Reasons for not operating for lumbar synostosis Lumbar synostosis is to some extent a self-limiting or self-healing disease, and about 80% to 90% of patients can be treated satisfactorily with non-operative treatment, while only 10% to 20% of patients require surgery. Except for patients with persistent aggravation of cauda equina damage, non-operative treatment should be preferred for lumbar synostosis. However, it is common for surgical treatment to be the first choice in clinical practice. This overtreatment not only wastes valuable medical resources, increases the patient’s surgical pain and economic burden, but also leads to a high incidence of surgical failure in the pain department of Beijing Traditional Chinese Medicine Hospital Guo Ren, which should be a concern. According to statistics, 21.5% to 40% of patients with lumbar synostosis still have symptoms of varying degrees of lumbar and leg pain after surgical treatment. Some foreign scholars observed the efficacy of lumbar discectomy in adolescents, and during the 45-year follow-up period, 20 out of 72 cases, i.e., as many as 28% of patients, required reoperation. Foreign experts have conducted a large literature review on the indications, methodology and complications of surgical resection for lumbar synostosis. They found that, after surgical treatment of patients with lumbar synostosis, although the protruding disc can be removed and the narrowed nerve root canal can be enlarged, the recent efficacy is remarkable and the excellent rate of surgery can reach 75% to 95%, the long-term efficacy is not much advantageous compared with non-surgical treatment and the natural course of the disease. So, what are the reasons for the unsatisfactory surgical results? It starts with the etiology of lumbar synostosis. Surgery cannot eliminate the root cause of lumbar synostosis For many years, the medical profession has believed that mechanical compression such as a protruding disc or bone flab is the main cause of nerve root pain and lumbar synostosis, i.e., the mechanical compression theory is the cause of lumbar synostosis. However, this theory cannot explain: ① In the lifetime of a normal person, many people will develop degeneration and herniation of the intervertebral discs and other lumbar degeneration. Some experts have found through CT studies that 30% of normal people can have a herniated lumbar disc without any symptoms. Clinically, we often see that the degree of structural or morphological changes of lesions in some patients with lumbar herniation is not positively correlated with the severity of lumbar pain and disabling condition. Some have large herniated nucleus pulposus but no nerve root symptoms, i.e., asymptomatic lumbar disc herniation (ALPH); while others have severe nerve root pain symptoms despite no signs of herniated nucleus pulposus. Long-term clinical observation shows that degenerative changes such as lumbar disc herniation are difficult to reverse once they appear, while neurogenic pain often fluctuates and has a long asymptomatic interval. ③In recent years, it has been found that after a herniated disc, if there is only mechanical compression of the nerve root, the patient will often only experience abnormalities in sensation, but not clinical symptoms such as pain. Only when there is inflammatory congestion and edema around the nerve root can pain symptoms appear.4 Clinically, some nerve root compression pain can be cured or relieved by conservative treatment alone without releasing the compression. These suggest that the etiology of lumbar synostosis was once oversimplified. The inflammatory etiology is worthy of attention. So, what is the exact cause of lumbar synostosis that leads to back and leg pain? In 1965, Bobechko et al. suggested that the nucleus pulposus had been isolated from other tissues in the body before herniation, and thus had autoimmune foreign body properties. This is manifested by abnormalities in cellular and humoral immunity, triggering radicular inflammation and causing pain through the interaction between antigens, T and B lymphocytes. Other scholars have done a lot of basic research on the pathogenesis of lumbar synostosis and concluded that inflammatory mediators may be an important factor. Inflammatory substances such as immunoglobulins, cytokines, and nucleus pulposus antigens can escape into the epidural space with disc degeneration or herniation, triggering local or systemic immune responses and causing persistent pain. This pain caused by inflammatory substances escaping from the disc is called discogenic pain. This explains the phenomenon that patients with lumbar disc herniation or only disc degeneration without herniation can develop clinical symptoms whenever inflammatory substances escape. Therefore, these chemicals that cause lumbar herniation, which irritate the nerve fibers, may be more important than mechanical compression alone and may play a dominant role in the pathogenesis of lumbar herniation. This is the inflammatory etiology of lumbar synostosis, one of the main causes of lumbar synostosis, and the underlying reason why simple removal of the intervertebral disc does not eliminate clinical symptoms. This has been recognized by more and more scholars, and has had an important hint and positive impact on the non-surgical treatment of lumbar synostosis. Complex reasons for surgical failure Of course, the reasons for poor surgical outcome or even failure are very complex. In addition to the main reasons, there are other factors: ① multisegmental disc herniation accounts for about 10% to 20% of patients with lumbar herniation, which can lead to inaccurate preoperative disc positioning or omission during surgery for multisegmental disc herniation. ②Omission of preoperative complications. About 66.6% of patients with lumbar herniation have varying degrees of lateral saphenous fossa stenosis, intervertebral small joint hyperplasia, ligamentous hypertrophy and calcification, and even lumbar spinal stenosis. Although the surgery removes the nucleus pulposus, which compresses and stimulates the nerve roots, it often fails to remove the continuous compression and stimulation of the nerve roots by the lateral saphenous fossa, intervertebral foramen and spinal stenosis, i.e., the nerve root compression factors are not completely removed. If the indications for minimally invasive surgery are not strictly mastered, non-traditional procedures such as percutaneous discectomy and aspiration, nucleolysis and percutaneous laser discectomy are performed for compound complex lumbar synostosis, and although these procedures are less invasive than traditional surgery, they cannot relieve the compression and stimulation of the lateral saphenous fossa and other nerve roots, which is also the reason for the high incidence of surgical failure.4. After laminectomy, the resulting local damage has to be The local damage caused after laminectomy is repaired by the proliferation of fibrous tissue, rather than the reconstruction of anatomical structures. Therefore, fibrous scar is an inevitable product after laminectomy, which can lead to fibrosis around the dura and nerve roots at the resection site, and a large amount of scar makes the dura and the tissues around the nerve roots and sacrospinous muscle adhere together, pulling and compressing and stimulating the nerve roots and causing postoperative symptoms. In recent years, it was found that although re-operation could loosen the adhesions and remove the scar, the adhesions and scar were recreated 3 to 6 months after surgery, and eventually the symptoms of low back pain did not improve significantly in most patients, or even worsened. ⑤ The long-term compression and stimulation of the herniated disc causes adhesion, degeneration and atrophy of the nerve root, resulting in postoperative hypesthesia and numbness of the lower limbs or toes that cannot be relieved. ⑥After removal of the diseased disc, the physiological gravitational balance of the spine is imbalanced, and a lumbar disc herniation in another segment is induced. Therefore, surgery for lumbar herniation is not the best choice. Three principles of conservative treatment Based on the inflammatory etiology of lumbar herniation, non-surgical treatment should be the first choice, except for surgery for lumbar herniation with severe damage to the cauda equina. In the conservative treatment of lumbar synostosis, three principles must be followed: first, to remove the irritation of inflammatory substances, second, to relieve the compression of nerve roots by intervertebral discs, and third, to accelerate the repair of the annulus fibrosus. For this reason, we mostly adopt the method of combined internal and external treatment of traditional Chinese medicine, together with traction, physiotherapy, acupuncture, sacral injection, etc. In addition to having significant effects of dispelling wind and opening the veins, resolving stasis and relieving pain, nourishing blood and benefiting tendons, expelling phlegm and eliminating swelling, tonifying kidney and strengthening bones, it can also improve blood circulation around the fibrous ring, increase the nutrient supply around the cartilage plate, improve the absorption of nutrients by the nucleus pulposus, relieve muscle spasm, promote the inflammation and stasis of blood in the tissues around the nerve roots It can activate the degenerated tissue cells, promote the formation of fibrous wrapping around the herniated disc, strengthen the fixation of the disc fiber rupture, and achieve the effect of anti-relapse. The combination of internal and external treatment of Chinese medicine, so that the effects of medicine in the same way, can receive both the symptoms and the root cause of satisfactory results. So far, many patients with lumbar synostosis have been cured, many of whom are patients who are proposed to undergo surgery in various places. This therapy is also effective for patients who have failed surgery and for patients with lumbar spinal stenosis and lumbar osteophytes or complex lumbar spine diseases.