• 검색 결과가 없습니다.

저작자표시

N/A
N/A
Protected

Academic year: 2022

Share "저작자표시"

Copied!
35
0
0

로드 중.... (전체 텍스트 보기)

전체 글

(1)

저작자표시-비영리-변경금지 2.0 대한민국 이용자는 아래의 조건을 따르는 경우에 한하여 자유롭게

l 이 저작물을 복제, 배포, 전송, 전시, 공연 및 방송할 수 있습니다. 다음과 같은 조건을 따라야 합니다:

l 귀하는, 이 저작물의 재이용이나 배포의 경우, 이 저작물에 적용된 이용허락조건 을 명확하게 나타내어야 합니다.

l 저작권자로부터 별도의 허가를 받으면 이러한 조건들은 적용되지 않습니다.

저작권법에 따른 이용자의 권리는 위의 내용에 의하여 영향을 받지 않습니다. 이것은 이용허락규약(Legal Code)을 이해하기 쉽게 요약한 것입니다.

Disclaimer

저작자표시. 귀하는 원저작자를 표시하여야 합니다.

비영리. 귀하는 이 저작물을 영리 목적으로 이용할 수 없습니다.

변경금지. 귀하는 이 저작물을 개작, 변형 또는 가공할 수 없습니다.

(2)

2 0 1 4 8

외상

후 감각 이상

환자 에 대한

외상 성 말초

삼차 신 경 병변

진단 기준 적용

및 지속 적 신경 병변 의 위험 인자 분석

2014년 8월 박사학위 논문

외상 후 감각이상 환자에 대한 외상성 말초 삼차신경 병변

진단기준 적용 및 지속적 신경병변의 위험인자 분석

조선대학교 대학원

치 의 학 과

유 지 원

(3)

외상 후 감각이상 환자에 대한 외상성 말초 삼차신경 병변

진단기준 적용 및 지속적 신경병변의 위험인자 분석

Appl i c at i on of pe r i phe r al t r aumat i c t r i ge mi na l ne ur opat hy c r i t e r i a t o pa t i e nt s wi t h al t e r e d s e ns at i on af t e r t r auma and out c ome pr e di c t or s af f e c t i ng pe r mane ntne ur opat hy

2 0 1 4 년 8 월 2 5 일

조선대학교 대학원

치 의 학 과

유 지 원

(4)

외상 후 감각이상 환자에 대한 외상성 말초 삼차신경 병변

진단기준 적용 및 지속적 신경병변의 위험인자 분석

지도교수 윤 창 륙

이 논문을 치의학 박사학위신청 논문으로 제출함.

2 0 14 년 4월

조선대학교 대학원

치 의 학 과

유 지 원

(5)

유지원의 박사학위 논문을 인준함

위원장 조선대학교 교수 김 흥 중 ( 인) 위 원 조선대학교 교수 윤 창 륙 ( 인) 위 원 조선대학교 교수 국 중 기 ( 인)

위 원 연세대학교 교수 최 종 훈 ( 인)

위 원 연세대학교 교수 김 성 택 ( 인)

2 0 14 년 6월

조선대학교 대학원

(6)

목 차

표 목 차 ···ⅱ

국문초록 ···ⅲ

Ⅰ.Introduction···1

Ⅱ.MaterialsandMethods···4

Ⅲ.Results···8

Ⅳ.Discussion···17

Ⅴ.Conclusions···22

References···23

(7)

표 목 차

Table1.Demographicfindingsinstudiedpopulation……… 8

Table2.Distributionsofinitiating eventsaffecting alteredsensationor pain……… 9

Table3.Differencesbetweenpatientprofilesintransientandpersistent group……… 10

Table4.Differencesbetweenresultsofmechanosensorytestingintran sientandpersistentgroup ……… 11

Table5.Diagnosesofsensorysignatures……… 12

Table6.Outcomepredictorsaffectingpersistentneuropathy………… 13

Table7.Sensitivity,specificity,PPV,NPV ofindividualcriteria,andfi naldiagnosesofPPTTN criteria……… 14

Table8.Sensitivity,specificity,PPV,NPV ofeach outcomepredictor, anddiagnosesofadjustedoutcomepredictorsredistributedaccordingto thePPTTN criteria……… 16

(8)

초록

외상 후 감각이상 환자에 대한 외상성 말초 삼차신경 병변 진단기준 적용 및 지속적 신경병변의 위험인자 분석

유 지 원

지도교수 :윤 창 륙

조선대학교 대학원 치의학과

연구목적:본 연구는 외상 후 감각이상 및 통증을 호소하는 환자에게 외상성 말초 삼차신경 병변의 진단기준을 적용하였을 경우 그 유용성을 평가하고, 환자의 주관적,객관적 특성을 비교 분석하여 지속적인 신경손상의 가능성에 대한 위험인자를 분석하고자 함이다.

연구대상 및 연구 방법:본 연구는 삼차 신경 영역의 외상 후 감각이상 및 통증을 호소하는 환자를 대상으로 후향적 연구를 시행하였다.환자의 증상 지속 기간에 따라 3개월 이내 증상이 경감된 환자는 일시적 신경손상,3개월 이상 증상이 지속된 경우는 지속적 신경손상 군으로 분류하였다.지속적인 신경손상 병변의 위험인자를 평가하기 위하여,진료기록을 토대로,환자 병력 에 따른 증상의 평가,방사선사진 상 신경손상의 징후,임상적 이학검사,전 류인지 역치 검사 결과를 비교하여,각 그룹 간 유의성 있는 변수에 대해 다 중회귀분석을 시행하였다.또한,외상성 말초 삼차신경 병변 기준을 적용하 여,민감도,특이도,양성 예측도,음성예측도를 평가하였다.다중회귀분석 상 유의성 있는 변수를 토대로,지속적 신경손상을 평가하는 기준을 재정립하여, 해당 기준의 민감도,특이도,양성 예측도,음성예측도를 산출하였다.

결과:연구기간 내,총 111명의 환자가 삼차신경 영역 외상 후,감각 이상 및

(9)

통증을 호소하였으며,일시적 신경손상 군은 23명,지속적 신경손상 군은 88 명이었다.외상성 말초 삼차신경 병변 기준의 민감도,특이도를 산출한 결과, 낮은 민감도,높은 특이도를 나타내었다.지속적 신경손상 군은 일시적 신경 손상 군에 비해 파노라마 방사선 상 신경 손상의 징후,이학 검사 상,핀 자 극 시 감각저하 및 자극이 방사상으로 퍼지는 증상,접촉 자극 시 자극이 방 사상으로 퍼지는 증상,이질통이 통계학적으로 유의성 있게 나오는 결과를 보였다.이를 토대로 다중 회귀분석을 시행한 결과,파노라마 방사선 사진 상 신경 손상의 징후,핀 자극시 감각저하,핀 자극 및 접촉 자극 시 방사상으로 퍼지는 증상이 집단에 영향을 끼치는 것으로 나타났으며,설명력은 60.7%로 나타났다.

결론:본 연구 결과,삼차신경 영역의 외상 후 감각이상 또는 통증을 호소하 는 환자에게 외상성 말초 삼차신경 병변 기준의 적용은 실질적으로 유용하다 볼 수 있다.그러나 외상 직후 증상의 지속 여부를 예측하는 위험인자의 보 완은 특히 의원성 외상의 경우,감각이상의 발생한 환자의 예후 평가 및 환 자의 기대수준을 적절하게 설정하는데 도움이 될 수 있다.추후 많은 환자군 을 대상으로 다기관 평가를 시행할 경우,본 연구를 보완하여,보다 정확한 위험인자 예측을 하는 것이 필요할 것이다.

주제어:삼차신경,신경손상,위험인자,외상,의원성,민감도,특이도

(10)

Ⅰ.I nt r oduct i on

Nervedamagefrom varietyoffactorscancausechronicneuropathic pain.Iatrogenicnervedamage,especially,canresultinmedico-legal issues.Indentistry,thetreatmentitselfisthesurgicalapproach,and cancauseharm totheperipheralnerve,whichintheorofacialareais aportionofthetrigeminalnerve.Dentaltreatmentswithreportsof nerveinjuryincludetheCaldwell-Lucintervention,orthognathic mandibularadvancementsurgery,extrusionofrootcanalfilling material,administrationoflocalanesthetic,andimplantsurgery,with thirdmolarextractionasthemostfrequentcause.1,2)Allthesechanges canbetransientorpersistentdependingonthedegreeofthethe nerveinsult.3)

Nervedamagecanaffectasinglenerveorseveralnerves,and resultinsensory,motor,and/orautonomicdeficitsintheaffected region.2)Damagetosensorynervescanresultinanesthesia,

paraesthesia,pain,oracombinationofthethree.Theresultingpain couldalsocreatesignificantfunctionalproblems.4)Patientswith trigeminalnervetraumaoftencomplainthatthesensorydisturbance and/orpaininterferewithdailyfunction,decreasingqualityoflifeand potentiallyleadingtosignificantpsychosocialproblems.5)The

significantdisabilityassociatedwiththesenerveinjuriesmayalso resultinincreasingnumbersofmedico-legalclaims.4)

AccordingtothereportoftheKoreaConsumerAgency,outof302 casesseekinglegalredressfordentaltreatment,101cases(33.4%) werecompensatedandreimbursed.Thenumberofcasesofsensory alterationwas34,11.3% ofallmedico-legalclaims.Theaverage amountofindemnitywas9,670,000(KRW)incasesoflingualnerve

(11)

injury(LNI),and6,230,000(KRW)inthoseofinferioralveolarnerve injury(IANI).Especially,incasesofdentalimplantplacement,the indemnitywasjudgedabout31,360,000(KRW).

Becauseofthesehighindemnities,andforthepatients’and

clinicians’ownwell-being,cliniciansshouldmakeparticularlystrong effortstopreventiatrogenicnervedamage.However,ifpatients complainaboutalteredsensationand/orpainafterdentalprocedures, thesepatientsshouldbereassessedfortheirconditions,medically managedforthem whenneeded,andreferredtoorofacialpainor oromaxillofacialsurgicalspecialistsforpropertreatment.Inaddition, orofacialpainororomaxillofacialsurgicalspecialistsshoulddiagnose theirconditionsproperly,andassessriskfactorsforchronic

neuropathy,toprovidethem withrealisticoutcomeexpectations.

Unfortunately,neuropathicpainduetotrigeminalinjuryhasbeen poorlydefined.Therearenostandardsorphysicalexaminationsto diagnosetheseconditions.Inarecentarticle,diagnosticcriteriafor

“PeripheralPainfulTraumaticTrigeminalNeuropathy(PPTTN)”were proposed.6)Theauthorstriedtocharacterizetheconditionand

coordinateitwiththeInternationalHeadacheSociety(IHS)criteria.In thatstudy,clinicalphenotypeswerecomparedbetweenPPTTN

patientsandclassicaltrigeminalneuralgia,andthestudyconcluded thatPPTTN criteriacouldbeclinicallyuseful.However,theclinical symptomsandpathophysiologyofthesetwodisordersarecompletely different.Inaddition,applyingthesecriteriainclinicswouldrequire evaluationofthePPTTN criteriaforbothsensitivityandspecificity.

Themaintargetpopulationwouldbepatientswithalteredsensation and/orpain,whichisthetypicalsymptom ofPPTTN.

(12)

Toourknowledge,therehavebeennostudiesevaluatingthe sensitivityandspecificityofPPTTN criteria,andassessingtherisk factorsofpermanentnervedamage.

Consequently,theaimsofthisstudyweretoevaluatethevalidity andreliabilityofPPTTN criteriaforpatientswithalteredsensation and/orpainbyevaluatingtheirsensitivityandspecificity,andto determineoutcomepredictorsaffectingpermanentneuropathy.

(13)

Ⅱ.Mat er i al sandMet hods

A.Subj ect s

Thiswasaretrospectivestudyofpatientswhocomplainedofaltered sensationorpainfollowingtrigeminalnervetrauma,from 2010to2013, whowerevisitingtheDepartmentofOralMedicine,ChosunUniversity, DentalHospital.

Thisstudywasnotconfinedtopatientswithiatrogenicnervedamage. Trigeminalneuropathicsymptomsafterfracturesortrafficaccidentscould alsobesubjectsofinsuranceclaims,sothesecaseswerealsoincluded.

Patientswithtrigeminalneuropathycausedbysystemicdiseaseorlocal inflammationwereexcludedinthisstudy.Inaddition,studiedpopulation wasconfinedtothedistributionofthetrigeminalnervethirdbranch,i.e., symptomsaffectedtothefirstandsecondbranchesofthetrigeminal nervewereexcluded.

Thisstudywasapprovedbytheinstitutionalreview boardofChosun University,DentalHospital,2013.

B.Met hods

Thepatienthistoriesandclinicalexaminationsweredocumented

accordingtoroutineproceduresforsensoryalterationaftertraumainthe DepartmentofOralMedicine,ChosunUniversity,DentalHospital.

Demographicdatacollectedfrom eachpatientincludedageofonsetand gender.From consecutiverecords,patientsforwhom thesymptoms

resolvedinlessthan3monthsweredesignatedthe“transientgroup”.The

“persistentgroup”wascomprisedofpatientswhosesymptomscontinued formorethan3monthsaftertrauma,accordingtopatienthistoryor

(14)

consecutiverecords.From theincludedpopulation’smedicalrecords, variableswerecollectedforcomparisonwiththoseofthepreviousstudy.6)

1.Var i abl esf r om pat i enthi st or y

Painintensitywasmeasuredusingavisualanaloguescale(VAS), where0wasnopainand10wasworstpainimaginable.Tomatch variableswiththepreviousstudy,6)thequalityofthepainwasadjusted byonedoctor(RyuJW)afterreviewingthemedicalrecords,whochose oneormoreofthefollowingdescriptiveterms:electrical,stabbing, throbbing,pressure,burning,oranycombinationofthefiveterms.This wasthesameforthetemporalpatterns,adjustedaccordingtoattack frequencyanddurationparameters:episodic,daily,andcontinuous. Patientswereaskedtoreportthepaindurationrepresentingthatofa typicalattack.Thepresenceofautonomicsignssuchastearing,redness, orswellingwasalsorecorded.Patientswereaskedabouttheirqualityof sleepafterthesymptomsstarted.A traumahistorywascollectedverbally andfrom relevantdocumentation(e.g.,thirdmolarextraction,dental implant,trafficaccident,fractureofjaws,etc.).

2.Var i abl esf r om cl i ni calexami nat i on

Theclinicalexaminationincludedmechanosensorytesting,and

radiographicexamination,toassessthesubjectivesymptomsofpatients. Mechanosensorytestingoftheaffectedandcontralateralareasincluded theuseofpinprickstimuli(withadentalexplorer)andbluntstimuli(with cottonswabs).Exceptforpatientswithlingualnervedamageonly(6 cases),allmechanosensorytestsweregiventotheextraoralaffectedarea.

Duringthetest,patientswereaskedtorateofresponsetoeachstimulus basedonascaleof0to100,suchthat0meantacompletesensory

(15)

deficittothegivenstimulus,while100meantthesameintensityof feelingasthatofthecontralateralarea.Whenpatientsreportedsensitivity over100(hypersensitivity),theywereaskedtoratethefeeling

numerically(>100).Thesetestswerecomplementedbyexaminingthe radiatingsensationcausedbyeachstimulus.Forstatisticalanalysis,the scoresofeachstimuluswerecategorizedinto4degrees:verylow (0-39), low (40-79),normal(80-119)andhigh(120-).Themechanosensorytests wererepeatedthreetimes.Basedonthesetests,affectedareaswere diagnosedasto“sensorysignature”tomatchthediagnosesofthe previousstudy.6)Inaddition,patientswhoagreedtofurtherevaluation proceduresfordefiningtheirsymptomsunderwentquantitativesensory testing(QST)usingtranscutaneouselectricalstimulideliveredbythe NeurometerNervscanNS3000device(Neurotron).TheNeurometerQST procedureswerematchedwithanotherpreviousstudythatevaluated neurosensoryalterationinorthognathicsurgeries.7)Stimuliweredeliveredat 250HztoassessthesensorythresholdassociatedwithA-δ fiber

stimulation,andat2,000Hzand5HzforA-β andC fiberevoked sensorythresholds,respectively.Subjectswereinstructedtoreleasea controlbuttonuponthefirstsensation.Bothoperatorandpatientswere blindedtothestimulusintensityprovided.Thescoresobtainedwitheach stimuluswereconvertedratios,oftheaffectedareatothecontralateral area.6)

Allpatientsunderwentpanoramicradiographicexaminationtoevaluate thenerveinjury.Additionalconebeam computedtomography(CBCT) imagingwastakentopatientswhoagreedtofurtherevaluationinorder tolocateandgrosslyassesstheextentofnervedamage.

3.Appl i cat i on t oPPTTN cr i t er i a

From medicalrecords,symptomsrelatedtotrigeminalneuropathywere

(16)

evaluatedaccordingtoPPTTN criteria.Sensitivityandspecificity,positive predictivevalue(PPV),andnegativepredictivevalue(NPV)were

calculatedoneachitems,andfinaldiagnoses.Item B (duration)was excluded,becausethedurationofthesymptomswasthecriterionby whichthestudiedpopulationwasgrouped.

4.Det er mi nat i on ofout comepr edi ct or saf f ect i ng per manentneur opat hy

Tofindoutthestatisticaldifferencesbetweenthetransientand persistentgroups,statisticalanalysiswasperformedviaPearson’s

chi-squaretest(χ2).Differencesbetweencontinuousvariables(onsetage andpainintensity)wereanalyzedwithStudent’st-test.

Toexplorepossiblecontributingfactorsaffectingthepermanenceof nerveinjury,theabovevariableswithsignificantdifferenceswere analyzedwithmultipleregressionanalysis.

Basedontheresultsoftheregressionanalysis,thevariableswith significancewereplacedontheitemsaccordingtotheirrespective

PPTTN criteria.Sensitivityandspecificity,PPV,andNPV werecalculated foreachitem,andfordiagnosesofoutcomepredictors.

C.St at i st i calAnal yses

DatawereanalyzedwithSPSS version18forWindows(SPSS, Chicago,Illinois,version18.0).

Statisticalsignificance was defined as p < 0.05,with a 95% confidence interval.

(17)

Group Onsetage(y±SD) Gender(M;F ratio) Transient(n=23) 40.30±16.25 8:15

Persistent(n=88) 46.51±15.27 35:53 Total(n=111) 45.23±15.61 43:68

Ⅲ.Resul t s

Intotal,111patientswerecollectedforthestudy,ofwhom 5.4% presentedwithLNI(6patients)and94.6% withIANI(96patients).The transientgroupwascomprisedof23patientsandthepersistentgroup wascomprisedof88patients.

A.Compar i son ofpat i entpr of i l esbet ween t he t r ansi entandper si st entgr oups

ThedemographicfeaturesofeachgrouparesummarizedinTable1.

Therewerenodifferencesinonsetageorgenderratiobetweengroups. Inevaluationofthelocation,theleftsidewasaffectedin50cases (45.05%),andtherightsidewasin48cases(43.24%).Bothsides (mentum area)wereaffectedin13cases(11.71%).

Table1.Demographicfindingsinstudiedpopulation

M:F ratio,male:femaleratio.

Onsetagewaspresentedasmeanyear±standarddeviation.

The distributions ofinitiating events causing altered sensation orpain aresummarized in Table2,whilethedifferencesbetween patientprofiles inthetransientandpersistentgroupsaredescribedinTable3.Patientsin the transientgroup mostly reported the quality ofpain to be pressure (73.90%), while the persistent group mostly reported burning pain (60.20%).Within groups,there were no significantdifferences in quality descriptors(χ2,p> 0.05).

(18)

Table 2. Distributions of initiating events affecting altered sensationorpain

Causes Cases Percentages(%)

Anesthesia 3 2.70

Massexcision 5 4.50 Endodontictreatment 9 8.11 Thirdmolarextraction 25 22.52 Fractureofmandible 18 16.22 Orthognathicsurgery 8 7.21 Incisionanddrainage 1 0.90 Implantplacement 31 27.93 Operative/Periodontictreatment 5 4.50

Wound 6 5.41

Pain intensity showed no differences in VAS scores between groups. The average(± SD)scores ofpain intensity were5.09± 1.98,and 5.48±

1.97inthetransientandpersistentgroups,respectively.

Inevaluationoftemporalpatterns,mostpatientsreportedcontinuous (87% and90.90% inthetransientandpersistentgroups,respectively)pain, withnosignificantdifferencesbetweengroups.

For35patients,qualityofsleepwasreportedasbadbecauseofthe trauma.Thisvariablewasnotstatisticallydifferentbetweenthegroups.

In theradiographicimaging tests,therewasa significantdifference(p

< 0.05) in the panoramic view test.Allpatients underwentpanoramic radiographs,and 59 patients (53.15%)also underwentCBCT imaging of thearea.Therewere14positivesignsofnervedamageusing CBCT out of46cases(30.43%),whileinpanoramicview therewerenosign.

(19)

Parameter Transient(n=23) Persistent(n=88) Statistics Intensity

(meanVAS±SD) 5.09±1.98 5.48±1.97 T,p=0.399

Temporalpattern

Daily=3(13.00%) Continuous=20 (87%)

Daily=8(9.10%) Continuous=80 (90.90%)

χ2,p=0.695

Autonomicsigns No=22(95.70%) Yes=1(4.30%)

No=85(96.60%)

Yes=3(3.40%) χ2,p=1.000

Sleepquality

No change= 16(72.70%) Bad=6(27.30%)

No change= 55(65.50%) Bad=29(34.50%)

χ2,p=0.439

Quality ofPain

Electric No=15(65.2%) Yes=8(34.80%)

No=47(53.40%)

Yes=41(46.60%) χ2,p=0.310 Stabbing No=15(65.2%)

Yes=8(34.80%)

No=58(65.90%)

Yes=30(34.10%) χ2,p=0.950 Throbbing No=23(100%)

Yes=0(0%)

No=84(95.50%)

Yes=4(4.50%) χ2,p=0.579 Pressure No=6(26.10%)

Yes=17(73.90%)

No=36(40.90%)

Yes=52(59.10%) χ2,p=0.192 Burning No=12(52.20%)

Yes=11(47.8%)

No=35(39.80%)

Yes=53(60.20%) χ2,p=0.284 Panoramic view

result

Yes=9(30.40%) No=14(60.90%)

Yes=56(63.60%) No=32(36.40%)

χ2,p=0.034*

Table 3.Differences between patient profiles in transientand persistentgroup

SD,standard deviation of mean value; T,Student’s t-test; χ2, Pearson’schi-squaretest.

*p<0.05(byPearson’schi-squaretest).

In the results ofmechanosensory testing,mostpatients suffered from reducedsensationcomparedtothecontralateralarea(Table4).Withblunt mechanical stimulus from cotton swabs,73.90% of the transient and 60.90% of the persistent group reported reduced sensation. With pin stimulus,69.50% of the transient and 58.60% of the persistent group

(20)

Parameter Transient(n=23) Persistent(n=88) p-value

Physical exam

Blunt stimulus

Very

low=11(47.80%) Low=6(26.10%) Normal=2(8.70%) High=4(17.40%)

Very

low=18(20.70%) Low=35(40.20%) Normal=10(11.50%) High=24(27.60%)

p=0.074

Radiating afterblunt stimulus

No=17(73.9%) Yes=6(26.10%)

No=29(33%)

Yes=59(67%) p=0.000***

Pin stimulus

Very

low=13(56.50%) Low=3(13.00%) Normal=0(0.00%) High=7(30.40%)

Very

low=23(26.40%) Low=28(32.20%) Normal=13(14.90)% )

High=23(26.40%)

p=0.012*

Radiating afterpin stimulus

No=19(82.60%) Yes=4(17.40%)

No=38(43.20%)

Yes=50(56.80%) p=0.0001** reported reduced sensation.Between groups,there was a statistically significant difference in the result of the pinprick test (p < 0.05). Radiating symptoms after blunt and pinprick stimuli were also significantlydifferentbetweengroups.

Eleven patientsin thetransientand 67patientsin thepersistentgroup underwentthe QST procedures with the Neurometer.The ratios ofthe scores(affectedarea:contralateralarea)in A-β,A-δ,andC fiberswere allsignificantly higherthan expected,butbetween thegroups,therewere nodifferences.

Table 4.Differences between results ofmechanosensory testing intransientandpersistentgroup

*p<0.05,**p<0.01,***p<0.001(byPearson’schi-squaretest).

(21)

Sensorysignatures Transient Persistent p-value

Hypoalgesia No 7(30.40) 30(34.10)

0.741 Yes 16(69.60) 58(65.90)

Hyperalgesia No 16(69.60) 64(72.70)

0.763 Yes 7(30.40) 24(27.30)

Hypoesthesia No 4(17.40) 24(27.30)

0.331 Yes 19(82.60) 64(72.70)

Hyperesthesia No 19(82.60) 64(72.70)

0.331 Yes 4(17.40) 24(27.30)

Allodynia No 16(69.60) 27(30.70)

0.001**

Yes 7(30.40) 61(69.30)

DiagnosesofsensorysignaturesaredescribedinTable5.Inthe transientgroup,hypoesthesiaandhypoalgesiawerethemainfeaturesof thesensorysignature.Inthepersistentgroup,hypoesthesia,hypoalgesia, andallodyniawerethemainfeatures.Betweengroups,therewasa statisticallysignificantdifferenceintheallodyniasignature(p< 0.01).

Table5.Diagnosesofsensorysignatures

**p<0.01(byPearson’schi-squaretest).

B.Out comepr edi ct or saf f ect i ng per si st ent neur opat hi csympt oms

Basedonthechi-squareandt-tests,thevariableswithsignificant differencesbetweengroupswereidentified:panoramicview result,reduced sensation,andradiationinthepinpricktest,radiationinthebluntstimulus test,andallodynia.Multipleregressionanalysiswasthenperformedon thesevariables(Table6).Theresultsrevealedthatthepresenceofa neurologiclesioninthepanoramicview result,reducedsensationinthe

(22)

Parameters β Wald Nagelkerke

R2 Exp(B) Panoramicview result 1.449 7.751**

0.607

4.258 Normalorexaggerated

sensationinthepinprick test

-0.536 1.405 0.585

Reducedsensationinthe

pinpricktest -2.018 5.778* 0.133 Radiatingafterblunt

stimulus 1.749 1.273 5.751 Radiatingafterpin

stimulus 1.917 5.606* 6.798 Allodynia -0.232 0.022 0.793 pinpricktest,andradiationinthepinpricktestcouldaffectthepersistent group,withNagelkerke’sR2calculatedtobe0.607.

Table6.Outcomepredictorsaffectingpersistentneuropathy

*p<0.05,**p<0.01,***p<0.001(bytheWaldtest).

C.Sensi t i vi t y,speci f i ci t y,PPV,andNPV f or PPTTN cr i t er i a

Table7showedestimatesforsensitivity,specificity,PPV,andNPV for theindividualitemsofthePPTTN criteria(A,C toE)andfinal

diagnosis.Eachitem showedsensitivitiesrangingfrom alow of20.72%

for“notattributedtoanotherdisorder”toahighof36.36% for“imaging orneurophysiologicsign”.Sensitivityofitem C (clinicalevidentsign)was notcalculatedbecauseallpatientsshowedatleastoneclinicallyevident neurologicdysfunction.Specificitiesrangedfrom 79.28% for“atleastone clinicalevidentneurologicdysfunction”to83.15% for“imagingor

(23)

Diagnosticcriteriaand

Diagnosticlevel Sensitivity Specificity PPV NPV A.spontaneousortouch-evoked

painpredominantlyaffectingthe receptivefieldofoneormore divisionsofthetrigeminalnerve

28.57 80.58 9.09 94.32

C.atleastoneclinicallyevident

neurologicdysfunction - 79.28 0.00 100.00 D.imagingorneurophysiologic

demonstratinganeurologic lesionanditlocation

36.36 83.15 34.78 84.09

E.notattributedtoanother

disorder 20.72 - 100.00 0.00 PossiblePPTTN

(criteriaA andE) 13.04 94.32 37.50 80.58 ProbablePPTTN

(criteriaA,C orD,andE) 13.04 94.32 37.50 80.58 DefinitePPTTN

(criteriaA,C andD,andE) 39.13 79.55 33.33 83.33 neurophysiologydemonstratinganeurologiclesionanditslocation”. Possible,probable,anddefinitePPTTN criteriawereobservedtohave sensitivitiesof13.04,13.04,and39.13% andspecificitiesof94.32,94.32, and79.55%,respectively.ThePPVsforthePPTTN criteriaA,andC to E are9.09to100%,andtheNPVsare0to94.32%.

Inthisstudy,applicationtocriteriaofPPTTN providedlow sensitivity andPPV,althoughspecificityandNPV wererelativelyhigh.

Table7.Sensitivity,specificity,PPV,NPV ofindividualcriteria, andfinaldiagnosesofPPTTN criteria

PPV,positive predictive value;NPV,negative predictive value;PPTTN, PeripheralPainfulTraumaticTrigeminalNeuropathy.

(24)

D.Sensi t i vi t y,speci f i ci t y,PPV,andNPV f or out comepr edi ct or sanddi agnosi s

Table8providesestimatesforsensitivity,specificity,PPV,andNPV for individualvariableswithsignificance,andfordiagnosesofoutcome

predictors.

ComparedtotheresultsofthePPTTN criteria,thisempiricalapproach withadjustmentandincombinationwithoutcomepredictorsresultedina profoundincrementinsensitivity,butalsoasmalldecrementin

specificity.

Wegeneratedanreceiveroperatingcharacteristic(ROC)curveby plottingthesensitivityofthescreenertotalscoreagainstthevalueofone minusthespecificity.8)

TheitemsthathadanareaundertheROC curve(AUC)ofmorethan 0.5weretouch(blunt)radiating,pinprickradiating,andallodynia.Once adjustedandcombinedwithoutcomepredictors,allvariablesshowed greaterthan0.5AUC exceptforpanoramicview result+radiatingafter pinstimulus.

(25)

Outcomepredictor

(matchedtoPPTTN criteria) Sensitivity Specificity PPV NPV Reducedsensationinthe

pinpricktest(C) 30.44 65.91 18.92 78.38 Radiatingafterpinstimulus(C) 82.61 56.82 33.33 92.59 Panoramicview result(D) 60.87 63.64 30.44 86.15 Reducedsensationinthe

pinpricktest(C)

+Panoramicview result(D)

73.91 36.36 23.29 84.21

Radiatingafterpinstimulus(C)

+Panoramicview result(D) 95.65 36.36 28.21 96.97 Receptivefield(A)

+Panoramicview result(D) 60.87 60.23 28.57 85.48 Receptivefield(A)

+Reducedsensationinthe pinpricktest(C)

39.13 62.50 21.43 79.71

Receptivefield(A)

+Reducedsensationinthe pinpricktest(C)

+Panoramicview result(D)

69.57 39.77 23.19 83.33

Table 8.Sensitivity,specificity,PPV,NPV of each outcome predictor, and diagnoses of adjusted outcome predictors redistributedaccordingtothePPTTN criteria

PPV,positive predictive value;NPV,negative predictive value;PPTTN, PeripheralPainfulTraumaticTrigeminalNeuropathy.

(26)

Ⅳ.Di scussi on

Recently,traumatictrigeminalneuropathyhasbeenasignificant researchinterestfordentistry.5,8)Itisamajor,largelyunrecognized

clinicalproblem,whichisdistressingforandreducesthequalityoflifeof patients.10)

Therefore,thereisneedforaconsensusandstandardizationof

assessmentoftraumatictrigeminalneuropathy,whilealsosimultaneously differentiatingtemporaryfrom permanentinjuriescausedintheearly traumaticevent,inordertoencouragepatientstoseektheappropriate interventions.However,therehasbeennoagreeddiagnosticmethodor testtounequivocallyshow thepresenceofneuropathicpainthusfar. Consequently,itisimportantfordentiststodesignthediagnosticcriteria, andthetreatmentprotocolsforthesediagnoses.

Inthisstudy,enrolledpatientsweregroupedaccordingtodurationof symptoms,withthecriticaltimesetat3months.Definingthetimeat whichpermanentnerveinjuryisdiagnosedmightbeperformeddifferently bydifferentauthors.Inmostpreviousarticles,injurieswereregardedas permanentifthepatienthadsymptomsformorethan6months,because paresthesiawasfoundtobetemporary,andtendedtosubsidewithinthe first6months.5,11-13)Basedonthesestudies,clinicianshaveatendencyto instructpatientswhoshow signsofnervedamagetowaitatleastsix months.However,fullrecoveryofnervefunctionislesslikelywhenthe patientisseenalongtimeafterasevereinjury.5)Furthermore,proposing thePPTTN criteriadefinedasPPTTN ashavingcontinuedsymptomsfor 3months.Thiswasinlinewitharecentreview articlethatpositedthat after3months,permanentcentralandperipheralchangesoccurwithinthe nervoussystem subsequenttoinjurythatareunlikelytorespondto surgicalintervention.10,14)Furthermore,itisimportanttodifferentiate neuropathicfrom non-neuropathiccausesforthediagnosisandtreatment

(27)

oftheconditions.A keyfeatureofneuropathicpainisthecombinationof sensorylosswithparadoxicalhypersensitivity.Damagetotheafferent transmissionsystem causespartialorcompletelossofinputtothe nervoussystem,leadingtonegativesensoryphenomena,suchaslossof touchortemperatureorpressuresensations.13)Incontrast,inflammatory painheightenspainsensitivityinresponsetotissueinjuryand

inflammation,anditisalsoassociatedwithhypersensitivitytonormal sensoryinputs.10)Accordingly,symptomsthatoccurredforlessthan3 monthscouldoriginatefrom eitherinflammatoryorneuropathicconditions. Therefore,definingthetimebetweentransientandpersistentneuropathy as3monthsinthisstudyseemedmostappropriate.

Inthisstudy,mostpatients(84outof111,75.67%)hadneuropathic pain,whileonly17patientshadloweredorcompletelynumbsensation withoutpain.Itisknownthatapproximately35% ofchronicpainpatients sufferfrom neuropathicpain.5)Followingtheinjurytotrigeminalnerve branches,chronicpaindevelopsinabout3-5% ofpatients.6,15)These symptomscoupledwithneuropathicpaincouldbeespeciallytroublesome topatients,andresultinaseverereductionoftheiroverallqualityoflife.

Thedistributionsofinitiatingeventsaffectingalteredsensationorpain aresummarizedinTable2.Injurytothetrigeminalnervemayoccurfrom avarietyofdifferentdentaltreatments,includingthirdmolarextraction,16) implantplacement,17,18)dentallocalanestheticinjection,19)endodontic treatment,20)andorthognathicsurgery.21)Non-iatrogeniccausessuchas skullfracturecouldalsoresultinconsiderablenerveinjury.Inthisstudy, implantplacementcausedthehighestincidenceoftrigeminalnerveinjuries (27.93%).Incontrast,previousstudiesstatethatthirdmolarextraction causedthehighestincidenceofiatrogenictrigeminalnerveinjuries,9,22) whichwasthesecondmostcommoncauseinthisstudy(22.52%).Local anesthetic-relatedinjurywasonly2.70% oftheincidenceinthisstudy.

Thedifferencecouldbeexplainedbythefactthatneuropathyrelatedto thirdmolarextractionorlocalanestheticinjectionisusuallytemporary,23)

(28)

andthuspatientsdonotseeksecondaryortertiaryreferrals.Notably, somepatientsdevelopchronicneuropathicpainfollowingnegligiblenerve traumasuchassuturingofwounds,operativedentaltreatment,and periodontictreatment.

Inthecomparisonofpatientprofiles,thepresenceofaneurologiclesion inthepanoramicview result,reducedsensationandradiationinthe pinpricktest,radiatingsensationwiththebluntstimulus,andallodynia showeddifferencesbetweenthetransientandpersistentgroups(Table.6). Accordingtotheresultofthemultipleregressionanalysis,thepresenceof aneurologiclesioninpanoramicview resultandreducedsensationand radiatingsymptomsinthepinpricktestwouldbedefiningfeaturesofone ofthemainclinicalfeaturesofpersistentneuropathy.Mostpatientswith delayedvisitscomplainedthattheirdoctorhadadvisedthem towaitand see,withoutanyattempttorelievetheirsymptoms.Fastreferralfasttoa specialistinorofacialpainororalsurgerymayhelpmaximizethe

resolutionofneuropathy,byinterruptingandreversingthecascadeof traumaticevents.5,24)Manyauthorsrecommendthereferralofinjuries before4monthsbutthismaybetoolateformanyperipheralsensory nerveinjuries,5)sincethefirstfew monthsmaydeterminethedegreeof nervehealing.4)Thistimewouldneedtobeveryshort,perhapswithin24 hoursoftheinjury,inthecasesofimplantorendodontic-related

injury.20,25)Therefore,identifyingriskfactorsaffectingpermanent neuropathywouldhelpclinicianstoreferpatientswithneuropathic symptomsatthebestpossibletime.

Thepanoramicview couldprovidegrossinformationoninvolvementof inferioralveolarnerveinjury(IANI),demonstratingthelossofthelamina duraoftheIAN canal,impingementofimplantfixtures,andoverfillingof endodonticmaterialsintotheIAN canal.However,inthecaseoflingual nerveinjury(LNI),andsometimesofmentalnerveinjury(MNI),the panoramicview doesnotprovideproperinformationregardingnerve damage.Conebeam CT (CBCT)scanningmightbeanalternativeoption,26)

(29)

butseveralpapershavereportedtheweaknessofCBCT evaluationin identifyingthecanal,resultinginpoorersensitivityandspecificity.27,28)In thisstudy,however,therewere14positivesignsofnervedamagein CBCT,whiletherewere46casesofnosigninthepanoramicview.

Thus,usingCBCT maynotbearoutineproceduretoassesstheextent ofnervedamage,butitcouldbenecessaryifthepanoramicimagefails todetectsignsofnervedamage.

Ifanerveinjuryissuspected,theclinicianshouldperform abasic neurosensoryexaminationoftheneuropathicareaandascertainwhether ornotthepatientisexperiencingpain,alteredsensation,ornumbness.4)In thisstudy,reducedsensationinthepinpricktest(hypoalgesia)was

statisticallysignificantlymorefrequentinthepersistentgroupthaninthe transientgroup.Sensorylossisauniversalresponsetonervedamage,10) buthypoalgesia,inassessingsensorysignature,wasnotpredominantin thepersistentgroup.Inthecomparisonaboutsensorysignature,allodynia showedstatisticallysignificanceinthepersistentgroup,comparedtothe transientgroup(Table5).Afterthenerveinjury,reactivechanges centrallyproduceabnormalneuralfunction.Allodynia(painevokedby innocuousstimuli),andhyperpathia(anexplosive,abnormalpainthat outlastsastimulus)wouldindicatealteredactivityofperipheralnerves andtheircentralpathway.4)Therefore,acombinationofdullsensation, allodynicandhyperpathicresponsesinaneurosensoryexaminationcould serveasanoutcomepredictorforthelikelihoodofpermanentneuropathy.

Inthisstudy,Nagelkerke’sR2,whichrepresentsthepowerofexplanation ofthemodel,29)was0.607.AsscoresofNagelkerke'sR2above0.5would indicateastrongassociationwiththegroup.30)Ourvalueof0.607is indicatativeofastrongassociationwiththepersistentgroup.Toour knowledge,thisisthefirststudytoassessthedifferenceinpatient profilesbetweenthetransientandpersistentgroups.Basedonthisstudy, furtherinvestigationswithlargerstudypopulationsarewarranted.

ApplicationofPPTTN criteriainthisstudyprovidedlow sensitivityand

(30)

PPV,butrelativelyhighspecificityandNPV.Theresultofthisstudy confirmsthatPPTTN criteriawouldbeclinicallyapplicable,butwouldnot yetbeagoldstandardforevaluationoftraumatictrigeminalneuropathy.

Therefore,wetookanempiricalapproachusingadjustmentand combinationswithoutcomepredictor.Comparedtotheresultsofthe PPTTN criteria,thisapproachgeneratedaprofoundincrementin sensitivity,butwithasmalldecrementinspecificity.However,all variablesadjustedandcombinedwithoutcomepredictorsexceptfor panoramicview result+radiatingafterpinstimulusshowedmorethan 0.5AUC.TheareaundertheROC curve(AUC)isameasureofthe correlationbetweenthepredictionofthescreenerandthegoldstandard diagnosis.BecauseanAUC scoreabove0.5representslow tomoderate accuracy(andhighaccuracyifabove0.9),31)ourresultsindicatedthat thesefeaturescouldimprovePPTTN criteriaintermsofsensitivityand specificity.However,applicationofthem tothisstudypopulationproduced goodspecificityandlow sensitivity.Therefore,theseoutcomepredictors couldserveasascreeningtool,butnotasadiagnosticcriteria.Onthe otherhand,theuseofthisscreeningtoolmightrepresentanimportant steptowardeffectivetreatmentandrealisticexpectationsforpatients. Furtherstudywillbeneededwithlargersample,andmulti-centerdesign, suchasheadachevalidationstudy.32)

Anidealmodelforstudyingthedevelopmentofchronictraumatic neuropathicpain,andestablishingpredictivefactorsforthecondition, wouldincludepreoperativeandpostoperativeassessmentofpsychological andneurophysiologicalfactors,detailedintraoperativedataonhandlingof tissueandnerves,anddetailedearlyandlatepostoperativepaindata,as wellasathoroughclinicalinvestigationtoexcludeothercausesofthe chronicpainstate.10)Inthisstudy,psychologicalevaluationwasnot performed.Consideringtheriskfactorsforpostsurgicalpain,psychological evaluationshouldbeincludedinfuturestudies.

(31)

Ⅴ.Concl usi ons

1.The presence of a neurologic lesion in panoramic view result and reduced sensation and radiating symptomsin thepin prick testwould be defining features of one of the main clinical features of persistent neuropathy.These features could serve asoutcomepredictors diagnosing thepermanentnerveinjuryintrigeminalnerve.

2.ApplicationofPPTTN criteriainthisstudyshowedlow sensitivityand positive predictive value (PPV),but sensitivity and negative predictive value (NPV) were relatively high.PPTTN criteria would be clinically applicable,butthey mightnotyetbe a gold standard forevaluation of traumatictrigeminalneupathyasitis.

3.Compared to theresultsofthePPTTN criteria,an empiricalapproach using adjustmentand combinations with outcome predictor generated a profound increment in sensitivity, but with a small decrement in specificity.Therefore,theseoutcomepredictorscouldserveasascreening tool,butnotas a diagnostic criteria.Furtherstudy willbe needed with largersample,andmulti-centerdesign

(32)

Re f e r e nc e s

1.Woda A. Painful posttraumatic trigeminal neuropathy: a recently recognizedentity.JOrofacPain.2013;27(2):97-98.

2.Ryu JW,Gwon JS.Dysesthesia after tooth extraction and implant surgeryreportedbydentists.KoreanJOralMed.2007;32(3):263-272.

3.MerrillRG.Prevention,treatment,andprognosisfornerveinjuryrelated tothedifficultimpaction.DentClinNorthAm.1979;23(3):471-488.

4.Renton T.Prevention ofiatrogenic inferior alveolar nerve injuries in relationtodentalprocedures.DentUpdate.2010;37(6):350-363.

5.RentonT,YilmazZ.Profiling ofpatientspresenting with posttraumatic neuropathyofthetrigeminalnerve.JOrofacPain.2011;25(4):333-344.

6.BenolielR,Zadik Y,Eliav E,Sharav Y.Peripheralpainfultraumatic trigeminalneuropathy:clinicalfeaturesin 91casesand proposalofnovel diagnosticcriteria.JOrofacPain.2012;26(1):49-58.

7.Park JW,Choung PH,KhoHS,Kim YK,Chung JW.A comparison of neurosensory alteration and recovery pattern among different types of orthognathic surgeries using the currentperception threshold.OralSurg OralMedOralPatholOralRadiolEndod.2011;111(1):24-33.

8.Kraemer H. Evaluating medical tests. Objective and quantitative guidelines.ThousandOaks,CA:SagePublications,1992.

9.Hillerup S.Iatrogenic injury to the inferior alveolar nerve:etiology, signsand symptoms,and observationson recovery.IntJOralMaxillofac Surg.2008;37(8):704-709.

10.Kehlet H,Jensen TS,Woolf CJ.Persistent postsurgicalpain:risk factorsandprevention.Lancet.2006;367(9522):1618-1625.

11.Jerjes W,Swinson B,Moles DR,et al.Permanent sensory nerve impairmentfollowing third molarsurgery:a prospectivestudy.OralSurg OralMedOralPatholOralRadiolEndod.2006;102(4):e1-7.

(33)

12.OsbornTP,FredericksonG Jr,SmallIA,TorgersonTS.A prospective study ofcomplications related to mandibularthird molarsurgery.JOral MaxillofacSurg.1985;43(10):767-769.

13.Wofford DT,Miller RI.Prospective study of dysesthesia following odontectomy ofimpactedmandibularthirdmolars.JOralMaxillofacSurg.

1987;45(1):15-19.

14.ZiccardiVB,SteinbergMJ.Timingoftrigeminalnervemicrosurgery:a review oftheliterature.JOralMaxillofacSurg.2007;65(7):1341-1345.

15.BenolielR,Birenboim R,Regev E,Eliav E.Neurosensory changesin theinfraorbitalnerve following zygomaticfractures.OralSurg OralMed OralPatholOralRadiolEndod.2005;99(6):657-665.

16.MasonDA.Lingualnervedamagefollowinglowerthirdmolarsurgery.

IntJOralMaxillofacSurg.1988;17(5):290-294.

17.Wismeijer D, van Waas MA, Vermeeren JI, Kalk W. Patients' perception ofsensory disturbances ofthe mentalnerve before and after implantsurgery:aprospectivestudy of110patients.BrJOralMaxillofac Surg.1997;35(4):254-259.

18.KrautRA,ChahalO.Managementofpatients with trigeminalnerve injuries after mandibular implant placement. J Am Dent Assoc.

2002;133(10):1351-1354.

19.Hillerup S, Jensen R. Nerve injury caused by mandibular block analgesia.IntJOralMaxillofacSurg.2006;35(5):437-443.

20.Grötz KA, Al-Nawas B, de Aguiar EG, Schulz A, Wagner W.

Treatment of injuries to the inferior alveolar nerve after endodontic procedures.ClinOralInvestig.1998;2(2):73-76.

21.Jääskeläinen SK,Teerijoki-Oksa T,Virtanen A,Tenovuo O,Forssell H.Sensoryregenerationfollowingintraoperativelyverifiedtrigeminalnerve injury.Neurology.2004;62(11):1951-1957.

22.Bataineh AB.Sensory nerve impairment following mandibular third molarsurgery.JOralMaxillofacSurg.2001;59(9):1012-1017.

23.Hillerup S.Iatrogenicinjury to oralbranchesofthetrigeminalnerve:

(34)

recordsof449cases.ClinOralInvestig.2007;11(2):133-142.

24.Susarla SM, Lam NP, Donoff RB, Kaban LB, Dodson TB. A comparison of patient satisfaction and objective assessment of neurosensory function after trigeminal nerve repair.J Oral Maxillofac Surg.2005;63(8):1138-1144.

25.Khawaja N,Renton T.Case studies on implantremovalinfluencing the resolution of inferior alveolar nerve injury. Br Dent J. 2009;206(7):365-370.

26.Friedland B, Donoff B, Dodson TB. The use of 3-dimensional reconstructions to evaluate the anatomic relationship of the mandibular canal and impacted mandibular third molars.J Oral Maxillofac Surg.

2008;66(8):1678-1685.

27.TantanapornkulW,OkouchiK,FujiwaraY,etal.A comparativestudy of cone-beam computed tomography and conventional panoramic radiography in assessing the topographic relationship between the mandibular canaland impacted third molars.OralSurg OralMed Oral PatholOralRadiolEndod.2007;103(2):253-259.

28.Tantanapornkul W, Okochi K, Bhakdinaronk A, Ohbayashi N, KurabayashiT.Correlation of darkening of impacted mandibular third molar root on digital panoramic images with cone beam computed tomographyfindings.DentomaxillofacRadiol.2009;38(1):11-16.

29.Pace NL,EberhartLH,Kranke PR.Quantifying prognosis with risk predictions.EurJAnaesthesiol.2012;29(1):7-16.

30.GreinerM,PfeifferD,SmithRD.Principlesandpracticalapplicationof thereceiver-operatingcharacteristicanalysisfordiagnostictests.Prev Vet Med.2000May;45(1-2):23-41.

31.GreinerM,PfeifferD,SmithRD.Principlesandpracticalapplicationof thereceiver-operatingcharacteristicanalysisfordiagnostictests.Prev Vet Med2000;45:23-41.

32.Lipton RB,Dodick D,Sadovsky R etal.A self-administered screener for migraine in primary care: The ID Migraine validation study.

(35)

Neurology.2003;61(3):375-382.

참조

관련 문서

본 연구는 무용공연 사회공헌활동이 지역주민인식 및 지지협력의사에 미치는 영향을 규명하기 위해 연구를 진행하였으며, 지자체에서 실시하고 있는 무용공연 활동에

본 연구의 제한점으로는 G광역시 한 개 상급종합병원의 간호사만을 대상으로 하 였기 때문에 본 연구를 일반화 하는 데는 어려움이 있다.또한 본 연구는 단면연구

구급대원의 외상 후 스트레스와 직무만족도의 관계를 살펴보면 정상군은 86. 01 3) .이는 선행연구와 일치하는 결과 로 Koni ar e k &amp; Dude k는 폴란드 소방대원을 대상으로

이에 본 연구는 제 6기 국민건강영양조사 자료를 이용하여 만 40세 이상 COPD 환자를 대상으로 걷기, 근력 운동, 유연성 운동 등의 신체활동과 사회인구 학적 특성 및

본 저자들은 본원에서 시행한 질식 자궁절제술 및 복강경 보조 질식 천골질 고정술이 본 연구를 바탕으로 완전 자궁탈출증이 있는 환자를 교정하는 술식 으로

본 연구는 국내외 기업의 디자인경영 성공사례를 분석하여 제품디자인 경영전략과 기 업성과 간의 관계를 규명하고자 한다.본 연구를 수행하기 위한

해양경찰공무원을 대상으로 한 외상 후 스트레스 장애 및 알코올 사용 장애에 대한 선행연구를 살펴보면, 외상 후 스트레스 장애와 관련된 연구 들은 몇몇 이루어져

이는 생활습관 및 식습관 요소를 확인하였다.하지만 본 연구는 적은 수의 환자를 대상으로 일 대학병원의 표본에 국한되므로 남· 여 담석증 환자의 차이를