Cd Recovery Proxial [TOP]
In 1983, Weber14 conducteda retrospective study of 63 patients and reported a 70% rate ofrecovery independent of operative or non-operative treatment. Otherstudies have reported similar findings.12,16,17,30 He reported that surgical treatmentproduced better results than conservative management at one year,but no significant difference after four years.14 Long-term (> tenyears) results from Atlas et al31 showedthat patients treated operatively had worse baseline symptoms thanthose treated non-operatively but after ten years the mean and standarddeviation of the sciatic index frequency (pain score, pain frequency, weaknessscore, weakness frequency)31 wasnot significantly different between the two groups. Patients treated operativelyreported better early outcomes.31
Cd Recovery Proxial
There is consistent evidence that the outcome after surgery isrelated to the degree of pre-operative weakness.40,42,43,46,47 Ghahreman et al46 reported completerecovery (MRC grade 5) in 38 (68%) of their total 56 patients inwhom the power of dorsiflexion against gravity was preserved (MRCgrade 3 and 4). There was complete recovery in only ten patients(27%) who had more severe weakness pre-operatively (MRC grade
There seems to be no association between gender and the outcomeof surgery,40,41,46 and the association between ageand recovery of radicular weakness after surgery is unclear. Somestudies report that age has an adverse effect on the recovery ofradicular weakness.41,42,45,50 Aonoet al42 reportedthat increasing age at surgery adversely affected post-operativetibialis anterior strength (1.45 times with each ten year rise inage). However, multiple linear regression analysis eliminated ageas a significant factor in favour of duration of symptoms as olderpatients were weaker for longer.42 Ghahremanet al46 reportedthat younger patients made a better recovery in the first six weeksafter surgery. Stratification of patients based on age revealedthat patients between the ages of 25 and 40 years make a betterrecovery than those between the ages of 41 and 60 years, who alsomake a better recovery than patients over the age of 60. Maricondaet al41 reportedthat older age and longer pre-operative duration of symptoms arenegative predictors for the recovery of radicular weakness aftersurgery.
Other studies have reported no significant correlation betweenage and the recovery of motor weakness after surgery.20,40,43,45 Girardi et al43 reported thatage was not a predictor of full motor recovery.
The level most frequently affected by degenerative disease ofthe lumbar spine is L4/5.42 Compressionof two nerve roots by a disc herniation is seen more commonly inpatients with radicular weakness. Similarly, multiple levels includingL4-5 are commonly decompressed in patients with weakness due tospinal stenosis.48 Aonoet al42 reportedno significant difference in motor recovery between patients withsingle-level and multi-level compression.
Extruded and sequestrated herniations are weakly associated witha severe or very severe pre-operative deficit and only partial recoveryafter surgery.40 Theperonei, extensor hallucis longus (EHL)and tibialis anterior havethe least capacity to recover to their normal strength. Both Matsui et al44 and Girardi etal43 reportedthat the recovery of extensor hallucis longus is slower than thatof tibialis anterior. Girardi et al43 also noted that persistent weakness of extensorhallucis longus is the most common deficit, remaining present in36% of those who were weak pre-operatively.
The quadriceps femoris is rarely severely weakened, and all patientsso affected will make a complete or almost complete recovery.40 This is of clinicalrelevance as isolated EHL weakness rarely causes disability whileeven moderate quadriceps weakness will cause some disability.
The difference in outcome between the patient with a painlessfoot drop and one with a painful foot drop is unclear. Aono et al42 reported no significantdifference in neurological recovery between patients with painlessand painful motor weakness in surgically treated patients. Andersonand Carlsson45 and Naylor51 reported poorrecovery in weakness of the foot extensors, especially when painlessin surgically treated patients. These two conflicting reports allowus to draw no specific conclusion about the effect of radicularpain on the recovery of strength after surgery. Clinically, if apatient still has radicular pain two or three months after the onsetof symptoms, then the main indication for surgery is the relief ofpain and improvement in motor function is less likely to occur.Following decompression surgery, there is no evidence at the currentmoment, that the absence of pain predicts a worse outcome in termsof radicular weakness.
The rate of recovery has been well documented and most studiesagree that recovery happens soon after surgery. Ghahreman et al46 reported thatmost clinically significant improvement in weakness occurs within sixweeks of surgery for disc herniation. In their study, none of thepatients improved by more than one MRC grade after this. In 37 patients(66%) there was no improvement after six weeks.46 Aono et al42 reported thatthe earliest recovery to full strength was at six weeks and thelatest at two years. Jönsson and Strömqvist52 reported that 17 patients (50%)recovered motor power within two years of surgery, but most occurredwithin the first four months. Postacchini et al40 found that 96patients (83%) recovered most of their strength between two andfour months after surgery, while five (4%) showed no further improvement aftersix months. Patients with a severe pre-operative motor deficit wereslower to recover: six patients (16%) were still showing furthersigns of improvement at six months.
In summary, most of the recovery happens within the first sixmonths of surgery but motor recovery can continue, for up to twoyears after surgery. After discectomy, pain relief occurs first,followed by motor function and finally by improvement in sensation.8 Persistence of a minordermatomal sensory deficit is common and usually trivial.8
There is some evidence that Oxiplex gel/SP Gel (FzioMed, Inc.,San Luis Obispo, California) may improve motor recovery after surgery.A randomised controlled trial looking at its effectiveness also evaluatedits effect on motor weakness in patients having surgery for discherniation.55 Theauthors, who were funded by the manufacturers, found a greater improvement inmotor weakness in those patients treated with Oxiplex than in thosewho were not.55 However,this was a secondary outcome measure and further studies are needed.
Significant radicular weakness affects the long-term functionaloutcome. If a patient has had significant pain and weakness fortwo or three months, the risks and potential benefits of surgeryfor both problems should be discussed. If radicular weakness persistsbut is not causing disability, surgery is not indicated. If radicularweakness is causing significant disability after two to three monthsand there is no significant radicular pain, surgery should be considered.The chances of recovery are better with less severe weakness, youngerage, L2-L4 nerve involvement and disc herniation rather than stenosis.
How might purpose in life protect against depression, the body and brain ravages of growing older, and the accumulated toll of stress and challenges over the years? Based on the accumulating evidence, we hypothesize that one mechanism through which high purpose in life may protect against depression and the wear and tear of life stress is by providing a buffer from negative events, promoting reappraisal and motivated coping processes, decreasing brooding and ruminative thinking styles, supporting faster and better recovery, and thus increasing resiliency. Therefore, we hypothesize that higher levels of self-reported purpose in life will be associated with laboratory measures of emotional recovery, specifically, better automatic regulation of negative emotion as exhibited by better recovery from negative emotional stimuli. Importantly, this hypothesis combines phenomenologically-experienced aspects of well-being with objectively measured laboratory assessments of the time course of emotional responses, as this combination may offer unique windows on adaptive human functioning.
Note that although subjects A and B have similar initial reactivity during the 4 s picture presentation period, after picture offset they differ in emotional recovery. Subject A shows a prolonged poor recovery, whereas Subject B recovers more rapidly. Subject C demonstrates greater initial reactivity with rapid recovery, whereas Subject D exemplifies an individual who may show smaller, blunted emotional reactivity but severely impaired recovery.
Manipulation check. We used a linear mixed-effects model to test the expected valence (negative, neutral, positive) modulation effect, a main effect of probe time (reactivity, recovery), and a valence x probe time interaction on EBR magnitude. The model included a family-specific random effect to account for within-family dependence between twins and siblings, as well as a participant-within-family-specific random effect to account for the within-person dependence between EBR measurements. Pairwise comparisons between valences (negative, neutral, and positive) and probe times (reactivity, recovery) were adjusted for multiple comparisons using the Bonferroni correction.