Nerve Injury After Surgical Excision of Mandibular Third Molars Under Local Anesthesia: An Audit.

BACKGROUND: Injury of the inferior alveolar nerve (IAN) sustained during surgical removal of an impacted lower third molar may cause paresthesia of the lower lip, chin, lower gingivae and anterior teeth. Lingual nerve (LN) injuries may result in ipsilateral paresthesia of the anterior two thirds of the tongue, mucosa of floor of mouth and lingual gingivae. A close anatomic relationship between the roots of the third molar and mandibular canal places the IAN at risk of damage. PURPOSE: The primary aim of this retrospective audit was to ascertain the incidence of IAN and LN damage after mandibular third molar surgery in National Dental Centre Singapore. A secondary aim was to identify the contributory factors for the risk of IAN and LN nerve injury on the basis of the data collected. METHODS: This retrospective audit included 1276 mandibular third molar surgical removals performed in the local anesthesia operating theatre (LAOT) at the National Dental Centre Singapore (NDCS) from April to December 2013. Data included patient details, clinical characteristics, and 1 week postoperative presence/absence of sensory alteration as reported by the patient. RESULTS: Summary of results- Out of 1276 third molar sites audited, 8 (0.62%) sites had altered sensation of the IAN and 1 (0.078%) had altered sensation of the LN at 1 week postoperative review. CONCLUSION: The incidence of IAN injury (0.62%) and lingual Nerve injury (0.08%) after one week from surgery in our audit was low compared to similar studies. This retrospective audit did not show any correlation of nerve injury to age, gender, race, site, angulation of tooth, grade of operator, removal of bone or tooth division. There was no single radiological sign associated with paresthesia, although the most common radiological signs were interruption of the canal line and darkening of the roots.

Using a checklist to assess if a child undergoing MRI needs general anaesthesia.

AIM: To assess if a child-assessment checklist covering tasks children are expected to perform during magnetic resonance imaging (MRI) can determine whether the child requires general anaesthesia (GA) during MRI. MATERIALS AND METHODS: In this institute review board approved study, children who underwent MRI from September 2016 to June 2017 at KK Women's and Children's Hospital were assessed using a checklist by a research assistant before their examination. During this project, the checklist had no influence on whether the MRI was performed under GA or not. The checklist consisted of five items rated on a binary scale assessing the child's behaviour. Binary logistic regression was performed separately on the overall sample and for a subset of younger children to identify variables associated with the requirement for GA. RESULTS: The mean age of the overall sample (798 children) and the subset of children <8 years (124 children) were 11.7±3.7 and 5.5±1.3 years, respectively. In both groups, children who required GA were significantly younger than those who did not (p<0.001). No gender differences were observed. Children who required GA scored higher on the checklist compared to those who did not in both groups (p<0.001). The diagnostic accuracy of the checklist was found to be good (area under the curve [AUC]=0.97 for both groups), with a suggested cut-off score of 4. Intraclass correlation coefficient of the ratings by two independent individuals was 0.78. CONCLUSION: The child assessment checklist was useful in identifying GA requirement in children undergoing MRI and can be administered by non-medical staff with good inter-rater reliability.

Early morbidity associated with fasciotomies for acute compartment syndrome in children.

PURPOSE: Acute compartment syndrome (ACS) requires urgent fasciotomy to decompress the relevant muscle compartment/s prior to onset of irreversible myonecrosis and nerve injury. A fasciotomy is not a benign procedure. This study aims to describe and quantify early morbidity directly associated with fasciotomies for ACS in children. METHODS: Clinical charts of 104 children who underwent 112 fasciotomies over a 13-year period at a tertiary children's hospital were reviewed. The following were analyzed: ACS aetiology, fasciotomy site, number of subsequent procedures, method of wound closure, short-term complications and length of hospital stay. RESULTS: Short-term complications included wound infections (6.7%) and the need for blood transfusion (7.7%). Median number of additional operations for wound closure was two (0 to 10) and median inpatient stay was 12 days (3 to 63; SD 11.7). After three unsuccessful attempts at primary closure, likelihood of needing skin grafting for coverage exceeded 80%. Analyses showed that fasciotomy-wound infections were associated with higher risk for four or more closure procedures. Number of procedures required for wound closure correlated with longer inpatient stay as did ACS associated with non-orthopaedic causes. CONCLUSION: Fasciotomy is associated with significant early morbidity, the need for multiple closure operations, and prolonged hospital stay. The decision for fasciotomy needs careful consideration to avoid unnecessary fasciotomies, without increasing the risk of permanent injury from missed or delayed diagnosis. Skin grafting should be considered after three unsuccessful closure attempts. Less invasive tests or continuous monitoring (for high-risk patients) for compartment syndrome may help reduce unnecessary fasciotomies. LEVEL OF EVIDENCE: Level IV, Case series.

The impact of non-motor symptoms on the quality of life of Parkinson's disease patients: a longitudinal study.

BACKGROUND AND PURPOSE: Non-motor symptoms (NMSs) are common amongst patients with Parkinson's disease (PD); however, little is known about their influence on the health-related quality of life (QoL) over a defined follow-up period. The study was aimed to establish the impact of NMSs on the QoL of patients with PD over a 2-year follow-up period. METHOD: A total of 227 newly referred PD patients were prospectively recruited between 2013 and 2014. The Non-Motor Symptoms Scale was used to evaluate NMSs burden whilst QoL was assessed with the Parkinson's Disease Questionnaire-39 items. Motor disabilities were assessed using the Part III (motor) Unified Parkinson's Disease Rating Scale (UPDRSm). RESULTS: The mean age was 64.37 (10.18) years; 59.9% were males and a majority (89.0%) were ethnic Chinese. Almost 65% were unemployed and 84.6% had attained no more than secondary level of education. In the univariate analysis, total NMSs burden, age, gender, subsequent visit, Hoehn and Yahr staging, disease duration and UPDRSm score were individually predictive of change in the Parkinson's Disease Questionnaire Summary Index score from baseline to follow-up visit. However, in the multivariate analysis, total NMSs burden significantly predicted the QoL scores whilst motor scores did not. Specifically, NMS domains 2 (sleep/fatigue), 3 (mood/apathy) and 5 (attention/memory) were most significantly predictive of QoL change. CONCLUSION: Unlike motor disabilities, NMSs burden, in particular sleep, mood and attention, have a significant impact on the QoL of PD patients over a 2-year follow-up period.