Arrange investigations

• Bone blood screen (U & E, LFT, calcium, vitamin D)
• Myeloma screen (Immunoglobulins, protein electrophoresis, urine BJP)

Consider metastasis

Consider referral to orthopaedics via back pain pathway for consideration of MRI if there is intractable, severe pain despite appropriate analgesia

Urgent MRI through the Emergency Department if “red flags” are present

• Inform and advise the patient of fragility fracture
• Pain management according to the pain pyramid
• Provide information on vertebral fractures, osteoporosis and fracture risk reduction or signpost to Royal Osteoporosis Society
• Encourage mobilisation and exercise - DG Doing More
• Refer physio if restricted mobility or falls risk
• Refer for DEXA as baseline except in frail elderly where the result would not alter management

Start treatment with Alendronate/Risedronate. No need to wait for DEXA

Review after 5 years as per review template

Refer to Osteoporosis Clinic via SCI Gateway - DGRI...Rheumatology...General Referral:

• One severe or multiple vertebral fractures and T-score < -1.5 at any site or < -4.0 in spine (Teriparatide or Romosozumab may be indicated)
• Adverse effects alendronate/risedronate
• If general advice or counselling required re osteoporosis or fracture risk reduction

Refer to orthopaedics via SCI Gateway - DGRI...Orthopaedic Surgery...Lower back pain:

• Patients with intractable, severe pain despite appropriate analgesia