Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with acute onset of localized lumbar back pain following [mechanism of injury/minor trauma]. Pain is exacerbated by movement, weight-bearing, and spinal flexion. No reported radiculopathy, bowel/bladder dysfunction, or saddle anesthesia. Pain intensity rated at [X]/10.
Clinical Examination Findings
Physical examination reveals localized tenderness over the [L1-L5] spinous process. Paraspinal muscle spasm noted. Neurological examination: motor strength 5/5 in bilateral lower extremities, intact sensation to light touch in all dermatomes, deep tendon reflexes 2+ and symmetric. No midline step-off or gross deformity. Gait is guarded but stable.
Treatment Protocol
Conservative management initiated: activity modification, avoidance of heavy lifting, and bracing as indicated. Analgesic regimen includes NSAIDs and/or acetaminophen for pain control. Physical therapy referral for core stabilization and progressive mobilization. Follow-up imaging in [X] weeks to assess healing.