Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with chronic mechanical low back pain, localized to the lumbar region, exacerbated by prolonged standing and extension. Symptoms are consistent with Grade 1 degenerative spondylolisthesis at L4-L5. No focal neurological deficits, bowel/bladder dysfunction, or saddle anesthesia reported. Pain is rated at [X]/10, intermittent, and partially relieved by rest and flexion.
Clinical Examination Findings
Lumbar spine examination reveals mild paraspinal muscle tenderness at L4-L5 level. Range of motion is limited in extension due to discomfort. Neurological exam: motor strength 5/5 in bilateral lower extremities, intact sensation to light touch in L4-L5 dermatomes, patellar and Achilles reflexes 2+ bilaterally. Negative straight leg raise (SLR) test. No gait abnormalities observed.
Treatment Protocol
Conservative management initiated: physical therapy focusing on core stabilization and lumbar flexion exercises. Prescription of NSAIDs as needed for pain control. Activity modification to avoid heavy lifting and repetitive lumbar extension. Follow-up imaging in [X] months to monitor stability of the L4-L5 slip.