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Rapid Responses: Rapid Responses published:
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cervical spondylosis and dizziness
- Nicola A Cooper (9 March 2007)
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cervical spondylosis and dizziness
- Akhtar Sherin (11 March 2007)
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Why is laser therapy repeatedly forgotten in rheumatologists´ reviews of musculoskeletal pain management?
- Jan M. Bjordal, Rodrigo A. B. L. Martins, Bård Bogen, Jon Joensen, Mark I. Johnson (13 March 2007)
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Cervical Spondylosis
- Sameer Chadha, Shikha Mehta, Medical Student , Maulana Azad Medical College, New Delhi ,India (13 March 2007)
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Cervical spondylosis, a pain in the neck
- R HARISH (13 March 2007)
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Cervical spondylosis and Dizziness
- Akhtar Sherin (13 March 2007)
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Any place for steroids?
- Anton E Joseph (21 March 2007)
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Anyone for steroids?
- Richard Bartley (23 March 2007)
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Local anaesthetic nerve blockade in cervicogenic headache
- Eriko Morino (24 March 2007)
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Chronic Neck pain: importance of comorbidity and postural management at home and workplace.
- Andrew O. Frank (2 April 2007)
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Some neurological aspects of cervical spondylosis
- Michael D. O'Brien (10 April 2007)
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It is not true
- Alvaro E Georg, Porto Alegre - RS Brazil (16 April 2007)
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Surgical option over epidural steroid injection?
- Sau-Hsien Yap (18 April 2007)
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Nicola A Cooper, Consultant Physician Leeds General Infirmary, LS1 3EX
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Sir I was dismayed to read that "dizziness or vertigo" were listed as presenting features of cervical spondylosis in this week's review article. Dizziness is extremely common, especially in elderly people (many of whom have more than one type of dizziness) and causes a significant degree of morbidity. Nearly all elderly patients will have a degree of cervical spondylosis when X-rayed. Because most doctors are not trained in "dizziness", many of these patients do not get a proper diagnosis, and the myth of dizziness or vertigo (especially on looking up) due to cervical spondlyosis is perpetuated. Many of these patients have benign positional vertigo or other very treatable diagnoses. Generalists and trainees need to be aware that "dizziness or vertigo due to cervical spondylosis" is generally considered to be a "non-diagnosis" by those who specialise in the diagnosis and management of dizziness. But perhaps others have a different point of view? Yours faithfully Competing interests: None declared |
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Akhtar Sherin, Dr KIMS, Kohat NWFP Pakistan
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I agree with the comments of Nicola A Cooper, regarding cervical spondylosis and dizziness. Dizzeness is a very broad term and needs detailed assessment before lablelling someone as "Dizzy due to cervical spondylosis" Competing interests: None declared |
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Jan M. Bjordal, Associate Professor Bergen University College & University of Bergen, 5020 Bergen, Norway, Rodrigo A. B. L. Martins, Bård Bogen, Jon Joensen, Mark I. Johnson
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We have read the narrative review from dr. Binder about cervical spondylosis and neck pain [1]. Although the review is seemingly addressing the various pharmacological and non-pharmacological treatment options extensively, it surprises us that there is no mention of laser therapy. Completely or partly omitting physical treatments in narrative reviews of musculoskeletal disorders does unfortunately seem to be a recurring problem in the journal. We have emphasised the need to review physical treatments appropriately [2] in response to a recent review of osteoarthritis [3]. It is worrying that leading rheumatologists repeatedly seem to either miss or ignore scientific evidence of physical modalities and laser therapy in particular. For example, dr.Binder cites an 11 year old systematic review [4] as a key text to support physical medicine even though part of the review was withdrawn from the Cochrane Library more than 4 years ago [5]. We believe that the most recently updated review about conservative treatment from the same review group would have been a more appropriate citation [6]. This update of the review includes laser therapy as one of the few modalities that has moderate evidence for chronic degenerative neck pain. Recent good quality trials [7] and another systematic review [8] have also found that laser therapy gives clinically relevant effects in chronic neck pain. Laser therapy may not be a panacea in musculoskeletal pain, but to our knowledge there are now 13 randomised placebo-controlled trials published on laser therapy for chronic neck pain. Surely, this evidence deserves a mention. Perhaps BMJ could improve its peer review procedures to prevent the omission of large bodies of evidence for physical modalities in future reviews. References 1. Binder, A.I., Cervical spondylosis and neck pain. BMJ, 2007. 334(7592): p. 527-31. 2. Bjordal, J.M., Lopes-Martins, R.A.B., Bogen, B., and Johnson, M., Physical treatments have valuable role in osteoarthritis. BMJ, 2006. 332(7545): p. 853-4. 3. Hunter, D.J. and Felson, D.T., Osteoarthritis. BMJ, 2006. 332(7542): p. 639-42. 4. Aker, P.D., Gross, A.R., Goldsmith, C.H., and Peloso, P., Conservative management of mechanical neck pain: systematic overview and meta-analysis. Bmj, 1996. 313(7068): p. 1291-6. 5. Gross, A.R., Aker, P.D., Goldsmith, C.H., and Peloso, P., Conservative management of mechanical neck disorders. Part 2: physical medicine modalities. (Cochrane review). In The Cochrane Library, Issue 1, 2001, Oxford, England, Update Software, updated quaterly., 2001. 6. Gross, A.R., Goldsmith, C., Hoving, J.L., Haines, T., Peloso, P., Aker, P., Santaguida, P., and Myers, C., Conservative Management of Mechanical Neck Disorders: A Systematic Review. J Rheumatol, 2007. 7. Chow, R., Laser acupuncture studies should not be included in systematic reveiws of phototherapy. Photomed Laser Surg, 2006. 24(1): p. 69. 8. Chow, R.T. and Barnsley, L., Systematic review of the literature of low -level laser therapy (LLLT) in the management of neck pain. Lasers Surg Med, 2005. Competing interests: None declared |
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Sameer Chadha, Medical Student Maulana Azad Medical College, New Delhi, India, Shikha Mehta, Medical Student , Maulana Azad Medical College, New Delhi ,India
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Osteoarthritis of the cervical spine produces neck pain that radiates into back of the head, shoulders, arms and can cause headaches in the posterior occipital region. Osteophyte formation in the hypertrophic facet joints can lead to monoradiculopathy. It may also compress the cervical spinal cord. Other causes of the cord compression may be ossification of posterior longitudnal ligament or a large central disk. Combinations of Myelopathy and Radiculopathy can occur . Lhermitte symptom can be there. The differentilal diagnosis includes Amyotrophic Lateral Sclerosis, Multiple Sclerosis, Syringomyelia or spinal cord tumors when there is little or no neck pain accompanying the cord compression. MRI or CT-myelography can define the abnormalities and EMG and nerve conduction studies can localise and assess the severity of nerve root injury. Competing interests: None declared |
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R HARISH, Consultant Anaesthetist Morriston hospital, swansea SA6 6NL
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Dear Author, I read with enthusiasm your excellent review on a broad subject like cervical spondylosis, even though in actual practice managing it can be a pain in the neck. I have a special interest in pain, and the majority of neck pain encountered in practice have a mechanical origin with a significant myofacial component, due to underlying significant or insignificant degenerative disease of cervical and or lumbar spine. With regards to clinical symptoms there is evidence that cervical spondylosis may rarely present as dysphagia or airway obstruction (1,2,3,4,5) due to large anterior osteophytes causing mechanical compression of oesophagus or perioesophagial inflammation and conservative treatment with anti- inflammatory medications for mild to moderate cases, and surgery for severe cases.(3) One must consider ruling out metabolic causes of myelopathy in cervical spondylosis by checking vitamin B12 levels and a serum rapid reagin test. I would like to add here for the reader's interest a syndrome seen complicating cervical spondylosis,called central cord syndrome which typically occurs in elderly following a hyperextension injury resulting in acute cord compression due to ventral osteophytes, where one presents with greater upper limb weakness than lower extremity weakness and some degree of sensory disturbance and bladder retention. I would also like to comment on a subject which the author has not touched is the use of neck collar in cervical spondylosis, which is advocated extensively in primary care. It is believed to work by placebo effect and not shown to change long term outcomes; infact the use of rigid collars may reduce muscle tone and increase neck stiffness from disuse. Even though there is conflicting evidence about the effectiveness of cervical traction, retrospective studies have noticed a 81% symptom relief with intermittent traction(6)but its cost effectiveness long term is questionable. In conclusion, thre is no substitution for regular stretching exercise, mobilisation and physiotherapy combined with or without analgesics as the mainstay in the treatment of uncomplicated or conservatively managed cervical spondylosis. References 1 Kaye JJ,Dunn AW:cervical spondylotic dysphagia. South Med J 1977 May; 70(5):613-4 2 Umerah BC, Mukherjee BK, Ibekwe O:Cervical spondylosis and dysphagia. J Laryngol Otol 1981 Nov; 95(11):1179-83 3 Sobol SM,Rigual NR:Anterolateral extrapharyngeal approach for cervical osteophyte-induced dysphagia. Literature review. Ann Otol Rhinol Laryngol 1984 Sep-Oct; 93:498-50 4 Fraooqi NA, Doran M,Buxton N: Cervical Osteophytes:a cause of potentially life threatening laryngeal spasms. Case report. J Neurosurg Spine 2006 May:4(5): 419-20 5 Kanbay M, Selcuk H, Yilmaz U: Dysphagia caused by cervical osteophytes: a rare case. J Am Geriatrics Soc 2006 july; 54(7):1147-8 6 Swezey AM, Warner K: Efficacy of home cervical traction therapy. Am J Phys Med Rehabilitation 1999 jan-Feb; 78(1):30-2 Competing interests: Consultant Anaesthetist with interest in pain |
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Akhtar Sherin, Dr KIMS, Kohat NWFP Pakistan
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Cervical vertigo is the term used for dizziness associated with cervical spondylosis. Position receptors located in the facets of the cervical spine are important in the coordination of head and neck movements and cervical proprioceptive dysfuntion is a common cause of vertigo riggered by neck movements.1 Rotational Vertebral Artery Occlusion has been shown as another Mechanism of Vertebrobasilar Insufficiency leading to neurological signs.2 However Structural abnormalities of the brain and neck are common in both dizzy and non-dizzy subjects.A study has shown that there were no significant differences in the prevalence of cord compression, cervical subluxation, facet joint degeneration, vertebral artery compression, or vertebral artery occlusion between dizzy and non-dizzy subjects. Although cervical spondylosis has been identified as the cause of dizzines, expensive investigations are rarely helpful in dizzy elderly people.4 The cause of the dizziness can be diagnosed in most cases on the basis of a thorough clinical examination without recourse to hospital referral. 1:Jacklor Rk, Kaplan MJ. Ear nose & throat. Chap 8. In: Tierney Jr LM, McPhee SJ, Papadakis MA (ed).Current Medical disgnosis and treatment.2006 45th Edition Lange Meical Books,New York. 2: Kuether, Todd A. Nesbit, Gary M. Clark, Wayne M. et al. Rotational Vertebral Artery Occlusion: A Mechanism of Vertebrobasilar Insufficiency.Anatomic Report. Neurosurgery. 41(2):427-433, August 1997. 3: Colledge N, Lewis S, Mead G, SellarR, Wardlaw J, Wilson J.Magnetic resonance brain imaging in people with dizziness: a comparison with non-dizzy people.Journal of Neurology Neurosurgery and Psychiatry 2002;72:587-589 4:Colledge NR, Barr-Hamilton RM, et al. Evaluation of investigations to diagnose the cause of dizziness in elderly people: a community based controlled study.BMJ. 1996 Sep 28;313(7060):788-92. Competing interests: None declared |
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Anton E Joseph, Consultant Radiologist Mayday University Hospital, Croydon CR7 7YE
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As a radiologist I make no claim to have any expertise in the treatment of cervical spondylosis. The purpose of my communication is to relate my personal experience of cervical spondylosis and the treatment I was given by my consultant rheumatologist. I admit that treatment cannot be based on one anecdote. The MRI of my cervical spine would have served as a perfect illustration for a good going cervical spondylosis and is virtually indistinguishable from the illustration in the article. It would be reasonable to conclude that these changes did not happen overnight. Further I was virtually symptom free. I did however experience a 'crepitus' like sensation on rotation of the neck (my amateurism is clearly showing here) for the last few months. Three weeks ago I developed acute pain at the root of my neck on the right side of the spine with pain radiating down my arm with pins and needles sensation on the back of my hand. Within twentyfour hours I had to cancel my ultrasound list. I saw the rheumatologist the next day (clearly jumping the queue, one of the few perks some of us enjoy as members of the profession). Having performed the usual clinical examination he suggested that I take some steroids (the dosage is not particularly relevant here). The logic behind it seemed straight forward. The changes seen on the MRI must have been present for a very long time. Something acute had happened to bring the pain on suddenly and with that degree of severity. There was no traumatic incident. Is it reasonable to assume that some irritation, inflammation and oedema might have made it a tight squeeze in the foramina. The pain improved dramatically within forty eight hours and I was pretty comfortable in seventy two hours. I was on steroids for two weeks in all and apart from some discomfort now pain free. Intermitent use of paracetomol helps. Some mild sensory symptoms still persist. There is no mention of steroids in this article. I have consulted my consultant before submitting this communication. He clearly believes that there is room for steroids in my type of situation. He is arranging for me to see a physiotherapist and possible manipulation. My consultant I would be delighted to hear the views of others. Competing interests: A patient recovering from acute presentation of cervical spondylosis having been treated with steroids. Prior to this experience I had believed that there was no place for steroids. |
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Richard Bartley, Physiotherapist Denbigh LL16 3ES
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Acute facet joint synovitis could explain the previous correspondent's acute neck and brachialgic episode. Effusion of a single facet joint following mild subluxation could partially occlude the adjacent exit foramen, thus causing nerve root chaffing or compression. Prompt steroid therapy could therefore be effective. The challenge ahead is to be able to specifically diagnose facet joint dysfunction (acute or chronic) and differentiate it from other soft- tissue causes of neck pain. Unfortunately, current clinical tests and advanced imaging tools lack specificity for such accurate diagnosis. Competing interests: None declared |
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Eriko Morino, SHO Anaesthetics St Helier's Hospital, Carshalton, Surrey, SM5 1AA
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I commend the author of this article for concentrating on an often poorly understood and multifactorial condition. Indeed neck pain can be a cause for serious morbidity as well as substantial disbility and a major reason why people seek medical attention. I agree sufferers of osteoarthritis of the neck often have symptoms relating to the postural and mechanical basis of this degenerative disorder. The author mentions referred pain to the occiput and retro-orbital or temporal pain among clinical features of cervical spondylosis. Recent clinical observations support the concept that, due to various causes, the greater occipital nerve can be the structure that generates occipital and fronto-orbital pain (1-3). However local anaesthetic blockade of the occipital nerve was not mentioned as a treatment modality in cervicogenic headache. This anaesthetic injection has been used to treat diverse headache complaints for a few decades. Studies have shown that the regional blockade of the greater occipital nerve is effective as a treatment in migraine, tension-type and cervicogenic headache (4). There is also some evidence to suggest that other cervical dorsal root anaesthetic injections successfully relieve headaches. Injections of the atlanto-axial joints (C1-C2 origin), and isolated blockades of C2, C3, C4 and C5 have been documented to provide effective headache relief (4)(5). Presumably these local anaesthetic injections, sometimes given in conjunction with steroids, may cause a block in the conduction of the noxious stimulus or normalizes the response threshold of the epicranial neurones. It is a safe, effective technique and can be easily carried out in the primary care setting. 1. CA Caputi, V Firetto. Therapeutic blockade of greater occipital and supraorbital nerves in migraine patients. Headache 1997; 37: 174-179. 2. O Sjaastad, TA Frederiksen, A Stolt-Nielsen. Cervicogenic headache – C2 rhizopathy, and occipital neuralgia: a connection? Cephalagia 1986; 6: 189-195. 3. V Pfaffenrath, R Dandekar, W Pollmann. Cervicogenic headache – the clinical picture, radiological findings and hypotheses on its pathophysiology. Headache 1987; 27: 495-499. 4. G Bovim, T Sand. Cervicogenic headache, migraine without aura and tension-type headache. Diagnostic blockade of greater occipital and supra -orbital nerves. Pain 1992; 51: 43-38. 5. N Inan, A Ceyhan, L Inan, O Kavaklioglu, A Alptekin, N Unal. C2/C3 Nerve blocks and greater occipital nerve block in cervicogenic headache treatment. Functional Neurology 2001; 16: 239-243. Competing interests: None declared |
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Andrew O. Frank, Consultant Physician in Rehabilitation Medicine & Rheumatology Arthritis Centre, Northwick Park Hospital, Harrow, HA1 3UJ
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Alan Binder is to be congratulated on his erudite review of neck pain [1]. As a rheumatologist working in the secondary setting, my experience is based on patients with chronic neck pain with a total experience of pain of 76 months and an episode duration of 17 months [2]. Most had other musculoskeletal comorbidities, commonly lumbar or thoracic back pain (54%) and only 12% had no musculoskeletal comorbidity. Thus it is important to examine the whole spine when a patient presents with chronic neck pain. Patients may have spinal deformities e.g. a thoracic kyphus needing plain X-Rays to determine whether it reflects degenerative thoracic problems or previously undetected osteoporosis. The kyphus forces patients to hyperextend the neck in order to maintain vision straight ahead, giving rise to neck pain. Such patients are often helped by a cervical collar which reduces the strain on the posterior muscles, as noted previously [3]. Conversely, neck problems can present as low back pain, particularly cervical myelopathy with spasticity in the legs affecting the low back [4]. Binder is correct in stating that a balanced view of the management of neck pain cannot be given by discussing evidence-based treatments only. Poor posture may reflect home activities (e.g. needlework), with prolonged neck flexion or be present in the workplace. Advice is needed about workplace posture and activities in 13% of patients presenting to a hospital neck clinic [2]. The key advice for static postures is to take frequent small breaks. Whilst employers advise about the ergonomics of work stations, they appear not to advise small breaks, which I advise for a few seconds every half hour for those with static work posture. Work- site interventions appear a neglected form of advice for this economically important condition [5]. Binder’s advice to use one pillow at night recognises the importance of neck pain in disturbing sleep [2], but sleeping position may be equally important. As many patients sleep on their side, a pillow that fills the gap between the shoulder and the head will support the neck in neutral and many pillows are not large enough for this, needing two pillows. For those sleeping supine, however, one thin pillow will encourage spinal extension for those able to tolerate it. Finally, for those with disturbed sleep, a prescription of long-acting analgesia (as well as suitable pillows) is seen to be important in the management of chronic pain [6]. Reference List (1) Binder A, I. Cervical spondylosis and neck pain. BMJ (Clinical research ed ) 2007; 334(7592):527-531. (2) Frank AO, De Souza LH, Frank CA. Neck pain and disability: a cross-sectional survey of the demographic and clinical characteristics of neck pain seen in a rheumatology clinic. Int J Clin Pract 2005; 59(doi: 10.1111/j.1742-1241.2004.00237.x):173-182. (3) Harish R. Cervical spondylosis, a pain in the neck. eBMJ. http://www.bmj.com/cgi/eletters/334/7592/527#162134 (4) Bentley P, Grigor C, McNally J, Rigby S, Higgens C, Frank AO et al. Degenerate cervical disc disease presenting as cord compression in young adults. BMJ 2001; 322(17 February):414-415. (5) Swift MBM, Cole DCM, Beaton DEPB, Manno MM. Health Care Utilization and Workplace Interventions for Neck and Upper Limb Problems Among Newspaper Workers. [Article]. Journal of Occupational & Environmental Medicine March 2001; 43(3):265-275. (6) De Souza LH, Frank AO. Experiences of living with chronic back pain: the physical disabilities. Disabil Rehabil - in press. Competing interests: Dr Frank is a Medical Director of Kynixa, a vocational rehabilitation company |
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Michael D. O'Brien, Physician Emeritus Dept. of Neurology, Guy's Hospital, London
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The neurological aspects of Binders review of cervical spondylosis and neck pain contains a number of errors, confusions and some surprising omissions: 1. Dizziness and vertigo are not presentations of cervical spondylosis, this has already been dealt with in earlier rapid responses. 2. An inverted supinator jerk (see Box 1 and under ‘complications’) is not a ‘minor neurological change’, but a hard sign clearly indicating a reflex level with a reduced reflex at C6 (supinator) and an increased reflex below this at C8 (finger flexors). An absent triceps reflex (C7) and increased reflexes below this clearly indicates a lesion at C7. These signs require both a radiculopathy to reduce the reflex and a myelopathy to increase the reflexes below the level of the lesion. 3. There is considerable muddle in the section on myelopathy. Binder mentions a spastic catch (C6/C7) as if the lesion were at that level; whereas it must be somewhere above this. In the next sentence he says that wasting and fasciculation of biceps (C5/C6) or triceps (C7) are occasional findings, but this only occurs with radiculopathy or myelopathy at these levels. Severe myelopathy in the mid-cervical region can cause wasting and weakness of the small hand muscles, probably by compression of the anterior spinal artery. 4. The increase in tone in the legs with relatively little weakness is a marker of chronicity, by contrast, acute lesions cause marked weakness with little or no spasticity. The neurological deficit in the legs with a cervical myelopathy ranges from just an extensor plantar response to a severe spastic paraparesis. 5. A useful clinical point not mentioned by Binder is that the pain of a root lesion is felt in the myotome, (C5 into the shoulder and biceps, C6 into biceps and forearm extensors, C7 into triceps and forearm) whereas paraesthesiae are felt in the dermatome (C5 in the outer aspect of the arm, C6 into the thumb, C7 in the middle finger and C8 in the little finger) 6. Manipulations should be avoided in patients with myelopathy and radiculopathy. 7. Binder does not give the source of Fig 3, which includes several inaccuracies. He would do better to omit trigeminal distribution since this is not affected by cervical spondylosis and therefore irrelevant to his paper and his diagram bears no relationship to the true anatomy. A major problem with dermatome diagrams is that the area that has any contribution from a single root is quite extensive, as shown by the rash of herpes zoster. Whereas the area solely supplied by a single root may be very small. So that most diagrams are some sort of compromise. However from the practical clinical aspect, C5 does not extend down to the hand, the extensor aspect of the forearm is more C6. Competing interests: None declared |
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Alvaro E Georg, Physician/Neurosurgeon HospitaiLCristo Redentor e Hospital de Clínicas de Porto Alegre, Porto Alegre - RS Brazil
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The conclusions of the author that the results of the surgical treatment for cervical radiculopathy or cervical myelopathy are often disappointing are not true. As a neurosurgeon I see every week patients with an imediate and lasting improvement on theyr signs and symptoms. I mean, on the day after the surgery the patients are often feeling better and soon afterwards are walking better and so on. I do not know about the personnal experience of the author, but my feeling and I guess, the feeling of the vast majority of physicians treating these kind of patients is totally different . Competing interests: None declared |
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Sau-Hsien Yap, SpR Anaesthetics Ipswich Hspital IP4 5PD
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Dear Dr Binder, I am writing in response to your clinical review article in the BMJ entitled: Cervical spondylosis and neck pain (1). The article is concise and informative but there is a puzzling statement which I have to comment on. The specific statement in reference is under the subheading of “How do I treat cervical spondylosis complicated by neurological abnormalities?”, paragraph 2, line11-15. Quoting from your article:”Epidural injection in the cervical region is more invasive than in the lumbar region, and it should be considered in patients with severe intractable pain or radiculopathy only if surgical intervention is not an option.” Comments: Firstly, cervical epidural is not anymore invasive than lumbar epidural. However, its complications have more severe sequele compared to lumbar epidural. Secondly, The statement implies that surgical treatment is preferable to epidural injection, which also means that epidural is the last in the line of treatment options. This contradicts the treatment principle of providing the least invasive treatment in the first instance and then move on to more invasive treatment if necessary. There is still inadequate evidence out there to show that has better outcome and lower risks compared to cervical epidural. In your reference (No. 27), entitled “Epidural Steroids In the Management of Chronic Spinal Pain and Radiculopathy”, I have failed to find the statement which you have quoted (2). In the article, they have referenced Bogduk’s paper in 1999 (Ref. no 73) referring to cervical radicular pain concluded that “in the interest of helping patients avoid surgery when this is the only other therapeutic option being entertained, a cervical epidural injection of steroids might be offered, or preferably, if facilities are available, a periradicular injection of steroids might be offered”(3). This does not imply that cervical epidural is the last treatment option nor does it mean surgical treatment as an option prior to epidural injection. References: 1. Binder, Al. Cervical Spondylosis and Neck Pain. British Medical Journal; March 2007; vol334; no 7592; p527-531 2. Boswell, M. A., Hansen, H. C., Trescot, A. M., Hirsch, J. A.; Epidural Steroids In The Management of Chronic Spinal Pain And Radiculopathy. Pain Physician; 2003; Vol 6; p 319-334 3. Bogduk, N. (ed) Steroid injections. In medical Management of Acute Cervical Radicular Pain. 1st edition. University of Newcastle, Newcastle Bone and Joint Institute, Australia. 1999 p 85-90. Competing interests: None declared |
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