Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with localized lumbar pain, non-radicular in nature, exacerbated by movement and prolonged standing, and relieved by rest. Denies bowel/bladder incontinence, saddle anesthesia, or constitutional symptoms. Pain is mechanical, localized to the lumbosacral region, without evidence of neurological deficit.
Clinical Examination Findings
Lumbar spine inspection reveals normal alignment without deformity. Palpation demonstrates tenderness in the paraspinal muscles. Range of motion is restricted by pain in flexion and extension. Neurological exam: motor strength 5/5 in lower extremities, sensation intact to light touch, deep tendon reflexes 2+ and symmetric. Straight leg raise test is negative bilaterally.
Treatment Protocol
Initiate conservative management including activity modification, avoidance of heavy lifting, and physical therapy for core strengthening. Prescribe NSAIDs as needed for pain control and muscle relaxants for acute spasms. Follow-up in 4-6 weeks if symptoms persist.