Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with acute onset of thoracic back pain following [minor trauma/mechanical stress]. Pain is localized to the [T-level] region, exacerbated by movement, flexion, and weight-bearing, and relieved by rest. Patient denies radicular symptoms, bowel/bladder dysfunction, or lower extremity weakness. No history of malignancy or constitutional symptoms.
Clinical Examination Findings
Thoracic spine examination reveals localized tenderness to palpation over the [T-level] spinous process. No step-off deformity or paraspinal muscle spasm noted. Neurological examination is intact: motor strength 5/5 in all extremities, sensation intact to light touch, and deep tendon reflexes are 2+ and symmetric. Gait is antalgic but stable.
Treatment Protocol
Management plan includes conservative therapy: activity modification, avoidance of heavy lifting, and bracing (TLSO) as indicated for comfort. Analgesia initiated with [NSAIDs/Acetaminophen]. Referral to physical therapy for core strengthening once acute pain subsides. Follow-up imaging in [X] weeks to confirm stability.