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Tool to aid clinical judgement when serious spinal pathology suspected
Mechanical non-specific low back pain
Mechanical low back pain with no leg symptoms overview
Low back and leg pain/Lumbar radiculopathy
Lumbar radicular pathway overview
Coccygeal pain
Other specific causes of low back pain
When to order imaging
MSK SERVICES PATHWAY - LOW BACK PAIN PATHOLOGY
FOR PATIENTS AGED OVER 16 YEARS
- Spinal malignancy
- Metastatic Spinal CordCompression
- Fracture
- Cauda Equina
- Inflammatory Back Pain
- Infection
GPs to follow guidance offered within this pathway and where relevant refer using Ardens templates and within remit of CCG Restricted and Not Routinely funded policy.
RED FLAG
ASSESSMENT & DIAGNOSIS OF OTHER CONDITIONS
Diagnosis to
monitor
History &
Symptoms
Injury
Medical Professionals seeing patients with MSK complaints in primary care should be trained in assessing for alarming features and red flags in all patients.
Consider admission/urgent referral
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- Abdominal Aortic Aneurysm
- Visceral Referral
- Lumbar Radiculopathy with muscle power of < 3/5, such as drop foot.
RED FLAG SCREENING: SPECIFIC FOR LOW BACK PATHOLOGY
Red Flags/ conditions that will alter management immediately
Medical Professionals seeing patients with MSK complaints in primary care should be trained in assessing for alarming features and red flags in all patients.
- Spinal malignancy
- Metastatic Spinal Cord Compression
- Fracture
- Cauda Equina
- Inflammatory Back Pain
- Infection
- Abdominal Aortic Aneurysm
- Visceral Referral
- Lumbar Radiculopathy with muscle power of < 3/5, such as drop foot.
History & Symptoms
- Cauda equina syndrome^1. o Severe or progressive bilateral neurological deficit of the legs, such as major motor weakness with knee extension, ankle eversion, or foot dorsiflexion. o Recent-onset urinary retention (caused by bladder distension because the sensation of fullness is lost) and/or urinary incontinence (caused by loss of sensation when passing urine). o Recent-onset faecal incontinence (due to loss of sensation of rectal fullness). o Perianal or perineal sensory loss (saddle anaesthesia or paraesthesia). o Unexpected laxity of the anal sphincter. - Referral should be made to local A and E department immediately by assessing **clinician (GP, ANP, APP, Physiotherapist)
- For MSK APP triage staff and MSK Core physiotherapy staff, patient letter is available** on SystmOne to be completed and given to patient to attend A and E
- Spinal fracture 1. o Sudden onset of severe central spinal pain, which is relieved by lying down. o A history of major trauma (such as a road traffic collision or fall from a height), minor trauma, or even just strenuous lifting in people with osteoporosis or those who use corticosteroids. o Structural deformity of the spine (such as a step from one vertebra to an adjacent vertebra) may be present. o There may be point tenderness over a vertebral body. - Referral should be made to local A and E department immediately by assessing **clinician (GP, ANP, APP, Physiotherapist)
- Spinal Malignancy1^1.** o Age <20 or > 50 is higher risk group. o Gradual onset of symptoms. o Severe unremitting pain that remains when the person is supine, aching night pain that prevents or disturbs sleep, pain aggravated by straining (for example, at stool, or when coughing or sneezing), and thoracic pain. o Localised spinal tenderness. o No symptomatic improvement after four to six weeks of conservative low back pain therapy. o Unexplained weight loss, fever, malaise. o Past history of cancer - breast, lung, gastrointestinal, prostate, renal, and thyroid cancers are more likely to metastasize to the spine. - Referral should be made to local A and E department immediately by assessing clinician (GP, ANP, APP, Physiotherapist) if fractures are noted on any form of **radiological investigation
- Urgent referral should be made to local spinal unit
- Infection/Inflammatory back pain (such as Ankylosing Spondylitis, discitis, vertebral** osteomyelitis, or spinal epidural abscess)^1.
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RED FLAG SCREENING: SPECIFIC FOR LOW BACK PATHOLOGY
History & Symptoms
Visceral Referral 4
- Accounts for 2% of LBP (including AAA).
- Possible visceral referrals include: bladder, kidney (flank pain), ureter, liver (right-sided thoracolumbar pain). - If visceral referral possible cause and assessed by MSK Triage team or core physiotherapy team. Refer back to GP with letter.
References (^1) NICE endorsed low back pain pathway (2017) (^2) NICE 2008 MSCC guidelines (^3) Knaap and Powell (2011) (^4) Goodman and Synder (2012)
TOOL TO AID CLINICAL JUDGEMENT WHEN SERIOUS PATHOLOGY SUSPECTED
SUBJECTIVE EXAMINATION FINDINGS
HISTORY
RADIATION to leg?
MECHANISM OF INJURY High trauma or Penetrative trauma? Insiduous?
NEUROLOGY?
RED FLAGS/ CONSTITUTIONAL SYMPTOMS?
PAST MEDICAL HISTORY AND TREATMENT - VIEW COMPLIANCE/ RESPONSE
ALTERED SENSATION OR LOSS OF MOTOR CONTROL OF BOWEL/BLADDER?
PRIOR CANCER HISTORY? (Particularly those that metastasise to bone)
FAMILY HISTORY
RISK FACTORS
AGE/DEMOGRAPHIC
FURTHER EXAMINATION
- Recent/Sudden onset of deformity that is not passively correctable
SPINAL TENDERNESS & RED FLAGS
- Inpatient with known prior cancer
- If after violent trauma
- Abnormal neurology
- Positive UMN testing
- Loss of anal tone or peritineal sensation
AAA EXAMINATION
- History increases suspicion
- Pulsating Mass may be present on observation
- Presence of >3cm diameter on aorta palpation is regarded as AAA
- NB - ability to palpate is influenced by abdominal girth and diameter of aneurysm - do not go by objective examination findings alone
NEUROLOGICAL EXAMINATION Motor Power <3/5 at 1 neurological level and no serious abnormal neurology such as +ve UMN testing
Suspected vertebral Fracture
- can be due to neoplasm, osteoporosis, hemangioma or trauma
Suspected Metastatic Cord Compression Cauda Equina Syndrome
?Unstable spinal injury, visceral injury or spinal cord injury
X-ray within primary/ intermediate care if no red flags and pain controlled. Secondary Care - if red flags or pain not controlled.
If high index suspicion Urgent referral for oncology emergency (per local pathway)
Medical Emergency Urgent referral into A&E with accompanying letter from clinician
AAA or Ruptured AAA suspected
Lumbar Radiculopathy Motor Power < 3/5e.g. Drop Foot
AAA - suspected rupture/ high risk rupture (Emergency)
- Patient transported to A&E immediately. Clinician to phone A&E to notify them/ send letter once patient has left. Suspected AAA - not deemed high risk
- Letter to GP - Patient to see GP within 48 hours. GP to refer for AAA screening.
Lumbar Radiculopathy Motor Power <3/ Refer to MSK triage Hub for triage - NUH Surgical Clinic categorise as ‘urgent for spinal opinion’.
DIAGNOSIS: MECHANICAL NON-SPECIFIC LOW BACK PAIN (ACUTE, SUBACUTE, PERSISTENT)
TYPE OF INFORMATION GUIDELINES
Background information
- LBP is the largest single cause of loss of disability adjusted life years and the largest single cause of years lived with disability in England. 3
- It affects around one third of the adult population each month. 2
- In most people, low back pain is non-specific and serious/specific causes are rare.
- Patient-centred approach is best with a focus on self-management.
- Appropriate acute back pain management has the potential to reduce the disabling effects of spinal pain with improvements on physical, emotional and social function.
- Most episodes of non-specific back pain resolve within four weeks with self-care.
- People with low back pain who are at higher risk of long-term pain and functional disability include those with: o Pain lasting for longer than 12 weeks. o Psychosocial distress. o Maladaptive coping strategies such as avoidance of work, movement, or other activities due to fear of exacerbating back pain. o Pain coping characterised by excessively negative thoughts about the future (‘catastrophising’).
- People who have had low back pain often have episodes of recurrence and may develop repeated ‘acute on chronic’ symptoms.
- It is estimated that between 5 and 30% of patients who develop acute and subacute LBP go on to develop persistent low back pain 2.
Subjective History
- Tension, soreness or stiffness in the lumbosacral region which varies with changes in posture and/or movement. 2
- History questioning should include an assessment for the presence of red flag symptoms, which would imply serious conditions.
- If signs of serious conditions (red flags) present, specialist referral should be made.
- The assessment should also capture potential biopsychosocial barriers to an improvement in the patient’s condition so that subsequent treatment can be tailored to address these barriers. Examples of potential barriers include high levels of pain, perceived frailty or vulnerability, psychosocial factors and maladaptive strategies such as kinesophobia or prolonged bed rest.
- The assessing clinician could also use the StArt back pain tool to as part of the assessment for the person’s risk of back pain disability and this can then guide decisions regarding management^2.
- Subjective Markers could include:
- The level of function such as walking distance, whether the patient is at work.
- VAS score/duration of pain/duration of time it takes to relieve symptoms.
- Completion of STarT back tool At follow-up, if symptoms persist or are worsening the clinician should continually reassess for red flags and any barriers to the patient’s improvement (for example, maladaptive strategies and negative perception of condition).
Physical Examination findings
- Examination for features of mechanical back pain, for example pain is reproduced by back movement and/or changes in postures.
- Remaining examination led by patient history (for example functional demonstration of the movement/position identified by the patient to provoke their symptoms, neurological assessment).
- Assess for spinal deformity (scoliosis, kyphosis or otherwise).
- Neurological assessment if appropriate
- Screen hip and sacro-iliac joint
Investigations (^) • Do not offer imaging (x-ray, MRI) for patients with suspected mechanical non-specific low back pain in the absence of leg pain and or red flags
DIAGNOSIS: MECHANICAL NON-SPECIFIC LOW BACK PAIN (ACUTE, SUBACUTE, PERSISTENT)
TYPE OF INFORMATION GUIDELINES
Referral on for secondary care opinion:
- Spinal surgery is no longer available for non-specific Low Back Pain (see Nice Guidance 59) - if pain persists despite treatment, consider referral to local pain clinic. The spinal unit will no longer accept these referrals. Pain Management referral to PICs may be necessary:
- When there is diagnostic uncertainty
- Speciality as directed by clinical guidelines if alternative diagnosis is suspected
- If symptoms are not improving with 12-16 weeks of patient compliance with high-quality conservative management (including physiotherapy input) and if the patient has seen band 7/8 clinicians, consideration can be made by the band 7/8 clinician to refer the patient on for secondary care orthopaedic assessment to evaluate alternate diagnoses, consider investigative measures and direct treatment. FACET JOINT PAIN - Regarding facet joint pain - when to refer to secondary care pain management services:-
- The features subjectively include: Increased pain unilaterally or bilaterally on lumbar paraspinal palpation ▪ Increased back pain on 1 or more of the following: extension (more than flexion) • rotation, extension/side flexion, extension/rotation • No radicular symptoms • No sacroiliac joint pain elicited using a provocation test.^5
- The patient has trialled good-quality conservative management (as described above) before referring for consideration of radiofrequency denervation.
- For assessment for radiofrequency denervation for people with persistent low back pain when non-surgical treatment has not worked, AND the main source of pain is thought to come from structures supplied by the medial branch nerve, AND the person’s pain is limiting their quality of life.^1
- Only perform radiofrequency denervation in people with persistent low back pain after a positive response to a diagnostic medial branch block.^1
- Radiofrequency denervation may be repeated if this gave the patient 12-16 months of pain relief
- MRI is not necessary to aid diagnosis^5
- Therapeutic facet joint injections are not recommended.
- Patients should typically be having physical rehabilitation simultaneously with radiofrequency denervation treatment
References (^1) NICE 2016 guidelines low back pain and sciatica in over 16s (NG59) (^2) CKS Back Pain – Low (without radiculopathy) – April 2017. (^3) Global Burden of Disease 2013 (^4) STarT guidance (^5) National low back pain and radiculopathy pathway (2017)
MECHANICAL LOW BACK PAIN WITH NO LEG SYMPTOMS OVERVIEW
EARLY CLINICAL REVIEW
Assessment / recheck diagmosis
Check for Red Flags (6)
LOW RISK OF DISABILITY (4)
(STarT tool can be used)
MEDIUM-HIGH RISK OF DISABILITY
(STarT as optional guide)
Self-Manage (4).
- Direct patient to self- help information such as the MSK Together Website.
- Patient to return to clinician if symptoms not improving.
Access Secondary Care Pain Management Services for:
- Extra Guidance with regards to assessment and management.
- Consideration for medial nerve root branch blocks
- Re facet joint pain - consideration for radiofrequency denervation see facet joint pain overview p.5/p.11)
*Add-on Treatment options include:-
- Improving access to Psychological Therapies Return to work scheme (24), Community Gym Referral/ Weight management programme.
FINAL OUTCOME:
Discharge/Self-Manage
Low Intensity Combined Physiotherapy and Psychological Programme (10)
Physiotherapy Exercise +/- Manual Therapy (10)
MSK HUB TRIAGE
- Specialist electronic OR face to face Triage via Band 7 APP or BAND 8 ESP (9).
Comprehensive Multi- Disciplinary Physical
- Psychological programme (PICs) (12).
Note - the numbers in brackets refer to the boxes within the National Low back Pain and Radicular Pathway (2017).
DIAGNOSIS: LUMBAR RADICULOPATHY
TYPE OF INFORMATION GUIDELINES
Conservative management
Exercise +/- Manual therapy via Physiotherapy 2
- Take the patient’s specific needs and preferences into account when choosing the type of exercise, whether it is in a group or individual setting.
- Encourage activity and address inactivity; bed rest is not recommended.
- Graded Exposure. Try to address psychosocial barriers such as fear-avoidance of activity/ unhelpful beliefs.
- Promote and facilitate return to work – consider the return to work scheme if the patient would like additional support with this (box 24) 2.
- Goal setting (SHORT/MEDIUM/LONG). Give realistic time scales.
- Consider a referral into the Bfit programme (combined physical and psychological programme when there are psychological obstacles to recovery such as anxiety.^2 )
- The band 7/8 clinicians can refer to the MDT Pain Management Service (PICs) when there are psychological obstacles to recovery such as anxiety and depression, for example, avoiding normal activities based on inappropriate beliefs about their condition or when previous treatments have not been effective. Add-on Treatment options
- The patient can also self-refer to the 4 IAPT services (Insight, Trent PTS, Turning Point, Let’s Talk Wellbeing). This could be appropriate if there are psychological barriers to an improvement in their symptoms.
Referral on to secondary care consultant/pain management services
The patient should have had an MRI scan or CT scan if unable to have an MRI scan.^2 Prior to referral:-
- MRI report and imaging to be available
- Full medical history and medications to be available
- History/Examination – see above
- Assessment of severity of symptoms ▪
- Ask patient if tolerable, non-tolerable and whether improving, worsening or plateaued
- Outcome measures could include NPRS for leg/back pain, PSFS, EQ-5D, Oswestry Disability Index (ODI). Once referred to secondary care, the following non-conservative procedures can be considered for people who have radiculopathy. These can only be considered if the MDT feel there is ‘possible’ concordant nerve compression or the nerve root compressed may be responsible for the clinical findings: - 2
- Epidural injections/nerve root block (via Pain Management services)
- Spinal decompression (via surgical spinal teams)
Epidural injections/nerve root block may be considered for severe, non-controllable radicular pain in prolapsed intervertebral disc early in the clinical course for symptom control (box 22) 2 Consider referral to PICs or for spinal opinion for acute radicular pain if:
- No response to appropriate physiotherapy and analgesia (8-12 weeks if non-tolerable radicular pain which has been refractory to conservative treatment intervention, inclusing NSAIDs and a trial of at least 2 neuropathic medications at therapeutic dose (see APC, NICE (CG173 3 )
- Concordant MRI findings
- Very severe radicular pain, which is not controllable with analgesia or nerve root injection, may require early surgery likely to be at the 1-3 week stage. Early surgery may also be required if accompanied by major radicular weakness (motor power <3/
- Later surgery may occur in patients with symptoms of fluctuating severity (box 23). 2 )
- Patients are appropriate for spinal referral if they would not decline surgery if offered
DIAGNOSIS: LUMBAR RADICULOPATHY
TYPE OF INFORMATION GUIDELINES
Referral on to secondary care consultant/pain management services
Extra note:- Note - Injections for central or foraminal stenosis (without disc herniation) are not approved. Fusion surgery may still be considered as a necessary adjunct to another procedure performed for conditions other than non-specific low back pain, e.g. decompression for spinal stenosis with symptoms of claudication, radicular pain or other indication 2.
References (^1) NICE CKS Low Back Pain and Sciatica (2017). (^2) NICE Endorsed National Low Back and Radicular Pain Pathway (2017). (^3) NICE CG
DIAGNOSIS: COCCYGEAL PAIN
TYPE OF INFORMATION GUIDELINES
Background information
Conservative treatment is thought to be successful in 90% of cases, and many cases resolve without medical treatment. The incidence of coccygeal pain is unknown. Risk factors are thought to include obesity and female gender (5 x more common).
Subjective history
- The person complains of localised pain over the coccyx or over the “tailbone”.
- Symptoms could occur insidiously or through direct trauma.
- Aggravating factors could include prolonged sitting, leaning back when sitting, prolonged sitting and rising to a standing position, sexual intercourse and/or defecation.
Physical Examination findings
- Symptom reproduction with pain on palpation of the coccyx.
- Check for alternative diagnoses through neurological examination/assessment of functional movement/lumbar range of movement.
Investigations (^) • X-ray to assess for bony pathology/fracture.
- No other investigations would be typically required to aid the diagnosis of coccygeal pain.
Conservative management
Conservative treatment is thought to be successful in 90% of cases and many cases resolve without the person seeking medical treatment. Treatment should be individually tailored to address any underlying barriers to improvement
- such as reduced sleep, anxiety/depression, catastrophisation, kinesiophobia, and reduced physical activity levels. Use a specially designed coccyx cushion, which can reduce the pressure on the coccygeal region when sitting.
- Advice regarding regular movement - Avoid prolonged sitting whenever possible – try to stand up and walk around regularly; leaning forward while seated may also help.
- Heat/Cold Therapy could be used.
- Pharmacological Management: Take over-the-counter painkillers (such as paracetamol, ibuprofen)., Use of laxatives (medicines to treat constipation) if the pain is worse when the patient tries to open their bowels.
Referral on to secondary care consultant/pain management services
- Consider cortisone injections for coccygeal pain for patients in which good-quality conservative treatment has not eased their symptoms.
- Surgery for coccydynia is usually only recommended when all other treatments have failed. It may involve removing some of the tailbone (partial coccygectomy) or occasionally all of it (total coccygectomy). It takes a long time to recover from coccygectomy, anywhere from a few months to a year.
Prognosis (^) Patient with coccygeal pain usually respond well to conservative management strategies.
DIAGNOSIS: OTHER SPECIFIC CAUSES OF LOW BACK PAIN (E.G. SPONDYLOLISTHESIS)
TYPE OF INFORMATION GUIDELINES
Background information
- NICE CKS – “If an underlying cause for the low back pain has been identified, manage according to the specific diagnosis” 1
- Spondylolysthesis, regardless of the type, can be preceded by spondylolysis, a fractured pars interarticularis of the lumbar vertebrae.
- Spondyloysthesis can be asymptomatic and are graded as 1-4, with 4 being the highest amount of translation.
Subjective history
- Varies depending on the specific cause of the low back pain.
- Use subjective examination to aid diagnosis/lower suspicion of other causes e.g. vascular, hip pain etc.
Physical Examination findings
- Varies depending on the specific cause of the low back pain
- Use physical examination to aid diagnosis/lower suspicion of other causes e.g. vascular, hip pain etc.
Investigations (^) X-ray/MRI would be used to identify if suspicious of a specific cause for low back pain such as spondylolisthesis. In adults with radiculopathy, MRI should be considered.
Referral on to secondary care consultant/pain management services
Spinal Unit QMC recommendations - Persistent pain from specific cause (e.g. spondylolisthesis) MUST have had pain clinic opinion first prior to any referral to the spinal unit at QMC.
If a specific cause for the back pain (>3/12) is possible on MRI – review diagnosis, and spinal referral may be appropriate, but exclude other causes e.g. vascular, hip pain etc.)
Referral on to secondary care consultant/pain management services
- Consider cortisone injections for coccygeal pain for patients in which good-quality conservative treatment has not eased their symptoms.
- Surgery for coccydynia is usually only recommended when all other treatments have failed. It may involve removing some of the tailbone (partial coccygectomy) or occasionally all of it (total coccygectomy). It takes a long time to recover from coccygectomy, anywhere from a few months to a year.
Prognosis (^) Varies depending on the specific cause of the low back pain
References (^1) NICE CKS Low Back Pain and Sciatica (2017).
DIAGNOSIS: SPECIFIC CAUSE OF LOW BACK PAIN - OSTEOPOROTIC
FRACTURES
TYPE OF INFORMATION GUIDELINES
Physical Examination findings
Recommended assessment measures for osteoporosis by CSP
- BMI (height and weight).
- Chest expansion at xiphisternum level.
- Cervical/thoracic deformity as measured by tragus to wall.
- Shoulder flexion angle with patient against wall (indirect thoracic spine extension).
- Lumbar spine range of movement (Shoeber’s extension).
- Some measure of strength and endurance should be included.
- Balance assessment – 1 leg stand or Tinnetti or other measure.
- Functional assessment - could utilise the Osteoporosis Functional Disability Questionnaire.
- Pain Assessment - such as the VAS.
Investigations (^) Recommendations of investigative options (spinal):
- DXA
- Quantitative Computerized tomography (QCT). DXA
- Most accurate for assessing BMD and hence diagnosis of osteoporosis.
- BMD of femoral neck + sex + age = used for estimated predictive of fracture rusk. QCT
- Benefits – great detail.
- Disadvantages: high radiation dose and not always available. Plain radiographs:
- Plain radiographs should not be used to diagnose or exclude osteoporosis.
- If plain film radiograph suggest “severe osteopenia” then a DXA is indicated.
- Can be used is vertebral fractures suspected as to do so would alter management (by grading) and there is an established method for reporting these findings.
Quantitative US (QUS) of calcaneus cannot be used to diagnose osteoporosis or to target treatment.
Biomechanical markers of bone turnover should have no role in the diagnosis of osteoporosis.
Conservative management
Everyone with Osteoporosis should be encouraged to increase dietary calcium intake and also partake in weight bearing exercise. Aims of Treatment:
- Reduce the incidence of future fractures.
- Reduce fracture-related morbidity.
- Pain management
- Patient education.
- Improve psychological wellbeing.
- Improve muscle strength, balance and CV fitness.
- Reduce risk of falls.
- Improve balance. Exercise
- Benefits: reduces falls risk, minimizes further BMD loss.
- Modes of exercise:
- High intensity strength training.
- Low impact weight bearing exercise.
- Water-based/land-based depending on severity and irritability of the pain and level of function.
- See CSP guidelines for further detail.
DIAGNOSIS: SPECIFIC CAUSE OF LOW BACK PAIN - OSTEOPOROTIC FRACTURES
TYPE OF INFORMATION GUIDELINES
Conservative management
Calcium intake.
- Postmenopausal women should aim for dietary intake of 1000mg calcium per day.
- No evidence vitamin D supplements are needed for active people over age 65. Ipriflavone – should only be used in conjunction with other interventions.
Pain Management
- Vertebral fracture can be pain free or significantly painful.
- Acute vertebral fracture management
- Main aim: early mobilization plus adequate pain control.
- RICE
- Simple analgesia up to opioids (advice from pain management service may be required).
- Hospital admission may be required.
- Calcitonin is not license in the UK but has been shown to be of benefit for acute vertebral fractures for pain management.
Chronic Vertebral fracture management:
- Analgesia ladder.
- Back strengthening exercises should be considered.
- Psychological care is important – as sleep is often impaired.
- Consider trycyclic antidepressants for sleep and psychological needs.
Referral on to secondary care consultant/pain management services
Consider escalation to secondary care (spinal unit QMC) if there are any red flags, high severity of pain and/or a new fracture is suspected. Consider referral to pain management services. Surgical Treatment Options: NICE^1 recommends Percutaneous vertebroplasty, and percutaneous balloon kyphoplasty without stenting as options for treating osteoporotic vertebral compression fractures only in people:
- who have severe ongoing pain after a recent, unhealed vertebral fracture despite optimal pain management and
- in whom the pain has been confirmed to be at the level of the fracture by physical examination and imaging.
Prognosis (^) • In patients who have pain due to vertebral collapse due to osteoporosis and have balloon kyphoplasty – these patients have improved pain control at 24 months but not necessarily improved function.
- Early diagnosis and commencement of treatment results in fewer falls, fragility fractures and improved quality of life measures.
- Early and adequate pain management results in fewer acute vertebral fracture morbidities.
References (^2) NICE (2013)- Percutaneous vertebroplasty and percutaneous balloon kyphoplasty for treating osteoporotic vertebral compression fractures (2013). (^3) NICE CKS Osteoporosis (2017). (^4) SIGN - The management of osteoporosis: a national clinical guideline (2013).
