The spine is the pillar of the human body, especially the lumbar spine, not only alone to support the weight above the hip, flexion, extension, rotation and other multi-directional movements, but also to protect the spinal nerves in the weight and movement. Because of its complex function, the structure is also correspondingly complex, each section of the spine with small joints and intervertebral discs articulated with each other, interlocking dog teeth, each small joint has synovial membrane and joint capsule, surrounded by numerous ligaments of varying sizes and lengths and muscles governing the movement of the spine. All of these tissues are subject to constant pressure, wear and tear, degeneration and fatigue during weight-bearing and movement, causing back and leg pain, so people have a history of back pain almost all the time in their lives. The function and structure of the lumbar intervertebral disc is even more special, it is an elastic container surrounded by cartilage plates and fibrous rings, filled with jelly-like nucleus pulposus, with hydrodynamic characteristics, like a water cushion between the vertebrae, which can make the vertebrae move like a rocking chair to reduce the bony shock of the spine. The internal pressure is 60 to 70 kg when upright, and can increase by 30 to 50 kg when flexing and straightening. when exercising or carrying heavy objects, the pressure can instantly increase to hundreds of kilograms, and the normal pulpal nucleus can support 300 kg without rupture. after the age of 20, the annulus fibrosus begins to degenerate, and when the lumbar sprain, overexertion, cold, moisture or even mental overstimulation can cause the annulus fibrosus to rupture and cause herniation. Although herniated discs account for only a small percentage of the incidence of lumbar pain, the herniated material can compress the nerve roots and cause unbearable sciatica, so it attracts more attention. The incidence of lumbar discs is about 1% of the population in the United States, and among 100,000 adults, about 160 people develop the disease each year. Statistics from Sweden show that about 35% of low back pain will develop into lumbar disc herniation. In China, we have not yet seen systematic statistics, but in recent years, due to the progress of diagnostic means and surgical methods, the clinical diagnosis of this disease and the use of surgical treatment are showing an increasing trend. Weber et al. conducted a comparative study of surgical and non-surgical treatments and showed that satisfactory recovery was achieved regardless of the treatment, with a success rate of 90% for both. Surgical treatment is more effective in the short term, with pain subsiding 2-15 days after surgery; non-surgical treatment takes about 3 months, but there is no difference between the two in long-term follow-up (Hekelins, Weber), and the disease is considered to be a disease that can subside on its own. In about 10% of patients with treatment failure or symptom recurrence, a new herniation occurs in the same plane or other interval because of postoperative re-injury to the low back, but most of them are due to misdiagnosis, mistreatment and intraoperative errors. In some cases, the nerve root is mistakenly injured, the dura is torn, or the epidural plexus is damaged, resulting in excessive blood leakage or hematoma formation and later scar tissue or adhesion formation; in others, the small joint is excised excessively or the treatment of lateral saphenous fossa or root canal stenosis is missed. These surgical errors are not included in the self-reduction of symptoms. The formation of postoperative scar tissue or adhesions is the most common cause of recurrent pain and increases the rate of repeat surgery. Scarring can pull the dura posteriorly, restrict nerve root movement, and can even cause a longitudinal tear in the dura itself (MeCulloch). Adhesions of the dura to the disc can also interfere with the movement of the herniation, and dural tears can cause adhesions to the cauda equina, all of which can cause recurrence of symptoms. Scar contracture can involve the nerve roots below the plane of the herniation, and a herniated lumbar disc from L4 to L5 can affect the sacral nerve roots, so obscuring the clinical signs and making reoperation more difficult, often requiring a larger incision. After stripping the adhesions, further adhesion formation is inevitable. Herniated discs can shrink or be completely absorbed A herniated disc is the generic term for this condition, originally meaning disc herniation (disc herniation), defined as an asymmetric local extension of the disc beyond the intervertebral space. In terms of anatomical or pathological changes, there are three types of herniation (protrusion), extrusion (extrusion) and comminution (sequestration). Disc bulge is a four-way expansion of the disc tissue beyond the normal periphery without rupture of the annulus fibrosus, mainly due to loading or degeneration of one or more discs, and its contents are bulging due to compression, which can cause intermittent claudication in severe cases and generally does not cause neurological symptoms, so it is not included in the diagnosis of disc herniation. Bush et al. performed CT examinations on 165 patients with sciatica, 96% of whom had herniation, 86% of whom had resolution of symptoms after treatment, and 14% of whom had surgery. In 111 cases treated non-operatively, 76% of the herniations had major or complete resorption after one year of CT examination, which was not significantly different from non-operative patients. Eagerlund performed CT examinations on 30 patients with sciatica. Eagerlund concluded that the reduction of the herniation was closely related to sciatica. Patients with seizures were compared and the results did not differ. Of the 19 patients whose symptoms curved and subsided, only 3 had complete loss of the herniation. delauche-Cavallier had reduction of the herniation in 48% of 21 cases treated non-operatively, moderate reduction in 19% and no change in the rest. The herniation became more pronounced. In 26 cases treated non-operatively in Bozzao, 48% had 70% reduction after 6-15 months, 15% had 30%-70% reduction, 29% had no change, and 8% had enlargement, and all those with enlarged prominences had worsening of symptoms. In Marsuhara’s study, the reduction in size became more pronounced. The reason for this may be that the herniation penetrates the annulus fibrosus, destroying the epidural vessels and forming a hematoma, and the spillage of the disc contents may cause an inflammatory reaction in the epidural space. The faster reduction of larger protrusions may be related to the absorption of these materials. Callncci suggests that the expansion of symptoms in some patients 6 weeks after onset may be related to the growth of these granulation tissues. The disc itself has no circulation and can be absorbed relatively quickly when the free fragment penetrates the posterior longitudinal ligament and enters the circulating spinal canal. In the case of multiple disc bulges, shrinkage is rarely seen. Most scholars have similar findings to the above, differing only in the relationship between herniation size change and symptoms, which remains to be further observed and studied. Diagnostic triangulation The diagnosis of lumbar disc herniation is simple yet complex. The location of the herniation seen in the images generally section determines the degree of nerve involvement and the nature of clinical pain, but the degree of nerve involvement cannot be accurately diagnosed by the size, type and location of the herniation alone; asymptomatic individuals can often be found to have a herniation on MRI. A smaller protrusion can cause severe pain, while a large free fragment can even cause neurological deficits. Therefore, there are still different opinions on the cause of the pain, and some even consider that the influence of certain chemicals may also be greater than anatomical factors. Therefore, it is important to distinguish between anatomical changes and radicular pain in the clinical presentation. There are often multiple intervertebral disc herniations in the images, but it is often one of the intervertebral spaces that causes the symptoms. There is a patient-derived history that is often ambiguous, often leading to unnecessary testing and inappropriate assertions. For these reasons, it is not conclusive to make a diagnosis based on one piece of information alone. It is necessary to combine the nature, distribution and motor disorders of pain in the history, tests such as nerve root pulling in the physical examination, and anatomical changes in the imaging examination, to remove the crude and extract the essence, remove the false and keep the true, and synthesize the analysis in order to increase the accuracy of the diagnosis. In order to facilitate the memory of beginners, a triangle can be used to represent it (the figure below). In the triangle, the diagnosis is based on history and physical signs, and the presence and location of the herniated disc is confirmed by imaging. When receiving a patient, the posture and gait should be observed; when taking a history, the location and nature of the pain should be clarified. In the straight leg raising test, it is necessary to distinguish between true positives and false positives when the reason for the limitation of leg raising is radicular pain caused by the sciatic nerve or pain caused by other causes such as joints, muscles, fascia or peripheral nerve cords. In 2504 patients with proven lumbar disc herniation in Spangfort, the positive rate of straight leg raising test was 96.8%; the positive rate decreased with age and was almost completely positive in those under 30 years of age. Nerve root involvement alone can enhance or decrease reflexes due to many conditions. The muscle strength test should be performed routinely. extensor c longus is innervated by L5 nerve, quadriceps by L2 to L4, tibialis anterior by L4, gluteus medius by L5, gastrocnemius and hallux valgus by S1 to S2, and gluteus maximus by S1. In patients with subtalar symptoms, it is important to distinguish between L5 radicular pain or peroneal nerve injury. Diagnostic imaging, particularly magnetic resonance imaging (MRI), can determine the presence, location, and type of herniated disc, can be used as a reference for the degree of nerve and spinal membrane compression, and can determine whether the herniation is the cause of the pain. If there is no herniation present in MRI, in provides consideration of other causes to explain the symptoms or syndrome suffered. ct can diagnose extradural disc herniation. mri is more accurate in the diagnosis of crushed free disc fragments. the diagnostic accuracy is 90.3% for mri, 77% for ct, and 70% for myelography (Forristall, Fries) The surgical results are mainly in The success of surgical treatment of lumbar disc herniation rarely depends on the surgical method, but mainly on the choice of surgical indications, which has been recognized by most scholars. 90% of patients can recover from non-surgical treatment, and only 2%-4% of patients have surgical indications. An accurate diagnosis must be available before surgery. The imaging or anatomical changes must be compatible with the clinically involved nerve root, and the absence of abnormal imaging findings should be considered a contraindication to disc surgery. The indications for surgery are more consistent: 1. Strong surgical indications (1) Caudal syndrome with urinary and defecation dysfunction (caudaequina syndrome), with a minimum of saddle palsy. (2) More severe progressive motor dysfunction. If the muscle strength is less than grade 3, regardless of whether the straight leg raise test is positive or not, it should be considered as an indication for surgery. Relative indication (1) Intolerable sciatica, more than 6 months since the onset, or more than 3 months since the recurrent pain, which is not relieved by non-surgical treatment. (2) In some patients, the symptoms can be relieved by non-surgical treatment, but the patient is eager to relieve the pain, which can also be regarded as a relative indication. (3) Sciatica with spinal stenosis, whether congenital or acquired, can often cause severe pain, mostly in the elderly, and surgery may also be considered. What is done is nerve root surgery, not to remove the intervertebral disc The application of microsurgery, especially for the anastomosis of fine vessels and nerves, is an important development in the field of recent surgical techniques for lumbar discectomy, which can recognize the fissure of small epidural vessels, can observe the condition of the stump of the ligamentum flavum and the fibrous ring, can see the fine branches of the nerve root importation, can avoid damage to the dura and the nerve root. Fine fragments of the medullary nucleus can be seen. The disadvantage is that the operator loses the view around the operative field. Beyond 5 cm in diameter, nothing can be seen. For a more extensive view, the position of the lens must be adjusted. There is no room to use longer instruments in a small incision, and the operator only sees the tip of the instrument, losing coordinated hand and eye movements. If the positioning is wrong, it is difficult to count the order of the vertebrae alignment from top to bottom as in the traditional style. The lens is close to the incision, which can easily contaminate and affect the operation. The infection rate is also much higher (2%) than that of conventional surgery, and the reoperation rate is 16%. Some authors even believe that it is better for the operator to wear a mirror or use a long-handled biting forceps. Percutaneous discectomy is a recently developed surgical approach via a posterior posterolateral incision, which has the advantage of avoiding epidural bleeding and adhesion formation because the lamina is not removed and access to the spinal canal is not required. In addition, Hijikata reported the removal of herniated nucleus pulposus by percutaneous puncture with a biopsy forceps, and an automatic nucleus pulposus cutter was designed. 1987 saw the first laser disc decompression by Choy, but all these methods need further study and validation. Although there are many different procedures mentioned above, it must be remembered that the operation is a nerve root operation, not an operation to remove the disc, but to remove the disc in order to release or decompress the nerve root, so care must be taken not to accidentally injure the nerve root by removing the disc. Regardless of the operator’s experience, complete removal of the disc is not possible because of the risk of injury to the anterior tissues if the disc is removed too deeply or explored. Postoperative limitation of spinal flexion is directly proportional to the amount of disc removed. While some in the literature argue that complete resection reduces the recurrence rate, more scholars disagree and advocate limited resection instead. Everyone can perform the surgery, with varying skill, and the amount of resection should be sufficient to allow adequate release of the compressed nerve root. Experience and Lessons Learned Lumbar disc herniation was first reported by Mixter in 1934, and the operation in China began in 1945 with Professor Fang Xianzhi. The author operated on a sewing worker in 1949, and the diagnosis was made preoperatively simply on the basis of history and physical signs. The pain recurred a few weeks after surgery, and the surgery was repeated a year later. After several years of follow-up, the pain was not significantly relieved even though the sewing work was adhered to, and not only was the nerve root unresolved, but extensive adhesions were formed. The patient could have recovered with non-surgical treatment or even rest for a few weeks, but the botched surgery brought irreversible damage to the patient, which is still a cautionary tale and a regret. The so-called rest, the author’s opinion is not necessarily absolute rest and lying on a hard bed, but can be taken to make the muscle relaxation of any position, subject to self-conscious comfort. In the scope of the pain does not cause aggravation, you can gradually move to the ground, a symptom that is anxious to run around to seek medical help, often aggravate the symptoms, not conducive to recovery.