Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with chronic low back pain exacerbated by extension and prolonged standing, relieved by rest. Reports intermittent radicular symptoms in the lower extremities, including paresthesia and occasional weakness. Denies bowel or bladder dysfunction. Pain intensity is rated [X]/10, localized to the lumbar region with radiation to the [gluteal/thigh] area.
Clinical Examination Findings
Lumbar spine examination reveals a palpable step-off deformity at the [L4-L5/L5-S1] level. Paraspinal muscle tenderness and hypertonicity noted. Range of motion is limited in extension. Neurological exam: motor strength [X]/5 in lower extremities, sensation intact to light touch, deep tendon reflexes [diminished/normal/hyperactive] at patellar and Achilles levels. Straight leg raise test is [positive/negative].
Treatment Protocol
Conservative management initiated including physical therapy focused on core stabilization and pelvic tilt exercises. Prescribed NSAIDs for inflammation and pain control. Recommended activity modification to avoid heavy lifting and hyperextension. Follow-up imaging scheduled to monitor slip progression. Referral to pain management for potential epidural steroid injection if symptoms persist.