Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with chronic low back pain exacerbated by standing and extension, relieved by sitting or flexion. Symptoms include mechanical instability, occasional radicular pain, and neurogenic claudication. No history of acute trauma. Pain intensity is [X]/10, localized to the lumbar region with radiation to [buttocks/thighs].
Clinical Examination Findings
Lumbar spine examination reveals palpable step-off deformity at [L4-L5/L5-S1] level. Paraspinal muscle spasm noted. Range of motion limited in extension. Neurological exam: motor strength [5/5] in lower extremities, sensation intact to light touch, deep tendon reflexes [symmetrical/diminished], negative straight leg raise test. Gait is stable but guarded.
Treatment Protocol
Conservative management initiated: physical therapy focusing on core stabilization and flexion-based exercises. Prescription of NSAIDs for inflammation and muscle relaxants as needed. Activity modification to avoid heavy lifting and prolonged extension. Follow-up imaging [MRI/Flexion-Extension X-rays] to monitor progression of slippage.