ILC's Treatment for Spondylolisthesis
The "Cellgel Method" for Intervertebral disc repair and regeneration &
The "Florence Method", an advanced outpatient treatment for spinal canal stenosis
Are both now available in Japan!
For those who have been told it was impossible to operate,
For those who have had recurrence of pain post-surgery,
low-risk, outpatient treatments are now an option for you.
Contents
Table of Contents
Table of Contents
This page provides information on the main symptoms and causes of spondylolisthesis and our treatment procedures. The information includes the method of treatment, treatment time, and information about insurance. We use the Cellgel method, which is one of the most advanced methods in the world, and the characteristics of this method are also described in detail.
Please read this page especially if you have been told that you cannot be cured without surgery, if you have had surgery in the past but have not improved, or if you got better after surgery but the symptoms have recurred.
What is spondylolisthesis?
Sometimes, abnormalities in the spinal joints, called intervertebral joints, or in the intervertebral discs can cause the bones to shift. This is called "listhesis", meaning "slipping" or "sliding".
There are two types of slip syndromes: an anterior slip, in which the bone slips forward, and a posterior slip, in which the bone slips backward.
Most cases of spondylolisthesis are either degenerative spondylolisthesis or spondylolytic (cracked) spondylolisthesis. Back pain in degenerative spondylolisthesis is a symptom caused by a lumbar vertebra that has shifted from its original position. On the other hand, cracked spondylolisthesiss occurs when the back of the lumbar vertebrae become unstable due to cracks in the spinal process, caused by strain on a misaligned spine.
Although no clear cause is known, it is believed that lumbar spondylolisthesis is caused by the degeneration of tissues that hold the lumbar spine in place, such as intervertebral discs, ligaments, and joints, due to age or strenuous sports from a young age, and loss of stability in the lumbar spine. In addition, people suffering from these slip syndromes should refrain from strenuous exercise and twisting at the waist as much as possible. It is also necessary to refrain from doing anything that puts stress on the lower back in daily life.
Main symptoms of spondylolisthesis
Symptoms include numbness and pain in the buttocks and thighs after walking a short distance. After a short rest, the patient is able to walk again, but the characteristic symptom of spondylolisthesis is that the cycle of walking a short distance and taking a short rest is repeated over and over again.
In the case of a slipped lumbar spine, the nerve pathways that run behind the lumbar vertebrae may be compressed by the misalignment, resulting in symptoms (pain, numbness in legs and buttocks) similar to spinal canal stenosis.
Once a lumbar vertebra has slipped, it is difficult to reverse it because will not return to its natural position.
Causes of spondylolisthesis
With age, the tissues that hold the lumbar spine in place, such as intervertebral discs, ligaments, and joints, degenerate, and the resulting loss of stability in the lumbar spine is believed to be the cause of slipping.
Recent research indicates that degeneration of the intervertebral discs is the root cause of spondylolisthesis. In other words, the initial degeneration of the intervertebral disc causes increased burden, inflammation, and deformation of the intervertebral joints, instability of the ligaments, and instability of the muscles, and that the overall result of all of these causes is the development of a slipped lumbar spine.
Research has also shown that risk of spondylolisthesis is higher in women than in men due to hormonal factors, and that "driving as a profession, strenuous manual labor, and sedentary work" are also contributing factors.
Reference: Degenerative Spondylolisthesis: A Narrative Review (published 2022)
Excerpt: The main local causes likely contribute to the formation of DS are: Disc degeneration Causing segmental stability; arthritis of the facet joints; ligamentous stabilizing component failure, and inadequate muscular stabilization.
Our approach to the treatment of spondylolisthesis
Generally, the first step in the treatment of slips is conservative therapy. If symptoms do not improve with conservative treatment and are prolonged, surgery is often suggested.
However, conventional surgical methods such as lumbar fusion and posterior lumbar decompression require removal of the bone and even spinal fusion, and have high surgical risks and a high recurrence rate (within 2 years) of 30-46% because they do not treat the cause of the problem. Although there are now innovations such as endoscopic surgery and minimizing the size of the wound, the principle is the same, and since it does not treat the underlying cause, the risk and recurrence rate are still high.
Here at our clinic, we have the Cellgel treatent for spondylolisthesis. We can also accommodate elderly patients who are at high surgical risk or who wish to undergo revision treatment.
By repairing and regenerating the degenerated intervertebral disc, it can prevent the spine from becoming misaligned, which is the root cause of slipped vertebrae.
It also stabilizes the spine and prevents pain caused by pressure on the nerves.
Conventional Surgery
High risk, generally cannot be operated on a second time. High-risk treatment for the elderly. Also, the artificial material implanted cannot be used permanently and is likely to need to be replaced after a certain period of time.
Cellgel Method
Since many of our patients come from far away,
we are happy to give free consultations to see which treatment is best for you
We'll diagnose your MRI images for free！
About our clinic's treatment methods
Our clinic has five treatment methods: Cellgel method, Florence method, hybrid laser method, PODD method, and PLDD method.
The five treatment methods have different features and benefits, but we would like to first introduce you to the "Cellgel method" , which is the only treatment that can "repair the intervertebral disc", and the "Florence method'', which can "widen the stenosis".
What is the Florence method?
The Florence method is an advanced treatment for spinal canal stenosis that has been introduced mainly in Europe and South America.
Spinal stenosis is a condition in which the intervertebral discs degenerate, resulting in herniated discs, or when the vertebrae lose stability and slip, narrowing the spinal canal and putting pressure on the nerves. This causes symptoms such as lower back pain or pain and numbness in the lower limbs, making it difficult to walk.
Spinal canal stenosis is the most common spinal disease, according to the spine surgery survey report of the Japanese Society of Spine and Spinal Cord Disease. *1
It is particularly common among people over 50 years old, and one in two people over 70 years old may suffer from this disease. *2
*1 Reference source: Yutaka Nohara et al., “Spine Surgery Survey Report of the Japanese Society of Spinal and Spinal Cord Disease,” “Journal of the Japanese Society of Spine and Spinal Cord Disease,” Vol. 15, No. 2, 2004.
*2 Reference source: Ken Yamazaki, “Lumbar spinal stenosis treatment strategy: Epidemiological survey and QOL survey of lumbar spinal stenosis—Prevalence and health-related QOL survey of the general population in local cities,” “Monthly Book Orthopedics,” No. 23 No., 2010.
Florence Method Treatment
Under local anesthesia and using an X-ray fluoroscope, an incision of approximately 1 to 2 cm is made in the back, a special tube is placed between the spinous processes of the lumbar vertebrae to be treated, and a spacer is inserted.
The wings of the spacer are opened to widen the narrowed spinal canal.
Local anesthesia is used to minimize the burden on the body, leaving only a small scar, and after about 2 to 3 hours rest, you are allowed to go home, on the same day of treatment.
Characteristics of the Florence Method
- Treatment time is short, so it allows same-day treatment
- Since it is performed under local anesthesia, there is less burden on the body.
- Because it is a percutaneous procedure, the skin incision is small, there is no muscle damage, and there is no bone abrasion.
- It is possible to maintain the height of the intervertebral foramen and reduce the burden on the facet joints.
- Spacers are available in 6 sizes, allowing the doctors to insert a device that matches the patient's skeleton.
- It is also possible to remove the embedded spacer
Flow Treatment Flow
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1. Inquiry
Our clinic is by appointment only, so be sure to make an appointment before visiting us.
Contact us on Whatsapp or by our contact form on this page.
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2. Remote MRI Diagnosis
For Tokyo Clinic:
An MRI scan will be performed at a clinic affiliated with our clinic before your appointment at our clinic. Please send the MRI CD-ROM data to us via email prior to your visit. Also, if you have MRI images taken at another hospital, please let us know when you contact us.For Osaka Clinic:
The MRI scan will be performed at our clinic on the day of your appointment. -
3. Choose Treatment Date
If the diagnosis confirms that you're a suitable candidate for our treatments, you may proceed to make an appointment with us. Kindly keep in mind the time it may take for you to secure a visa to enter Japan. A Japanese tourist visa is sufficient.
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4. Travel Arrangements
As we are an outpatient facility, you will be discharged on the same day as your treatment. Patients are asked to take care of their own visas, travel and accommodation arrangements.
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5. Pre-Treatment Examination
For Tokyo Clinic:
Please have your health insurance card, various medical certificates, image data, etc. ready when you come to the reception desk. After the check-in,, we will take X-ray images. After the X-ray, the doctor will spend approximately 30 minutes thoroughly examining the patient, and will consider and recommend the most suitable treatment plan for each patient.At the Osaka Clinic:
After the MRI/X-ray examination, the doctor will spend approximately 30 minutes thoroughly examining the patient, and will consider and propose the most appropriate treatment plan for each patient. -
6. Treatment
The Florence method is currently only performed at the Osaka clinic.
After your consultation at each clinic, if you wish to receive treatment, please coordinate the treatment date and time with the staff.
On the day of your treatment, since you have already been examined, so we will begin your treatment immediately after you change your clothes and prepare. Treatment time is approximately 30 minutes per area. -
7. Discharge
After the treatment, we provide a recovery room for you to rest for about an hour to 1.5 hours.
You are free to return home after the doctor examines you. -
8. Follow-up
We will contact you regularly for follow-ups after your treatment.
If you have any questions, please feel free to contact us.
Price Costs of the Florence Method
| Number of Discs Treated | 1 disc | 2 discs |
|---|---|---|
| Treatment Cost | 1,540,000 JPY | 2,090,000 JPY |
* The cost of treatment is indicated including taxes.
*If treatment is performed at our clinic, all examination/diagnosis costs and test costs such as MRI are included in the above costs.
*This treatment method is not covered by Japanese health insurance, so you will have to pay for the entire treatment yourself.
*Payment by credit card (VISA, MasterCard, JCB, American Express, Diners, Discover) is also possible.
*If you would like rehabilitation (low back pain specialized rehabilitation), it is also possible to pay by bank transfer.
*If you live and work in Japan, you can receive a tax refund by filing your final medical expense return.
About Cellgel
The Cellgel method is an advanced treatment for low back pain that has been implemented in more than 54 countries worldwide, predominantly in Europe.
As with other treatments, it does not decrease the disc volume, and since the drug remains in the disc as a gel-like implant after treatment, the disc can be preserved. Recent studies have also shown that the volume of the disc increases after treatment.*1
It is also thought that by repairing the disc and preventing leakage of the Nucleus Pulposus, the disc itself will restore its normal function with its own regenerative ability (*2).
It is particularly recommended for patients who are concerned about the risk of conventional disc surgery (MED, PELD, etc.).
*1 Source: European Journal of Radiology 109 (2018) 101–107 , Efficiency of an ethyl alcohol gel in symptomatic disc hernation
*2 Source: International Journal of Spine Surgery Vol. 15 Appendix 1 from regenerative treatment of disc degeneration
"Very good or good results were obtained in 202 (91.4%) of the 221 patients in group A. Of the 44 patients in group B, 37 patients (84%) presented very good or good results and in 9 (82%) of the 11 patients of group C, we obtained similar results. There was no allergic complication in any of our patients. Long-term follow-up magnetic resonance showed a dramatic reduction in hernia volume."
- Dr. J. Theron, one of the world's leading experts in the treatment of Celgel method, from his research article "Percutaneous Treatment of Lumbar Intervertebral Disk Hernias With Radiopaque Gelified Ethanol - A preliminary study."
Merits of Cellgel
- Possibility to repair intervertebral discs where unable to using surgical or laser treatment
- As the disc is repaired, the disc itself regains its original normal function through its own regenerative ability
- The Cellgel method uses local anesthesia over general anesthesia used in conventional surgery, making it less burdensome on the body
- Treatment is done with a thin needle, so the wound is minimal and recovery is rapid
- Treatment is very short, allowing for outpatient day treatment
- Safe, modern treatment proven in more than 54 countries around the world
Flow Cellgel Treatment Process
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01 Examination
MRI and X-rays will be taken, followed by a doctor's diagnosis.
If the diagnosis proves the Cellgel method suitable, treatment can begin that same afternoon. -
02 Before
TreatmentAfter entering the treatment room and administering local anesthesia to the lower back, a needle is inserted into the intervertebral disc identified in the examination.
A contrast scan is performed to confirm the location of the damaged disc. -
03 Treatment
The Cellgel drug is administered to the damaged area while confirming the location of the disc with a fluoroscopy device.
Once the drug has been absorbed, the needle is removed and the bleeding is stopped.
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04 Returning
HomeAfter the treatment, the patient rests in a private room for about an hour, and then allowed to go home after the post-treatment examination.
*Resting time depends on the patient's symptoms and condition.
Price Cost of Treatment for the Cellgel Method
| Number of Discs Treated |
1 disc | 2 discs | 3 discs | 4 discs | 5 discs |
|---|---|---|---|---|---|
| Treatment Cost | 1,320,000 JPY | 1,430,000 JPY | 1,540,000 JPY | 1,650,000 JPY | 1,760,000 JPY |
Swipe left/righ
* The cost of treatment is indicated including taxes.
*If treatment is performed at our clinic, all examination/diagnosis costs and test costs such as MRI are included in the above costs.
*This treatment method is not covered by Japanese health insurance, so you will have to pay for the entire treatment yourself.
*Payment by credit card (VISA, MasterCard, JCB, American Express, Diners, Discover) is also possible.
*If you would like rehabilitation (low back pain specialized rehabilitation), it is also possible to pay by bank transfer.
*If you live and work in Japan, you can receive a tax refund by filing your final medical expense return.
FAQ Q&A Regarding our clinic's treatment methods and spondylolisthesis
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QRegarding the difference in recurrence rate between the Florence method and surgery
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ACommon surgical operations for spinal canal stenosis include laminectomy and spinal fusion, but it has been reported that severe back pain may recur within 10 years after surgery, the patient may be unable to walk long distances, or they may need another operation. This is because the surgical procedure carries a high risk of damage to surrounding tissues such as ligaments and muscles, as well as new damage to bones caused by the screws. Therefore, the recurrence rate of symptoms is high after surgery.
On the other hand, the Florence method is performed with local anesthesia, which is less risky, and because it is a percutaneous procedure that requires a skin incision of about 1 to 2 cm, there is no damage to ligaments or muscles, and the recurrence rate is extremely low.
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QHow is it decided where to treat?
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AThe doctor spends about 30 minutes carefully examining the patient while looking at MRI and X-ray images, determines the cause of the patient's condition, determines the treatment area, and explains the corresponding treatment method to the patient. MRI images can confirm changes in shape, pressure on nerves, presence of damage and inflammation, etc. of the intervertebral discs, nerves, ligaments, and joints, which are all mainly associated with low back pain. can. X-ray images can mainly be used to check the condition of bones.
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QCan the Florence Method and Cellgel Methods be used together?
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AYes, these two treatments can also be done at the same time. There is no problem in performing the Florence method after treatment with the Cellgel method.
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QCan my symptoms temporarily worsen after treatment?
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ANo, your symptoms will not worsen after treatment. Depending on the case, paresthesia in the lower limbs may improve immediately after treatment. However, for lower back pain, you may need to take pain medication after treatment.
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QWhat level of exercise can I do after treatment?
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AIf it is a hobby level of exercise or sports, it can be done without any problem.
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QPlease tell me what to be careful of after treatment.
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AAfter surgery, avoid lifting heavy objects and doing strenuous exercise that involves twisting, bending, or stooping. Light exercise will be possible in the second week. Weight training is possible after 3 months.
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QIs it covered by insurance?
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ANo, it is not covered by insurance. Please feel free to contact our staff.
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QHow long and how far can I walk after surgery?
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ABecause the treatment is outpatient only, you can walk home within 2 to 3 hours after the procedure.
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QHow many clinic visits do I need before surgery?
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AOne examination is required before the surgery date. At the first consultation, we will review the images together to confirm your current condition and decide which treatment method is best for you. If the Florence method is optimal, you will be scheduled for surgery on another day.
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QAre there any restrictions on my means of transportation after surgery?
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AIt is best to refrain from using public transportation for 3 days after treatment. From the third day onwards, you may only travel by train or plane if you are accompanied by a companion.
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QWhat's the difference in the reccurence rate between Cellgel and conventional surgery?
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A
Surgical procedures, which began in the 1960s, aimed to remove and sometimes fix deformed bones and herniated tissue. However, new bone damage caused by screws and the lack of fundamental treatment (repair of the intervertebral disc annulus fibrosus) resulted in the appearance of additional back pain and recurrence rates.
Therefore, in the 1980s, the need for fundamental treatment increased, and the intervertebral disc treatment (Cellgel) that we provide at our clinic began. Cellgel, in particular, have been proven to repair and regenerate the intervertebral disc, resulting in not only improvement of symptoms, but also an extremely low recurrence rate.
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QHow is the disc to be treated determined?
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AThe doctor will spend about 30 minutes with the patient while looking at the MRI and X-ray images to determine the cause of the condition, determine the treatment area, and explain the corresponding treatment method to the patient. MRI images show the main factors that contribute to back pain (disc, nerve, ligament, and joint), such as changes in shape, pressure on the nerve, presence or absence of damage, and inflammation. The x-ray image mainly confirms the condition of the bones.
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QWhy is the Cellgel method applicable to cases where surgery showed no improvement?
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ADuring surgery for spondylolisthesis, the prolapsed herniation is removed, but the damaged disc remains intact. As a result, fresh nucleus pulposus components leak from the damaged disc and inflammation persists. On the other hand, our treatment can treat the disc injury itself, thus suppressing inflammation by reducing the fresh leakage of nucleus pulposus components.
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QMy back pain may temporarily worsen after treatment. How long will it last?
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AThe reason for the lower back pain is that spinal ligaments that have been compressed are stretched; the lower back pain lasts for about two weeks and then subsides.
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QWhat level of exercise can I perform after treatment?
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AGeneral recreational exercise and sports can be done without any problem. For professional athletes, the possibility of new disc damage is high and should be discussed in consultation with a doctor.
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QPlease tell me about what I should be cautious about after treatment.
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ADuring the first few days after treatment, the patient should rest and avoid prolonged sitting, heavy lifting, twisting, bending, or strenuous exercise. Patients should be able to perform routine tasks one week after treatment and should be able to perform light exercise by the second week. Weight training is allowed after 3 months.
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QIs the treatment covered by the Japanese national health insurance?
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ANo, it is not covered by the national insurance. If you have life insurance, you may be eligible. Please feel free to consult our staff regarding this matter.
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QHow long must I wait to be able to walk after treatment?
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AIt is an outpatient/day treatment, so you can walk about an hour after the surgery.
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QHow many doctor visits do I need to make before treatment?
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AWe require an MRI to be taken within three months for remote diagnosis, either with our affiliated clinic or from data sent by you. You can receive treatment on the same day after phyiscal diagnosis. You may also request only the diagnosis and come back only for the treatment at a later date.
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QCan I fly immediately after the treatment?
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AIf there are no problems after the treatment, you may fly. If there is any pain after the treatment, flying may not be recommended depending on the doctor's evaluation.
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QDoes spondylolisthesis cause deformation of the entire spine?
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AYes, other back disorders may occur as the slip progresses.
In some cases, spinal canal stenosis, which compresses nerves and narrows the nerve pathways, and disc herniation due to disc deformity may also occur.
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QIs spondylolisthesis caused by poor posture?
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AThis is one of the causes. However, this is not the only cause. It is important to be careful not have habitually strained posture, but there are other strains on the body like aging, daily working environment, and other factors.
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QIs there a way to relieve the pain caused by spondylolisthesis?
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AIf the slip is mild, it can be alleviated by rehabilitation and medication, but if the symptoms are severe or the slip is advanced, surgical treatment is considered. We offer one-day back pain treatment for elderly patients who are unable to undergo surgical procedures or those at risk for complications.
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QAre there any exercises that should not be done with spondylolisthesis?
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AIf you are sliding forward (anterior slip), avoid any movement that bends the body backward.
If you are sliding backward (posterior slip), be careful of any forward bending movements.
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QHow can I prevent spondylolisthesis?
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ATry to avoid activities that put stress on the lower back.
Especially for those who have been diagnosed with herniated discs or spinal canal stenosis, it is recommended to do back exercises on a daily basis or moderate physical activities such as walking.
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QIs there a quick way to cure spondylolisthesis?
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A
Depending on the individual, it is estimated to take about 6 months to 1 year after treatment.
In addition, the time required for improvement of pain and numbness depends on the symptoms and condition of the patient.
ILC Rehabilitation X Spondylolisthesis Treatment
Although the Cellgel method can repair and regenerate the disc itself, and other treatment methods we offer can fundamentally heal the disc; it is possible that the cause of back pain is not only the disc, but also muscles, joints, and ligaments that are affected by the disc.
In cooperation with our rehabilitation specialists, we recommend treating back pain caused by muscles, joints, and ligaments together.
We also offer a short-term intensive program for patients who live far away or overseas.
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ILC's Low Back Pain Treatment
Outpatient Treatment
Improve back pain disorders/
symptoms in relation to the nerves
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ILC's Rehabilitation Program
Specialized Low Back Pain Rehabilitation
Improve back pain disorders/symptoms in
relation to the joints, muscles, ligaments
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01
ILC's Specialized Back Pain Rehabilitation
Our Rehabilitation Approach to Spondylolisthesis
Since lumbar degenerative spondylolisthesis is caused by structural failure of disc degeneration and intervertebral joints, we believe that treatment using the Cellgel method is necessary for a fundamental solution.
After reestablishing the stability of the disc, it is necessary to find out the habitual stresses on the surrounding tissues that contributed to the disc degeneration and to change the posture and body movements in daily life.
In addition, since aging, smoking, lifestyle habits such as diet, and oxidative stress are risk factors for disc degeneration, our rehabilitation center also reviews lifestyle habits from a dietary point of view by a nutritionist.
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02
ILC's Specialized Back Pain Rehabilitation
How to Evaluate Spondylolisthesis
In order to understand the state of degenerative spondylolisthesis of the lumbar spine, a consultation is held with the doctor to determine which part of the spine is under stress based on imaging findings and the condition of the intervertebral disc.
Using the findings as a reference, we will evaluate the aggravating and mitigating factors of the symptoms in the posture and movements of daily life while actually moving the body slowly.
Aggravating and mitigating factors are defined as movements that should not be performed, and mitigating factors are symptoms that can be alleviated by doing certain body movements. We will comphehensively evaluate these factors with muscle strength and stiffness, and explore the nature of the symptoms.
In addition, since inflammation is very closely related to the state of the physical body, we will also conduct a medical interview and evaluate the level of oxidative stress to evaluate the factors contributing to inflammation.
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03
ILC's Specialized Back Pain Rehabilitation
Rehabilitation Treatment for Spondylolisthesis
There are two main types of treatment methods for spondylolisthesis:
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Acupuncture and exercise therapy
To reduce or eliminate compression of the cauda equina nerve and nerve roots due to weakening of the ligaments and other components of spine due to its movement forward, inflammation, and the load placed on the disc
- Heat therapy to improve blood circulation around pain points
- Acupuncture for local pain relief and soft tissue lubrication throughout the body
- Postural improvement and core training
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Dietary Guidance
When disc degeneration is progressing, the disc is prone to irritate the nerves that cause pain. In addition to excessive stress, such a condition causes excessive production of reactive oxygen species (ROS).
ROS is a partially activated form of oxygen taken into the body. While ROS work as a cellular transmitter and immune function, excessive production of ROS is a substance that is greatly related to lifestyle-related diseases such as cancer and cardiovascular diseases. The state of excessive presence of reactive oxygen species in the body is called oxidative stress.Reactive oxygen species cause oxidation and damage to intervertebral discs. Antioxidant supplementation is necessary to control oxidative stress levels to normal levels.
Recent studies have proven that enzyme intake reduces oxidative stress better than the typical antioxidants, vitamins A, C, and E.Since oxidative stress causes disc degeneration, which is the cause of herniated discs and spinal canal stenosis, our facility offers therapeutic diets (such as brown rice meals and enzyme drinks) as part of our residential rehabilitation program.
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Acupuncture and exercise therapy
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ILC's Specialized Back Pain Rehabilitation
Treatment Period for Spondylolisthesis Rehabilitation
Generally, the inflammation of lumbar degenerative spondylolisthesis itself tends to be alleviated in about one to two weeks after the Cellgel treatment and rehabilitation, although it varies from person to person.
Although aging plays a major role in degeneration, diet and posture habits need to be improved. . Although aging plays a major role in degeneration, diet and posture habits need to be improved as a whole. It takes at least 3 months for the body to physically change upon consistent posture and diet improvements, such as enzyme intake. Since daily and consistency is the key to pain relief, many people use our residential rehabilitation as an opportunity to improve their eating habits and reduce smoking.
Our facility also has a dietitian on staff, so we aim to improve the body and nutrition habit under the guidance of these experts.
We aim to achieve 100% effectiveness of treatment while incorporating the latest technology, so we spend at least 30 minutes with each patient to carefully and meticulously examine the patient's concerns in order to make a proper diagnosis and propose the most suitable treatment methods.
We are certain to find a way to alleviate or eliminate the pain and numbness you are experiencing, so please do not give up and give us a call instead!
- Tadaaki Minowa, Clinic Director
