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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.

Pedicle screw breakage and loosening remain as clinical complications of short segment instrumentation procedures for spinal stabilization. This study has directly visualized and measured elastic, plastic and total vertebral pedicle trabecular bone full-field strains in the regions immediately surrounding the pedicle screw during pedicle screw insertion by utilizing functional microCT imaging and digital volume correlation. Human, porcine and polyurethane foam samples were analyzed and compared. Analysis showed that when osteoporotic human, normal human and porcine pedicle trabecular bone samples were compared, osteoporotic samples showed higher peak plastic strains and greater variability of these strains from their means. This suggests that osteoporotic human samples are non-uniformly elastic and plastic, while normal human and porcine samples are more uniformly elastic and plastic throughout the trabecular structure. PU-foams are not appropriate as models for pedicle trabecular bone in the in vivo environment since strain results showed dissimilar plastic and elastic strain magnitudes than human and porcine pedicle trabecular bone. This study may aid in the development of performance criteria for new PU-foams and improved pedicle screw designs. / Graduation date: 2004

Pathologic processes and surgical manipulations of the spinal column may result in alterations of the biomechanical properties of the spine through increases or decreases in the range of motion or stability of the spine. A decrease in range of motion between two adjacent vertebrae subsequent to arthrodesis or ankylosis appears, clinically, to be well tolerated without significant alterations to the functions of the spine; however, a decrease in spinal column stability as a result of pathologic changes or surgical alterations can result in catastrophic spinal cord injury. In order to determine the effect of various surgical procedures and trauma on the spinal column, in vitro biomechanical studies may be employed using a servohydraulic testing apparatus and cadaver vertebral motion units. The T₁₃ - L₁ vertebral motion units of 48 mix breed dogs were dissected free of surrounding musculature and prepared for biomechanical testing by mounting with cross pins and polymethylmethacrylate. Specimens were surgically altered by facetectomy, lateral fenestration, diskectomy, and combinations of these procedures. Specimens were subjected to lateral bending at a rate of 2.5 cm per minute to failure in a swing arm bending jig designed to simulate four point bending. The slopes of bending moment vs. angular displacement curves were compared and significance determined by the method of least squares. A statistical difference (p < 0.05) was found between the stiffness of all diskectomy groups when compared to any other group. Unilateral and bilateral facetectomies, and fenestration induced a non-significant decrease in stiffness in comparison to control specimens. This data may be combined with that of previous testing of the canine thoracolumbar spine in flexion-extension and rotation to determine the clinical effects of surgical manipulations and trauma on spinal stability. These results suggest that fenestrations and facetectomies do not appear to increase the risk of injury to the canine thoracolumbar spinal cord during lateral bending in the in vitro model; however, thoracolumbar spinal fractures involving the vertebral body as represented by the diskectomy in vitro model may significantly destabilize the spine in lateral bending. / Master of Science

Thesis (MMed (Surgical Sciences. Orthopaedic Surgery))--University of Stellenbosch, 2010. / Objective: This research paper reports on the radiographic outcome of unstable thoracolumbar injuries with short segment posterior instrumentation as standalone treatment; in order to review rate of instrumentation failure and identify possible contributing factors. Background: Short segment posterior instrumentation is the treatment method of choice for unstable thoracolumbar injuries in the Acute Spinal Cord Injury Unit (Groote Schuur Hospital). It is considered adequate treatment in fracture cases with an intact posterior longitudinal ligament, and Gaines score below 7 (Parker JW 2000); as well as fracture dislocations, and seatbelt-type injuries (without loss of bone column - bearing integrity). The available body of literature often states instrumentation failure rates of up to 50% (Alanay A 2001, Tezeren G 2005). The same high level of catastrophic hardware failure is not evident in the unit researched. Methods: Sixty-five consecutive patients undergoing the aforementioned surgery were studied. Patients were divided into two main cohorts, namely the “Fracture group” (n=40) consisting of unstable burst fractures and unstable compression fractures; and the “Dislocation group” (n=25) consisting of fracture dislocations and seatbelt-type injuries. The groups reflect similar goals in surgical treatment for the grouped injuries, with reduction in loss of sagittal profile and maintenance thereof being the main aim in the fracture group, appropriately treated with Schantz pin constructs; and maintenance in position only, the goal in the dislocation group, managed with pedicle screw constructs. Data was reviewed in terms of complications, correction of deformity, and subsequent loss of correction with associated instrumentation failure. Secondly, factors influencing the aforementioned were sought, and stratified in terms of relevance. Results: Average follow up was 278 days for the fracture group and 177 days for the dislocation group (all patients included were deemed to have achieved radiological fusion – if fusion technique was employed). There was an average correction in kyphotic deformity of 10.25 degrees. Subsequent loss in sagittal profile averaged 2 degrees (injured level) and 5 degrees (thoracolumbar region) in the combined fracture and dislocation group. The only factor showing a superior trend in loss of reduction achieved was the absence of bone graft (when non-fusion technique was employed). Instrumentation complications occurred in two cases (bent connection rods in a Schantz pin construct with exaggerated loss in regional sagittal profile, and bent Schantz pins). These complications represent a 3.07% hardware failure in total. None of the failures were considered catastrophic. Conclusion: Short segment posterior instrumentation is a safe and effective option in the treatment of unstable thoracolumbar fractures as a standalone measure.

Bibliography: leaves 102-116. / 116, [43] leaves, [51] leaves of plates : ill. (some col.) ; 30 cm. / Title page, contents and abstract only. The complete thesis in print form is available from the University Library. / Analyses the characteristics and relative incidence of annular defects in the human lumbar spine and investigates their role in the pathogenesis of invertebral disc degeneration. / Thesis (Ph.D.)--University of Adelaide, Dept. of Pathology, 1992

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.

The Behavioral Medicine Questionnare (BMQ) is a 44- item instrument administered via a computer CRT display or pencil and paper. The BMQ was designed to help primary care physicians treating spinal disorders to screen for emotional factors which warrant further psychological evaluation. The test is composed of three scales: Anxiety, Depression, and Somatization. Concurrent validity for each scale was determined through comparisons with subject (n = 133) scores on clinician judgement ratings, pain drawings, and the MMPI. The psychometric properties of the test were supported through statistical analysis. Significant correlations were found between the BMQ, MMPI, and clinician ratings, with the latter showing relationships of lesser strength. The only significant correlation to subject generated pain drawings was to the BMQ depression scale. Analysis indicated the need for seperate norms for males and females. Further research is needed to facilitate measurement and interpretation of the BMQ.

Submitted in partial compliance with the requirements for the Master’s Degree in Technology: Chiropractic, Durban University of Technology, Durban, South Africa, 2018. / Background: The World Spine Care (WSC) is a non-governmental organization that provides evidence-based spinal care to underserved communities around the world. The WSC opened a clinic in the Mahalapye District Hospital (MDH) in 2011 (Haldeman et al., 2015:2304). The WSC aims for long term presence in Botswana. They will require ‘buy in’ from the local community including the health care professionals of the region. Little is known about how WSC has been received by other health care professionals in the settings where they are present. Hence, this study aimed to determine the knowledge, attitudes and perceptions of health care professionals working at the MDH about the WSC. Method: A qualitative exploratory descriptive study was conducted using semi-structured interviews. Twenty health care professionals were interviewed at the Mahalapye District Hospital to ascertain their levels of knowledge, attitudes and perceptions. The interviews were semi- structured and conducted in English and later transcribed verbatim. The transcripts were then analyzed using the thematic analysis described by Graneheim and Lundman (2003:105). Thereafter codes, categories and themes were formed. Results: A variety of health care professionals from different departments were interviewed. Three overarching themes emerged from the data: knowledge of WSC and the management of spinal related disorders at the MDH, the perceived role of WSC, challenges to integration and possible solutions. The HCPs had varying levels of knowledge of the WSC depending on the amount of interaction they had with WSC. Some HCPs who had greater inter-professional interaction with WSC displayed more positive attitudes towards WSC. Many of the HCPs had a positive perception of the WSC though they were not confident in their knowledge of the WSC scope of practice which has limited referral by HCPs WSC. This is mainly due to an unclear referral pathway within the hospital and limited knowledge of WSC’s scope of practice. Increased awareness and an improved system of referral was a strong recommendation made. Many mentioned an unclear referral pathway for their patients. Those who had interacted with WSC generally had pleasant personal interactions with the WSC. Several of the HCPs had themselves been patients of the WSC. Most HCPs felt that WSC was beneficial to patients and made suggestions for WSC to expand to other centres across Botswana. Conclusion: Overall there was a positive perception of WSC however more effort to increase knowledge of what WSC offers and how it can be integrated into the hospital is necessary. Future studies should assess the perceptions of patients as well as knowledge and attitudes of HCPs towards WSC at other sites. / M