Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with acute/chronic low back pain radiating into the [Left/Right] lower extremity in a [L4/L5/S1] dermatomal distribution. Pain is described as [sharp/electric/burning], exacerbated by flexion, coughing, or Valsalva maneuver. Associated symptoms include [paresthesia/numbness/weakness] in the affected limb. Patient reports failure of conservative management including NSAIDs and physical therapy.
Clinical Examination Findings
Lumbar spine examination reveals restricted range of motion with paraspinal muscle spasm. Neurological exam demonstrates [positive/negative] straight leg raise (SLR) test at [degrees] degrees. Motor strength is [x/5] in [specific muscle group, e.g., extensor hallucis longus]. Sensory deficit noted in [dermatome]. Reflexes: [Patellar/Achilles] reflex is [diminished/absent/normal] on the affected side. No saddle anesthesia or bowel/bladder dysfunction noted.
Treatment Protocol
Plan includes continuation of activity modification and physical therapy focusing on core stabilization. Prescribed [NSAIDs/Muscle Relaxants/Neuropathic agents]. Consider epidural steroid injection (ESI) for radicular symptom management. If symptoms persist or progressive neurological deficit develops, surgical consultation for microdiscectomy will be pursued.