed by SLR (passive)

Above table 3 shows that maximum study subjects had good JOA score falling in the good outcome with 56.3%, followed by 35.4% having excellent outcome and only 4% were having 8.3% outcome

DISCUSSION

Lumbar laminectomy is the most common operation for a herniated lumbar disc. But laminectomy has its inherent draw backs of a prolonged surgical time, more blood loss and a delayed convalescence period as compared to fenestration7. The post-operative complication (e.g., Arachnoiditis and adhesions) are found to be more when laminectomy is used as a procedure. To add this it is also found to Jeopardize the mechanical stability of the Spine.7 In such a situation a surgical procedure which is less damaging to the stability of the spine, has a shorter surgical time, less blood loss, lesser incidence of post-operative complications and ultimately has a shorter convalescence period would be more beneficial. Excision of a herniated disc for relief of sciatica provides rapid relief of sciatica and low back pain.12 The best result is achieved if the patient was operated on before two months of onset of symptoms of disabling sciatica.13In the younger patients it is important to aim toward an early return to duty via surgical treatment.14 Discectomy by fenestration method is kind of a surgical procedure wherein only the inter laminar space is utilized with removal of minimal part of the superior lamina, the cord is exposed, retracted and the discectomy carried out. The present study analysis the results of this surgical technique on the basis of the functional outcome of the patient, it shows an improvement in activities of daily living, gait, back pain, leg pain, sensory, motor and bowel bladder symptoms. The change in improvement in all above parameters and outcome after surgery indicate JOA to be a useful tool in evaluation. Present study stated that there is near about 50% improvement in the patient’s condition when JOA Score was taken into consideration, and in some parameters there were upto 65% improvements. Other studies stated that there was not more significant difference in the surgical procedure used, and they found fenestration was complicated process and not much useful. Similar results were found with the fenestration surgery which was equivalent to the results of study done by Sharma et al.15 In the present study similar type of prognostic factors were used and the results were also similar with studies of Smith M et al and Spangfort et al study which showed that lumbosacral discectomy appear favorable as evaluated in this study. Preoperative factors useful as predictors of short-term outcome are much less reliable when considering the longterm results. These factors were number of previous hospitalization, duration of leg pain, straight leg-raise examination, and presence of osteophytes, disc bulge, and duration of surgery. 9,16, In the present study duration of symptoms in study subjects was associated with surgical outcome of fenestration technique similar was found in other studies.17In the present study it was found that the clinical outcome was better after the fenestration surgery similar was found in study conducted in Rohtak.3

CONCLUSION

Form the following study it can be concluded that Interlaminar technique of fenestration is a safe and reliable method for treating patients of lumbar disc prolapse which shows improvement in all the aspects of the criteria which was taken into consideration in JOA score, but patients has to be closely scrutinized for surgery. The outcome was excellent in 35.4%% patients good in 56.3% and fair in 8.3% this satisfactory outcome is only because of carefully selecting patients. Change in the outcome score preoperatively compared to post operative shows that JOA score is a useful tool for evaluation of fenestration technique. Good neurological recovery has been noted following fenestration.

ACKNOWLEDGEMENT

Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.

References:

1. F. Postacchini, G.cinnotti, lubar disc herniation, Etiopathogenesis inFranco postacchini in Lumbar disc herniation, Thompson press, newDelhi, springerwein 1999: 151-152.

2. R.Prasad, M.F. Hoda, M.M. Dhakal, K. Singh, et al: Epidemiological Characteristics of Lumbar Disc Prolapse in a Tertiary Care Hospital. The Internet Journal of Neurosurgery. 2006 Volume 3 Number 1.

3. SS Sangwan, ZS Kundu, Raj Singh, P Kamboj, RC Siwach, et al:Lumbar disc excision through fenestration, Indian journal ofOrthopaedics, [2006], 40[2]:86-9.

4. Bo Johnson 1996 “Neurological signs of lumbar disc herniations” acta Otho scand 67[5]:466-69.

5. Sasani M, Ozer AF, Oktenoglu T, Canbulat N, Sarioglu AC. Percutaneous endoscopic discectomy for far lateral lumbar disc. Herniations, Minim Invasive Neurosurg. 2007 Apr; 50[2]:91-7.

6. Savitz MH, Doughty H, Burns P. Percutaneous lumbar discectomy with a working endoscope and laser assistance. Neurosurg Focus.Cited 1998 Feb 15; 4[2]:e9.Available from: http://www. ncbi.nlm.nih.Gov/pubmed/17206772.

7. Nagi, O.M. ‘Early results of discectomy by Fenestration technique’ Indian Journal of Orthopaedics, 1985;19[1]: 15-9

8. Japanese Orthopaedic Association (JOA). Japanese Orthopaedic Association Assessment Criteria Guidelines Manual. 1996. p-46-9.

9. Spangfort EV. The Lumbar disc herniation – a computer aided analysis of 2504 operation. Acta Orthop. Scand suppl 142:3-95, 1972.

10. Astrand, 2000 “Pain and orthopaedic and neurologic signs after lumbar discectomy”. Clinical Orthopaedics and related reserch, 379: 154–160.

11. Loupasis, George A, Stamos, Konstadinos, Katonis, et.al Sevento 20-Year Outcome of Lumbar Discectomy, Spine, 1999 November, 24[22]:2313.

12. Toyone, T., Tanaka, T., Kato, D. and Kaneyama, R. Low-back pain Following surgery for lumbar disc herniation. A prospective study. J.Bone Joint Surg (Am). 2004; 5: 86-A (5): 893-896.

13. Deyo, R. A. Non-operative treatment of low back disorders: differentiating useful from useless therapy. In: Frymoyer J.W., editor. The adult spine: principles and practice. New York: Raven Press. 1991; 1559–1560.

14. Ishihara, H., Matsui, H., Hirano, N. and Tsuji, H. Lumbar intervertebral disc herniation in children less than

16 years of age. Long-term follow-up study of surgically managed cases. Spine. 1997; 22 (17): 2044-2049.

15. Sharma, 1980 “A clinical profile of prolapsed intervertebral disc and Its management”. Indian Journal of Orthopaedics, 14(2): 204–212. 16. Smith M, Gallagher J, Memanus F. Surgery in lumbar disc protrusion. A long term follows up. In Med J 76:25-26, 1983.

17. D. Olsen, D. McCord and M. Law. Laparoscopic discectomy with Anterior interbody fusion of L5-S1, surgical endoscopy, 1996. December; 10[12]:1158-63.

Announcements

Dr. Pramod Kumar Manjhi joined Editor-in-Chief since July 2021 onwards

COPE guidelines for Reviewers

SCOPUS indexing: 2014, 2019 to 2021


Awards, Research and Publication incentive Schemes by IJCRR

Best Article Award: 

One article from every issue is selected for the ‘Best Article Award’. Authors of selected ‘Best Article’ are rewarded with a certificate. IJCRR Editorial Board members select one ‘Best Article’ from the published issue based on originality, novelty, social usefulness of the work. The corresponding author of selected ‘Best Article Award’ is communicated and information of award is displayed on IJCRR’s website. Drop a mail to editor@ijcrr.com for more details.

Women Researcher Award:

This award is instituted to encourage women researchers to publish her work in IJCRR. Women researcher, who intends to publish her research work in IJCRR as the first author is eligible to apply for this award. Editorial Board members decide on the selection of women researchers based on the originality, novelty, and social contribution of the research work. The corresponding author of the selected manuscript is communicated and information is displayed on IJCRR’s website. Under this award selected women, the author is eligible for publication incentives. Drop a mail to editor@ijcrr.com for more details.

Emerging Researcher Award:

‘Emerging Researcher Award’ is instituted to encourage student researchers to publish their work in IJCRR. Student researchers, who intend to publish their research or review work in IJCRR as the first author are eligible to apply for this award. Editorial Board members decide on the selection of student researchers for the said award based on originality, novelty, and social applicability of the research work. Under this award selected student researcher is eligible for publication incentives. Drop a mail to editor@ijcrr.com for more details.


Best Article Award

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A study by Muhas C. et al. entitled \"Study on Knowledge & Awareness About Pharmacovigilance Among Pharmacists in South India\" is awarded Best article for Vol 14 issue 22
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A Study by Karimova II et al. entitled "Changes in the Activity of Intestinal Carbohydrases in Alloxan-Induced Diabetic Rats and Their Correction with Prenalon" is awarded Best Article of Vol 13 issue 22
A Study by Ashish B Roge et al. entitled "Development, Validation of RP-HPLC Method and GC MS Analysis of Desloratadine HCL and It’s Degradation Products" is awarded Best Article of Vol 13 issue 21
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A Study by Amr Y. Zakaria et al. entitled "Single Nucleotide Polymorphisms of ATP-Binding Cassette Gene(ABCC3 rs4793665) affect High Dose Methotrexate-Induced Nephrotoxicity in Children with Osteosarcoma" is awarded Best Article for Vol 13 issue 19
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A Study by Sarmila G. B. et al. entitled "Study to Compare the Efficacy of Orally Administered Melatonin and Clonidine for Attenuation of Hemodynamic Response During Laryngoscopy and Endotracheal Intubation in Gastrointestinal Surgeries" is awarded Best Article for Vol 13 issue 07
A Study by M. Muthu Uma Maheswari et al. entitled "A Study on C-reactive Protein and Liver Function Tests in Laboratory RT-PCR Positive Covid-19 Patients in a Tertiary Care Centre – A Retrospective Study" is awarded Best Article of Vol 13 issue 06 Special issue Modern approaches for diagnosis of COVID-19 and current status of awareness
A Study by Gainneos PD et al. entitled "A Comparative Evaluation of the Levels of Salivary IgA in HIV Affected Children and the Children of the General Population within the Age Group of 9 – 12 Years – A Cross-Sectional Study" is awarded Best Article of Vol 13 issue 05 Special issue on Recent Advances in Dentistry for better Oral Health
A Study by Alkhansa Mahmoud et al. entitled "mRNA Expression of Somatostatin Receptors (1-5) in MCF7 and MDA-MB231 Breast Cancer Cells" is awarded Best Article of Vol 13 issue 06
A Study by Chen YY and Ghazali SRB entitled "Lifetime Trauma, posttraumatic stress disorder Symptoms and Early Adolescence Risk Factors for Poor Physical Health Outcome Among Malaysian Adolescents" is awarded Best Article of Vol 13 issue 04 Special issue on Current Updates in Plant Biology to Medicine to Healthcare Awareness in Malaysia
A Study by Kumari PM et al. entitled "Study to Evaluate the Adverse Drug Reactions in a Tertiary Care Teaching Hospital in Tamilnadu - A Cross-Sectional Study" is awarded Best Article for Vol 13 issue 05
A Study by Anu et al. entitled "Effectiveness of Cytological Scoring Systems for Evaluation of Breast Lesion Cytology with its Histopathological Correlation" is awarded Best Article of Vol 13 issue 04
A Study by Sharipov R. Kh. et al. entitled "Interaction of Correction of Lipid Peroxidation Disorders with Oxibral" is awarded Best Article of Vol 13 issue 03
A Study by Tarek Elwakil et al. entitled "Led Light Photobiomodulation Effect on Wound Healing Combined with Phenytoin in Mice Model" is awarded Best Article of Vol 13 issue 02
A Study by Mohita Ray et al. entitled "Accuracy of Intra-Operative Frozen Section Consultation of Gastrointestinal Biopsy Samples in Correlation with the Final Histopathological Diagnosis" is awarded Best Article for Vol 13 issue 01
A Study by Badritdinova MN et al. entitled "Peculiarities of a Pain in Patients with Ischemic Heart Disease in the Presence of Individual Combines of the Metabolic Syndrome" is awarded Best Article for Vol 12 issue 24
A Study by Sindhu Priya E S et al. entitled "Neuroprotective activity of Pyrazolone Derivatives Against Paraquat-induced Oxidative Stress and Locomotor Impairment in Drosophila melanogaster" is awarded Best Article for Vol 12 issue 23
A Study by Habiba Suhail et al. entitled "Effect of Majoon Murmakki in Dysmenorrhoea (Usre Tams): A Standard Controlled Clinical Study" is awarded Best Article for Vol 12 issue 22
A Study by Ghaffar UB et al. entitled "Correlation between Height and Foot Length in Saudi Population in Majmaah, Saudi Arabia" is awarded Best Article for Vol 12 issue 21
A Study by Siti Sarah Binti Maidin entitled "Sleep Well: Mobile Application to Address Sleeping Problems" is awarded Best Article for Vol 12 issue 20
A Study by Avijit Singh"Comparison of Post Operative Clinical Outcomes Between “Made in India” TTK Chitra Mechanical Heart Valve Versus St Jude Mechanical Heart Valve in Valve Replacement Surgery" is awarded Best Article for Vol 12 issue 19
A Study by Sonali Banerjee and Mary Mathews N. entitled "Exploring Quality of Life and Perceived Experiences Among Couples Undergoing Fertility Treatment in Western India: A Mixed Methodology" is awarded Best Article for Vol 12 issue 18
A Study by Jabbar Desai et al. entitled "Prevalence of Obstructive Airway Disease in Patients with Ischemic Heart Disease and Hypertension" is awarded Best Article for Vol 12 issue 17
A Study by Juna Byun et al. entitled "Study on Difference in Coronavirus-19 Related Anxiety between Face-to-face and Non-face-to-face Classes among University Students in South Korea" is awarded Best Article for Vol 12 issue 16
A Study by Sudha Ramachandra & Vinay Chavan entitled "Enhanced-Hybrid-Age Layered Population Structure (E-Hybrid-ALPS): A Genetic Algorithm with Adaptive Crossover for Molecular Docking Studies of Drug Discovery Process" is awarded Best article for Vol 12 issue 15
A Study by Varsha M. Shindhe et al. entitled "A Study on Effect of Smokeless Tobacco on Pulmonary Function Tests in Class IV Workers of USM-KLE (Universiti Sains Malaysia-Karnataka Lingayat Education Society) International Medical Programme, Belagavi" is awarded Best article of Vol 12 issue 14, July 2020
A study by Amruta Choudhary et al. entitled "Family Planning Knowledge, Attitude and Practice Among Women of Reproductive Age from Rural Area of Central India" is awarded Best Article for special issue "Modern Therapeutics Applications"
A study by Raunak Das entitled "Study of Cardiovascular Dysfunctions in Interstitial Lung Diseas epatients by Correlating the Levels of Serum NT PRO BNP and Microalbuminuria (Biomarkers of Cardiovascular Dysfunction) with Echocardiographic, Bronchoscopic and HighResolution Computed Tomography Findings of These ILD Patients" is awarded Best Article of Vol 12 issue 13 
A Study by Kannamani Ramasamy et al. entitled "COVID-19 Situation at Chennai City – Forecasting for the Better Pandemic Management" is awarded best article for  Vol 12 issue 12
A Study by Muhammet Lutfi SELCUK and Fatma entitled "Distinction of Gray and White Matter for Some Histological Staining Methods in New Zealand Rabbit's Brain" is awarded best article for  Vol 12 issue 11
A Study by Anamul Haq et al. entitled "Etiology of Abnormal Uterine Bleeding in Adolescents – Emphasis Upon Polycystic Ovarian Syndrome" is awarded best article for  Vol 12 issue 10
A Study by entitled "Estimation of Reference Interval of Serum Progesterone During Three Trimesters of Normal Pregnancy in a Tertiary Care Hospital of Kolkata" is awarded best article for  Vol 12 issue 09
A Study by Ilona Gracie De Souza & Pavan Kumar G. entitled "Effect of Releasing Myofascial Chain in Patients with Patellofemoral Pain Syndrome - A Randomized Clinical Trial" is awarded best article for  Vol 12 issue 08
A Study by Virendra Atam et. al. entitled "Clinical Profile and Short - Term Mortality Predictors in Acute Stroke with Emphasis on Stress Hyperglycemia and THRIVE Score : An Observational Study" is awarded best article for  Vol 12 issue 07
A Study by K. Krupashree et. al. entitled "Protective Effects of Picrorhizakurroa Against Fumonisin B1 Induced Hepatotoxicity in Mice" is awarded best article for issue Vol 10 issue 20
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A study by Asha Menon "Women in Child Care and Early Education: Truly Nontraditional Work" is awarded Best Article for Vol 10 issue 13
A study by Deep J. M. "Prevalence of Molar-Incisor Hypomineralization in 7-13 Years Old Children of Biratnagar, Nepal: A Cross Sectional Study" is awarded Best Article for Vol 10 issue 11 of IJCRR
A review by Chitra et al to analyse relation between Obesity and Type 2 diabetes is awarded 'Best Article' for Vol 10 issue 10 by IJCRR. 
A study by Karanpreet et al "Pregnancy Induced Hypertension: A Study on Its Multisystem Involvement" is given Best Paper Award for Vol 10 issue 09

List of Awardees

A Study by Ese Anibor et al. "Evaluation of Temporomandibular Joint Disorders Among Delta State University Students in Abraka, Nigeria" from Vol 13 issue 16 received Emerging Researcher Award


A Study by Alkhansa Mahmoud et al. entitled "mRNA Expression of Somatostatin Receptors (1-5) in MCF7 and MDA-MB231 Breast Cancer Cells" from Vol 13 issue 06 received Emerging Researcher Award


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Disclaimer: International Journal of Current Research and Review (IJCRR) provides platform for researchers to publish and discuss their original research and review work. IJCRR can not be held responsible for views, opinions and written statements of researchers published in this journal.



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International Journal of Current Research and Review (IJCRR) provides platform for researchers to publish and discuss their original research and review work. IJCRR can not be held responsible for views, opinions and written statements of researchers published in this journal

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