{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,13]],"date-time":"2026-04-13T16:08:25Z","timestamp":1776096505564,"version":"3.50.1"},"reference-count":38,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"15","license":[{"start":{"date-parts":[[2026,4,13]],"date-time":"2026-04-13T00:00:00Z","timestamp":1776038400000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J Neurosurg Case Lessons"],"published-print":{"date-parts":[[2026,4,13]]},"abstract":"<jats:sec>\n                    <jats:title>BACKGROUND<\/jats:title>\n                    <jats:p>Cauda equina syndrome (CES) with sexual dysfunction is an uncommon but serious complication of lumbar disc herniation. Giant lumbar disc herniations, defined as occupying more than 50% of the spinal canal, can cause severe neural compression. Delayed decompression in CES is traditionally associated with poor neurological and autonomic recovery.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>OBSERVATIONS<\/jats:title>\n                    <jats:p>A 36-year-old man presented with a 1-year history of low back pain and progressive radiculopathy, followed by 3 months of incomplete CES manifested by urinary dysfunction, constipation, saddle hypoesthesia, sexual dysfunction, and right foot drop. MRI revealed a giant L4\u20135 disc extrusion with a cranially migrated sequestered fragment measuring nearly 10 cm in total length and extending 1.7 cm behind the L4 vertebral body, resulting in marked thecal sac compression. The patient underwent delayed microsurgical excision of the disc fragment. Postoperatively, back and leg pain improved immediately. Urinary symptoms resolved by 24 months, and sexual function fully recovered by 40 months, whereas motor deficits and muscle wasting showed minimal improvement.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>LESSONS<\/jats:title>\n                    <jats:p>Meaningful long-term recovery of bladder and sexual function is possible in incomplete CES despite delayed decompression, suggesting that neurological completeness at presentation may be a stronger prognostic factor than timing alone.<\/jats:p>\n                    <jats:p>\n                      <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"uri\" xlink:href=\"https:\/\/thejns.org\/doi\/10.3171\/CASE2647\">https:\/\/thejns.org\/doi\/10.3171\/CASE2647<\/jats:ext-link>\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.3171\/case2647","type":"journal-article","created":{"date-parts":[[2026,4,13]],"date-time":"2026-04-13T15:27:34Z","timestamp":1776094054000},"source":"Crossref","is-referenced-by-count":0,"title":["Long-term recovery of cauda equina syndrome and sexual dysfunction following delayed decompression of a giant lumbar disc herniation: illustrative case"],"prefix":"10.3171","volume":"11","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-1578-5579","authenticated-orcid":true,"given":"Mahesh","family":"Ramola","sequence":"first","affiliation":[{"name":"Department of Neurosurgery, S. G. R. R. Institute of Medical & Health Sciences, Dehradun, Uttarakhand"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0004-7676-5592","authenticated-orcid":true,"given":"Monika","family":"Ramola","sequence":"additional","affiliation":[{"name":"Department of Gynaecology and Obstetrics, S. G. R. R. Institute of Medical & Health Sciences, Dehradun, Uttarakhand, India"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0003-1099-8775","authenticated-orcid":true,"given":"Rajvi","family":"Dav","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, S. G. R. R. Institute of Medical & Health Sciences, Dehradun, Uttarakhand"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mahima","family":"Malhotra","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, S. G. R. R. Institute of Medical & Health Sciences, Dehradun, Uttarakhand"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1754","reference":[{"issue":"3","key":"bib1","series-title":"Acta Orthop Scand","first-page":"493","article-title":"Cauda equina syndrome in lumbar disc disease","volume":"51","author":"Choudhury","year":"1980","unstructured":"Choudhury ARTaylor JC.Cauda equina syndrome in lumbar disc disease. Acta Orthop Scand. 1980;51(3):493-499. doi:10.3109\/17453678008990830"},{"issue":"3","key":"bib2","series-title":"Spine (Phila Pa 1976)","first-page":"348","article-title":"Medical realities of cauda equina syndrome secondary to lumbar disc herniation","volume":"25","author":"Shapiro","year":"2000","unstructured":"Shapiro S.Medical realities of cauda equina syndrome secondary to lumbar disc herniation. Spine (Phila Pa 1976). 2000;25(3):348-352. doi:10.1097\/00007632-200002010-00015"},{"issue":"12","key":"bib3","series-title":"Spine (Phila Pa 1976)","first-page":"1515","article-title":"Cauda equina syndrome secondary to lumbar disc herniation: a meta-analysis of surgical outcomes","volume":"25","author":"Ahn","year":"2000","unstructured":"Ahn UMAhn NUBuchowski JMGarrett ESSieber ANKostuik JP.Cauda equina syndrome secondary to lumbar disc herniation: a meta-analysis of surgical outcomes. Spine (Phila Pa 1976). 2000;25(12):1515-1522. doi:10.1097\/00007632-200006150-00010"},{"issue":"3","key":"bib4","series-title":"Eur Spine J","first-page":"894","article-title":"Cauda equina syndrome: presentation, outcome, and predictors with focus on micturition, defecation, and sexual dysfunction","volume":"26","author":"Korse","year":"2017","unstructured":"Korse NSPijpers JAvan Zwet EElzevier HWVleggeert-Lankamp CLA.Cauda equina syndrome: presentation, outcome, and predictors with focus on micturition, defecation, and sexual dysfunction [presentation]. Eur Spine J. 2017;26(3):894-904. doi:10.1007\/s00586-017-4943-8"},{"issue":"4","key":"bib5","series-title":"Br J Neurosurg","first-page":"325","article-title":"Cauda equina syndrome: what is the relationship between timing of surgery and outcome?","volume":"16","author":"Gleave","year":"2002","unstructured":"Gleave JRMacfarlane R.Cauda equina syndrome: what is the relationship between timing of surgery and outcome? Br J Neurosurg. 2002;16(4):325-328. doi:10.1080\/0268869021000032887"},{"issue":"4","key":"bib6","series-title":"PLoS One","first-page":"e0175987","article-title":"The long term outcome of micturition, defecation and sexual function after spinal surgery for cauda equina syndrome","volume":"12","author":"Korse","year":"2017","unstructured":"Korse NSVeldman ABPeul WCVleggeert-Lankamp CLA.The long term outcome of micturition, defecation and sexual function after spinal surgery for cauda equina syndrome. PLoS One. 2017;12(4):e0175987. doi:10.1371\/journal.pone.0175987"},{"issue":"9","key":"bib7","series-title":"Acta Neurochir (Wien)","first-page":"1887","article-title":"An assessment of patient-reported long-term outcomes following surgery for cauda equina syndrome","volume":"161","author":"Hazelwood","year":"2019","unstructured":"Hazelwood JEHoeritzauer IPronin SDemetriades AK.An assessment of patient-reported long-term outcomes following surgery for cauda equina syndrome. Acta Neurochir (Wien). 2019;161(9):1887-1894. doi:10.1007\/s00701-019-03973-7"},{"issue":"6","key":"bib8","series-title":"Int J Impot Res","first-page":"319","article-title":"Development and evaluation of an abridged, 5-item version of the International Index of Erectile Function (IIEF-5) as a diagnostic tool for erectile dysfunction","volume":"11","author":"Rosen","year":"1999","unstructured":"Rosen RCCappelleri JCSmith MDLipsky JPe\u00f1a BM.Development and evaluation of an abridged, 5-item version of the International Index of Erectile Function (IIEF-5) as a diagnostic tool for erectile dysfunction. Int J Impot Res. 1999;11(6):319-326. doi:10.1038\/sj.ijir.3900472"},{"key":"bib9","series-title":"World Neurosurg","first-page":"133","article-title":"A simple new cost-effective retractor system for exposure in lumbar microdiscectomy: 1-year outcome analysis","volume":"165","author":"Ramola","year":"2022","unstructured":"Ramola MAggarwal ASingh R.A simple new cost-effective retractor system for exposure in lumbar microdiscectomy: 1-year outcome analysis. World Neurosurg. 2022;165:133-140. doi:10.1016\/j.wneu.2022.06.096"},{"issue":"9","key":"bib10","series-title":"Cureus","first-page":"e17952","article-title":"Massive lumbar disc herniation causing cauda equina syndrome that presents as bladder and bowel dysfunction in the absence of lower extremity weakness","volume":"13","author":"Nakamura","year":"2021","unstructured":"Nakamura KArizono TInokuchi AHamada TImamura R.Massive lumbar disc herniation causing cauda equina syndrome that presents as bladder and bowel dysfunction in the absence of lower extremity weakness. Cureus. 2021;13(9):e17952. doi:10.7759\/cureus.17952"},{"key":"bib11","series-title":"World Neurosurg","first-page":"e600","article-title":"Are there any risk factors associated with the presence of cauda equina syndrome in symptomatic lumbar disk herniation?","volume":"141","author":"Kaiser","year":"2020","unstructured":"Kaiser RKrajcov\u00e1 AWaldauf PSrikandarajah NMakel MBene\u0161 V.Are there any risk factors associated with the presence of cauda equina syndrome in symptomatic lumbar disk herniation? World Neurosurg. 2020;141:e600-e605. doi:10.1016\/j.wneu.2020.05.260"},{"issue":"10","key":"bib12","series-title":"PLOS One","first-page":"e0186148","article-title":"Lumbar spinal canal MRI diameter is smaller in herniated disc cauda equina syndrome patients","volume":"12","author":"Korse","year":"2017","unstructured":"Korse NSKruit MCPeul WCVleggeert-Lankamp CLA.Lumbar spinal canal MRI diameter is smaller in herniated disc cauda equina syndrome patients. PLOS One. 2017;12(10):e0186148. doi:10.1371\/journal.pone.0186148"},{"issue":"3","key":"bib13","series-title":"J Bone Joint Surg Am","first-page":"386","article-title":"Cauda equina syndrome and lumbar disc herniation","volume":"68","author":"Kostuik","year":"1986","unstructured":"Kostuik JPHarrington IAlexander DRand WEvans D.Cauda equina syndrome and lumbar disc herniation. J Bone Joint Surg Am. 1986;68(3):386-391. doi:10.2106\/00004623-198668030-00011"},{"issue":"4","key":"bib14","series-title":"J Neurosurg Spine","first-page":"305","article-title":"Timing of surgery in cauda equina syndrome with urinary retention: meta-analysis of observational studies","volume":"8","author":"DeLong","year":"2008","unstructured":"DeLong WBPolissar NNeradilek B.Timing of surgery in cauda equina syndrome with urinary retention: meta-analysis of observational studies. J Neurosurg Spine. 2008;8(4):305-320. doi:10.3171\/spi\/2008\/8\/4\/305"},{"issue":"12","key":"bib15","series-title":"Eur Spine J","first-page":"2143","article-title":"Cauda equina syndrome treated by surgical decompression: the influence of timing on surgical outcome","volume":"16","author":"Qureshi","year":"2007","unstructured":"Qureshi ASell P.Cauda equina syndrome treated by surgical decompression: the influence of timing on surgical outcome. Eur Spine J. 2007;16(12):2143-2151. doi:10.1007\/s00586-007-0491-y"},{"issue":"5","key":"bib16","series-title":"Neurosurgery","first-page":"743","article-title":"Cauda equina syndrome secondary to lumbar disc herniation","volume":"32","author":"Shapiro","year":"1993","unstructured":"Shapiro S.Cauda equina syndrome secondary to lumbar disc herniation. Neurosurgery. 1993;32(5):743-746. doi:10.1227\/00006123-199305000-00007"},{"issue":"4","key":"bib17","series-title":"Br J Neurosurg","first-page":"301","article-title":"Cauda equina syndrome: the timing of surgery probably does influence outcome","volume":"19","author":"Todd","year":"2005","unstructured":"Todd NV.Cauda equina syndrome: the timing of surgery probably does influence outcome. Br J Neurosurg. 2005;19(4):301-307. doi:10.1080\/02688690500305324"},{"issue":"7","key":"bib18","series-title":"J Bone Joint Surg Br","first-page":"1040","article-title":"Recovery of motor deficits after microdiscectomy for lumbar disc herniation","volume":"84","author":"Postacchini","year":"2002","unstructured":"Postacchini FGiannicola GCinotti G.Recovery of motor deficits after microdiscectomy for lumbar disc herniation. J Bone Joint Surg Br. 2002;84(7):1040-1045. doi:10.1302\/0301-620x.84b7.12948"},{"issue":"13","key":"bib19","series-title":"Dtsch Arztebl Int","first-page":"440","article-title":"Lumbar disc herniation\u2014the significance of symptom duration for the indication for surgery","volume":"121","author":"K\u00f6gl","year":"2024","unstructured":"K\u00f6gl NPetr OL\u00f6scher WLiljenqvist UThom\u00e9 C.Lumbar disc herniation\u2014the significance of symptom duration for the indication for surgery. Dtsch Arztebl Int. 2024;121(13):440-448. doi:10.3238\/arztebl.m2024.0074"},{"issue":"3","key":"bib1","series-title":"Acta Orthop Scand","first-page":"493","article-title":"Cauda equina syndrome in lumbar disc disease","volume":"51","author":"Choudhury","year":"1980","unstructured":"Choudhury ARTaylor JC.Cauda equina syndrome in lumbar disc disease. Acta Orthop Scand. 1980;51(3):493-499. doi:10.3109\/17453678008990830"},{"issue":"3","key":"bib2","series-title":"Spine (Phila Pa 1976)","first-page":"348","article-title":"Medical realities of cauda equina syndrome secondary to lumbar disc herniation","volume":"25","author":"Shapiro","year":"2000","unstructured":"Shapiro S.Medical realities of cauda equina syndrome secondary to lumbar disc herniation. Spine (Phila Pa 1976). 2000;25(3):348-352. doi:10.1097\/00007632-200002010-00015"},{"issue":"12","key":"bib3","series-title":"Spine (Phila Pa 1976)","first-page":"1515","article-title":"Cauda equina syndrome secondary to lumbar disc herniation: a meta-analysis of surgical outcomes","volume":"25","author":"Ahn","year":"2000","unstructured":"Ahn UMAhn NUBuchowski JMGarrett ESSieber ANKostuik JP.Cauda equina syndrome secondary to lumbar disc herniation: a meta-analysis of surgical outcomes. Spine (Phila Pa 1976). 2000;25(12):1515-1522. doi:10.1097\/00007632-200006150-00010"},{"issue":"3","key":"bib4","series-title":"Eur Spine J","first-page":"894","article-title":"Cauda equina syndrome: presentation, outcome, and predictors with focus on micturition, defecation, and sexual dysfunction","volume":"26","author":"Korse","year":"2017","unstructured":"Korse NSPijpers JAvan Zwet EElzevier HWVleggeert-Lankamp CLA.Cauda equina syndrome: presentation, outcome, and predictors with focus on micturition, defecation, and sexual dysfunction [presentation]. Eur Spine J. 2017;26(3):894-904. doi:10.1007\/s00586-017-4943-8"},{"issue":"4","key":"bib5","series-title":"Br J Neurosurg","first-page":"325","article-title":"Cauda equina syndrome: what is the relationship between timing of surgery and outcome?","volume":"16","author":"Gleave","year":"2002","unstructured":"Gleave JRMacfarlane R.Cauda equina syndrome: what is the relationship between timing of surgery and outcome? Br J Neurosurg. 2002;16(4):325-328. doi:10.1080\/0268869021000032887"},{"issue":"4","key":"bib6","series-title":"PLoS One","first-page":"e0175987","article-title":"The long term outcome of micturition, defecation and sexual function after spinal surgery for cauda equina syndrome","volume":"12","author":"Korse","year":"2017","unstructured":"Korse NSVeldman ABPeul WCVleggeert-Lankamp CLA.The long term outcome of micturition, defecation and sexual function after spinal surgery for cauda equina syndrome. PLoS One. 2017;12(4):e0175987. doi:10.1371\/journal.pone.0175987"},{"issue":"9","key":"bib7","series-title":"Acta Neurochir (Wien)","first-page":"1887","article-title":"An assessment of patient-reported long-term outcomes following surgery for cauda equina syndrome","volume":"161","author":"Hazelwood","year":"2019","unstructured":"Hazelwood JEHoeritzauer IPronin SDemetriades AK.An assessment of patient-reported long-term outcomes following surgery for cauda equina syndrome. Acta Neurochir (Wien). 2019;161(9):1887-1894. doi:10.1007\/s00701-019-03973-7"},{"issue":"6","key":"bib8","series-title":"Int J Impot Res","first-page":"319","article-title":"Development and evaluation of an abridged, 5-item version of the International Index of Erectile Function (IIEF-5) as a diagnostic tool for erectile dysfunction","volume":"11","author":"Rosen","year":"1999","unstructured":"Rosen RCCappelleri JCSmith MDLipsky JPe\u00f1a BM.Development and evaluation of an abridged, 5-item version of the International Index of Erectile Function (IIEF-5) as a diagnostic tool for erectile dysfunction. Int J Impot Res. 1999;11(6):319-326. doi:10.1038\/sj.ijir.3900472"},{"key":"bib9","series-title":"World Neurosurg","first-page":"133","article-title":"A simple new cost-effective retractor system for exposure in lumbar microdiscectomy: 1-year outcome analysis","volume":"165","author":"Ramola","year":"2022","unstructured":"Ramola MAggarwal ASingh R.A simple new cost-effective retractor system for exposure in lumbar microdiscectomy: 1-year outcome analysis. World Neurosurg. 2022;165:133-140. doi:10.1016\/j.wneu.2022.06.096"},{"issue":"9","key":"bib10","series-title":"Cureus","first-page":"e17952","article-title":"Massive lumbar disc herniation causing cauda equina syndrome that presents as bladder and bowel dysfunction in the absence of lower extremity weakness","volume":"13","author":"Nakamura","year":"2021","unstructured":"Nakamura KArizono TInokuchi AHamada TImamura R.Massive lumbar disc herniation causing cauda equina syndrome that presents as bladder and bowel dysfunction in the absence of lower extremity weakness. Cureus. 2021;13(9):e17952. doi:10.7759\/cureus.17952"},{"key":"bib11","series-title":"World Neurosurg","first-page":"e600","article-title":"Are there any risk factors associated with the presence of cauda equina syndrome in symptomatic lumbar disk herniation?","volume":"141","author":"Kaiser","year":"2020","unstructured":"Kaiser RKrajcov\u00e1 AWaldauf PSrikandarajah NMakel MBene\u0161 V.Are there any risk factors associated with the presence of cauda equina syndrome in symptomatic lumbar disk herniation? World Neurosurg. 2020;141:e600-e605. doi:10.1016\/j.wneu.2020.05.260"},{"issue":"10","key":"bib12","series-title":"PLOS One","first-page":"e0186148","article-title":"Lumbar spinal canal MRI diameter is smaller in herniated disc cauda equina syndrome patients","volume":"12","author":"Korse","year":"2017","unstructured":"Korse NSKruit MCPeul WCVleggeert-Lankamp CLA.Lumbar spinal canal MRI diameter is smaller in herniated disc cauda equina syndrome patients. PLOS One. 2017;12(10):e0186148. doi:10.1371\/journal.pone.0186148"},{"issue":"3","key":"bib13","series-title":"J Bone Joint Surg Am","first-page":"386","article-title":"Cauda equina syndrome and lumbar disc herniation","volume":"68","author":"Kostuik","year":"1986","unstructured":"Kostuik JPHarrington IAlexander DRand WEvans D.Cauda equina syndrome and lumbar disc herniation. J Bone Joint Surg Am. 1986;68(3):386-391. doi:10.2106\/00004623-198668030-00011"},{"issue":"4","key":"bib14","series-title":"J Neurosurg Spine","first-page":"305","article-title":"Timing of surgery in cauda equina syndrome with urinary retention: meta-analysis of observational studies","volume":"8","author":"DeLong","year":"2008","unstructured":"DeLong WBPolissar NNeradilek B.Timing of surgery in cauda equina syndrome with urinary retention: meta-analysis of observational studies. J Neurosurg Spine. 2008;8(4):305-320. doi:10.3171\/spi\/2008\/8\/4\/305"},{"issue":"12","key":"bib15","series-title":"Eur Spine J","first-page":"2143","article-title":"Cauda equina syndrome treated by surgical decompression: the influence of timing on surgical outcome","volume":"16","author":"Qureshi","year":"2007","unstructured":"Qureshi ASell P.Cauda equina syndrome treated by surgical decompression: the influence of timing on surgical outcome. Eur Spine J. 2007;16(12):2143-2151. doi:10.1007\/s00586-007-0491-y"},{"issue":"5","key":"bib16","series-title":"Neurosurgery","first-page":"743","article-title":"Cauda equina syndrome secondary to lumbar disc herniation","volume":"32","author":"Shapiro","year":"1993","unstructured":"Shapiro S.Cauda equina syndrome secondary to lumbar disc herniation. Neurosurgery. 1993;32(5):743-746. doi:10.1227\/00006123-199305000-00007"},{"issue":"4","key":"bib17","series-title":"Br J Neurosurg","first-page":"301","article-title":"Cauda equina syndrome: the timing of surgery probably does influence outcome","volume":"19","author":"Todd","year":"2005","unstructured":"Todd NV.Cauda equina syndrome: the timing of surgery probably does influence outcome. Br J Neurosurg. 2005;19(4):301-307. doi:10.1080\/02688690500305324"},{"issue":"7","key":"bib18","series-title":"J Bone Joint Surg Br","first-page":"1040","article-title":"Recovery of motor deficits after microdiscectomy for lumbar disc herniation","volume":"84","author":"Postacchini","year":"2002","unstructured":"Postacchini FGiannicola GCinotti G.Recovery of motor deficits after microdiscectomy for lumbar disc herniation. J Bone Joint Surg Br. 2002;84(7):1040-1045. doi:10.1302\/0301-620x.84b7.12948"},{"issue":"13","key":"bib19","series-title":"Dtsch Arztebl Int","first-page":"440","article-title":"Lumbar disc herniation\u2014the significance of symptom duration for the indication for surgery","volume":"121","author":"K\u00f6gl","year":"2024","unstructured":"K\u00f6gl NPetr OL\u00f6scher WLiljenqvist UThom\u00e9 C.Lumbar disc herniation\u2014the significance of symptom duration for the indication for surgery. Dtsch Arztebl Int. 2024;121(13):440-448. doi:10.3238\/arztebl.m2024.0074"}],"container-title":["Journal of Neurosurgery: Case Lessons"],"original-title":[],"link":[{"URL":"https:\/\/thejns.org\/view\/journals\/j-neurosurg-case-lessons\/11\/15\/article-CASE2647.xml","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/j-neurosurg-case-lessons\/11\/15\/article-CASE2647.xml","content-type":"text\/html","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/j-neurosurg-case-lessons\/11\/15\/article-CASE2647.xml","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,4,13]],"date-time":"2026-04-13T15:27:34Z","timestamp":1776094054000},"score":1,"resource":{"primary":{"URL":"https:\/\/thejns.org\/view\/journals\/j-neurosurg-case-lessons\/11\/15\/article-CASE2647.xml"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,4,13]]},"references-count":38,"journal-issue":{"issue":"15"},"URL":"https:\/\/doi.org\/10.3171\/case2647","relation":{},"ISSN":["2694-1902"],"issn-type":[{"value":"2694-1902","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,4,13]]}}}