Initial pre-referral workup

Clinical history

Back pain with activity, particularly adolescent high-level athletes can suggest development of spondylolysis (stress fracture of the posterior elements of the low lumbar spine – usually L4 or L5).

‘Sciatica’symptoms can suggest irritation of the low lumbar nerve roots (typically L5) in cases of high-grade spondylolisthesis.

Physical examination

• hyperlordotic lumbar spine
• hamstring tightness
• any radicular findings

Investigations

Standing PA/L at radiographs of the lumbar spine should be done to assess for spondylolisthesis if suspected.

Standing oblique radiographs of the lumbar spine are often better at demonstrating spondylolysis (stress fracture of the pars). MRI of the lumbar spine can show stress reaction in the pars/pedicle region in the low lumbar spine in patients pre-fracture. 

GP management

Activity modification or restriction is the first step in managing stress fractures of the lumbar spine.

NSAIDs/Panadol can be helpful for ongoing pain.

Core strengthening program

Asymptomatic spondylolysis (pars fracture) or low-grade spondylolisthesis (slippage less than 50 per cent) does not require any intervention and can be managed expectantly.

Indications for specialist referral

All patients should have plan radiographs taken to confirm the diagnosis of spondylolysis and/or spondylolisthesis prior to referral.

Routine

• spondylolisthesis in any pre-pubertal patient
• symptomatic patients with radiographic evidence of spondylolysis or spondylisthesis
• age 16 and older  – not suitable for the RCH, refer to an adult institution.