41.What should I pay attention to when using a lumbar girth for patients with lumbar disc herniation? The lumbar girth is widely used in the treatment of lumbar disc herniation, but its wearing and use is not arbitrary, the following issues should be paid attention to: (1) The wearing and use of the lumbar girth should be flexible according to the condition. (1) The use of the lumbar girth should be flexible according to the condition. After the patient has been treated with strong traction or long-term bed rest, the lumbar girth should be worn on the ground in strict compliance with medical advice to consolidate the treatment effect. When the condition is reduced and the symptoms disappear, the lumbar girth should not be dependent, and should be removed in time to strengthen the exercise of their own lumbar back muscles to strengthen the support and protection of the lumbar spine with their own muscle strength. Otherwise, the long-term unprincipled wearing of lumbar girth will cause disuse atrophy and joint ankylosis of the lumbar back muscles, and patients will not be able to leave the lumbar girth, otherwise the symptoms aggravate, which is harmful to the treatment of lumbar intervertebral disc herniation. (2) The specifications of the lumbar girth should be adapted to the patient’s body type, generally up to the lower rib arch and down to the iliac crest, the posterior side should not be excessively convex, and the front should not be tied too tightly, and the good physiological curvature of the lumbar spine should be maintained. If the waist circumference does not match the specifications, not only will the patient be uncomfortable after wearing it, but also it will not play its proper role. In short, patients should choose or wear lumbar circumference, under the guidance of a doctor, so as to make the best use of it. 42.What is the drug treatment for lumbar disc herniation? For the treatment of lumbar disc herniation, the following types of western drugs are more commonly used in clinical practice. (1) Acetylsalicylic acid (aspirin) is the most commonly used analgesic, with moderate effects, used for various neuralgia and joint pain. At present, aspirin is available in a variety of enteric solvent form, which is less irritating to the stomach. This drug is prohibited for long-term use in large quantities, but is relatively safe. Use with caution in patients with gastric ulcer. (2) Non-steroidal analgesics such as anti-inflammatory pain, ibuprofen, anti-inflammatory, etc. have stronger analgesic effect than aspirin, and stronger anti-inflammatory and anti-rheumatic effects. They have some side effects, such as headache, nausea, vomiting, rash and gastrointestinal reactions, and also have certain effects on blood picture and liver and kidney functions, so they should be taken under the guidance of doctors. In order to reduce adverse reactions, some drugs have emerged in new dosage forms, such as anti-inflammatory pain suppositories, ibuprofen enteric slow-release agent fenbid, etc. (3) Central muscle relaxants, such as clofentezan, have a role in relieving muscle pain. (4) For patients with lumbar disc herniation in the acute stage, as their spinal nerve roots are obviously edematous, causing severe pain and even secondary arachnoid adhesions, oral or sedative steroids, supplemented with diuretics or dehydrating agents, can be administered to eliminate nerve root edema. (5) Vitamin B1 and other neurotrophic drugs are also often used in some compound prescriptions. 43.Can lumbar disc herniation be treated with hyperbaric oxygen? Hyperbaric oxygen therapy improves blood oxygen diffusion and oxygen diffusion distance in tissues, increases oxygen storage, and accordingly improves oxygen tension in tissues, which can lead to improved local circulation. In addition, hyperbaric oxygen causes vasoconstriction, tissue blood flow decreases, vascular permeability decreases, edema of prominent compression is eliminated, and exudate is absorbed, thus relieving the stimulation of nociceptive receptors on nerve roots and peri-disc tissues, resulting in pain relief. At the same time, aerobic metabolism is enhanced under the effect of hyperbaric oxygen, glycolysis is reduced, lactate content is decreased and triphosphate production is increased, which can improve the nutrient supply to the intervertebral disc and facilitate the recovery of damaged nerves. In contrast, when the disease duration is long, the protruding disc compresses the nerve root for a long time, which may cause nerve fiber degeneration or surrounding adhesions, affecting the diffusion, storage and oxygen metabolism of hyperbaric oxygen. Therefore, the treatment effect is worse than that of short duration. When the intervertebral disc protrudes outward, it compresses the peripheral nerve, and hyperbaric oxygen can promote the regeneration of peripheral nerve. In tissue culture research, it is found that oxygen is necessary for cell therapy and mitosis, and a certain degree of hypoxia often occurs when the tissue is damaged, so that the cell activity is limited. Under hyperbaric oxygen the oxygen content within the tissue fluid is increased, which facilitates the use of oxygen by the cells in order to increase their wandering activity. Experimental evidence shows that under hyperbaric oxygen, not only the speed of nerve regeneration is accelerated, but also the amount of axon regeneration is increased, which has a good promotion effect on the regeneration of peripheral nerves and accelerates the recovery of nerve function. 44.How to identify and treat the symptoms of TCM? (1) Blood stasis: To activate blood circulation, resolve blood stasis, move Qi, and relieve pain, the formula is Blood Drainage and Stasis Soup with Addition: 15g of peony, 15g of angelica, 10g of Chuanxiong, 10g of peach kernel, 6g of safflower, 10g of Chuan Niu Knee, 10g of Panax ginseng, 15g of raw earth, 10g of sequestra, 15g of Eucommia, 5g of licorice, decoction in water, 1 dose daily. (2) Cold and dampness: the treatment is to warm the meridians and channels, disperse cold and dampness, using the formula of Duluxia sangfusheng plus reduction: Duluxia 10g, Sangfusheng 10g, Gentiana macrophylla 10g, Radix Achyranthes bidentata 15g, Angelica sinensis 10g, Paeonia lactiflora 15g, Duzhong 15g, Coix lacrymae 15g, Radix et Rhizoma sanguinis 15g, Glycyrrhiza glabra 5g, decoction in water, 1 dose daily. (3) Dampness-Heat evidence: To clear heat, it is better to expel dampness. The formula uses Ermiao San with flavour: Atractylodes macrocephala 10g, Phellodendron chinensis 10g, Eucommia lucidum 15g, Chuan Niu Knee 10g, Coix seed 15g, Dioscorea Z 10g, Glycyrrhiza glabra 5g, decoction with water, 1 dose daily. (4) Deficiency of liver and kidney: for Yang deficiency, the treatment is to warm up the kidney yang, using the formula of Siwu Tang combined with Zuo Gui Wan: 6g of Radix Aconiti, 3g of Cinnamon, 10g of Radix Angelicae Sinensis, 15g of Radix Paeoniae Alba, 15g of Duzhong, 25g of Radix Rehmanniae, 10g of Jujube Peel, 15g of Huai Shan, 10g of Semen Cuscutae, 15g of Fructus Lycii, 15g of Mulberry Branch, 5g of Licorice, decoction with water, 1 dose daily; for Yin deficiency, the treatment is to nourish the kidney yang, using the formula of Siwu Tang combined with Zuo Gui Wan: 25g of Radix Rehmanniae, 10g of Radix Angelicae Sinensis, 15g of Radix Paeoniae Alba, 10g of Rhizoma Ligustici Chuanxiong, 10g of Jujube Peel, 15g of Radix Huai Shan, 15g of Radix Achyranthes Bidentatae, 6g of Tortoise Board, 15g of Salviae Miltiorrhizae, 15g of Radix Wei Ling Xian, 5g of Glycyrrhiza Uralensis, decoction in water, 1 dose daily. 45.What is sacral therapy? Sacral therapy, also called sacral drip therapy, is a conservative treatment for lumbar disc herniation. It is injected through the sacral canal via the epidural cavity, and the drug acts directly on the herniated disc and the compressed nerve root to relieve the symptoms mainly caused by local sterile inflammation and nerve root edema. The common drug formula for sacral therapy is: 6ml of compound salvia injection, 3ml of 2% lidocaine, 500μg of vitamin B12, 5mg of galantamine, 30mg of dexamethasone, and 150ml of 0.9% physiological saline. During treatment, the patient was placed in a lateral position, and a triangular or circular depression could be felt at the sacrococcygeal union along the midline of the tailbone upward or along the sacral crest downward, and this was the sacral fissure. When the resistance to needling suddenly disappears and there is an obvious feeling of breakthrough, it means that the sacral fissure has been pierced. When there is no return blood from repeated aspiration and no resistance to air injection, the infusion tube can be attached to the needle and the drug is dripped in at a rate of 30 to 40 drops per minute. After treatment, the patient should rest flat on his back and showering is prohibited for 48 hours. Since sacral drip therapy may produce certain circulatory disturbance, sacral therapy is not recommended for those with severe anemia, hypertension and poor cardiac compensatory function. 46.What is the epidural closure therapy for lumbar disc herniation? Epidural hormone closure therapy is a widely used clinical method for the treatment of lumbar disc herniation. It is safe, reliable, easy to operate, and certainly effective, and can be used for both acute and chronic onset. The epidural cavity is a potential gap located in the spinal canal, not only 31 pairs of spinal nerves pass through this cavity, but also there are abundant nerve fibers and their endings distributed on the surface of the dura mater and nerve root sheath, the inner surface of the posterior longitudinal ligament and the yellow ligament. Stimulation of a herniated disc or other pathological factors can cause aseptic inflammation of the epidural cavity, causing nerve endings to conduct impulses in response to stimulation and produce nociception. The injection of hormones and anesthetic drugs into the epidural cavity can improve blood circulation and eliminate inflammatory reactions such as congestion and edema, while inhibiting the excitability of nerve endings and blocking the vicious cycle of pain. In addition, reports have confirmed that injecting enough drugs at the time of closure can generate fluid pressure as the drug diffuses along the intervertebral foramen, causing the nerve root to peel off the herniated disc tissue and relieving the compression. It follows that successful epidural closure may release both the chemical irritation and mechanical compression that cause the clinical symptoms of lumbar disc herniation. Of course, for the more serious nerve root compression caused by a huge herniation, it is difficult to receive good results with closure therapy because the stimulating compression factors that cause symptoms cannot be released. The operation of epidural closure therapy is not complicated, but it should also be fully and carefully prepared. The operation of the patient to take a lateral position, the affected limb in the lower, puncture plane is generally selected in the protruding parts of the two gaps. First make a mound at the closed puncture point, and then gradually go deeper, the tip of the needle through the yellow ligament can feel the obvious breakthrough, after the back suction and gas injection test, etc. to confirm the epidural cavity, you can slowly inject the drug solution. If the conventional posterior median puncture approach fails, the lateral puncture or sacral tube operation method can also be used. The commonly used closure solution often consists of hormonal drugs plus anesthetics such as procaine or lidocaine, diluted with saline. If procaine is used for closure, a skin test should be performed routinely to prevent allergic reactions. 47.What is called percutaneous chemical myelinolysis? After Smith first reported the successful treatment of lumbar disc herniation using percutaneous disc puncture and injection of papaya gel protease (chymopapain) in 1964, Sussman applied collagenase (colla-genase) to perform in vitro lysis of disc tissue in 1968 and reported 29 cases in 1981 based on animal experiments. In 1981, he reported the success of 29 patients based on animal studies. The basic principle of this technique is to use the hydrolysis of protease to dissolve the nucleus pulposus tissue, release water, and eventually atrophy, resulting in a decrease in intravertebral disc pressure, thus relieving nerve root compression. After a series of clinical studies, both papain and collagenase nucleolysis techniques were confirmed to have more definite efficacy. The excellent rate is 70% to 80%. The main advantage of percutaneous disc nucleolysis is that it does not enter the epidural space and therefore does not produce the epidural scar formation caused by conventional disc surgery and is less expensive to treat. The mortality rate is quite low at 0.02%. However, 0.5% of patients have allergic reactions to papain, and the incidence of paraplegia is only 0.03%, often secondary to misinjection of the enzyme into the spinal canal. Currently, collagenase is used more often, and its allergic reactions are lower than papain, and newer drugs include chondroitinase. Disc nucleolysis should generally have the following indications: (1) History of lumbar disc herniation for more than 2 months. (2) Systematic conservative treatment is ineffective. (3) The patient has an indication for surgery but is not suitable for surgery due to other circumstances. (4) Patients with poor results after surgery. (1) The patient is allergic to papaya rennet or collagen. (2) The patient has been previously treated with this enzyme and there is an increased risk of allergic reaction with re-injection. (3) The patient has lumbar disc herniation combined with spinal stenosis or lateral saphenous fossa stenosis. (4) The patient has lower limb numbness or bladder or rectal dysfunction. (5) Pregnant women, patients with diabetes mellitus and those under 14 years of age. While chemolysis of the nucleus pulposus has achieved certain efficacy in the treatment of lumbar disc herniation, it has also produced some complications, the incidence of which is about 2% to 3% according to statistics. The main ones are allergic reactions. (1) Allergic reaction is the heaviest complication of this therapy, which mostly occurs in women. The first manifestation of allergy is hair movement reaction, and other symptoms include dizziness, nausea, and rash. In severe cases, bronchospasm and hypotension occur. In case of allergic reaction, 1:10,000 epinephrine 0.05-0.1m1 should be given intravenously immediately. elevate the lower limbs during the onset of the reaction to facilitate blood return to the lower limbs. Postoperatively, prednisone 10mg can be given orally three times a day for four days. (2) Infection. Septic discitis or aseptic discitis may occur. The former can be treated with anti-inflammatory therapy, while the latter occurs for unknown reasons and manifests as low back pain and narrowing of the intervertebral space. (3) Burning neuralgia. The puncture needle injures the nerve root and nerve sheath, which may cause chemical irritation by allowing the drug to penetrate the nerve fibers through the injury site. (4) Secondary foraminal or spinal stenosis. In some patients, the vertebral space becomes significantly narrower after treatment, resulting in a smaller intervertebral foramen that compresses the nerve root. As the vertebral space is reduced, epidural connective tissue is formed, which may cause local spinal stenosis. Therefore, the long-term efficacy of this therapy is not as good as the recent efficacy, and some patients have their symptoms relieved after treatment, but the back pain will recur after a period of time. 48.Can ozone (O3) treat lumbar disc herniation? O3 has a strong oxidizing effect, which is second only to fluorine in its ability to complete oxidation instantly without permanent residue. o3’s powerful oxidizing effect can oxidize proteoglycans, causing them to lose their properties of fixed charge density and maintaining high osmotic pressure in the nucleus pulposus, resulting in a decrease in osmotic pressure and water loss in the nucleus pulposus. In addition, O3 also causes necrosis or decreased function of the nucleus pulposus cells and reduced ability to produce proteoglycans. O3 treatment not only has the advantages of general minimally invasive lumbar disc surgery, but also can be performed on an outpatient basis due to the use of 18-21G puncture needles to puncture the nucleus pulposus and inject O3, which is safe and non-invasive, simpler to operate, less painful for the patient, and less costly, and greatly reduces the chance of surgical infection. 49.What is percutaneous discectomy? Hi-jikata first reported the use of percutaneous puncture technique for the treatment of lumbar disc herniation in 1975, opening up a new pathway between open surgery and conservative treatment. 1985 Abramovitz designed an automatic nucleus pulposus cutter. Its purpose is to cut and aspirate the degenerated and herniated nucleus pulposus and relieve or release the compression of the herniated nucleus pulposus on the cauda equina or nerve root. The principle of treatment is to reduce the pressure within the disc by reducing the volume of the nucleus pulposus, thereby reducing the compression and irritation of the nerve root. Onik reported an efficiency of more than 90%, but it is difficult to perform if the herniated disc is combined with lumbar spinal stenosis or nerve root canal stenosis, otherwise the efficacy is compromised. The advantages of percutaneous discectomy are less trauma and faster recovery. The main disadvantage is that the operation is performed under fluoroscopy rather than direct vision, and the herniated disc tissue cannot be removed during the operation, making it difficult to obtain complete decompression. Therefore, it is only suitable for cases of simple and acute disc herniation. Common complications are intervertebral space infection, lumbar muscle hematoma, neurovascular and intestinal injury, and postoperative recurrence.