Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with acute onset of localized lower back pain following a minor mechanical event. Pain is described as sharp, non-radiating, and exacerbated by movement, standing, or spinal flexion. No history of high-energy trauma. Patient reports a known history of osteoporosis and denies bowel or bladder incontinence, saddle anesthesia, or progressive lower extremity weakness.
Clinical Examination Findings
Physical examination reveals localized tenderness to palpation over the L3 spinous process. Paraspinal muscle spasm noted in the lumbar region. Range of motion is significantly restricted due to pain. Neurological examination: motor strength 5/5 in bilateral lower extremities, intact sensation to light touch in all dermatomes, and symmetric deep tendon reflexes. No signs of myelopathy or radiculopathy.
Treatment Protocol
Treatment plan includes: 1) Activity modification and avoidance of heavy lifting. 2) Analgesic therapy with NSAIDs or acetaminophen as tolerated. 3) Orthotic bracing (TLSO) for spinal stabilization. 4) Referral for bone density (DEXA) scan and initiation of anti-osteoporotic pharmacological therapy. 5) Follow-up imaging in 2-4 weeks to monitor fracture stability.