Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with chronic, progressive low back pain localized to the lumbar region, exacerbated by prolonged standing, flexion, and axial loading. Reports intermittent radicular symptoms, stiffness, and mechanical instability. Pain is described as dull, aching, and non-radiating, with occasional exacerbations following physical exertion. No history of trauma, constitutional symptoms, or bowel/bladder dysfunction.
Clinical Examination Findings
Inspection reveals lumbar hyperlordosis or flattening with paravertebral muscle spasm. Palpation demonstrates tenderness over the lumbar spinous processes and paraspinal musculature. Range of motion (ROM) is restricted in flexion and extension. Neurological exam: motor strength 5/5 in bilateral lower extremities, intact sensation to light touch in L1-S1 dermatomes, and symmetric deep tendon reflexes (DTRs). Straight leg raise (SLR) test is negative bilaterally.
Treatment Protocol
Conservative management initiated: physical therapy focusing on core stabilization and lumbar strengthening exercises. Pharmacotherapy includes scheduled NSAIDs and muscle relaxants as needed. Advised weight management and ergonomic modifications. Follow-up imaging and clinical re-evaluation in 6-8 weeks. Referral to pain management for potential epidural steroid injections if symptoms persist.