Pain lasting longer than this is usually related to a degenerative condition of the disc or facet joints as opposed to a muscle strain. Although common, muscle strains will typically resolve within a few weeks. The physical exam should include an assessment of spinal range of motion and a focused neurologic exam of the lower extremities. Typically the patient will move slowly and painfully and the neurologic exam will be normal. Neurologic deficit on exam Figure 3.
Physical therapy is appropriate for pain that lasts more than a few weeks.
A four to six week program that emphasizes strengthening of the back and abdominal muscles seems to provide the greatest benefit. The patient should receive some education as to the cause of the problem as well as the most appropriate way to lift, sleep, etc. Surgery should be reserved for the rare patient who continues to have disabling back pain despite six months of aggressive conservative treatment. Since the pain is secondary to motion at a painful degenerative disc, surgery usually entails fusing the two vertebral bodies together to eliminate the motion. It is currently felt that a fusion between the vertebral bodies themselves gives the most predictable pain relief since this provides rigid immobilization of the annulus.