Capacidad discriminatoria de la gammagrafía ósea con SPECT y la tomografía axial computarizada para la localización del origen (niveles) del dolor lumbar crónico

El dolor lumbar crónico (DLC) es una causa importante de discapacidad global, cuyo diagnóstico se ve dificultado por su etiología multifactorial y la limitada correlación entre hallazgos clínicos y radiológicos. Este estudio incluyó a 129 pacientes entre enero de 2023 y junio de 2024, comparando la...

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Autores:
Paternina Páez, Alejandro Enrique
Tipo de recurso:
Fecha de publicación:
2025
Institución:
Universidad Autónoma de Bucaramanga - UNAB
Repositorio:
Repositorio UNAB
Idioma:
spa
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oai:repository.unab.edu.co:20.500.12749/29021
Acceso en línea:
http://hdl.handle.net/20.500.12749/29021
Palabra clave:
Medical sciences
Health sciences
Nuclear medicine
Radiation
Physiological effect
Chronic low back pain, Bone scintigraphy, SPECT, Computed tomography (CT), Diagnostic concordance, Discriminatory capacity
Ciencias médicas
Medicina nuclear
Radiación
Efectos fisiológicos
Ciencias de la salud
Dolor lumbar
Gammagrafía ósea,
Tomografía axial computarizada,
Concordancia
Capacidad discriminatoria
Rights
License
http://creativecommons.org/licenses/by-nc-nd/2.5/co/
id UNAB2_3315136524f138e278c4a89ea53b832b
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network_acronym_str UNAB2
network_name_str Repositorio UNAB
repository_id_str
dc.title.spa.fl_str_mv Capacidad discriminatoria de la gammagrafía ósea con SPECT y la tomografía axial computarizada para la localización del origen (niveles) del dolor lumbar crónico
dc.title.translated.spa.fl_str_mv Discriminatory capacity of bone scintigraphy with SPECT and computed tomography for the localization of the origin (levels) of chronic low back pain
title Capacidad discriminatoria de la gammagrafía ósea con SPECT y la tomografía axial computarizada para la localización del origen (niveles) del dolor lumbar crónico
spellingShingle Capacidad discriminatoria de la gammagrafía ósea con SPECT y la tomografía axial computarizada para la localización del origen (niveles) del dolor lumbar crónico
Medical sciences
Health sciences
Nuclear medicine
Radiation
Physiological effect
Chronic low back pain, Bone scintigraphy, SPECT, Computed tomography (CT), Diagnostic concordance, Discriminatory capacity
Ciencias médicas
Medicina nuclear
Radiación
Efectos fisiológicos
Ciencias de la salud
Dolor lumbar
Gammagrafía ósea,
Tomografía axial computarizada,
Concordancia
Capacidad discriminatoria
title_short Capacidad discriminatoria de la gammagrafía ósea con SPECT y la tomografía axial computarizada para la localización del origen (niveles) del dolor lumbar crónico
title_full Capacidad discriminatoria de la gammagrafía ósea con SPECT y la tomografía axial computarizada para la localización del origen (niveles) del dolor lumbar crónico
title_fullStr Capacidad discriminatoria de la gammagrafía ósea con SPECT y la tomografía axial computarizada para la localización del origen (niveles) del dolor lumbar crónico
title_full_unstemmed Capacidad discriminatoria de la gammagrafía ósea con SPECT y la tomografía axial computarizada para la localización del origen (niveles) del dolor lumbar crónico
title_sort Capacidad discriminatoria de la gammagrafía ósea con SPECT y la tomografía axial computarizada para la localización del origen (niveles) del dolor lumbar crónico
dc.creator.fl_str_mv Paternina Páez, Alejandro Enrique
dc.contributor.advisor.none.fl_str_mv Morales Avellaneda, Tatiana
dc.contributor.author.none.fl_str_mv Paternina Páez, Alejandro Enrique
dc.contributor.cvlac.spa.fl_str_mv Paternina Páez, Alejandro Enrique[0001839522]
dc.contributor.orcid.spa.fl_str_mv Paternina Páez, Alejandro Enrique[0009-0000-1460-2721]
dc.contributor.corporatename.spa.fl_str_mv SPECT Medicina Nuclear SAS
dc.subject.keywords.spa.fl_str_mv Medical sciences
Health sciences
Nuclear medicine
Radiation
Physiological effect
Chronic low back pain, Bone scintigraphy, SPECT, Computed tomography (CT), Diagnostic concordance, Discriminatory capacity
topic Medical sciences
Health sciences
Nuclear medicine
Radiation
Physiological effect
Chronic low back pain, Bone scintigraphy, SPECT, Computed tomography (CT), Diagnostic concordance, Discriminatory capacity
Ciencias médicas
Medicina nuclear
Radiación
Efectos fisiológicos
Ciencias de la salud
Dolor lumbar
Gammagrafía ósea,
Tomografía axial computarizada,
Concordancia
Capacidad discriminatoria
dc.subject.lemb.spa.fl_str_mv Ciencias médicas
Medicina nuclear
Radiación
Efectos fisiológicos
dc.subject.proposal.spa.fl_str_mv Ciencias de la salud
Dolor lumbar
Gammagrafía ósea,
Tomografía axial computarizada,
Concordancia
Capacidad discriminatoria
description El dolor lumbar crónico (DLC) es una causa importante de discapacidad global, cuyo diagnóstico se ve dificultado por su etiología multifactorial y la limitada correlación entre hallazgos clínicos y radiológicos. Este estudio incluyó a 129 pacientes entre enero de 2023 y junio de 2024, comparando la capacidad discriminatoria y la concordancia diagnóstica de la gammagrafía ósea con SPECT y la tomografía axial computarizada (TAC) para localizar el origen vertebral del dolor. Se encontró una concordancia moderada en L1-L2 (Kappa = 0.42) y baja en otros niveles, con la SPECT mostrando mayor sensibilidad, especialmente en L3-L4 y L4-L5, aunque con menor especificidad. El mayor poder discriminatorio de la SPECT se evidenció en L1-L2 (AUC = 0.81). Se concluye que la SPECT ofrece ventajas funcionales clave, complementando a la TAC y mejorando la precisión diagnóstica y las decisiones terapéuticas
publishDate 2025
dc.date.accessioned.none.fl_str_mv 2025-05-05T15:58:08Z
dc.date.available.none.fl_str_mv 2025-05-05T15:58:08Z
dc.date.issued.none.fl_str_mv 2025-04-28
dc.type.driver.none.fl_str_mv info:eu-repo/semantics/masterThesis
dc.type.local.spa.fl_str_mv Tesis
dc.type.redcol.none.fl_str_mv http://purl.org/redcol/resource_type/TM
dc.type.coarversion.spa.fl_str_mv http://purl.org/coar/version/c_b1a7d7d4d402bcce
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dc.identifier.instname.spa.fl_str_mv instname:Universidad Autónoma de Bucaramanga - UNAB
dc.identifier.reponame.spa.fl_str_mv reponame:Repositorio Institucional UNAB
dc.identifier.repourl.spa.fl_str_mv repourl:https://repository.unab.edu.co
url http://hdl.handle.net/20.500.12749/29021
identifier_str_mv instname:Universidad Autónoma de Bucaramanga - UNAB
reponame:Repositorio Institucional UNAB
repourl:https://repository.unab.edu.co
dc.language.iso.spa.fl_str_mv spa
language spa
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4. Nemoto O, Kitada A, Naitou S, Tsuda Y, Matsukawa K, Ukegawa Y. A longitudinal study for incidence of low back pain and radiological changes of lumbar spine in asymptomatic Japanese military young adults. Eur Spine J. 2013; 22:453–8.
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7. Carstensen MH, Al-Harbi M, Urbain JL, Belhocine TZ. SPECT/CT imaging of the lumbar spine in chronic low back pain: a case report. Chiropr Man Therap. 2011;19:2.
8. Lee I, Budiawan H, Moon JY, Cheon GJ, Kim YC, Paeng JC, Kang KW, Chung JK, Lee DS. The value of SPECT/CT in localizing pain site and prediction of treatment response in patients with chronic low back pain. J Korean Med Sci. 2014;29:1711–6.
9. Harisankar CN, Preethi GR, George M. Hybrid SPECT/CT evaluation of dual ectopia of thyroid in the absence of orthotopic thyroid gland. Clin Nucl Med. 2012;37:602–3.
10. Weinstein JN, Lurie JD, Tosteson TD, Hanscom B, Tosteson AN, Blood EA, Birkmeyer NJ, Hilibrand AS, Herkowitz H, Cammisa FP, et al. Surgical versus nonsurgical treatment for lumbar degenerative spondylolisthesis. N Engl J Med. 2007; 356:2257–70.
11. Zhong ZA, Peck A, Li S, VanOss J, Snider J, Droscha CJ, Chang TA, Williams BO. (99m) TC-methylene diphosphonate uptake at injury site correlates with osteoblast differentiation and mineralization during bone healing in mice. Bone Res. 2015;3:15013.
12. Delbeke D, Schöder H, Martin WH, Wahl RL. Hybrid imaging (SPECT/CT and PET/CT): improving therapeutic decisions. Semin Nucl Med. 2009;39:308–340. doi: 10.1053/j.semnuclmed.2009.03.002.
13. Filippi L, Schillaci O. Usefulness of hybrid SPECT/CT in 99mTc-HMPAO-labeled leukocyte scintigraphy for bone and joint infections. J Nucl Med. 2006;47:1908–1913.
14. Manchikanti L, Boswell MV, Singh V, Pampati V, Damron KS, Beyer CD. Prevalence of facet joint pain in chronic spinal pain of cervical, thoracic, and lumbar regions. BMC Musculoskelet Disord. 2004;5:15. doi: 10.1186/1471-2474-5-15
15. Dolan AL, Ryan PJ, Arden NK, Stratton R, Wedley JR, Hamann W, Fogelman I, Gibson T. The value of SPECT scans in identifying back pain is likely to benefit from facet joint injection. Br J Rheumatol. 1996;35:1269–1273. doi: 10.1093/rheumatology/35.12.1269.
16. Dutton JA, Hughes SP, Peters AM. SPECT in the management of patients with back pain and spondylolysis. Clin Nucl Med. 2000; 25:93–96. doi: 10.1097/00003072-200002000-00001.
17. Holder LE, Machin JL, Asdourian PL, Links JM, Sexton CC. Planar and high-resolution SPECT bone imaging in the diagnosis of facet syndrome. J Nucl Med. 1995; 36:37–44.
18. Shur N, Corrigan A, Agrawal K, Desai A, Gnanasegaran G. Radiological and Radionuclide Imaging of Degenerative Disease of the Facet Joints. Indian J Nucl Med. 2015 Jul-Sep;30(3):191-8
19. Cohen SP, Raja SN. Pathogenesis, diagnosis, and treatment of lumbar zygapophysial (facet) joint pain. Anesthesiology 2007;106:591-614
20. Long DM, BenDebba M, Torgerson WS, Boyd RJ, Dawson EG, Hardy RW, et al. Persistent back pain and sciatica in the United States: Patient characteristics. J Spinal Disord 1996; 9:40-58
21. Palestro CJ, Kim CK, Swyer AJ, Vallabhajosula S, Goldsmith SJ. Radionuclide diagnosis of vertebral osteomyelitis: indium-111-leucocyte and techne- tium-99m-methylene diphosphonate bone scintigraphy. J Nucl Med 1991; 32:1861–1865.
22. Becker W. The contribution of nuclear medicine to the patient with infection. Eur J Nucl Med 1995; 22:1195–1211
23. Holder LE, Machin JL, Asdourian PL, Links JM, Sexton CC. Planar and high-resolution SPECT bone imaging in the diagnosis of facet syndrome. J Nucl Med 1995; 36:37–44.
24. Even-Sapir E, Martin RH, Barnes DC, et al. Role of SPECT in differentiating malignant from benign lesions in the lower thoracic and lumbar vertebrae. Radiology 1993; 187:193–198.
25. Delpassand ES, García JR, Bhadkmkar V, et al. Value of SPECT imaging of the thoraco-lumbar spine in cancer patients. Clin Nucl Med 1995; 20:1047– 1051.
26. De Maeseneer M, Lenchik L, Everaert H, Marcelis S, Bossuyt A, Osteaux M, Beeckman P. Evaluation of lower back pain with bone scintigraphy and SPECT. Radiographics. 1999 Jul-Aug;19(4):901-12; discussion 912-4.
27. Ryan PJ, Evans PA, Gibson T, Fogelman I. Chronic low back pain: comparison of bone SPECT with radiography and CT. Radiology 1992; 182:849–854.
28. Connolly LP, d'Hemecourt PA, Connolly SA, Drubach LA, Micheli LJ, Treves ST. Skeletal scintigraphy of young patients with low-back pain and a lumbosacral transitional vertebra. Journal of nuclear medicine: official publication, Society of Nuclear Medicine. 2003;44(6):909–14.
29. Konin GP, Walz DM. Lumbosacral transitional vertebrae: classification, imaging findings, and clinical relevance. AJNR American journal of neuroradiology. 2010;31(10):1778–86.
30. Makki D, Khazim R, Zaidan AA, Ravi K, Toma T. Single photon emission computerized tomography (SPECT) scan-positive facet joints and other spinal structures in a hospital-wide population with spinal pain. Spine J 2010;10:58-62.
31. Gopinathan A, Peh W. Image guided facet joint injection. Biomed Imaging Interv J 2011;7:e4.
32. Blair Allen Winegar, Matthew Derek Kay, Mihra Taljanovic.Pol J Radiol. 2020; 85: e550–e574. Published online 2020 Sep 25. doi: 10.5114/pjr.2020.99887
33. Van der Wall H, Lee A, Magee M, Frater C, Wijesinghe H, Kannangara S. Radionuclide bone scintigraphy in sports injuries. Semin Nucl Med 2010;40:16-30.
34. Ryan PJ, Evans PA, Gibson T, Fogelman I. Chronic low back pain: Comparison of bone SPECT with radiography and CT. Radiology 1992;182:849-54.
35. Ornilla E, Sancho L, Beorlegui C, Ribelles MJ, Aquerreta D, Prieto E, Bondia JM, Cuadrado MJ, Richter JÁ. Diagnostic value of quantitative SPECT/CT in assessing active sacroiliitis in patients with axial spondylarthritis and/or inflammatory low back pain. An Sist Sanit Navar. 2022 Apr 28;45(1):e0953.
36. Holder LE, Machin JL, Asdourian PL, Links JM, Sexton CC. Planar and high-resolution SPECT bone imaging in the diagnosis of facet syndrome. J Nucl Med 1995; 36:37-44.
37. Dolan AL, Ryan PJ, Arden NK, Stratton R, Wedley JR, Hamann W, et al. The value of SPECT scans in identifying back pain is likely to benefit from facet joint injection. Br J Rheumatol 1996;35:1269-73.
38. Pneumaticos SG, Chatziioannou SN, Hipp JA, Moore WH, Esses SI. Low back pain: Prediction of short-term outcome of facet joint injection with bone scintigraphy. Radiology 2006;238:693-8.
39. Matar HE, Navalkissoor S, Berovic M, Shetty R, Garlick N, Casey AT, et al. Is hybrid imaging (SPECT/CT) a useful adjunct in the management of suspected facet joints arthropathy? Int Orthop 2013;37:865-70.
40. Trout AT, Sharp SE, Anton CG, Gelfand MJ, Mehlman CT. Spondylolysis and Beyond: Value of SPECT/CT in Evaluation of Low Back Pain in Children and Young Adults. Radiographics. 2015 May-Jun;35(3):819-34.
41. Perolat R, Kastler A, Nicot B, Pellat JM, Tahon F, Attye A, Heck O, Boubagra K, Grand S, Krainik A. Facet joint syndrome: from diagnosis to interventional management. Insights Imaging. 2018 Oct;9(5):773-789.
42. Barrios-Henao EG, Gallego E, Uribe A, Martínez Soto D, Rodríguez N. Perfil clínico, epidemiológico y descripción de los resultados de la tomografía ósea computarizada con emisión simple de fotones (SPECT) en pacientes con dolor de cuello y espalda. Estudio de cohorte transversal. Rev Colomb Ortop Traumatol. 2021;35:236-243.
43. Tender GC, Davidson C, Shields J, Robichaux J, Park J, Crutcher CL, et al. Primary pain generator identification by CT-SPECT in patients with degenerative spinal disease. Neurosurg Focus. 2019;47(6).
44. Jain A, Jain S, Agarwal A, Gambhir S, Shamshery C, Agarwal A. Evaluation of efficacy of bone scan with SPECT/CT in the management of low back pain: a study supported by differential diagnostic local anesthetic blocks. Clin J Pain. 2015;31(12):1054-1059.
45. Lee I, Budiawan H, Moon JY, Cheon GJ, Kim YC, Paeng JC, et al. The value of SPECT/CT in localizing pain site and prediction of treatment response in patients with chronic low back pain. J Korean Med Sci. 2014;29(12):1711-1716.
46. Russo VM, Dhawan RT, Baudracco I, Dharmarajah N, Lazzarino AI, Casey AT. Hybrid bone SPECT/CT imaging in evaluation of chronic low back pain: correlation with facet joint arthropathy. World Neurosurg. 2017;107:732-738.
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dc.publisher.faculty.spa.fl_str_mv Facultad Ciencias de la Salud
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spelling Morales Avellaneda, Tatianafeffb104-96aa-4759-8d63-1bbe91f5b894Paternina Páez, Alejandro Enriqued8c5d139-5f39-4a0a-ad41-3f3f4aff5255Paternina Páez, Alejandro Enrique[0001839522]Paternina Páez, Alejandro Enrique[0009-0000-1460-2721]SPECT Medicina Nuclear SASFloridablancaUNAB Campus Bucaramanga2025-05-05T15:58:08Z2025-05-05T15:58:08Z2025-04-28http://hdl.handle.net/20.500.12749/29021instname:Universidad Autónoma de Bucaramanga - UNABreponame:Repositorio Institucional UNABrepourl:https://repository.unab.edu.coEl dolor lumbar crónico (DLC) es una causa importante de discapacidad global, cuyo diagnóstico se ve dificultado por su etiología multifactorial y la limitada correlación entre hallazgos clínicos y radiológicos. Este estudio incluyó a 129 pacientes entre enero de 2023 y junio de 2024, comparando la capacidad discriminatoria y la concordancia diagnóstica de la gammagrafía ósea con SPECT y la tomografía axial computarizada (TAC) para localizar el origen vertebral del dolor. Se encontró una concordancia moderada en L1-L2 (Kappa = 0.42) y baja en otros niveles, con la SPECT mostrando mayor sensibilidad, especialmente en L3-L4 y L4-L5, aunque con menor especificidad. El mayor poder discriminatorio de la SPECT se evidenció en L1-L2 (AUC = 0.81). Se concluye que la SPECT ofrece ventajas funcionales clave, complementando a la TAC y mejorando la precisión diagnóstica y las decisiones terapéuticasTABLA DE CONTENIDO 1. INTRODUCCIÓN 5 2. DESCRIPCIÓN DEL PROBLEMA 8 2.1. PLANTEAMIENTO DEL PROBLEMA 8 2.2. JUSTIFICACIÓN 10 2.3. PREGUNTA DE INVESTIGACIÓN 11 3. MARCO TEÓRICO 12 3.1. GENERALIDADES 12 3.2. ANATOMÍA FUNCIONAL 13 3.3. CAUSAS DE DOLOR 16 3.3.1. Condiciones Patológicas 17 3.4. DIAGNÓSTICO 22 3.5. IMÁGENES ANATÓMICAS DIAGNÓSTICAS 23 3.5.1. Radiografía simple: 23 3.5.2. Tomografía axial Computarizada 23 3.5.3. Imagen de resonancia magnética 23 3.6. IMÁGENES DE RADIONÚCLIDOS 25 3.6.1. Gammagrafía ósea planar 25 3.6.2. Tomografía computarizada por emisión de fotón único (SPECT) 25 3.6.3. Predicción de la respuesta al tratamiento 25 3.6.4. Tomografía computarizada por emisión de fotón único/tomografía computarizada 26 3.7. EL PAPEL DE LA IMAGENOLOGÍA EN EL TRATAMIENTO 26 3.7.1. Bloqueos intraarticulares guiados por imágenes 26 4. ESTADO DEL ARTE. 28 5. OBJETIVOS 33 5.1. OBJETIVO GENERAL 33 5.2. OBJETIVOS ESPECÍFICOS 33 6. METODOLOGÍA 34 6.1. TIPO DE ESTUDIO 34 6.2. POBLACIÓN 34 6.3. CRITERIOS DE INCLUSIÓN 34 6.4. CRITERIOS DE EXCLUSIÓN 34 6.5. CÁLCULO DE TAMAÑO DE MUESTRA 35 6.6. RECOLECCIÓN DE LA INFORMACIÓN 35 6.7. VARIABLES 36 6.8. PLAN DE ANÁLISIS 38 6.9. CONSIDERACIONES ÉTICAS 39 7. RESULTADOS 41 7.1. CARACTERIZACIÓN GENERAL DE LA POBLACIÓN DE ESTUDIO 41 7.2. ANÁLISIS BIVARIADO 44 8. DISCUSION 47 9. CONCLUSIONES 49 10. BIBLIOGRAFÍA 50EspecializaciónChronic low back pain (CLBP) is a major cause of global disability, with diagnosis challenged by its multifactorial etiology and the limited correlation between clinical and radiological findings. This study included 129 patients between January 2023 and June 2024, comparing the discriminatory capacity and diagnostic concordance of bone scintigraphy with SPECT and computed tomography (CT) for localizing the vertebral origin of pain. Moderate concordance was found at the L1-L2 level (Kappa = 0.42) and low concordance at other levels, with SPECT showing greater sensitivity, particularly at L3-L4 and L4-L5, although with lower specificity. The highest discriminatory power of SPECT was observed at L1-L2 (AUC = 0.81). It is concluded that SPECT provides key functional advantages, complementing CT and improving diagnostic accuracy and therapeutic decision-making.Modalidad Presencialapplication/pdfspahttp://creativecommons.org/licenses/by-nc-nd/2.5/co/Abierto (Texto Completo)Atribución-NoComercial-SinDerivadas 2.5 Colombiahttp://purl.org/coar/access_right/c_abf2Capacidad discriminatoria de la gammagrafía ósea con SPECT y la tomografía axial computarizada para la localización del origen (niveles) del dolor lumbar crónicoDiscriminatory capacity of bone scintigraphy with SPECT and computed tomography for the localization of the origin (levels) of chronic low back painEspecialista en Medicina NuclearUniversidad Autónoma de Bucaramanga UNABFacultad Ciencias de la SaludEspecialización en Medicina NuclearEMN-1322info:eu-repo/semantics/masterThesisTesishttp://purl.org/redcol/resource_type/TMhttp://purl.org/coar/version/c_b1a7d7d4d402bcceMedical sciencesHealth sciencesNuclear medicineRadiationPhysiological effectChronic low back pain, Bone scintigraphy, SPECT, Computed tomography (CT), Diagnostic concordance, Discriminatory capacityCiencias médicasMedicina nuclearRadiaciónEfectos fisiológicosCiencias de la saludDolor lumbarGammagrafía ósea,Tomografía axial computarizada,ConcordanciaCapacidad discriminatoria1. 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World Neurosurg. 2017;107:732-738.ORIGINALTesis_Medicina_nuclear_Alejandro_Paternina_2025.pdfTesis_Medicina_nuclear_Alejandro_Paternina_2025.pdfDocumento final de tesisapplication/pdf875712https://repository.unab.edu.co/bitstream/20.500.12749/29021/1/Tesis_Medicina_nuclear_Alejandro_Paternina_2025.pdffb6ec0694ce71b210a7fab91c83eb65eMD51open accessFormato Autorizacion.pdfFormato Autorizacion.pdfAutorización autorapplication/pdf188668https://repository.unab.edu.co/bitstream/20.500.12749/29021/2/Formato%20Autorizacion.pdf52f2424d0ff78cafcb6586f5d638ab84MD52open accessCarta de aprobación de la Facultad-Alejandro Paternina.pdfCarta de aprobación de la Facultad-Alejandro Paternina.pdfAprobaciónapplication/pdf136763https://repository.unab.edu.co/bitstream/20.500.12749/29021/3/Carta%20de%20aprobaci%c3%b3n%20de%20la%20Facultad-Alejandro%20Paternina.pdf5a2653bfe60d5f15e4aa0b465a01be47MD53open accessLICENSElicense.txtlicense.txttext/plain; charset=utf-8829https://repository.unab.edu.co/bitstream/20.500.12749/29021/4/license.txt3755c0cfdb77e29f2b9125d7a45dd316MD54open accessTHUMBNAILTesis_Medicina_nuclear_Alejandro_Paternina_2025.pdf.jpgTesis_Medicina_nuclear_Alejandro_Paternina_2025.pdf.jpgIM Thumbnailimage/jpeg6594https://repository.unab.edu.co/bitstream/20.500.12749/29021/5/Tesis_Medicina_nuclear_Alejandro_Paternina_2025.pdf.jpg96febab37cde28a7600c975371e5a9ecMD55open accessFormato Autorizacion.pdf.jpgFormato Autorizacion.pdf.jpgIM Thumbnailimage/jpeg13261https://repository.unab.edu.co/bitstream/20.500.12749/29021/6/Formato%20Autorizacion.pdf.jpgb95df07ec94f6c4aa7405ecf4a1086e0MD56open accessCarta de aprobación de la Facultad-Alejandro Paternina.pdf.jpgCarta de aprobación de la Facultad-Alejandro Paternina.pdf.jpgIM Thumbnailimage/jpeg9695https://repository.unab.edu.co/bitstream/20.500.12749/29021/7/Carta%20de%20aprobaci%c3%b3n%20de%20la%20Facultad-Alejandro%20Paternina.pdf.jpgfc205b44a5730e7366d52a5b02bf0a07MD57open access20.500.12749/29021oai:repository.unab.edu.co:20.500.12749/290212025-05-05 22:00:17.966open accessRepositorio Institucional | Universidad Autónoma de Bucaramanga - UNABrepositorio@unab.edu.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