tethered cord surgery in adults recovery time

Terminal syringohydromyelia and occult spinal dysraphism. Going from horizontal to vertical felt like being hit in the back of the head with a baseball bat. CSF leakage and urinary infection each occurred in 1 patient in untethering surgery cases, and massive intraoperative bleeding (more than 3,000 mL) was observed in 1 patient in the SSO group. The purpose of this study was thus to fill in this knowledge gap by comparing the surgical results of untethering surgery and SSO for treating TCS in adults. Surgery in adult patients with a tethered cord syndrome should be reserved for those with symptoms. The tethered spinal cord is developed by the following ways: A . Duraplasty using substitute materials was performed at the close of surgery. Wolters Kluwer Health Neurophysiological monitoring for safe surgical tethered cord syndrome release in adults. Features of the condition may include foot and spinal abnormalities; weakness in the legs; loss of sensation (feeling) in the lower limbs; lower back pain; scoliosis; and urinary incontinence. As this is just a retrospective study that does not involve any interventions, ethical approval was not necessary according to the rules of the hospital. Symptoms of Tethered Spinal Cord Syndrome in Teens and Adults. Throughout the entire surgery, the care team will check how your childs spinal cord is working properly. Thus, additional prospective randomized large-scale studies are needed to confirm our results. Typically, there is also a short filum and, as a result of both anomalies, a tethered cord. The surgical procedure performed at L1 is described below. Tethered cord syndrome (TCS) is a neurologic disorder caused by abnormal traction of the spinal cord resulting from several pathologic conditions: thickened filum terminale, meningocele, lipomyelomeningocele, and split cord malformation.1 Foley catheter removed on postoperative day one. A tethered cord release reduces or removes the . All 6 patients had tethered spinal cords, and 1 patient in each group had diastematomyelia. By preoperative Hoffman grading, in the 20 cases with grade 1, 8 cases of patients indicated symptoms improvement to grade 0; in cases with grade 2, 6 cases of patients were improved and transferred to grade 1, and 2 cases of patients transferred into grade 0; in cases with grade 3, 4 cases of patients showed improved symptoms and changed into grade 2; in cases with grade 4, 2 cases were improved and changed into grade 3. Adult intradural lipoma with tethered spinal cord syndrome. Methods: It is not a substitute for medical advice and should not be used to treatment of any medical conditions. 11 In syringomyelia, the watery liquid known as . All patients were followed up, no death occurred. 13 Preoperative shorter duration of symptoms is associated with favorable clinical outcome because the pathophysiology of TCS is associated with impaired oxidative metabolism in the affected spinal cord.7 2 In some people, these symptoms may not be noticeable until adulthood. Klekamp J. Tethered cord syndrome in adults. 2007;23(2):E11. This keeps the spinal cord from moving freely, leading to stretching and tension that can cause nerve damage. However, untethering carries risks of spinal cord injury and re-tethering. WebOnce the myelomeningocele is freed from all scarred attachments, the dura and the wound are closed. Only two of the 28 patients interviewed had received Workers' Compensation benefits; both of these had good outcomes and returned to work. Patient age ranged from 19 to 75 years. As first-line treatment, patients presenting with TCS typically undergo direct spinal cord untethering, often as young children or infants. As an alternative to untethering, Kokubun et al introduced spine-shortening osteotomy (SSO) for patients with TCS caused by a lipomyelomeningocele.11 SSO reduces the tension in the spinal cord and minimizes the perioperative complications.10 4 This prevents the spinal cord from moving to keep up with the lengthening of the spine as it grows. Careers, Unable to load your collection due to an error. Funding/support: This study was supported by Peking Union Medical College Youth Research Funds (2016) (project no. Unauthorized use of these marks is strictly prohibited. 7 WebAdult Tethered Cord Release - cns.org Open Access The Nexus online library is your free comprehensive resource for neurosurgical cases and approaches. In children, the surgery to de-tether the spinal cord is more common and can be done at many institutions; the procedure is also lower risk in children than in adults. In a baby with Spina bifida the spinal cord is still attached to the skin around it preventing it from rising properly. Tethered Spinal Cord in Teens and Adults | Memorial Hermann 10 Twenty-eight patients remained in stable clinical condition. For instance, if a traditional fusion surgery is performed, recovery time will be longer and thus differ from a less invasive, motion preserving spine procedure. Their clinical charts, operative records, and follow-up data were reviewed. Surgeries were performed under continuous electrophysiologic neuromonitoring with somatosensory-evoked potentials, combined with motor-evoked potentials, and electromyography with direct nerve root stimulation. Untethering surgery was performed as a first procedure at our institution, and a massive arachnoidal scar and adhesion were found intraoperatively. One patient in the untethering surgery group underwent SSO because the symptoms worsened 1year after untethering. Following a tethered cord release surgery, children are typically discharged in 1-2 days after surgery. 19. For all patients, pain was the most common major complaint. FOIA Cui ZG, Xiu B, Xiao K, et al. In adults, if the only abnormality is a thickened, shortened filum, then a limited lumbosacral laminectomy may suffice, with division of the filum once identified. [2], In 1886, Von Reeklinghausen reported autopsy results of the patients with lumbosacral hypertrichosis accompanied with spina bifida, showing that the spinal cord was adhered to fat in the lumbosacral region, conus terminalis was indicated to be tensed. 6 So for you to be re-tethered isn't because there may have been a misstake made during the first surgery, but because your body produced more scarring that caused the cord to reattach itself. Please enable it to take advantage of the complete set of features! [20] Therefore, early diagnosis and early surgical treatment will be possible to obtain a better prognosis for patients with symptomatic adult TCS. Chapman P H. Congenital intraspinal lipomas: anatomic considerations and surgical treatment. 8600 Rockville Pike The care team will discuss the type of tethered cord your child has when they review the imaging of their spine with you. Shooting pain in the legs. Some have ended up completely paralyzed from the surgeries. He experienced improvement in leg pain and motor strength after untethering. Physical therapy. Stetler WR Jr, Park P, Sullivan S. Pathophysiology of adult tethered cord syndrome: review of the literature. In addition, in terms of cost-effectiveness, SSO is substantially more costly than untethering, which means that SSO can be a financially viable option mainly just in very challenging cases of adult TCS. Urologic dysfunction subjectively improved in 36% of the patients with that complaint. This site needs JavaScript to work properly. A retrospective analysis of 82 adult patients (17 male cases, 82% and 24 female cases, 59%) with TCS treated by surgery was conducted between March, 2005 and December, 2015, with an average age of 31.6 years and average disease course of 6.7 years. 6 He presented with symptoms of lower back pain and legs pain. Surgical experience of 120 patients with lumbosacral lipomas. Tethered cord is usually present at birth . 13 On the other hand, even when the neurologic deficits are not severe at the time of presentation,9 sensory deficits and urologic dysfunction are more likely to remain static.1 Surgery may also restore some function or Iskandar BJ, Oakes WJ, McLaughlin C, Osumi AK, Tien RD. After the tumor was removed, the dura mater spinalis with low tonus was closed by water, and the dura mater spinalis with high tonus was formed by the autogenous fascia. Tethered spinal cord syndrome in adults is an uncommon entity that can become symptomatic. Since 1991, data obtained in 2515 patients with spinal cord pathologies were entered into the spinal cord database, and prospective follow-up was performed through outpatient visits and questionnaires. Tethered Spinal Cord Syndrome Causes, Diagnosis and Treatments In some instances, what is thought to be adult tethered cord syndrome is actually a similar abnormality affecting the spine. The .gov means its official. Call Today. The tethering effect was caused either by a split cord malformation, a thick filum terminale, a conus medullaris lipoma with extradural extension, or various combinations of these mechanisms. Despite having symptoms from birth, I was only recently . Because neurological deficits are generally irreversible, early surgery is recommended. Surgical treatments on adult tethered cord Tethered spinal cord syndrome is a neurologic disorder as well as a stretch-induced functional disorder caused . MeSH Abstract. WebThe surgery typically takes about four hours, but often takes longer as the neurosurgeon works to remove the adhesion. The mean estimated blood loss during surgery (300 ml in the open group vs 167 ml in the mini-open group, p = 0.313) and the mean length of stay (7 days in the open group vs 6.3 days in the mini-open group, p = 0.718) were similar between the 2 groups. Nakashima H, Imagama S, Matsui H, Yukawa Y, Sato K, Kanemura T, Kamiya M, Ito K, Matsuyama Y, Ishiguro N, Kato F. Global Spine J. The tethered spinal cord: its protean manifestations, diagnosis and surgical correction. Epub 2017 Feb 13. Statistical analyses were performed using SPSS version 18 (SPSS Inc., Chicago, Illinois, United States). 1994 Oct;81(4):513-9. doi: 10.3171/jns.1994.81.4.0513. Careers. FOLLOW ME ON INSTAGRAM-https://www.instagram.com/mattandemmHello, my name is Emily and I'm here to give you a peek into my daily life. Tethered Cord: Post-Operative Care Adult tethered cord is rare. This is common problem for people after any surgery, takes time. This may take a few attempts, so it is important to not become discouraged after their first try. 14. In some instances, what is thought to be adult tethered cord syndrome is actually a similar abnormality affecting the spine. [Intramedullary mature teratoma associated with an attached cord and an intradural lipoma. Stretching and tension, especially in a growing child, can cause neurologic damage. Treating A Tethered Spinal Cord In Adults - Sinicropi To investigate effects of surgical treatment on adult tethered cord syndrome (TCS). Yamada S, Won D J, Pezeshkpour G. et al. to maintaining your privacy and will not share your personal information without tethered cord surgery in adults recovery time The records of 22 patients ranging from 4 days to 10 years old (mean 2.7 The .gov means its official. WebPatients were examined by the same neurologist in a standardized fashion before and after surgery, and most were followed for at least 2 years postoperatively. This causes extra stress on the nerves and can cause a range of symptoms known as tethered cord syndrome. stretching. Correspondence: Yongning Li, Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, No. Webtom kenny rick and morty characters. Abbreviation: TCS = tethered cord syndrome. 2021 Feb 16;88(3):637-647. doi: 10.1093/neuros/nyaa491. Comparative Study of Untethering and Spine-Shortening Surgery Tethered cord syndrome: surgical outcome of 43 cases Some error has occurred while processing your request. According to Hoffman grading system, the neurologic symptoms were improved in 22 patients (27%) and stabilized in 60 patients (73%). Scheduled medications for pain relief during the early post-operative period at home include: There may be additional pain medications given as needed for breakthrough pain. Severe neurological deficits were rare. An official website of the United States government. 8600 Rockville Pike 11 Romagna A, Suchorska B, Schwartz C, Tonn J C, Zausinger S. Detethering of a congenital tethered cord in adult patients: an outcome analysis. Neurosurg Focus. Before Then, temporary rods were fixed in place for column stability while we performed the osteotomy. Yamada S, Zinke DE, Sanders D. Pathophysiology of tethered cord syndrome. flag football tournaments 2022 tethered spinal cord surgery recovery time. [2] As for normal embryo under 20 weeks, the termination of spinal cord was located at the level of L4 to L5, and at the level of L3 under 40 weeks, when the baby was born, it was located at the level of L1 to L2. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). [] This entity was first described by Garceau (1953) and Bethesda, MD 20894, Web Policies (C) Postoperative lateral radiograph 3 years after surgery shows complete bone union and significant spine shortening. 2022 Oct 6;10(28):10375-10383. doi: 10.12998/wjcc.v10.i28.10375. 1A and B). In adults, symptoms of tethered cord usually develop slowly. This is not associated with spina bifida, but may occur in patients with Chiari malformation. Federal government websites often end in .gov or .mil. The nurse will help schedule the COVID-19 PCR test. In this group of patients, postoperative pain symptoms of lumbosacral portion and both lower extremities improved significantly and remarkably, the defecation dysfunction in most patients was improved to some extent, but there were still some patients having frequent micturition and urinary retention; furthermore, muscle strength of lower limbs also increased, most patients had different degrees of improvement of muscle strength, which was basic consistent with the conclusion draw from Htittmann. Recovery was mostly seen in infants and only in one older child. This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Gao, Jun MD, PhD; Kong, Xiangyi MD; Li, Zhimin MD; Wang, Tianyu MD; Li, Yongning MD, aDepartment of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, People's Republic of China. Learn about career opportunities, search for positions and apply for a job. Please enable scripts and reload this page. All the patients were from China and of Asian ethnicity. For more information about these cookies and the data Before [4] In 1953, Garceau described the filum terminal syndrome, suspected that the tensive filum terminal pulled the spinal cord might cause defecation dysfunction and other symptoms. The patient with tight terminal filum underwent untethering surgery. Tethered cord syndromea study of the short-term effects of surgical detethering on markers of neuronal injury and electrophysiologic parameters. This causes stretching of the spinal cord as your child grows, leading to extra stress on nerves. Surgery Improvement in clinical features was compared in the untethering and SSO groups (Table 3). Based on this small retrospective case series, SSO appears to provide clinical improvement at least comparable to that of the untethering procedure, especially in more challenging cases (complex malformations or revision surgery). Highlight selected keywords in the article text. Object: In the adult population, many patients receive inadequate care unless they are seen at a multidisciplinary clinic. School-age children are typically out of school for 2 weeks. However, some neurological and motor impairments may not be fully correctable. Of the 2515 patients, 85 adults with a tethered cord syndrome formed the basis of this study. Untethering (tethered cord release) is the gold standard treatment for TCS. 17. collected, please refer to our Privacy Policy. One of the most common complications related to this surgery is wound infection, especially if the incision (cut into the skin) is made around the low back. For this procedure, the patient is placed under general anesthesia. Because the incision is lower on the back around a part of the spine that does not bear your childs body weight, pain is limited. Fax: 214-456-2497. Garceau theorized that tension on the . The clinical records were reviewed for preoperative symptoms, duration of symptoms, complications, and neurologic improvements. The https:// ensures that you are connecting to the Cerebrospinal fluid leakage and urinary infection occurred in 1 patient each among those with untethering, and massive intraoperative bleeding occurred in 1 patient with SSO. WebTethering can happen before or after birth in children and adults with Spina Bfida, and most often occurs in the lower (lumbar) level of the spine. Number of patients with organ space infection within 30 days of principal operative procedure Readmission within 30 days Return to the OR within 30 days Educational Module Download Tethered Cord: Post-Operative Care Educational Module Updated February 12, 2021 Key References: Bowman RM, Mohan A, Ito J, Seibly JM, Tethered cord syndrome in adults - PubMed The .gov means its official. WebIn adults, symptoms of tethered cord often develop slowly, but they can become quite severe. It is important for patients to discuss the goal of surgery with their doctor. Short-term results were determined within 3 months of surgery, whereas long-term outcomes (clinical recurrences) were evaluated using Kaplan-Meier statistics. No patients showed worsening of foot deformities and scoliosis. Most people have physical or occupational therapy to help regain function after surgery. WebMedian time to symptomatic improvement was least for pain (1 month), then motor (2.3 months), and then urinary symptoms (4.3 months; p = 0.04). 11/2021. Tethered cord due to spina bifida occulta presenting in adulthood: a tricenter review of 61 patients. As a result, the spinal cord can't move freely within the spinal canal. Doctor en Historia Econmica por la Universidad de Barcelona y Economista por la Universidad de la Repblica (Uruguay). This site needs JavaScript to work properly. 6 Repeated bladder infections. WebA retrospective analysis of 82 adult patients (17 male cases, 82% and 24 female cases, 59%) with TCS treated by surgery was conducted between March, 2005 and December, 2015, with an average age of 31.6 years and average disease course of 6.7 years. Clinical features at presentation are summarized in Table 1. For cyst wall with many serious adhesions of cauda equina nerve, partial resection of the cyst wall can be performed under electrophysiological monitoring, which will also have a good operation effect. A total of 32 consecutive adult patients underwent untethering surgery for secondary tethered cord syndrome in our department from January 2008 until December 2018. Among individuals who did not undergo surgery, 17 patients refused surgery and 25 patients underwent recommended conservative treatment. Adult tethered cord syndrome. 11. Surgical options include: Suboccipital decompression for Chiari malformation. The child usually can resume normal activities within a few weeks. 3332016010; grant recipient: XK) and Peking Union Medical College Graduate Student Innovation Fund (2015) (project no. 1999 Jan;90(1):175. doi: 10.3171/jns.1999.90.1.0175. 2 The photograph shows thick filum terminale isolated at the time of surgery before sectioning. Disclaimer. Recovery of lost muscle and bladder function depends upon the degree and length of preoperative implications. Rev. In the patients who had undergone myelomeningocele repair during infancy or previous untethering surgery, meticulous dissection was required to ensure complete release of the spinal cord because of extensive arachnoidal adhesions. Yamada S, Lonser R R. Adult tethered cord syndrome. At surgery, the spinal cord was freed from its attachments to the dura, and the symptoms resolved [13]. 20. WebFollowing a tethered cord release surgery, children are typically discharged in 1-2 days after surgery. Learn about the many ways you can get involved and support Mass General. Tethered cord syndrome (TCS) refers to a series of neurological dysfunction caused by the retraction of the conus medullaris related to a variety of reasons, which is manifested by both lower extremities orbicularis weakness, sensory abnormalities, defecation dysfunction, and so on.[1]. Spinal column shortening is an indirect detethering surgery which shortens and fuses the spine to relieve longitudinal pressure on the spinal cord. Recovery Surgery in adults Because neurological deficits are generally irreversible, early surgery is recommended. Tethered Cord Syndrome can be difficult to diagnose in babies and children since the symptoms may be subtle and insidious over time. Recovery from the surgery is one to two weeks of . 1). In adults, surgery to free the spinal cord can reduce the size and further development of cysts in the cord and may restore some function or alleviate other symptoms. During the first 24 hours, your child will remain flat on their back to prevent fluid leak from the incision. A total of 72 cases applied positive straight incision, 10 cases of lumbosacral lipoma with longitudinal incision. Although surgery in adults involves greater risk of neurological injury than in children, it is a low-risk procedure with encouraging results. The surgical release degrees for TCS with different pathologic changes are shown in Table 1. Of 40 cases without occupying lesions of tethered spinal cord, the symptoms were improved in 14 cases. The mean age at onset of symptoms and diagnosis was 30 years and 37 years, respectively. Back and leg pain improved in 50 and 63% of patients, respectively. I had tethered cord release and had micro leaks for 7 months with 3 blood patches at different levels. Methods: WebRecurrent tethered cord syndrome (TCS) can lead to significant progressive disability in adults. Tethered cord syndrome is a stretch-induced functional disorder associated with the fixation (tethering) effect of inelastic tissue on the caudal spinal cord, limiting its movement. We talked about bracing but it had to be delayed because a follow up MRI showed a tethered cord that needed surgery. To investigate effects of surgical treatment on adult TCS, a retrospective analysis of 82 adult patients with TCS treated by surgery was conducted between March 2005 and December 2015. . doi: 10.1093/jscr/rjaa041. Back pain: 14% better; 14% worse; leg pain: 11% better; 11% worse, Back pain: 78% better; 3% worse; leg pain: 83% better; 7% worse, Back pain: 77% better; leg pain: 47% better, 2% extradural hematoma/paraparesis; 5% revision CSF; 2% permanent neurologic worsening, 3% neurologic deterioration; 3% reoperation. However, his condition subsequently deteriorated, and he could not walk by himself 1year after untethering surgery. A conservative approach is warranted, however, in adult patients without neurological deficits. Chern JJ, Dauser RC, Whitehead WE, Curry DJ, Luerssen TG, Jea A. Spine (Phila Pa 1976). Neurological outcome after surgical management of This keeps the spinal cord from moving freely. Post-operative radiotherapy for recurrent dermoid cysts of the spine: a report of 3 cases. There were no significant differences in age, sex, and length of follow-up between the two groups. Tethered cord, also called tethered spinal cord syndrome, occurs when the spinal cord has abnormal attachments inside the spinal canal, usually at the base of the spine. and transmitted securely. Management of adult tethered cord syndrome: our experience and review of literature. Log in now and start Some surgeons require the patient to remain flat in bed for a couple of days to minimize the risk of spinal fluid (CSF) leakage from the wound. 12 The causes of tethering, preoperative duration of symptoms, and completeness of untethering could cause the outcomes to vary. 4 Pathophysiology of tethered cord syndrome and similar complex disorders. Imaging is very important for the diagnosis of tethered cord. Bulbocavernosus reflex (BCR) monitoring is used to assess the integrity of urinary and bowel function. Federal government websites often end in .gov or .mil. Lew SM, Kothbauer KF. Major or serious complications are uncommon during this surgery. A retrospective analysis of 82 adult patients with TCS treated by surgery was conducted between March 2005 and December 2015 in Peking Union Medical College Hospital. Copyright 2007-2023. 2020 Oct 29;11:362. doi: 10.25259/SNI_641_2020. To be included, patients (1) had to be>18 years old at the time of surgery and (2) had to have undergone spinal surgery for TCS. All patients were followed up, no death occurred. To investigate effects of surgical treatment on adult tethered cord syndrome (TCS). The horizontal sacrum as an indicator of the tethered spinal cord in spina bifida aperta and occulta. SSO was performed at the level of T12 or L1 (Fig. Mass General for Children and Massachusetts General Hospital do not endorse any of the brands listed on this handout. PMC Accessibility A retrospective analysis of 82 adult patients (17 male cases, 82% and 24 female cases, 59%) with TCS treated by surgery was conducted between March, 2005 and December, 2015, with an average age of 31.6 years and average disease course of 6.7 years. This lessens the chance of any major complications caused by damage to the spinal cord. In adults, surgery to detether (free) the spinal cord can reduce the size and further development of cysts in the cord and may . Klekamp J. Tethered cord syndrome in adults. There were 10 cases of lumbosacral intraspinal canal lipoma (12%), 32 cases of (39%) dermoid cyst and epidermoid cyst, and 40 cases (49%) without occupying lesions of tethered spinal cord. Tethered Spinal Cord | Boston Children's Hospital Treatment helps patients with tethered spinal cord syndrome have a normal life expectancy. We would like to thank our colleagues from the Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, and the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Harvard University. Frequent micturition, diminished knee and ankle reflexes, and difficulty in bending were exhibited in partial patients. It is essential to make surgical corrections on time and prevent irreversible damage to nerve tissue and consequent neurological deficits. Epub 2012 Jul 13. 6 8 This condition is In the case of adult tethered cord not . Each time she had a surgery to scrape away the scar tissue, there was more of it, and her doctors had to make larger incisions on her back. After surgery, the lipoma was removed almost completely (Fig. Activity modification. Surg Neurol Int. Postoperative Orders . Asian J Neurosurg. For patients treated conservatively, follow-up information could be obtained in 33 of 42 patients. 7 Surgical treatment on adult patients with TCS can improve the neurologic deficits which are associated with the course of disease, early treatment has much better curative effect. 6 Unauthorized use of these marks is strictly prohibited. Note: Results are the number of patients with improvement/the number of patients with each symptom preoperatively. Milano JB, Barcelos ACES, Onishi FJ, Daniel JW, Botelho RV, Dantas FR, Neto ER, de Freitas Bertolini E, Mudo ML, Brock RS, de Oliveira RS, Joaquim AF. Following postoperative lumbar spine reexamination by MRI, corresponding results were as follows: postoperative position of coni medullaris was relatively improved than that of the preoperative, and the width was broadened to the posterior wall of the thecal sac; the tension of filum terminale was decreased, filum terminale, and cauda equina showed relatively normal morphology, filum terminale apart from the posterior wall of the thecal sac was found in a part of cases of TCS patients; and if there was occupying lesions, volumes of occupying lesions showed decreased trends and indicated alleviated adhesion or compression to the coni medullaris or cauda equina. 11 Depending on your childs age, symptoms of tethered cord syndrome vary. The author analyzes data obtained in patients who were diagnosed with a tethered cord in adulthood and either underwent surgical or conservative therapy between 1991 and 2009. By clinical analysis of 611 cases of patients with lipoma-oriented TCS, Cui et al[19] proved that patients with no symptoms and mild symptoms obtained satisfactory postoperative curative effects, according to Hoffman grading evaluation of preoperative and postoperative changes of symptoms, whereas the curative effect was relatively poor in patients showing severe symptoms after operation, early surgical treatment was therefore recommended to obtain better curative effect.

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