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

Conservative management is recommended for this pars defects, (spondylolysis) and grade 1 spondylolisthesis without neurology. Please cease high-impact sporting activities for 3 months and refer to a local physiotherapist for a structured rehabilitation program. Monitor for neurological symptoms including weakness, sensory changes, gait disturbance, or bowel/bladder dysfunction. Please re-refer if neurological symptoms develop, symptoms worsen, or there are ongoing concerns following 6 months of conservative management.