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{{Scoliosis}}
{{Scoliosis}}


{{CMG}}; AE {{Rohan}}
{{CMG}}; {{AE}} {{Rohan}}


==Overview==
==Overview==
Patients with scoliosis usually appear normal. Physical examination of patients with scoliosis is usually remarkable for shoulder asymmetry, waist-line asymmetry, thoracic wall or breast asymmetry, and truncal decompensation.
Patients with [[scoliosis]] usually appear normal. Physical examination of patients with scoliosis is usually remarkable for [[shoulder]] asymmetry, waist-line asymmetry, [[thoracic wall]] or [[breast]] asymmetry, and truncal decompensation.


==Physical Examination==
==Physical Examination==
Physical examination of patients with scoliosis is usually remarkable for shoulder asymmetry, waist-line asymmetry, thoracic wall or breast asymmetry, and truncal decompensation.
{| align="right"
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[[File:Scoliosis physical exam.jpg|300px|thumb|none|Scoliosis physical findings.[https://commons.wikimedia.org/w/index.php?curid=36219861 Source: By https://wellcomeimages.org/indexplus/obf_images/8c/4f/9ae55eeb2f2735757102bb251795.jpg]]]
|}
Physical examination of patients with [[scoliosis]] is usually remarkable for [[Shoulder|shoulde]]<nowiki/>r asymmetry, waist-line asymmetry, [[thoracic wall]] or [[breast]] asymmetry, and truncal decompensation.<ref>{{cite book | last = Kapoor | first = Sudhir | title = Orthopaedic clinics spine : with video demonstration | publisher = CBS Publishers & Distributors | location = New Delhi | year = 2008 | isbn = 8123915993 }}</ref><ref name="pmid19030463">{{cite journal| author=Janicki JA, Alman B| title=Scoliosis: Review of diagnosis and treatment. | journal=Paediatr Child Health | year= 2007 | volume= 12 | issue= 9 | pages= 771-6 | pmid=19030463 | doi= | pmc=2532872 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19030463  }} </ref><ref>Azar, F., Canale, S., Beaty, J. & Campbell, W. (2017). Campbell's operative orthopaedics. Philadelphia, PA: Elsevier. Page: 1898-2028.</ref>


===Appearance of the Patient===
===Appearance of the Patient===
*Patients with scoliosis usually appear well.
*Patients with [[scoliosis]] usually appear well.
*Tanner staging done to predict magnitude of curve progression.
*[[Tanner stage|Tanner staging]] done to predict magnitude of curve progression.


===Vital Signs===
===Vital Signs===
Patients with scoliosis and other complications may have:
Patients with [[scoliosis]] and other complications may have:
*High blood pressure due to pulmonary hypertension and cor pulmonale
*[[Hypertension|High blood pressure]] due to [[pulmonary hypertension]] and [[cor pulmonale]]


===Skin===
===Skin===
Line 23: Line 27:


===HEENT===
===HEENT===
* HEENT examination of patients with Scoliosis is usually normal.
*HEENT examination of patients with [[scoliosis]] is usually normal.


===Neck===
===Neck===
* Neck examination of patients with scoliosis is usually normal. But, patients may have lateral bending of their neck due primary or secondary curve.
*Neck examination of patients with [[scoliosis]] is usually normal. But, patients may have lateral bending of their neck due primary or secondary curve.
* when scoliosis is complicated with pulmonary hypertension, it's physical findings may include:
*when [[scoliosis]] is complicated with [[pulmonary hypertension]], it's physical findings may include:
Prominent 'a' wave: due to forced atrial contraction  
**Prominent 'a' wave: due to forced atrial contraction  
**Prominent 'v' wave: later if [[Tricuspid regurgitation|tricuspid regurgitation]] develops with [[right ventricular failure]]
**Prominent 'v' wave: later if [[Tricuspid regurgitation|tricuspid regurgitation]] develops with [[right ventricular failure]]
**Elevated [[JVP]]: can be present if [[right ventricular failure]] develops
**Elevated [[JVP]]: can be present if [[right ventricular failure]] develops
Line 34: Line 38:


===Lungs===
===Lungs===
Patients with scoliosis and other complications may have:
Patients with [[scoliosis]] and other complications may have:
*Chest wall or breast asymmetry is seen
*[[Thoracic cavity|Chest wall]] or [[breast]] asymmetry is seen
*Decrease breast sounds upon auscultation of the lung  
*Decreased [[breast sounds]] upon auscultation of the [[lung]]


===Heart===
===Heart===
Patients with scoliosis and it's late complications such as pulmonary hypertension and cor pulmonale include physical findings:<ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref><ref name="isbn0-07-055417-X">{{cite book |author=Alexander, R. McNeill; Hurst, J. Willis; Schlant, Robert C. |title=The Heart, arteries and veins |publisher=McGraw-Hill, Health Professions Division |location=New York |year=1994 |pages= |isbn=0-07-055417-X |oclc= |doi= |accessdate=}}</ref><ref name="isbn0-7020-2993-9">{{cite book |author=Clark, Michael; Kumar, Parveen J. |title=Kumar and Clark's clinical medicine |publisher=Elsevier Saunders |location=St. Louis, Mo |year=2009 |pages= |isbn=0-7020-2993-9 |oclc= |doi= |accessdate=}}</ref>
Patients with [[scoliosis]] and it's late complications such as [[pulmonary hypertension]] and [[cor pulmonale]] include physical findings:<ref name="isbn0-7295-3905-9">{{cite book |author=Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP |title=Clinical Examination: A Systematic Guide to Physical Diagnosis |publisher=Churchill Livingstone |location=Edinburgh |year=2009 |pages= |isbn=0-7295-3905-9 |oclc= |doi= |accessdate=}}</ref><ref name="isbn0-07-055417-X">{{cite book |author=Alexander, R. McNeill; Hurst, J. Willis; Schlant, Robert C. |title=The Heart, arteries and veins |publisher=McGraw-Hill, Health Professions Division |location=New York |year=1994 |pages= |isbn=0-07-055417-X |oclc= |doi= |accessdate=}}</ref><ref name="isbn0-7020-2993-9">{{cite book |author=Clark, Michael; Kumar, Parveen J. |title=Kumar and Clark's clinical medicine |publisher=Elsevier Saunders |location=St. Louis, Mo |year=2009 |pages= |isbn=0-7020-2993-9 |oclc= |doi= |accessdate=}}</ref>
*Left parasternal heave: due to hyperdynamic right ventricle
*'''Left [[parasternal heave]]'''
*Palpable P2: correlates with severity of the disease
**Due to hyperdynamic right ventricle
*Ausculation
*'''Palpable [[P2]]'''
**Correlates with severity of the disease
*'''Ausculation'''
**First and second heart sound (S1,S2)
**First and second heart sound (S1,S2)
***Loud P2 component of S2: this is due to the forceful closure of the valve because of increased pulmonary pressure. It can be heard mostly in the pulmonary area (upper right sternal border). If it is evident at the cardiac apex, this indicates more severe disease. It is best appreciated on inspiration.
***Loud P2 component of S2: this is due to the forceful closure of the valve because of increased pulmonary pressure. It can be heard mostly in the pulmonary area (upper right sternal border). If it is evident at the [[Apex of the heart|cardiac apex]], this indicates more severe disease. It is best appreciated on inspiration.
**Splitting of S2
**'''Splitting of S2'''
***Narrowed splitting of S2: in chronic pulmonary hypertension, pulmonary artery compliance decreases leading to earlier pulmonary valve closure and narrowed splitting.
***Narrowed splitting of S2: in chronic [[pulmonary hypertension]], [[pulmonary artery]] compliance decreases leading to earlier [[pulmonary valve]] closure and narrowed splitting.
***Widened splitting of S2: widened splitting may occur later if right ventricular failure or bundle branch block develops.
***Widened splitting of S2: widened splitting may occur later if right ventricular failure or bundle branch block develops.
**Extra Heart Sounds
**'''Extra Heart Sounds'''
***S4: due to right ventricular hypertrophy and therefore reduced compliance secondary to pulmonary hypertension. It is increased with inspiration.
***S4: due to [[right ventricular hypertrophy]] and therefore reduced compliance secondary to [[pulmonary hypertension]]. It is increased with [[Inhalation|inspiration]].
***S3: if right ventricular failure develops. Increased with inspiration.
***S3: if [[Right heart failure|right ventricular failure]] develops. Increased with [[inspiration]].
**Additional Sounds
**'''Additional Sounds'''
***Systolic pulmonary ejection click: increased with inspiration
***Systolic pulmonary ejection click: increased with [[inspiration]]
**Murmurs
**'''Murmurs'''
***Ejection midsystolic murmur: increased with inspiration
***Ejection [[midsystolic murmur]]: increased with [[inspiration]]
***Diastolic murmur (Graham-Steele murmur): indicates pulmonary regurgitation
***[[Diastolic murmurs|Diastolic murmur]] (Graham-Steele murmur): indicates pulmonary regurgitation
***Pansystolic murmur: indicates tricuspid regurgitation and developing right ventricular failure[5]
***Pansystolic [[murmur]]: indicates [[tricuspid regurgitation]] and developing [[Right heart failure|right ventricular failure]]


===Abdomen===
===Abdomen===
*Abdominal examination of patients with Scoliosis is usually normal.
*Abdominal examination of patients with [[scoliosis]] is usually normal
*Flank fullness may be seen
*Flank fullness may be seen


===Genitourinary===
===Genitourinary===
*Genitourinary examination of patients with scoliosis is usually normal. But, in neuromuscular scoliosis, patient may present with bowel and bladder incontinence.
*Genitourinary examination of patients with [[scoliosis]] is usually normal. But, in [[neuromuscular scoliosis]], patient may present with bowel and bladder [[incontinence]].


===Neuromuscular===
===Neuromuscular (Spine)===
*Patient is usually oriented to persons, place, and time


===Spine===
====Gait====
*Patient is usually oriented to persons, place, and time<ref>{{cite book | last = Kapoor | first = Sudhir | title = Orthopaedic clinics spine : with video demonstration | publisher = CBS Publishers & Distributors | location = New Delhi | year = 2008 | isbn = 8123915993 }}</ref><ref name="pmid19030463">{{cite journal| author=Janicki JA, Alman B| title=Scoliosis: Review of diagnosis and treatment. | journal=Paediatr Child Health | year= 2007 | volume= 12 | issue= 9 | pages= 771-6 | pmid=19030463 | doi= | pmc=2532872 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19030463  }} </ref><ref>Azar, F., Canale, S., Beaty, J. & Campbell, W. (2017). Campbell's operative orthopaedics. Philadelphia, PA: Elsevier. Page: 1898-2028.</ref>
*Patients usually walk with bipedal unassisted [[Gait (human)|gait]].
*Some patients with neuromuscular scoliosis walk with a spastic [[Gait (human)|gait]].


===Gait===
====Palpation====
*Patients usually walk with bipedal unassisted gait.
*Some patients with neuromuscular scoliosis walk with a spastic gait.
 
===Palpation===
*No local rise in temperature
*No local rise in temperature
*Tenderness is usually not present.  
*[[Tenderness]] is usually not present.  
*Head may be centered or tilted away from pelvis
*Head may be centered or tilted away from pelvis
*Shoulders asymmetry  
*[[Shoulders]] asymmetry  
*Scapular asymmetry with one scapula being farther away from the the mid-line  
*[[Scapula|Scapular]] asymmetry with one scapula being farther away from the the mid-line  
*Spinous process are deviated away from mid-line
*[[Spinous process]] are deviated away from mid-line
*Lateral curvature of the spine, with curve described in terms of convexity directed to right or left
*Lateral curvature of the [[spine]], with curve described in terms of convexity directed to right or left
*Paraspinal muscle spasm may be present
*Paraspinal muscle spasm may be present
*Rib razor hump is usually present
*[[Rib]] razor hump is usually present
*Posterior Superior Iliac spine (PSIS) asymmetry seen
*Posterior Superior Iliac spine (PSIS) asymmetry seen
*Anterior Superior Iliac spine (ASIS) asymmetry seen
*Anterior Superior Iliac spine (ASIS) asymmetry seen
*List and step are usually not present
*List and step are usually not present
*Sagittal balance (Head in line with sacrum) may be disturbed
*Sagittal balance (Head in line with sacrum) may be disturbed
*Sinuses and tuft of hair may be present
*[[Sinuses]] and tuft of hair may be present
*Flank fullness may be seen
*Flank fullness may be seen


===Movement===
====Movement====
*Flexion and extension are usually affected
*[[Flexion]] and [[extension]] are usually affected
* Lateral flexion and rotation helps to identify rigidity of the curve
* Lateral flexion and rotation helps to identify [[rigidity]] of the curve


===Flexibility Test===
====Flexibility Test====
*Lateral bending test are usually affected
*Lateral bending test are usually affected
*Traction test are usually abnormal
*[[Traction (orthopedics)|Traction]] test are usually abnormal
*Prone position test are usually abnormal   
*Prone position test are usually abnormal   


===Neurological===
====Neurological====
*Motor
*Motor
**Motor weakness may be seen
**Motor [[Muscle weakness|weakness]] may be seen
**Spasticity and rigidity may be seen depending on level of involvement
**[[Spasticity]] and rigidity may be seen depending on level of involvement
**Sensory
**Sensory
***Fine touch and crude touch may be lost
***Fine touch and crude touch may be lost
***Hypoasthesia may be seen
***[[Hypoesthesia]] may be seen
***Postion sense and vibration may be disturbed
***Postion sense and vibration may be disturbed
***Two point discrimination may be lost
***Two point discrimination may be lost
**Reflexes
**Reflexes
*** Hypo or Hyper reflexia may be seen depending on level of involvement
*** Hypo or Hyper [[reflexia]] may be seen depending on level of involvement
***CLonus may be seen
***[[Clonus]] may be seen
**Cordination
**Coordination
***Cordination may be affected when scoliosis is associated with CNS involvement such arnold-chiari malformation
***[[Motor coordination|Coordination]] may be affected when scoliosis is associated with CNS involvement such arnold-chiari malformation


===Rib Hump===
====Rib Hump====
*Adam's forward bending test makes the hump prominent
*Adam's forward bending test makes the hump prominent


===Measurement===
====Measurement====
*Hump height
*Hump height
*Chest expansion is usually decreased
*[[Chest expansion]] is usually decreased
*Limb length discrepancy may be present
*[[Limb length discrepancy]] may be present
*Trunkal height is measured in standing and sitting position, which is usually abnormal
*Truncal height is measured in standing and sitting position, which is usually abnormal
*Scoliometer is used to measure the curve
*Scoliometer is used to measure the curve


===Special Test===
====Special Test====
*Straight leg raising (SLR) test may be positive
*'''Straight leg raising (SLR) test''' may be positive
**Test:
**Test:
***Patient in supine position with knee and hip in extension
***Patient in supine position with [[knee]] and [[Hip (anatomy)|hip]] in [[extension]]
***Elevate the patient's leg in air, so the hip gets gradually flexed with knees in extension
***Elevate the patient's leg in air, so the hip gets gradually flexed with knees in extension
***Presence of radiating pain in the leg between 30-70 degrees of hip flexion indicates a positive test
***Presence of radiating pain in the leg between 30-70 degrees of hip flexion indicates a positive test
   
   
*Cross SLR is usually absent
*'''Cross SLR''' is usually absent
**Test:
**Test:
***Patient in supine position with knee and hip in extension
***Patient in supine position with [[knee]] and [[Hip (anatomy)|hip]] in [[extension]]
***Elevate the patient's contralateral leg in air, so the hip gets gradually flexed with knees in extension
***Elevate the patient's contralateral leg in air, so the hip gets gradually flexed with knees in extension
***Presence of radiating pain in the ipsilateral leg indicates a positive test
***Presence of radiating pain in the ipsilateral leg indicates a positive test
   
   
*Lassegue test may be positive
*'''Lassegue test''' may be positive
**Test:
**Test:
***Patient in supine position with knee and hip in extension
***Patient in supine position with [[knee]] and [[Hip (anatomy)|hip]] in [[extension]]
***Elevate the patient's leg in air, so the hip gets gradually flexed with knees in extension
***Elevate the patient's leg in air, so the hip gets gradually flexed with knees in extension
***If radiating pain present in the legs between 30-70 degrees of hip flexion, then slightly lower down the angle of flexion at the hip and dorsiflex the ankle
***If radiating pain present in the legs between 30-70 degrees of hip flexion, then slightly lower down the angle of flexion at the hip and dorsiflex the ankle
***Presence of radiating pain in the leg again indicates a positive test
***Presence of radiating pain in the leg again indicates a positive test
   
   
*Bowstring test may be positive
*'''Bowstring test''' may be positive
**Test:
**Test:
***Patient in supine position with knee and hip in extension
***Patient in supine position with [[knee]] and [[Hip (anatomy)|hip]] in [[extension]]
***Elevate the patient's leg in air, so the hip gets gradually flexed with knees in extension
***Elevate the patient's leg in air, so the hip gets gradually flexed with knees in extension
***If radiating pain present in the legs between 30-70 degrees of hip flexion, then slightly bend the kneewhich will relieve the symptoms
***If radiating pain present in the legs between 30-70 degrees of hip flexion, then slightly bend the kneewhich will relieve the symptoms
Line 153: Line 157:
***Reproduction of radiating pain indicates nerve compression
***Reproduction of radiating pain indicates nerve compression


*Femoral stretch test may be positive
*'''Femoral stretch''' '''test''' may be positive
**Test:
**Test:
***Patient in prone position with knee bend to 90 degrees and hip in extension
***Patient in prone position with [[knee]] bend to 90 degrees and [[Hip (anatomy)|hip]] in [[extension]]
***Grasp the lower end of the femur and extend the hip
***Grasp the lower end of the [[femur]] and extend the [[Hip (anatomy)|hip]]
***Presence of pain on the anterior aspect suggests compression of the femoral nerve
***Presence of pain on the anterior aspect suggests [[Spinal cord compression|compression]] of the [[femoral nerve]]


===Extremities===
====Extremities====
*Feet may show cavovarus deformity
*Feet may show cavovarus deformity


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}


[[Category:Orthopedics]]
[[Category:Orthopedics]]

Latest revision as of 16:08, 10 December 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rohan A. Bhimani, M.B.B.S., D.N.B., M.Ch.[2]

Overview

Patients with scoliosis usually appear normal. Physical examination of patients with scoliosis is usually remarkable for shoulder asymmetry, waist-line asymmetry, thoracic wall or breast asymmetry, and truncal decompensation.

Physical Examination

Scoliosis physical findings.Source: By https://wellcomeimages.org/indexplus/obf_images/8c/4f/9ae55eeb2f2735757102bb251795.jpg

Physical examination of patients with scoliosis is usually remarkable for shoulder asymmetry, waist-line asymmetry, thoracic wall or breast asymmetry, and truncal decompensation.[1][2][3]

Appearance of the Patient

Vital Signs

Patients with scoliosis and other complications may have:

Skin

HEENT

  • HEENT examination of patients with scoliosis is usually normal.

Neck

Lungs

Patients with scoliosis and other complications may have:

Heart

Patients with scoliosis and it's late complications such as pulmonary hypertension and cor pulmonale include physical findings:[4][5][6]

Abdomen

  • Abdominal examination of patients with scoliosis is usually normal
  • Flank fullness may be seen

Genitourinary

Neuromuscular (Spine)

  • Patient is usually oriented to persons, place, and time

Gait

  • Patients usually walk with bipedal unassisted gait.
  • Some patients with neuromuscular scoliosis walk with a spastic gait.

Palpation

  • No local rise in temperature
  • Tenderness is usually not present.
  • Head may be centered or tilted away from pelvis
  • Shoulders asymmetry
  • Scapular asymmetry with one scapula being farther away from the the mid-line
  • Spinous process are deviated away from mid-line
  • Lateral curvature of the spine, with curve described in terms of convexity directed to right or left
  • Paraspinal muscle spasm may be present
  • Rib razor hump is usually present
  • Posterior Superior Iliac spine (PSIS) asymmetry seen
  • Anterior Superior Iliac spine (ASIS) asymmetry seen
  • List and step are usually not present
  • Sagittal balance (Head in line with sacrum) may be disturbed
  • Sinuses and tuft of hair may be present
  • Flank fullness may be seen

Movement

Flexibility Test

  • Lateral bending test are usually affected
  • Traction test are usually abnormal
  • Prone position test are usually abnormal

Neurological

  • Motor
    • Motor weakness may be seen
    • Spasticity and rigidity may be seen depending on level of involvement
    • Sensory
      • Fine touch and crude touch may be lost
      • Hypoesthesia may be seen
      • Postion sense and vibration may be disturbed
      • Two point discrimination may be lost
    • Reflexes
      • Hypo or Hyper reflexia may be seen depending on level of involvement
      • Clonus may be seen
    • Coordination
      • Coordination may be affected when scoliosis is associated with CNS involvement such arnold-chiari malformation

Rib Hump

  • Adam's forward bending test makes the hump prominent

Measurement

  • Hump height
  • Chest expansion is usually decreased
  • Limb length discrepancy may be present
  • Truncal height is measured in standing and sitting position, which is usually abnormal
  • Scoliometer is used to measure the curve

Special Test

  • Straight leg raising (SLR) test may be positive
    • Test:
      • Patient in supine position with knee and hip in extension
      • Elevate the patient's leg in air, so the hip gets gradually flexed with knees in extension
      • Presence of radiating pain in the leg between 30-70 degrees of hip flexion indicates a positive test
  • Cross SLR is usually absent
    • Test:
      • Patient in supine position with knee and hip in extension
      • Elevate the patient's contralateral leg in air, so the hip gets gradually flexed with knees in extension
      • Presence of radiating pain in the ipsilateral leg indicates a positive test
  • Lassegue test may be positive
    • Test:
      • Patient in supine position with knee and hip in extension
      • Elevate the patient's leg in air, so the hip gets gradually flexed with knees in extension
      • If radiating pain present in the legs between 30-70 degrees of hip flexion, then slightly lower down the angle of flexion at the hip and dorsiflex the ankle
      • Presence of radiating pain in the leg again indicates a positive test
  • Bowstring test may be positive
    • Test:
      • Patient in supine position with knee and hip in extension
      • Elevate the patient's leg in air, so the hip gets gradually flexed with knees in extension
      • If radiating pain present in the legs between 30-70 degrees of hip flexion, then slightly bend the kneewhich will relieve the symptoms
      • Apply digital pressure in popliteal fossa over the posterior aspect of sciatic nerve
      • Reproduction of radiating pain indicates nerve compression
  • Femoral stretch test may be positive

Extremities

  • Feet may show cavovarus deformity

References

  1. ↑ Kapoor, Sudhir (2008). Orthopaedic clinics spine : with video demonstration. New Delhi: CBS Publishers & Distributors. ISBN 8123915993.
  2. ↑ Janicki JA, Alman B (2007). "Scoliosis: Review of diagnosis and treatment". Paediatr Child Health. 12 (9): 771–6. PMC 2532872. PMID 19030463.
  3. ↑ Azar, F., Canale, S., Beaty, J. & Campbell, W. (2017). Campbell's operative orthopaedics. Philadelphia, PA: Elsevier. Page: 1898-2028.
  4. ↑ Simon O'Connor MBBS FRACP DDU; Nicholas P. Hirsch MBBS FRCA FRCP (2009). Clinical Examination: A Systematic Guide to Physical Diagnosis. Edinburgh: Churchill Livingstone. ISBN 0-7295-3905-9.
  5. ↑ Alexander, R. McNeill; Hurst, J. Willis; Schlant, Robert C. (1994). The Heart, arteries and veins. New York: McGraw-Hill, Health Professions Division. ISBN 0-07-055417-X.
  6. ↑ Clark, Michael; Kumar, Parveen J. (2009). Kumar and Clark's clinical medicine. St. Louis, Mo: Elsevier Saunders. ISBN 0-7020-2993-9.

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