published_or_final_version / Medicine / Master / Doctor of Medicine

Dissertation submitted in partial compliance with the requirements for the Master’s Degree in Technology: Chiropractic, Durban University of Technology, 2011. / BACKGROUND: Plain film radiography is the most common imaging technique requested by chiropractors to assist in the management of patients with musculoskeletal complaints. There is a paucity literature indicating that chiropractors’ interpretive radiographic skills are consistently able to achieve the same outcome given a particular set of radiographs. An important indication for the use of radiography in chiropractic is to exclude any possible contraindications to spinal manipulative therapy (SMT) that could cause serious injury to a patient if it is left unmodified or excluded as a treatment option. OBJECTIVES: The study aimed to investigate the inter- and intra-examiner reliability of chiropractor’s diagnosis on cervical spine radiographs. Additionally, the effect of clinical history added to the radiographs was assessed. METHODS: Inter- and intra-examiner evaluations occurred on two consecutive readings of 30 radiographs by six qualified chiropractors. No clinical history was given during Round One, but was available during Round Two. RESULTS: The inter-observer agreement for categorisation and management went from “poor agreement” in Round One (Κ=0.1962 and Κ=0.1996 respectively) to “fair agreement” (Κ= 0.2041 and Κ=0.2036 respectively) beyond that expected by chance in Round Two. Identification remained “fair agreement” beyond that expected by chance over both rounds (Κ=0.3113 and Κ=0.2159). Sensitivity at Round One was 94.4% and the specificity was 61.1%. At Round Two the sensitivity had decreased to 93.8% and the specificity had decreased to 50%. There was no significant difference between the accuracy of the Round One and Round Two results for categorisation (p=0.243) and management (p=0.220), but there was a clinical difference for identification (p=0.014). iii CONCLUSION: Differences in the result were small indicating clinical relevance with regards to inter-examiner reliability was fair in most instances. Although clinical history did not influence categorisation or management, it did improve accuracy of identification of pathology. Chiropractors successfully identified between 93.8% and 94.4% of abnormal radiographic findings demonstrating that chiropractors use of radiographs as a diagnostic tool when looking for contraindications to spinal manipulative therapy was sensitive. This demonstrates that its use as a diagnostic tool for contraindications to spinal manipulative therapy (SMT) is sensitive.

Orientador: Alberto Cliquet Junior / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-23T16:33:33Z (GMT). No. of bitstreams: 1 Sakai_DenisSeguchi_M.pdf: 2873973 bytes, checksum: aeb14c04fce3c257f6e361abd03d43e1 (MD5) Previous issue date: 2013 / Resumo: Introdução: O trauma raquimedular apresenta maior incidência em indivíduos do sexo masculino entre 15 e 40 anos de idade. A denervação da musculatura segmentar da coluna vertebral abaixo do nível da lesão medular altera a postura do tronco no plano sagital destes indivíduos. Adaptações posturais ocorrem na coluna cervical e podem predispor à degeneração precoce do disco intervertebral e/ou das articulações facetárias, resultando na formação de osteófitos nos corpos vertebrais, diminuição do calibre dos forâmens intervertebrais e do canal vertebral. O envelhecimento da coluna cervical (espondilose cervical) é um processo lento. Sua sintomatologia é imprevisível e ocorre após a 5a década de vida na população geral, podendo decorrer de compressões radiculares ou medulares. As compressões radiculares apresentam-se clinicamente como dores irradiadas nos membros superiores, diminuição da força muscular (paresia) e alterações da sensibilidade (parestesia). Já as compressões medulares (ou mielopatia cervical) levam à incoordenação dos movimentos finos nas mãos, alterações de marcha (claudicação), do equilíbrio e disfunções no controle esfincteriano vesical e anal. Os paraplégicos preservam as funções nos membros superiores e dependem exclusivamente destes para a realização das atividades diárias. As alterações mecânicas no plano sagital na coluna cervical de indivíduos paraplégicos poderiam, deste modo, desencadear precocemente o processo de envelhecimento da coluna cervical levando a sintomas compressivos radiculares e/ou medulares cervicais com uma importante perda de função para estes indivíduos. Objetivo: O objetivo primário deste estudo foi correlacionar o alinhamento da coluna cervical no plano sagital de indivíduos paraplégicos com o nível de lesão neurológica torácica. O objetivo secundário foi caracterizar e comparar as alterações degenerativas radiográficas em diferentes níveis de lesão medular torácica. viii Metodologia: Foi realizada a análise radiográfica da coluna cervical de 12 indivíduos paraplégicos torácicos (9 do sexo masculino e 3 do sexo feminino) com lesão medular há mais de 1 ano (média de 9,1 anos, de 4 a 15 anos). Os indivíduos foram divididos em 2 grupos: 6 apresentavam lesão medular abaixo de T9 e outros 6, acima ou em T8, de acordo com a classificação da American Spinal Injury Association (ASIA). A lordose global, mensurada de C2 a C7 e a lordose local, mensurada para cada nível cervical foram comparadas. Sinais radiográficos de degeneração cervical (diminuição da altura do disco intervertebral, formação de osteófitos e esclerose dos platôs vertebrais) também foram analisados utilizando o método de Gore et al., e os resultados foram comparados entre os grupos. Resultados: O grupo com lesão medular em T8 ou acima apresentou maiores medidas de lordose global (55o ± 5,7o vs 26,2o ± 3,8o, p<0,0001), especialmente nos segmentos C5-C6 (10,7o ± 5,9o vs 1o ± 3,1o, p=0,02) e C6-C7 (18o ± 3,5o vs 4,5o ± 3,6o, p<0,0001). Não foram encontradas diferenças quanto às alterações degenerativas radiográficas entre os grupos em C4-C5 (p=0,16), C5-C6 (p=0,06) e C6-C7 (p=0,31). Conclusão: Este estudo preliminar indica que o nível de lesão medular influencia o alinhamento cervical no plano sagital aumentando a lordose especialmente nos segmentos mais distais e nos indivíduos com lesão medular em T8 ou acima / Abstract: Introduction: Spinal cord injury occurs more frequently in males between 15 and 40 years old. The loss of innervation in the segmental musculature of the spine below the level of spinal cord injury modifies the posture of the trunk in these subjects. Consequently, adaptative postural changes occur in the cervical spine predisposing to early degeneration of the intervertebral disc and/or facet joints, osteophyte formation and narrowing of the spinal canal and foramina. The degeneration of the cervical spine, known as cervical spondylosis, is a slow process and its symptoms usually occur after the 5th decade of life, and may result in radicular and/or cord compressions. Radicular compressions may present as radiating pain to the upper extremities, diminished strength and abnormal sensation. Spinal cord compressions, on the other hand, may present as a loss of fine movements in the hands, abnormal gait, impaired balance and dysfunctions in the vesical and anal sphincters. Paraplegics depend on the upper extremities for everyday activities and the development of radicular and/or spinal cord compressive symptoms in these subjects can be devastating. Mechanical changes in the sagittal plane of the cervical spine of paraplegics might result in early degeneration of this segment and an increasing disability for everyday activities over time. Objective: The primary endpoint of this study was to analyse the differences in the cervical spine alignment in paraplegics according to their level of spinal cord injury. The secondary endpoint was to compare degenerative findings on conventional radiographs between two different groups of paraplegics. Participants/methods: Twelve paraplegics (9 males and 3 females) sustaining more than 1 year of injury (average 9,1, from 4 to 15 years) had their sagittal cervical spine x-rays analyzed. They were divided into 2 groups: 6 patients had injuries below T9 and another 6, at or above T8, according to the American Spinal Injury Association (ASIA) classification. The global lordosis, x measured from C2 to C7, and the local lordosis, measured for each level were compared between the groups. Radiographic cervical degeneration (loss of disc height, osteophytes formation and end-plate sclerosis) was also quantified using a previous method described by Gore et al. and compared between the groups. Results: Results indicate that paraplegics sustaining higher spinal cord injuries (at or above T8) have an increased global lordosis (55o ± 5,7o vs 26,2o ± 3,8o, p<0,0001) specially in the lower segments - C5-C6 (10,7o ± 5,9o vs 1o ± 3,1o, p=0,02) and C6-C7 (18o ± 3,5o vs 4,5o ± 3,6o, p<0,0001). No differences were found comparing the radiographic scores for cervical degeneration between the groups at C4-C5 (p=0,16), C5-C6 (p=0,06) and C6-C7 (p=0,31). Conclusion: This preliminary study indicates that the level of spinal cord injury influences the cervical sagittal alignment with an increase in lordosis specially in the lower segments and in subjects with spinal cord injury at or above T8 / Mestrado / Fisiopatologia Cirúrgica / Mestre em Ciências

Dissertation submitted in partial compliance with the requirements for the Master’s Degree in Technology: Chiropractic, Durban University of Technology, 2011. / Introduction: Radiographic parameters of the cervical spine are utilized by chiropractors and spinal surgeons for making diagnoses and determining management protocols. However several researchers have reported discrepancies in these parameters which need to be investigated across ethnic groups and gender. Aim: To evaluate the normal selected cervical spine radiographic parameters i.e. the cervical lordosis (CL), sagittal canal diameter (SCD), interpedicular distance (IPD), and the cervical gravity line (CGL) in apparently healthy young to middle-aged males across four ethnic groups in Durban, KwaZulu Natal. Participants: Eighty healthy male participants between 18 and 45 years of age of White, Black, Indian and Coloured ethnicity. Methodology: A case history, physical examination and an orthopedic assessment of the cervical spine was conducted for each participant. Study-specific data such as age, ethnicity, weight and height were recorded. A lateral and an A-P radiograph of the cervical spine was taken of each participant. Selected radiographic parameters viz. SCD, IPD, CL, CGL were assessed and recorded. SPSS version 15.0 (SPSS Inc., Chicago, Illinois, USA) was used for data analysis. Results: The mean (± SD) values of the CL, SCD and IPD are shown in the table below for the respective ethnic groups Parameter Ethnic Group Black (Mean (± SD)) White(Mean (± SD)) Indian(Mean (± SD)) Coloured (Mean (± SD)) CL° (C1-C7 method) 42.6° (± 9.6°) 46.2° (± 11.0°) 46.5° (± 11.3°) 47.7° (± 9.1°) CL° (C2-C7 method) 15.1° (± 6.4°) 17.4° (± 9.3°) 13.1° (± 10.2°) 18.1° (± 10.4°) SCD (mm) C2 22.1mm (± 1.6) 24.1mm (± 1.4) 22.8mm (± 1.7) 22.9mm (± 1.5) C3 19.5mm (± 1.6) 20.6mm (± 1.4) 19.7mm (± 1.6) 20.0mm (± 1.5) C4 18.6mm (± 1.9) 19.9mm (± 1.3) 19.1mm (± 1.6) 19.5mm (± 1.3) C5 18.9mm (± 1.8) 20.0mm (± 1.5) 19.3mm (± 1.7) 19.8mm (± 1.6) C6 18.8mm (± 1.7) 20.4mm (± 1.5) 19.5mm (± 1.6) 20.0mm (± 1.8) iv C7 18.5mm (± 1.7) 20.3mm (± 1.5) 19.4mm (± 1.6) 19.7mm (± 1.9) IPD (mm) C3 28.2mm (± 1.2) 28.9mm (± 1.8) 27.8mm (± 1.1) 29.1mm (± 1.4) C4 28.6mm (± 1.4) 29.6mm (± 1.8) 28.5mm (± 1.4) 29.5mm (± 1.6) C5 29.4mm (± 1.2) 30.0mm (± 1.7) 28.8mm (± 1.2) 30.1mm (± 1.5) C6 29.3mm (± 1.6) 30.7mm (± 1.6) 30.0mm (± 1.6) 30.1mm (± 1.5) C7 29.3mm (± 1.2) 30.1mm (± 1.5) 29.6mm (± 1.6) 30.3mm (± 1.9) There was anterior placement of the CGL in 60% of the Black ethnic group, 45% of the White ethnic group, 55.6% of the Indian ethnic group and 52.6% of the Coloured ethnic group. No significant differences in mean CL was observed across the four ethnic groups for both methods utilized (p > 0.05). The significant differences in SCD lay between the White and Black ethnic groups at C2, C6 and C7 (p = 0.002, 0.030 and 0.017, respectively, ANOVA). The C3 and C5 IPD varied significantly between the Coloured and Indian ethnic group (p = 0.048 and 0.027, respectively, ANOVA). The CGL was not influenced by the CL in all the ethnic groups. Conclusion: Significant differences were observed between ethnic groups for the SCD and IPD. These will assist South African health care practitioners with patient management within these ethnic groups when diagnosing spinal stenosis and tumors. A larger South African based population should be evaluated to confirm the trends observed utilizing digitized diagnostic imaging modalities including radiographs, CT and MRI scans as errors may occur during manual assessment of conventional radiographs.

Dissertation submitted in partial compliance with the requirements for the Master’s Degree in Technology: Chiropractic, Durban University of Technology, 2012. / Aim: To evaluate the normal selected cervical spine radiographic parameters i.e. the cervical lordosis (CL), sagittal canal diameter (SCD), interpedicular distance (IPD) and cervical gravity line (CGL) in asymptomatic young to middle-aged females across four ethnic groups (Black, White, Indian and Coloured) in Durban, KwaZulu Natal, South Africa. Participants: Eighty apparently healthy females between the ages of 18 and 45 years from the Black, Indian, Coloured and White ethnic groups in Durban, KwaZulu Natal. Methodology: Written informed consent was obtained from each participant. A case history, physical examination and an orthopaedic assessment of the cervical spine was conducted for each participant. Study specific data such as ethnicity, age, height and weight was recorded. A lateral and an A-P radiograph of the cervical spine were taken for each participant. The selected radiographic parameters viz. cervical lordosis (CL), sagittal canal diameter (SCD), interpedicular distance (IPD) and cervical gravity line (CGL) were evaluated according to methods described previously. SPSS version 15.0 (SPSS Inc., Chicago, Illinois, USA) was used for data analysis. Coefficients of variation were calculated within ethnic groups to assess intra-group variation. Inter-group variation was assessed using ANOVA testing with Bonferroni-adjusted post-hoc tests in the case of a significant ANOVA test. Pearson’s chi square test was used to assess the association between ethnic groups and position of the CGL. T-tests were used to compare mean CL between those with anterior and normally placed CGL within each ethnic group. Results: The mean ± SD of the CL in South African females by ethnic group using the C1-C7 and C2- C7 methods CERVICAL LORDOSIS (mean ± SD) (°) ETHNICITY C1-C7 C2-C7 Black 42.1° (±13.4) 16.3° (±8.3) White 37.4° (±10.3) 9.9° (±4.8) Indian 33.7° (±9.7) 6.9° (±4.8) Coloured 42.5°(±10.9) 12.1° (±9.5) The mean ± SD of the SCD in South African females by ethnic group SAGITTAL CANAL DIAMETER (mean ±SD)(mm) ETHNICITY Black White Indian Coloured SCDC2 SCDC3 SCDC4 SCDC5 SCDC6 SCDC7 20.2 (±1.7) 17.4 (±1.4) 17.2 (±1.4) 17.0 (±1.4) 17.6 (±1.3) 17.5 (±1.4) 20.8 (± 2.2) 17.9 (±1.6) 17.6 (±1.6) 17.4 (±1.6) 17.6 (±1.4) 21.0 (±2.0) 18.2 (±1.7) 17.5 (±1.5) 17.4 (±1.7) 17.6 (±1.6) 17.1 (±1.5) 20.3 (±1.6) 17.5 (±1.8) 17.4 (±1.5) 17.7 (±1.2) 17.6 (±1.3) 16.9 (±1.2) 16.9 (±1.4) The mean ± SD of the IPD in South African females by ethnic group INTERPEDICULAR DISTANCE (mean ±SD)(mm) ETHNICITY IPDC3 IPDC4 IPDC5 IPDC6 IPDC7 Black 27.0 (±2.8) 27.6 (±3.2) 28.2 (±4.0) 28.9 (±4.2) 27.5 (±3.5) White 28.4 (±2.6) 28.8 (±2.2) 29.5 (±2.3) 29.3 (±2.5) 28.2 (±2.9) Indian 27.2 (±1.8) 27.5 (±1.8) 27.9 (±1.6) 27.9 (±1.6) 27.5 (±2.0) Coloured 27.9 (±2.3) 27.8 (±2.3) 28.3 (±2.2) 28.4 (±1.8) 28.2 (±1.7) The placement of the CGL in South African females in each ethnic group CERVICAL GRAVITY LINE ETHNICITY PLACEMENT OF CGL Black 70% anterior placement White 70% anterior placement Indian 60% anterior placement Coloured 60% anterior placement The C1-C7 measurements and the C2-C7 CL measurements were significantly different amongst the ethnic groups. For the C2-C7 method, Blacks differed significantly from both Whites (p = 0.037) and Indians (p = 0.001; Bonferroni adjusted post-hoc test); with the values for the Blacks being higher than both Whites and Indians. There was no correlation between CL and BMI amongst any of the selected ethnic groups. There were no significant differences in the mean SCD and IPD amongst the ethnic groups (p > 0.05; ANOVA test). There was no significant association between any ethnic group and the position of the CGL (p = 0.830; Pearson’s chi square test). In Black females, those with a normally positioned CGL had significantly higher C2-C7 CL measurements (p = 0.008; T- tests). There was no correlation between the CL and anterior placing of the CGL in any of the ethnic groups. Conclusion: No individual differences were observed in the CL amongst the ethnic groups when using the C1-C7 method. However, significant differences were observed when the C2-C7 method was used. There were no significant differences observed in the mean SCD and IPD amongst the ethnic groups. In Black females, those with a normally positioned CGL had significantly higher C2-C7 CL measurements. The trends observed in this research study and the differences in the findings to those of previous studies lay the platform for a larger population-based study across South Africa to establish normative reference values for each radiographic parameter specific for gender and ethnicity.