Lumbar disc herniation
A herniated disc is a rupture of the intervertebral disc’s annulus fibrosus, with the nucleus pulposus tissue protruding (or prolapsing) from the site of the rupture into the posterior or spinal canal. This is really just a pathological change, or imaging manifestation, and is almost an inevitable part of the human aging process, just like the appearance of wrinkles on the face and graying hair, it is not a disease.
According to the literature, there is a high incidence of lumbar disc herniation in asymptomatic people. One study performed MRI scans on 102 asymptomatic volunteers, aged 14-82 years with a mean of 46.3 years, and found rates of disc herniation, annulus fibrosus tears, and nucleus pulposus degeneration of 81.4%, 76.1%, and 75.8%, respectively.
A study published in the JBJS showed that more than 20% of asymptomatic volunteers under the age of 60 had disc herniation, and a study in Spine also showed that 40% of asymptomatic volunteers under the age of 30 had disc degeneration, rising to 90% of volunteers aged 50-55.
Additional long-term follow-up studies have found no correlation between the presence of a herniated disc in these volunteers and the subsequent development and duration of low back pain.
Lumbar disc herniation
Lumbar disc herniation, on the other hand, is a clinical syndrome in which a herniated lumbar disc causes irritation or compression of the adjacent spinal nerve roots, resulting in a series of symptoms such as low back pain, numbness and pain in one or both lower extremities.
In fact, in English literature and monographs, there is no such term as lumbar disc herniation, but the terms “sciatica” and “lumbar disk herniation” appear very frequently in the relevant literature, and in many contexts are probably similar to the Chinese term “lumbar intervertebral disc herniation In many contexts, it is probably similar to the Chinese term “lumbar disc herniation”. Of course, the expression “asymptomatic lumbar disc herniation” is also used.
Professor McCulloch was a landmark figure in the study of lumbar degenerative diseases, and the diagnostic criteria he proposed have been used to this day.
1. leg pain greater than lumbar pain, mainly confined to the sciatic or femoral innervation zone.
2, abnormal sensation in the dermatomal region.
3, positive straight leg raise test with an angle less than 50% of normal, or positive straight leg raise test on the healthy side.
4, having two of the four items such as muscle atrophy, weakness, hypoesthesia, and diminished tendon reflexes.
5, imaging features consistent with clinical manifestations.
According to the above diagnostic criteria and the pathological features of lumbar disc herniation, lumbar disc herniation must not only have pathological changes of lumbar disc herniation (imaging manifestations), but also clinical manifestations of damage to the corresponding nerve structures, pain and numbness, etc. with radicular distribution.
Therefore, even if there is an obvious lumbar disc herniation on imaging and there is also regional pain in the lumbar region, buttocks or thighs, etc., the diagnosis of lumbar disc herniation is questionable if there is no pattern of radicular distribution of nerves.
Must I be bedridden for conservative treatment of lumbar disc herniation?
Most of the domestic monographs, Chinese literature, and even textbooks advocate strict bed rest for conservative treatment of lumbar disc herniation. However, a search of the English literature suggests otherwise.
Spine, the most authoritative journal in spine surgery, has published a Cochrane systematic review with the highest level of evidence-based medicine, concluding that patients with acute low back pain are advised to obtain less benefit (pain, functional recovery) from bed rest than from continuing to maintain daily activities; and that there is little difference between bed rest and maintaining activity in patients with lumbar disc herniation.
There is a large body of literature that is consistent with these views and few studies have been reported that advocate strict bed rest. This shows that bed rest is not necessary, and if the patient’s pain and dysfunction are not so severe that it is difficult to walk, there is no need to artificially restrict their activities and strictly require bed rest.
Indications for surgery for lumbar disc herniation
There is no unified opinion on this. But should surgery be performed if there are typical neurological symptoms and signs?
From the point of view of the NEJM, BMJ and other high-quality literature, surgery can be considered for the following patients: patients with clearly diagnosed lumbar disc herniation.
1, presenting with cauda equina syndrome or acute severe local paresis or progressive worsening of paresis.
2. with intractable neurogenic pain (not relieved by morphine) or not relieved by systematic conservative treatment for 6-8 weeks.
In general, surgery is safe and has a lower incidence of complications, and symptoms can usually be improved faster and to a greater extent with surgery; however, non-surgery is also safe, unless cauda equina syndrome occurs as well as progressive nerve damage at home, and non-surgical treatment is chosen for a better outcome in the end.
This means that most discectomies can be avoided and without any long-term damage. If their symptoms are intolerable, surgical treatment may be considered if early recovery is desired.
For patients who have a herniated lumbar disc with non-specific back pain, please do not cut the disc in the name of lumbar disc herniation.