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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA
BANGALORE
ANNEXURE – II
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1
Name of the Candidate
and Address
(in Block Letters)
2
Name of the Institution
Dr. NITIN GOYAL
S/o MR. M.L.GOYAL,
HOUSE NO-1179
SECTOR-43 B
CHANDIGARH-160022
J.J.M. MEDICAL COLLEGE,
DAVANGERE – 577 004.
3
Course of the Study and Subject
POSTGRADUATE
M.D. IN RADIO-DIAGNOSIS
4
Date of Admission to Course
5
Title of the Topic
1st JUNE, 2012
“ULTRASOUND AND MRI
CORRELATION OF ROTATOR CUFF
INJURIES”.
6
BRIEF RESUME OF THE INTENDED WORK
6.1 Need for the Study:
Rotator cuff disease is one of the most common causes of shoulder pain. In
addition to history and physical examination, evaluation of a patient with shoulder
pain often involves assessment of the rotator cuff with a diagnostic test such as high
resolution ultrasonography or MRI2.
Several radiological techniques have been used to detect tears of the rotator
cuff. Each has limitations and no clear consensus on the optimum diagnostic study
has emerged1.
The radiological diagnosis of rotator cuff tears has traditionally been
performed with arthrography and more recently with ultrasonography and MRI3.
1
Arthrography is quite accurate in detecting complete tears but it is an
invasive procedure with some associated risk and discomfort, in addition it is
insensitive to partial tears involving superficial surface or substance of the cuff.
The diagnosis of partial tears, however, is important because many orthopedic
surgeons will operate to relieve impingement of supraspinatus tendon before it
progresses to full thickness tear. The relative ease with which they are seen on
MRI suggests that MRI may have a role in their diagnosis3.
MRI can provide information about rotator cuff tears such as tear
dimensions, tear depth or thickness and tear shape, involvement of adjacent
structures (eg, rotator interval, long head of biceps brachii tendon etc) and muscle
atrophy, all of which have implications for rotator cuff treatment and prognosis.
Information about coracoacromial arch and impingement as it relates to rotator
cuff tears can also be obtained with MRI4.
Although non-invasive, MRI is considerably more expensive than
ultrasonography and will probably not replace it as a screening procedure for those
trained in its use. For those cases in which the sonogram yields indeterminate
results or in those institutions in which no one is trained to do sonography of the
shoulder, MRI may be a useful screening test3.
The major disadvantages of MRI are the long examination time, expense
and that the study may be unsuccessful in very large or claustrophobic patients5.
Ultrasonography is effective for detecting tears of the rotator cuff. The size
of the tears can be classified and the findings used as a basis for management
decisions1.
Ultrasonography can also reveal the presence of other abnormalities that
may mimic rotator cuff tear including tendinosis, calcific tendinitis, subacromial
subdeltoid bursitis, greater tuberosity fracture and adhesive capsulitis7.
2
Ultrasonography of rotator cuff is quick and painless. There is no risk of
infection and in contrast to arthrography there is no discomfort following the
procedure8. The simplicity, rapidity, low cost and accuracy of the examination
make it especially attractive as a screening and presurgical staging study1.
Arthrography appears to be more accurate in diagnosing rotator cuff injuries
than either MRI or ultrasound but that benefit must be set against the invasiveness
and potential discomfort to patients. Ultrasonography is as accurate as MRI for
both full thickness and partial thickness tears, these results combined with low
cost for ultrasound suggests that ultrasound may be the most cost effective
imaging method of screening for rotator cuff injuries provided that the examiner is
trained in this operator dependent technique. For practitioners without ultrasound
expertise, MRI can be used. Arthrography can be performed in those cases in
which ultrasound and MRI are not definitive6.
Thus a study design for evaluation of role of USG and MRI in rotator cuff
injuries and correlation of their findings.
6.2 Review of Literatures:
Both USG and MRI are widely used for evaluation of shoulder joint
pathology and essentially obviate the need for conventional arthrography. The first
article about the use of USG in the assessment of rotator cuff was published in
1979 by seltzer SE, Finberg HG and Weissman BN, that for MRI in 1986 by
Kneeland JB, Carrea GF and Middleton WD. Technical improvements coupled
with advances in understanding of anatomic and pathological characteristics of the
rotator cuff, have resulted in the maturation of these two modalities.
J.G Smith (1984) first describes the rotator cuff tears in his report published
in the London medical gazette. He described a series of traumatic rotator cuff
ruptures in seven patients9.
Codman EA was the first to perform the surgical repair of the rotator cuff.
In 1911 he published the tendon repair results in two patients. He proposed the
pathogenesis of cuff tears as traumatic. He published his classic book ‘The
Shoulder’ IN 1934. In 1934 Codman published that of his 30 clinically diagnosed
rotator cuff tears; only 21 cases had tears at surgery10.
3
Fred Moseley H and Ian Goldie (1963) studied the arterial pattern of rotator
cuff and suggested that the morphological pattern of arteries in the rotator cuff
does not produce any evidence that the ‘critical zone’ for ruptures and calcified
deposits is much less vascularised than any other part of the tendinous cuff. But
showed conclusively that the critical zone of the rotator cuff corresponds to the
zone of anastomoses between the osseous and tendinous vessels. They also
described that the age does not seem to have a decisive influence on the
morphological pattern of the arteries11.
Dennis S Weiner and Ian Macnab(1970) studied the acromio-humeral
interval in sixty normal and fifty-nine shoulders with known rotator cuff tears.
Wherein, they found the acromio-humeral interval to range between seven to
fourteen millimeters and narrowing was a frequent finding in rotator cuff tears. An
interval of five millimeters or less was considered compatible with a tear and was
due to upward migration of humeral head because of action of deltoid muscle,
following a complete tear of supraspinatus12.
Kenneth Mugde M et al (1984) studies eight patients with shoulder pain,
one with bilateral involvement, who had a rotator cuff tear and an associated
lesion delineated roentgenographic a separate fragment of the acromian that was
believed to be an ununited ossification centre of the acromian( os acromiale). It
was thought unlikely that such an association is coincidental because it appeared
that patients showed an abnormal motion existed the site of fibrous union of the
acromian and may have contributed to the impingement of the acromian on the
rotator cuff. Six patients underwent repair of the rotator cuff with removal of the
loose fragment of the acromian13.
Jeffrey R. Crass (1985) did a study on patients with shoulder pain, who
underwent bilateral shoulder USG and found that ultrasonography was more
reliable than arthrography in the diagnosis of the normal rotator cuff. They found
no patients to have a normal sonographic pattern in patients who had an abnormal
surgical exploration. However, they found calcified and postoperative tendon as
major diagnostic pitfalls8.
4
William D. Middleton et al (1985) studied thirty–nine consecutive patients
referred for shoulder arthrography, underwent shoulder sonography to determine
the ability of sonography to detect rotator cuff tears. Fifteen patients has
arthrographically proven rotator cuff tears. Of these, fourteen were detected by
sonography, with a sensitivity of 93%. Three sonographic criteria indicative of
rotator cuff tear were postulated:
1. Discontinuity in the normal homogenous echogenicity of the rotator cuff.
2. Replacement of the normal homogenous echogenicity by a central
echogenic band; and
3. Non-visualization of the rotator cuff.
Out of the thirty-nine patients, twenty patients had normal sonographic
examinations, nineteen of which were normal by arthrography. Therefore the
predictive value of negative sonogram was 95%. They described focal thinning of
rotator cuff has a 100% predictive value in diagnosing rotator cuff tears.
Discontinuity in the homogenous echogenicity of the rotator cuff is another
sonographic finding of rotator cuff tear14.
Thomas D. Brandt (1989) conducted a retrospective and prospective
evaluation of clinical usefulness of shoulder sonography, which was done with
ninety-eight patients having rotator cuff tears. Sixty-two patients underwent
double contrast arthrography on the same day as sonography, and thirty-eight
patients underwent surgery after sonography. Rotator cuff injuries have been
classified as incomplete or complete ruptures. A comparison of sonography with
surgery, using this study criteria, demonstrated a sensitivity of 57% and specificity
of 76%. Complete ruptures are further classified as (a) pure transverse tears (b)
pure vertical or longitudinal tears, (c) tears with retraction of tendon edges, (d)
massive avulsion of the cuff (global tear)15.
5
Soble MG (1989) described the major sonographic diagnostic criteria for
diagnosing rotator cuff tear, which included (a) a well defined discontinuity
usually visible as a hypoechoic focus within the cuff, (b) non-visualization of the
cuff and (c) an echogenic focus within the cuff. In his study seventy-five patients
underwent both sonography and arthrography. Compared with arthrography alone,
ultrasound examinations enabled detection of 92% of rotator cuff tears (24 of 26
tears), with a specificity of 84% and a negative predictive value of 95%.
Correlation was obtained in 30 of these patients who underwent surgery for rotator
cuff tear or otherwise soft tissue abnormality. In this group, the sensitivity of
sonography for detection of a tear was 93%, with a specificity of 73%, while for
arthrography, sensitivity was 87% and specificity was 100%16.
Burk DL Jr and his associates (1989), in their prospective study, examined
38 patients with suspected rotator cuff tears at 1.5 T MRI and the findings were
compared prospectively in a blinded fashion with positive results from double
contrast arthrography in all 38 patients, high resolution sonography in 23 patients
and surgically in 16 patients. MRI and arthrography are comparable both in
sensitivity and specificity. In the study sonography was not accurate as were the
other two techniques. These results suggest that MRI should be considered as the
non-invasive test of choice for patients with suspected rotator cuff disease5.
Timothy E., Farle Christian H., Neumann Lynn S., Steinabah Arlon (1992)
studied the MRI findings in full thickness tears of the rotator cuff and conclude
that interruption of the tendon continuity is the most specific MRI finding of full
thickness rotator cuff tears, while subacromial fluid is the most common finding17.
Kumagai, H. Ito and Kubo A. (1994) performed sonography on 41 patients
with symptoms referable to rotator cuff. Sonography was performed immediately
after MRI, so that the information obtained by MRI could be applied to
sonographic diagnosis. Twenty patients were diagnosed from T2-weighted images
as having complete tears of the rotator cuff. Sonography showed full thickness
anechoic area in 12 0f the 20 patients, heterogeneous hyperechoic areas in 12, but
no abnormal findings in the other one. Thirteen patients were diagnosed as having
incomplete tears with MRI. Sonography showed heterogeneous hyperechoic areas
6
in 12, but no abnormal findings in one of the 13. Hyperechoic areas in the rotator
cuff were shown in four of eight patients who had been diagnosed from T2weighted images as not having tears. They considered anechoic areas to be
specific findings of complete tears, although some patients with rotator cuff tears
did not show this finding18.
Van Moppes FI (1995) determined the accuracy of USG in the detection of
rotator cuff tears. In his prospective study of 41 patients, the ultrasound results
could be compared with the combined results of CT arthrography, arthroscopy and
operation. The sensitivity of sonography in the detection of partial and total rotator
cuff tears was 86%, the specificity 91%, the positive predictive value 96% and the
negative predictive value 73%19.
Mary S. Hollister et al (1995) retrospectively reviewed the preoperative
shoulder sonography reports of 163 patients for the presence of fluid in the
subacromial-subdeltoid bursa or glenohumeral joint. Sixty seven (41%) of the 163
patients had joint effusion, bursal fluid or both. Joint effusion alone was seen in 35
patients. Fourteen of these had a normal rotator cuff at surgery, and 21 had a
rotator cuff tear (sensitivity, 22%; specificity 79%; positive predictive value 70%).
In 22 patients fluid was seen in both the bursa and the joint, 21 had surgically
proven rotator cuff tears (sensitivity 22%; specificity 99%; positive predictive
value 99%). The sonographic finding of intra-articular fluid alone (without bursal
fluid) has both low sensitivity and specificity for the diagnosis of rotator cuff tears.
However, the finding of fluid in the subacromial-subdeltiod bursa especially when
combined with a joint effusion is highly specific and has a high positive predictive
value for associated rotator cuff tears20.
Marnix T.van Holsbeeck et al (1995) tested previously defined ultrasound
criteria for identification of partial thickness tears of the rotator cuff. 52 patients
were examined. The criteria used to detect partial–thickness tears of the rotator
cuff were (a) mixed hyper and hypoechoic lesion visualized in two orthogonal
imaging planes with either articular or bursal extension. The sensitivity of USG in
depicting partial thickness tears was 93% and specificity was 94%21.
7
Urwin M, Symmons D, Allison T, Brammah T, Busby H, Roxby M et al
(1998) predicted the burden of shoulder disorders in the community. They
concluded that rotator cuff tears tend to prevail in the dominant arm and
occupational history may reveal heavy lifting or repetitive movements, especially
above the level of the shoulder22.
Wallny T (1999) from Germany developed a sonographic index to diagnose
rotator cuff tears. Ratio of the thickness of the biceps tendon to the thickness of the
supraspinatus tendon, of more than 0.8 is considered diagnostic of rotator cuff
tear23.
Shalene A. Teefey (1999) stated that shoulder ultrasonography was
improving over the last decade, with the advent of high frequency probes. He
emphasizes on musculoskeletal anatomy, sonographic technique, normal
sonographical anatomy, pathophysiology of rotator cuff and bicep tendon disease
and sonographic findings of rotator cuff tears24.
Martin Hervas .C and his associates in another study (2001), who examined
all painful shoulders in 1998 by subjecting them to USG and MRI, have stated that
the diagnosis of full thickness rotator cuff tears was highly specific on both
imaging techniques (100% for USG and 97.1% for MRI) but was not as sensitive
using USG (67.9% for USG and 75.5% for MRI). Thus they concluded that USG
should be a good imaging technique based on its specificity for the initial study of
all painful shoulder joints. But the low sensitivity makes it necessary to undertake
an additional MRI25.
Bryant L. et al (2002) compared the ability of clinical estimation, diagnostic
USG, MRI and arthroscopy to estimate the size of rotator cuff tears. Estimates of
rotator cuff tear size were compared with findings at open operation in 33
consecutive patients with a presumptive diagnosis of rotator cuff tear. Arthroscopy
of rotator cuff tear size correlated best with actual tear size (Pearson correlation
coefficient r = 0.92; p<0.001). MRI (r = 0.74; p<0.001) was similar to USG( r =
0.73; p<0.001).26
8
William D. Middleton et al (2004) one hundred and eight cases of shoulder
pain that had a clinically suspected rotator cuff tear and these patients underwent
both USD and MRI and filled out satisfaction surveys after both tests and the
results of satisfaction scores were higher for USG in 54 patients, higher for MRI
in 13 patients and the same for both in 50 patients (p<0.001). All patients were
willing to repeat USG but 10 patients were not willing for MRI (p<0.002). Ninetythree patients preferred sonography, eight patients preferred MRI and 17 patients
had no preference and concluded that most patients with shoulder pain prefer USG
to MRI27.
Zlatkin MB et al conducted MRI studies on painful shoulder. They reported
that the rotator cuff tears in 51% of the patients were associated with type 3
acromia, os acromiale or antero-inferior bone spurs. They also diagnostic
performance of MRI in rotator cuff tears and reported sensitivity, specificity and
accuracy of 91%, 88%, and 89% respectively for all rotator cuff tears, partial and
complete using conventional MRI28.
Vlychou M et al (2009) conclude in their study of 56 patients with
symptomatic impingement syndrome, of which all patients underwent USG and
MRI scans prior to surgical intervention. Both imaging modalities detected
successfully 44 cases of partial tears of supraspinatus tendon. USG imaging yield
a sensitivity of 95.6%, a specificity of 70%, an accuracy of 91% and a positive
predictive value of 93.6%. The corresponding values for MRI were 97.7%, 63.6%,
91%, and 91.7% respectively. USG imaging can be considered almost equally
effective in detecting partial tears of the rotator cuff compared to MRI, particularly
located in the area of the supraspinatus tendon. MRI may be reserved for doubtful
or complex cases, in which delineation of adjacent structures is mandatory prior to
surgical intervention29.
6.3 Objectives of the Study:
 Evaluation of role of MRI in rotator cuff injuries.
 Evaluation of role of high resolution ultrasound in rotator cuff injuries.
 Correlation of high resolution ultrasound findings with MRI findings.
9
7. MATERIALS AND METHODS
7.1 Source of Data:
The main source of data for the study are patients from the following
teaching Hospital attached to Bapuji Education Association, J.J.M. Medical
College, Davangere.
1. Bapuji Hospital.
2. Chigateri General Hospital.
Appropriate MRI sequences and multiplanar imaging and ultrasonogram
will be performed for every patient
TECHNIQUE:
Imaging will be done with 1.5 Tesla Philips achieva machine using shoulder coil
the following sequences will be selected as required
1) Coronal oblique T1W/ proton density weighted (PDW) fast spin echo
(FSE) sequence.
2) Coronal oblique fat suppressed (FS) PDW FSE / T2 – W FSE sequence.
3) Sagittal oblique T2 W FSE sequence (with / without fat suppression).
4) Axial T2 – W gradient echo (GE) sequence.
5) Axial PDW FSE (with / without fat suppression)
Field of view 14-16 cm, slice thickness 2-3 mm and matrix 512 x 512.
7.2 Method of Collection of Data (including sampling procedure if any):
All patients referred to the department of Radio diagnosis with clinically
suspected rotator cuff injuries in a period of 2 years from Nov 2012 to November
2014 will be subjected for the study.
Initially a minimum of 30 cases are intended to be taken up, however the
scope of increasing the number of cases exists depending upon the availability
within the study period.
10
Inclusion criteria:
The study includes
 All patients with clinical suspicious of rotator cuff injuries.
 Cases of all age groups irrespective of sex
Exclusion criteria:
The study will exclude
 Patient having history of claustrophobia.
 Patient having history of metallic implants insertion, cardiac pacemakers and
metallic foreign body insitu.
Duration of study: 2 years.
Data Analysis: Proportion study.
7.3 Does the study require any investigations or interventions to be conducted
on patients or other humans or animals? If so please describe briefly.
YES.
The study is mainly based on investigations as Radiology itself is a tool of
Investigation. . The study involves only humans. Informed consent would be taken
after explaining about and before any procedure. Routine investigations, laboratory
investigations, Ultrasonogram and MRI.
7.4 Has ethical clearance been obtained from your institution in case of 7.3?
Yes.
Ethical clearance has been obtained from the Research and Dissertation
Committee/ Ethical Committee of the institution for this study
11
8
LIST OF REFERENCES
1. Stephen N. Wiener, William H. Seitz, Jr. Sonography of the shoulder in
patients with tears of rotator cuff: Accuracy and value for selecting surgical
options. AJR. Jan 1993;160:103-107.
2. Sharlene A. Teefey, William D. Middleton, William T. Payne, Ken
Yamaguchi. Detection and measurement of rotator cuff tears with
sonography: Analysis of diagnostic errors. AJR. June 2005;184:1768-1773.
3. J.Bruce Kneeland, William D.Middleton, Guillermo F. Carrera, Robert C.
Zeuge, Andrzej Jesmanowicz, Wojciech Froncisz, James S. Hyde. MR
Imaging of the shoulder; Diagnosis of rotator cuff tears. AJR. August
1987;149:333-337.
4. Yoav Morag, Jon A. Jacobson, Bruce Miller, Michel De Maeseneer,
Gandikota Girish,David Jamadar. MR Imaging of rotator cuff injury: What
the clinician needs to know. Radiographics 2006;26:1045-1065.
5. D. Lawrence Burk, Jr, David Karasick, Alfred B. Kurtz, Donald G.
Mitchell, Matthew D. Rifkin, Cynthia L. Miller, David W. Levy, John M.
Fenlin, Arthur R. Bartolozzi. Rotator cuff tears: Prospective comparison of
MR Imaging with Arthrography, Sonography and Surgery. AJR July
1989;153:87-92.
6. Joseph O. De Jesus, Laurence Parker, Andrea J. Frangos, Levon N.
Nazarian. Accuracy of MRI, MR Arthrography, and Ultrasound in the
diagnosis of rotator cuff tears: A Meta-analysis. AJR. June 2009;192:17011707.
7. Josh B. Moosikasuwan, Theodore T. Miller, Brian J. Burke. Rotator cuff
tears:
Clinical,Radiographic
and
US
findings.
Radiographics.
2005;25:1591-1607
8. Jeffrey R. Crass, Edward V. Craig, Carl Bretzke, Samuel B. Feinberg.
Ultrasonography of the rotator cuff. Radiographics. November 1985;5:941953.
12
9. Smith JG.Pathological appearances of seven cases of injury of the shoulder
joint with remarks. London Med Gazette1834;14:280-285.
10. Codman EA. Complete rupture of supraspinatus tendon:operative treatment
with report of two successful cases. Boston Med Surg J 1911;164:708-710.
11. Moseley HF. The arterial pattern of the rotator cuff of the shoulder. J Bone
Joint Surg 1963;45B:780-789.
12. Weiner DS and Ian Macnab: Superior migration of the humeral head. A
radiological aid in the diagnosis of tears of rotator cuff.1970;52(3):524527.
13. MK Mugde, V Wood, and GK Erykman. Rotator cuff tears associated with
os acromiale. J Bone Joint Surg.1984;66:427-429.
14. William D. Middleton, Gerald Edelstein, William R. Remus, G. Leland
Melson, William G. Totty, William A. Murphy. Sonographic Detection of
rotator cuff tears. AJR . Feb 1985;144:349-353
15. Brandt TD, Cardone BW, Grant TH, et al . Rotator cuff sonography: A
Reassessment. Radiology.1989;173(2):323-327.
16. Soble MG, Kaye AD and Guay RC. Rotator cuff tear:clinical experience
with sonographic detection. Radiology.1989;173(2):319-321.
17. Farley TE, Christian NH, Lynn et al. Full thickness tears of the rotator cuff
of the shoulder: Diagnosis with the MRI.AJR. 1992;158:347-351
18. Kumagai, H Ito and Kubo A. Sonographic findings of rotator cuff tears:
correlation with MRI imaging. Nippon Igaku Hoshasen Gakkai Zasshi.
1994;54(6):459-464.
19. Floris I. van Moppes, Onno Veldkampb, Jan Roordab. Role of shoulder
ultrasonography in the evaluation of the painful shoulder. Eur J
Radiol.1995;19:142-146.
20. Hollister MS, Mack LA, Patten RM, et al:Association of sonographically
detected subacromial/subdeltoid bursa effusion and intra-articular fluid
with rotator cuff tear.AJR Am J Roentgenol 1995 Sep;165(3):605-608.
13
21. Van Holsbeeck MT, Kolowich PA, Eyler WR, et al. US depiction of partial
thickness tear of the rotator cuff. Radiology. 1995;197:443-446.
22. Urwin M, Symmons D, Allison T, Brammah T, Busby H, Roxby M, et al.
Estimating the burden of musculoskeletal disorders in the community: the
comparative prevalence of symptoms at different anatomical sites and the
relation to social deprivation. Ann Rheum Dis.1998;57:649-655.
23. 23. Wallny T, Wagner UA, Prange S, Scmitt O, Reich H. Evaluation of
chronic tears of rotator cuff by ultrasound. J Bone Joint Surg. 1999;81:675678.
24. Shalene A. Teefey, WD. Middleton, Ken Yamaguchi. Shoulder
sonography:state of the art. 1999:37(4):767-785.
25. Martin Harvas C, Romero J, Navas-Acien A, Reboiras JJ, Munuera L.
Ultrasonographic and MR imaging of rotator cuff lesions compared with
arthroscopy
or
open
surgery
findings.J
Shoulder
Elbow
Surg.2001;10(5);410-415.
26. Bryant L, Shiner L, Bryant C, Murrell GA. A comparison of clinical
estimation, ultrasonography, magnetic resonance imaging and arthroscopy
in determining the size of rotator cuff tears. J Shoulder Elbow.2002 MayJune;11(3):219-224.
27. William D. Middleton, William T. Payne, Sharlene A. Teefey, Charles F.
Hildebolt , David A. Rubin, Ken Yamaguchi. Sonography and MRI of the
shoulder:comparison of patient satisfaction. AJR. 2004;183:1449-1452.
28. Zlatkin MB. Rotator cuff tears, diagnostic performance of MRI. Radiology
1989;172:223-229.
29. Vlychou M, Dailiana Z, Fotiadou A, Papanagiotou M, Fezoulidis IV,
Malizos K. Symptomatic partial rotator cuff tears: diagnostic performance
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Acta Radiol.2009;50(1):101-105.
14
9
Signature of Candidate
10
Remarks of the Guide
11
Name and Designation of
(in block letters)
11.1 Guide
Study is viable since the study is non invasive
which helps in proper patient management.
Dr. J PRAMOD SETTY MD
PROFESSOR AND HEAD,
DEPARTMENT OF RADIO-DIAGNOSIS,
J.J.M. MEDICAL COLLEGE,
DAVANGERE – 577 004.
11.2 Signature
11.3 Co-Guide (if any)
11.4 Signature
11.5 Head of Department
Dr. J .PRAMOD SETTY M.D.,
PROFESSOR AND HEAD,
DEPARTMENT OF RADIO-DIAGNOSIS,
J.J.M. MEDICAL COLLEGE,
DAVANGERE – 577 004.
11.6 Signature
12
12.1 Remarks of the
Chairman and Principal
12.2 Signature
15