Advances in the treatment of lumbar disc herniation I. Efficacy of conventional surgery for lumbar disc herniation 1. Evaluation of the long-term efficacy of classic lumbar discectomy Yorimitsu et al. conducted a systematic review of patients who had undergone classic lumbar discectomy for more than 10 years using the JOA score by means of direct examination or questionnaires to analyze the problems associated with postoperative residual low back pain or recurrence of the disc herniation after the operation. The mean improvement rate of JOA score at follow-up was 73.5±21.7%; 74.6% of the patients had residual low back pain, and only 12.7% had severe lower back pain. The majority of those with severe lower back pain were younger than 35 years of age at the time of surgery and had preoperative progressive disc degeneration [1]. Loupasis et al. retrospectively analyzed 109 patients with lumbar disc herniation, and follow-up included relief of low back and leg pain, satisfaction with surgical efficacy, need for analgesic medication postoperatively, activity, ability to work, and reoperation. At the final follow-up, 64% of patients were satisfied with the efficacy of the procedure, with a mean ODI score of 18.9. 28% of the 101 patients who underwent initial surgery still had significant low back and leg pain. Regarding the outcome of the surgery, 65% of the patients were very satisfied, 29% were satisfied, and 6% were dissatisfied. Factors such as heavy physical labor, especially in agriculture, and low level of education were found to be negative indicators of good outcome in the analysis. The use of these indicators preoperatively can estimate patients at high risk of poor long-term outcome [2]. Dvorak et al. retrospectively analyzed 575 patients who underwent primary surgery for lumbar disc herniation, of which 371 (4-17 years postoperatively) were followed up. 255 (70%) still had low back pain, 83 (23%) had persistent and severe pain; 172 (45%) had residual sciatica, 131 (35%) still required follow-up, and 17% underwent a second surgery [ 3]. In China, Hou Shuxun et al. studied the long-term efficacy of patients with lumbar disc herniation after nucleus pulposus removal. 104 of 1000 patients with lumbar disc herniation treated with nucleus pulposus removal (open window method, hemilaminectomy and total laminectomy) were followed up, and the patients’ postoperative symptomatic relief, return to work, and satisfaction with the surgery were analyzed by answering questionnaires, and the lumbar spinal interspace heights and stability before and after the surgery were compared with those patients with complete retention of radiological data. The excellent rates of surgical efficacy in the three groups were 83.8%, 77.3%, and 43.5%, respectively; the average return-to-work time and return-to-work status were 4.3 months and 84.6%, 4.6 months and 86.4%, and 4.4 months and 77.8%, respectively. The efficacy of the open-window group and half-laminectomy group was significantly better than that of the total laminectomy group. The difference between the open group and the hemilaminar group was not significant. The average loss of lumbar interbody height at 9 years after surgery was 36%, but the majority of patients did not develop localized instability. The authors concluded that the open-window method and hemilaminectomy nucleus pulposus removal for the treatment of lumbar disc herniation can achieve good long-term efficacy. The decrease in intervertebral space height after nucleus pulposus removal does not necessarily lead to intervertebral instability and nerve root compression, and nucleus pulposus removal is still a reliable and effective method for treating lumbar disc herniation [4]. Chen Bohua et al. retrospectively analyzed the mid- and long-term outcomes of 273 patients with lumbar disc herniation who underwent nucleus pulposus removal, and the results showed that the mid-term postoperative efficacy was better; however, the excellent rate declined with the extension of time. The authors concluded that open nucleus pulposus decompression was superior to hemilaminectomy decompression and total laminectomy decompression [5]. Postoperative lumbar instability is one of the major long-term complications of classic lumbar discectomy, but its incidence is low.Cauchoix et al. followed up 520 lumbar discectomy patients for 18 years and found that the incidence of lumbar instability was only 5.9% (31 patients). The authors concluded that the occurrence of lumbar instability after lumbar discectomy is relatively rare and does not require fusion at the time of initial surgery [6].Padua et al. analyzed 150 patients using questionnaires, objective scores, and power position X-rays, and the imaging results showed that spinal instability was present in 20% (30) of the patients, but symptoms were present in only 6% (9) of the patients [7]. This shows that the long-term efficacy of initial lumbar disc herniation using classical discectomy is satisfactory, and young manual laborers still have a certain recurrence rate (especially patients with highly preserved postoperative discs), residual lower back pain, lumbar spine instability, psychological disorders, and many other problems after classical surgical treatment. 2, lumbar discectomy supplemented by fusion of long-term efficacy of lumbar disc herniation classic surgery there are certain problems, so some scholars try to lumbar discectomy based on the same time, supplemented with internal fixation or spinal fusion without internal fixation. The therapeutic effect of this type of surgery is still controversial. Takeshima et al. conducted a prospective study on the clinical efficacy and imaging results of 96 patients with lumbar disc herniation. Among them, 45 cases of lumbar discectomy alone and 51 cases of lumbar discectomy with fusion were performed. Clinical outcomes were evaluated using the JOA low back pain score. The results showed that the efficacy rates of the non-fusion group and the fusion group were 73% and 82%, respectively, with no significant difference in efficacy. However, the degree of postoperative lower back pain relief was more significant in the fusion group, and the recurrence rate of lumbar disc herniation in the operated segment was higher in the nonfusion group, while there was no recurrence in the fusion group; intraoperative hemorrhage, operative time, hospitalization time, and hospitalization cost in the nonfusion group were significantly less than those in the fusion group. Imaging showed that the intervertebral space height decreased over time in both the fusion and non-fusion groups, and the change in intervertebral space height and lumbar spine mobility were not related to clinical outcomes [8]. Although the pros and cons of fusion after lumbar discectomy are controversial, there is no indication for fusion in patients with lumbar disc herniation at the initial surgery. Lumbar fusion for lumbar disc herniation does not improve surgical outcomes. Young followed 1005 patients who underwent surgery for lumbar disc herniation for an average of 8 years. Of these, 450 underwent posterior fusion with lumbar discectomy and 555 underwent lumbar discectomy only. It was found that there was no difference in the rate of excellent efficacy between the fusion and non-fusion groups (73%, 82%, respectively). However, the long-term relief rates of sciatica in the two groups were 73% and 48%, respectively; while the long-term relief rates of lumbago were 68% and 52%, respectively. The fusion group was significantly better than the non-fusion group in relieving low back pain and sciatica. The cases in this group included isthmic fissure, slip, lateral convex congenital developmental anomalies small joint synostosis degeneration, fracture, and recurrence, suggesting that adjunctive fusion is feasible when lumbar disc herniation is combined with other abnormalities [9]. Eie followed up 259 patients with lumbar disc herniation, of which 119 cases had simple lumbar discectomy, and 68 patients underwent lumbar discectomy without fixed fusion. Early postoperative outcomes were similar in both groups, with satisfaction rates of 89% and 88%, respectively. There was no difference in efficacy between the two groups at the 6-7 year postoperative follow-up. For pain relief, the satisfaction rate was 85% in the fusion group compared with 76% in the non-fusion group, which was superior to the non-fusion group. The recurrence rate of pain in the lumbar discectomy alone group and lumbar discectomy and fusion group was 27% and 15%, respectively. Causes of pain in the nonfusion group: recurrence of disc herniation (10%), adhesions or osteochondral lesions (17%). Causes of pain in the fusion group: pseudoarthrosis (9%), recurrence of lumbar disc herniation (3%), and other causes (3%), suggesting that the fusion group is better able to minimize residual postoperative low back pain, and that fusion is a more complex procedure than classic surgery, with its own associated complications, and is recommended to be used in young manual laborers [10].The results of a study by Matsunaga et al. reached the same conclusion [11]. Donceel et al. retrospectively analyzed the return to work of 3956 patients operated for lumbar disc herniation, including 126 cases of percutaneous nucleus pulposus resection, 286 cases of lumbar discectomy and fusion, and 3544 cases of classical lumbar discectomy. Seventy percent of the classic lumbar discectomy group or percutaneous nucleotomy group returned to work within 12 months after surgery, and only 45% of the fusion group, and lumbar discectomy plus fusion did not improve surgical outcomes [12]. Inoue et al. reported an 8.5-year follow-up of 350 patients undergoing anterior discectomy and fusion for lumbar disc herniation, with 94.3% obtaining bony fusion. Postoperative myelography confirmed that anterior discectomy resulted in adequate neural decompression. 223 cases had good surgical outcomes at long-term follow-up. The favorable clinical outcome was related to the restoration of the intervertebral space height and normal alignment of the vertebral bodies by anterior surgery. The authors concluded that this surgical approach is suitable for young manual workers with low back pain and sciatica and for patients with spinal instability [13]. Matssunaga et al. conducted a retrospective study of a group of manual laborers and athletes who underwent incisional or percutaneous lumbar discectomy (51 patients) or lumbar discectomy and fusion (29 patients) and found that patients with simple lumbar discectomy returned to work in a shorter period of time but that 22% of the patients in the simple lumbar discectomy group were unable to return to their preoperative activity level. The rates of return to preoperative work or sports programs after lumbar discectomy alone and lumbar discectomy and fusion at 1 year postoperatively were 54% and 89%, respectively. The authors concluded that lumbar discectomy supplemented with fusion should be used for manual laborers and athletes [11]. Most of the literature reports that surgical treatment of lumbar disc herniation with the addition of spinal fusion reduces residual postoperative low back pain but does not improve surgical outcomes, and there is no convincing medical evidence to support that fusion should be routinely performed at the time of initial lumbar discectomy. Fusion may be considered as an option for young sports and manual laborers, long-segment lumbar disc herniation combined with severe axial pain, and lumbar disc herniation combined with other abnormalities. According to Hu Yougu, the purpose of classic surgery for lumbar disc herniation with lumbar fusion is to achieve lumbar stabilization and reduce disc reherniation, and should be considered in the following cases: (1) T12/L1 and L1/2 high lumbar disc herniation. After removal of one segment of the disc at the thoracolumbar junction, another segment is prone to herniation due to biomechanical reasons. ( 2) Total laminectomy and synovectomy, lumbar instability or lumbar spondylolisthesis will easily occur after the operation, which will affect the efficacy of the treatment and induce the reherniation of the intervertebral disc. ( 3) Lumbar spinal stenosis with lumbar disc herniation, because of the need to remove the stenosis of the nerve root canal or the central canal when removing the intervertebral disc, the posterior spinal structure is too much destroyed, which affects the stability of the spine. ( 4) Extremely lateral lumbar disc herniation (herniation in region IV) through synovectomy approach, one side of the synovectomy is missing after surgery, which affects the stability of this segment. ( 5) Lumbar disc herniation combined with lumbosacral vertebral developmental deformity, the herniation occurred in the L5/S1 segment, due to the stress change of the lower lumbar spine in the original deformity, it is easy to re-protrude in the original segment or protrude in another segment. ( 6) Re-operation for lumbar disc herniation, which is more destructive to the posterior lumbar spine structure, may affect spinal stability and herniation of another segment [14]. Minimally invasive treatment progress 1, intradiscal electrothermal therapy (IDET): its principle is to make collagen tissue solidification through heat, coagulation of the lesion on the annulus fibrosus and granulation tissue, inactivation of the pain receptors in the lesion in order to prevent the transmission of pain. This method is suitable for intradiscal rupture type discogenic low back pain which has persisted for more than 6 months, ineffective conservative treatment, negative straight leg raising test, MRI does not show nerve root compression, and discography shows that the pain is aggravated by the ruptured disc. 2, percutaneous chemical nucleolysis chemonucleolysis: in 1964, Smith first papaya curd protease for clinical treatment of lumbar disc herniation. kuh SU reported percutaneous chemical nucleolysis, minimally invasive surgical discectomy, posterior disc (implant) fusion for the treatment of intervertebral disc herniation, the rate of satisfaction with the efficacy of the treatment was 91%, 95%, 89%. Numbness of lumbar back is the most common side effect of chemical nucleolysis, and the most serious complication is paraplegia caused by accidental injection of protease into the spinal canal. 3, percutaneous puncture ozone injection (Minimally invasive oxygen-ozone therapy): a large sample of foreign statistics, percutaneous puncture ozone injection treatment of disc herniation, the total effective rate of 68% ~ 80%. Bocci V, et al. believe that ozone treatment of lumbar disc herniation analgesic mechanism is to inhibit spinal cord injury receptor fibers, activate the body’s anti-injury system. Bocci V et al. believe that the mechanism of ozone analgesia in the treatment of lumbar disc herniation is to inhibit the spinal cord injury receptor fibers, activate the body’s anti-injury system, and stimulate inhibitory interneurons to release enkephalins, which is similar to the mechanism of chemical acupuncture. Through the ozone to make the nucleus pulposus cell degeneration, necrosis, matrix fibrosis, so that the structure of the nucleus pulposus was destroyed, the nucleus pulposus volume shrinkage, solid shrinkage, to relieve the pressure on the nerve root. 4, percutaneous lumbar disc removal (PLD) since 1975 Hijikata S first reported. It includes percutaneous manual lumbar disc removal (PLD) and percutaneous automatic lumbar disc removal (APLD). By entering the intervertebral disc through the posterior lateral approach, drilling holes and opening windows in the annulus fibrosus, part of the nucleus pulposus is removed to reduce the pressure in the intervertebral disc and alleviate the stimulation to the nerve roots and pain receptors around the intervertebral disc to achieve the therapeutic purpose. However, clinical results showed that most of the herniated discs did not have obvious retraction, and some patients did not have obvious improvement of clinical symptoms. 1985, Onik G [13] developed a pneumatic automatic extractor integrating cutting, rinsing, and suctioning, and improved PLD into APLD, whose therapeutic mechanism is to cut and suction out part of the nucleus pulposus, reduce the pressure in the intervertebral disc, and alleviate stimulation to the nerve root and peripheral pain receptors of the disc. The mechanism of treatment is to cut and suction out part of the nucleus pulposus to reduce the pressure in the intervertebral disc and to reduce the stimulation to the nerve roots and pain receptors in the intervertebral disc. Degobbis A et al. reported that APLD was used to treat 506 cases of lumbar disc herniation with satisfactory efficacy, and compared with traditional lumbar disc removal surgery, the hospitalization time was short, the risk of surgery was small, and even if the surgery was unsuccessful, there were no complications as in traditional surgeries. 5. Posterior microendoscopic lumbar discectomy (MED) Since 1997, Smith M and others first reported the application of posterior microendoscopic lumbar discectomy for lumbar disc herniation. MED is a new minimally invasive procedure that combines traditional open disc removal techniques with endoscopic techniques. With the help of endoscopic display system, the operator can clearly understand the relationship between the dural sac, nerve root and herniated disc, which can completely solve the nerve root compression, avoiding damage to the nerve root and dural sac, and stopping bleeding completely. This surgery can completely preserve the structure of the middle and posterior spine without affecting the biomechanical structure of the spine, which greatly reduces the incidence of postoperative complications such as spinal slippage and lower back pain. With this surgical system, lumbar disc removal, laminectomy, medial facetectomy, foramenoplasty, lateral socket decompression and other surgeries can be accomplished. At the same time, lumbar spinal stenosis and nerve root canal stenosis can be solved with the help of auxiliary tools. Compared with traditional surgery, MED has the advantages of small trauma, fast recovery, short operation and hospitalization time, low comprehensive medical cost and wider indications for surgery. 6.Percutaneous laser disc decompression ression (PLDD) PLDD is developed on the basis of percutaneous disc removal. The principle of PLDD is to use laser pulse to vaporize and burn the nucleus pulposus until the intervertebral disc tissue is no longer retracted, thus reducing the pressure in the intervertebral disc and relieving the compression and irritation of the intervertebral disc tissue on the nerve root and spinal cord, thus achieving the therapeutic purpose. 1987, Choy et al. were the first to report that the laser treatment of lumbar disc herniation had achieved a satisfactory efficacy. This procedure has the advantages of less trauma, less bleeding, faster recovery, no damage to spinal stability, etc. The excellent rate of the operation reaches 70%~87%. Percutaneous endoscopic laser disc removal technology can not improve the spinal stenosis, neural canal stenosis, osteophytes and synovial hypertrophy and cohesion, and its surgical indications have certain limitations. 7, total endoscopic lumbar disc removal Ruetten S et al. compared total endoscopic lumbar disc removal with traditional minimally invasive surgery, and the results showed that the two surgical modalities had similar treatment results, while total endoscopic lumbar disc removal had obvious advantages in back pain, postoperative complications, trauma, and recovery time. Ruetten S et al. performed total endoscopic nucleus pulposus removal on 463 patients with extreme lateral lumbar disc herniation, and the results showed that 81% of the patients had no symptoms of low back pain, 14% had occasional pain, and there were no patients with worsening symptoms. The results showed that 81% of the patients had no symptoms of low back pain, 14% had occasional pain, and there were no patients with worsening symptoms. Total endoscopic discectomy has significant advantages over existing minimally invasive treatments. The advantages of total endoscopic disc removal include small incision, limited damage to tissues, good illumination in the surgical field, easy operation, more complete resolution of nerve root compression by destroying the stable structure of the spinal column, avoiding injury to the nerve root and the dural sac, and quick recovery of the patient after the operation. Nucleus pulposus removal has been considered clinically with clear indications for this procedure, and patients are usually under 50 years of age. Relative contraindications to surgery include: intermittent claudication, typical lumbar spinal stenosis, symptoms that do not match the physical examination, developmental, degenerative, hyperplastic spinal stenosis, severe calcification, ossification, as confirmed by CT, MRI. Comparison of the efficacy of minimally invasive surgery and conventional surgery 1. Immediate outcome (Immediate outcome) There was no significant difference in the amount of surgical bleeding, hospitalization time, and the VAS score of lumbar pain at 3 days after the surgery, but minimally invasive surgery can effectively reduce the operation time. Minimally invasive surgery significantly reduces postoperative recovery time. It facilitates early return to normal work. Short-term outcome Thome et al. reported that there was no difference in SF-36 score between minimally invasive surgery and conventional surgery in the short term (6 months), and there was no difference in lumbar pain and lower extremity pain VAS after 1 year.Carragee reported that minimally invasive surgery was better than conventional surgery for 1 year after surgery in terms of lumbar pain, lower extremity pain VAS and Oswestry score, but no significant difference was found at the 2-year follow-up after surgery. Carragee reported that minimally invasive surgery was superior to conventional surgery at 1 year after surgery, but no significant difference was found at the 2-year follow-up. Long-term outcome There is no high-level literature comparing the long-term outcomes of the two procedures. Several papers with a level of evidence of 4 have reported that minimally invasive surgery has a significantly lower rate of poor outcome (Fair and Poor) (7-16%) than conventional surgery (19-36%). 4, Recurrent disc herniation (Recurrent disc herniation) One literature with evidence level 2 reported no difference in the rate of postoperative recurrence between the two, but with a shorter follow-up period (less than 2 years). The one literature with evidence level 3 reported an increasing trend in disc recurrence at 2 years postoperatively (18% vs. 9%). In the remaining 4 levels of literature, the recurrence rate for minimally invasive surgery was 6-18% compared to only 2-9% for conventional surgery. The recurrence rate of minimally invasive surgery was significantly higher than that of conventional surgery, and the results of more than 2 years of follow-up similarly support these findings. CONCLUSION: Minimally invasive surgery is effective in reducing operative time and facilitating early return to work. However, at short-term postoperative follow-up, there was no difference in outcome compared with conventional surgery. More evidence confirms that the recurrence rate of minimally invasive surgery is significantly higher than that of conventional surgery. However, overall there is less high grade literature. Fourth, the surgical efficacy of lumbar disc herniation recurrence There are no comparative studies on the efficacy of lumbar disc herniation recurrence using lumbar disc re-excision and lumbar disc re-excision supplemented with spinal fusion. Most of the available reports are related to recurrent patients who underwent lumbar disc re-excision or lumbar disc re-excision supplemented with fusion, and the efficacy varies widely. Suk et al. reported that the efficacy of lumbar disc re-excision in patients with recurrent lumbar disc herniation was similar to that of initial surgery [17].Cinotti et al. reported that the efficacy of lumbar disc re-excision in 26 patients with recurrent lumbar disc herniation was 85%, and the rate of return to work was 81% [18].Ozgen et al. performed secondary decompression in 114 patients, and the group of cases included 89 cases of In this group, which included 89 patients with recurrent lumbar disc herniation, the excellent rate of secondary surgery was 69% [19]. These reports suggest that the efficacy of reoperation for recurrent lumbar disc herniation is almost equal to that of the initial surgery. Glassman et al. conducted a prospective study on a group of patients with recurrent lumbar disc herniation undergoing secondary decompression and fusion using the SF-36 scale, and the patients’ limb function, social activities, and pain improved significantly 1 year after surgery [20].Chen et al. reported 28 cases of recurrent lumbar disc herniation, which was associated with lumbar pain and spondylolisthesis, and was treated with posterior decompression and intervertebral Fusion was performed, with postoperative follow-up ranging from 8 to 39 months (average 14 months), 93% were satisfied with the outcome, and 82% had bony fusion confirmed by imaging [21].Chitnavis et al. also reported a group of 50 lumbar disc herniation recurrences, which were all characterized by low back pain or spinal instability, and underwent posterior decompression and interbody fusion, with a follow up ranging from 6 months to 5 years. 92% of the patients had improved symptoms, and 90% of the patients were satisfied with the outcome. improved, 90% of patients were very satisfied with the efficacy, and the interbody fusion rate was 95% [22]. When recurrence of lumbar disc herniation requires reoperation, if there is little loss of posterior spinal structures, the majority of patients can still obtain the same efficacy as the initial surgery without fusion; if instability has occurred before reoperation, accompanied by severe deformity, chronic axial low back pain, or excessive intraoperative loss of spinal structures should be supplemented with fusion at the same time. V. Surgical efficacy of non-fusion technology for lumbar disc herniation In recent years, more non-fusion technologies have appeared, including artificial disc, artificial nucleus pulposus, Graf ligament, Dynesys spinal system, Wallis system, X-Stop, DIAM, etc. However, at present, the treatment of lumbar disc herniation by non-fusion surgery is still immature and in the exploratory stage.