1, discogenic low back pain The intervertebral disc is one of the components of the spine, which exists between the vertebrae of one section, it has both the function of spring cushion to cushion the vibration and conduct stress, and the function of joint to maintain the mobility of the spine. The intervertebral disc has a central nucleus pulposus and a peripheral fibrous ring; the nucleus pulposus is composed of a water-rich peptide-like substance, and the fibrous ring is composed of repeatedly overlapping bands of strong collagen fibers that surround the central nucleus pulposus. The intervertebral disc is usually mechanically loaded. Starting around the age of 15, with increasing age and repeated stimulation by stress, there is a gradual decrease in water degeneration of the nucleus pulposus, also known as degenerative aging. As a result of this aging, the supportive and spring cushion effect of the disc begins to diminish, which may create irritation to the surrounding nerve endings and increase the burden on tissues such as ligaments, joints and muscles, becoming a cause of low back pain. This condition of low back pain caused by disc degeneration is called discogenic low back pain, not lumbar disc herniation. In discogenic low back pain, the symptoms are mainly acute and chronic low back pain, mostly aggravated by activities (especially forward flexion) and weight bearing, rarely accompanied by lower limb and urinary and fecal symptoms. The diagnosis of discogenic low back pain is difficult by physical examination alone, and most of the ordinary X-ray films do not show significant abnormalities, so it is necessary to do MRI examination. Treatment mainly consists of oral pain medication and conservative treatment such as wearing a lumbar bra and a tight corset, and the symptoms will be relieved in most cases. In most cases, the symptoms will be relieved. In individual cases, if the back pain persists for a long time and affects daily life and work, surgery is required. Surgery involves either complete removal of the disc, artificial disc replacement, or bone grafting into the vertebral space for lumbar spine fixation and fusion. To determine if surgery is appropriate, a discogram is performed at the time of admission. Of course, not all people with abnormal discs on MRI will have low back pain. The diagnosis of discogenic low back pain requires extensive experience and expertise, so it is recommended to seek consultation with a spine specialist when there is chronic low back pain. 2, lumbar disc herniation The intervertebral disc consists of soft tissue called the nucleus pulposus and its surrounding outer structure called the annulus fibrosus. The nucleus pulposus is gelatinous in childhood and young adulthood and decreases in moisture with age. In the prime of life, the annulus fibrosus develops a fissure that causes low back pain. If the fissure passes to the outer layer of the annulus fibrosus, the nucleus pulposus, the content of the intervertebral disc, is extruded and protrudes, which is called a herniated disc; if it compresses or stimulates the nerves to produce symptoms such as lumbago and sciatica, it is called a herniated disc. Some of the herniated discs only mainly compress the nerve roots and produce pain in the lower limbs; however, if the compression damages the lumbar nerve called cauda equina, urination and defecation disorders occur. It is necessary to visit a spine specialist for herniated lumbar discs. Most conservative treatments can relieve symptoms, but patients with recurrent, severe pain, increased weakness or numbness in the lower extremities, and urinary and bowel dysfunction require surgery. 3, lumbar spine isthmus crack, lumbar spine slippage lumbar spine isthmus crack, refers to the lumbar spine originally continuous intact small inter-articular (isthmus) bone, a disease of continuity interruption (crack, separation), mainly in the fifth lumbar spine. It is more frequent in children engaged in sports activities and is generally considered to be a fatigue fracture caused by repeated external stimulation of the lumbar region, with some genetic factors also involved. The main symptom of this disease is low back pain, which is evident during sports and can be asymptomatic in general; it is not uncommon for the pain to go unnoticed. This disease has the promise of healing of the fracture if appropriate treatment is given early, such as wearing a brace or plaster immobilization. Therefore, if your child develops low back pain while playing sports, it is important to receive an early consultation with a spine specialist. If left untreated, an isthmic fracture will compromise the stability of the adjacent vertebrae, and misalignment between the vertebrae will occur with age, at which point it is called a lumbar spondylolisthesis. Severe slippage can lead to lumbar instability and lumbar spinal stenosis, resulting in pain and numbness in the lower back and lower extremities, sometimes necessitating surgery. Regardless of whether surgery is performed or not, the prognosis for lumbar spondylolisthesis is generally good if proper treatment is received. When there is chronic low back pain and pain and numbness in the lower extremities, early consultation with a spine specialist is recommended. 4. Lumbar spinal stenosis The canal through which nerves pass in the spine is called the spinal canal, which is a nearly circular and triangular-shaped orifice. The spine, which supports the body, degenerates over the years, resulting in pathological changes such as disc bulging, osteophytes, and ligamentous hypertrophy, so that the spinal canal becomes narrow, which is called lumbar spinal stenosis. If this narrowing causes symptoms such as back pain, leg pain, and inability to walk long distances, it is called lumbar spinal stenosis, which generally increases slowly after the age of 50. Once the spinal canal is narrowed, the nerves (cauda equina and nerve roots) that pass through it become compressed and are accompanied by neuralgia and paresthesia (weakness) in the lower extremities. In addition to numbness in both lower extremities, there is also a feeling of heaviness in the buttocks and thighs, and symptoms of the bladder and rectum such as a feeling of incomplete urination (residual urination) and constipation after urination. These symptoms mainly appear or worsen after walking, therefore, patients suffering from lumbar spinal stenosis cannot walk long distances continuously, but must walk and stop, walk and stop, showing a state of intermittent limping. Once walking, lower extremity pain and numbness appear or worsen, or lower extremity symptoms accompanied by abnormal urination, squatting or sitting down symptoms relief, cycling without lumbar pain, we should highly suspect lumbar spinal stenosis and recommend consultation with a spine specialist. 5, degenerative lumbar spondylolisthesis degenerative lumbar spondylolisthesis, is a disease of the lumbar spine front and back misalignment, which occurs in middle-aged and elderly women, often between the 4th and 5th lumbar vertebrae. The cause of this is not well understood, and most scholars believe that as age increases, the intervertebral discs, joints, and ligaments of the lumbar spine become relaxed, resulting in anterior-posterior or lateral slippage of the lumbar spine and instability of the lumbar spine, bringing about narrowing of the spinal canal (nerve channel) and compression of nerves, resulting in back pain, lower limb pain, and numbness. With the progress of the disease, the symptoms will also change, the early stage of back pain caused by intervertebral disc and intervertebral joint lesions; with the aggravation of the disease will form lumbar spinal stenosis, intermittent claudication (can not walk long distances continuously, lower limb pain and numbness, must walk and stop, walk and rest, sitting or squatting rest can be relieved), to the late stage of bed rest will also appear pain and numbness in the lower limbs. Treatment is mainly conservative, and when symptoms are severe, it is extremely important to wear a brace or lumbar girth, avoid actions that aggravate the lumbar burden in daily life, and rest. If oral anti-inflammatory and pain medication can be effective, stretching and muscle training of the lumbar region is performed. When pain is significant, nerve injection closure therapy can be tried. If the symptoms are not relieved by these conservative treatments, decompression surgery and lumbar spine fixation and fusion will be required. Most of them have a good prognosis if appropriate treatment is given, and early consultation with a spine specialist is desirable. 6, degenerative scoliosis Degenerative scoliosis is a degeneration of the intervertebral discs and intervertebral joints with age, the ability to support the vertebral body is weakened, the spine shows a lateral bending (scoliosis) state, mostly in the lumbar region. Early symptoms are mainly low back pain, and later the vertebrae are deformed with bone spurs and the spinal vertebrae are rotated. Sometimes these pathological changes can compress the nerve roots and cauda equina, producing symptoms such as lower limb paralysis, pain and low muscle strength. In addition, as the scoliosis worsens, it is accompanied by intractable back pain, and the line of holding force of the trunk becomes worse, which significantly affects daily life. When symptoms are mild, conservative treatment such as wearing a brace is feasible, while surgery is necessary in severe cases. Surgery is sometimes simple, and the symptoms can be relieved by removing the degenerative changes of bone and cartilage (decompression surgery) and decompressing the nerve roots and cauda equina. However, since decompression can further aggravate the degeneration and further instability can occur, depending on the degree of scoliosis and the state of nerve compression, it is sometimes necessary to perform a lumbar fixation and fusion, which requires the implantation of special metal screws and rods or plates to support the fixed spine. Thus, we say that degenerative scoliosis, both in the choice of treatment and in the determination of the extent of fixation, requires expertise and skills, and spine disease specialists are the solution to these problems. 7, osteoporosis, vertebral compression fractures Bone consists of minerals (mainly calcium and phosphorus) and proteins (collagen, etc.) and the cells that regulate their metabolism (osteocytes, osteoblasts, etc.). Osteoporosis is a condition in which bone metabolism is out of balance, bone resorption exceeds bone formation, and bone mass decreases, and bone quality changes, becoming brittle. It is especially prevalent in women after menopause, and this disease does not attract much attention, with less than 10% actually receiving treatment. Patients with osteoporosis are prone to fractures of the vertebrae and femur from minor trauma, or even if there is no obvious trauma. Fractures that occur in the spine, where the quadrilateral vertebral body breaks down and flattens, are called compression fractures. Once fractured, the spine does not return to its original shape and the vertebral body becomes wedge-shaped after the bone heals. Therefore, after the pain disappears, sequelae such as posterior spinal protrusion and shortening of height are left behind. The incidence of osteoporotic compression fractures is higher in Oriental women because with one fracture, it is increasingly easy to have fractures in the future, so early treatment is very important. Treatment is in principle conservative and systematic drug therapy must be adhered to. To prevent the occurrence of significant kyphotic deformity (hunchback), a brace can be worn. Without appropriate and effective treatment in the hospital, some patients also suffer from non-healing bone and persistent pain over time. There is a minimally invasive procedure, vertebroplasty, in which a small amount of bone cement is injected into the fractured vertebrae via percutaneous puncture, and the fracture is fixed within minutes of solidification, the pain disappears immediately, and you can soon walk with weight. Severe compression fractures, which can damage the nerves passing through the spine, require surgery. Patients who receive proper treatment and pay attention to dietary therapy and physical activity can effectively inhibit bone loss and reduce the risk of fracture. 8, cervical disc herniation The intervertebral disc is one of the components of the spine – cervical, thoracic and lumbar – and exists between one vertebra after another, which has both the function of a spring cushion to cushion vibration and conduct stress, and the joint function to maintain the mobility of the spine. The central part of the disc is the nucleus pulposus, which is surrounded by a fibrous ring. The nucleus pulposus is composed of a water-rich, peptide-like substance, and the fibrous ring is formed by repeatedly overlapping bands of strong collagen fibers that surround the central nucleus pulposus. The intervertebral disc is usually mechanically loaded, and starting around age 15, with increasing age and repeated stimulation by stress, the nucleus pulposus gradually degenerates with reduced water and the annulus fibrosus develops small chafing or fractures. The nucleus pulposus prolapses from the small fracture of the annulus fibrosus, which is a disc herniation. A herniated disc that occurs in the cervical spine and causes symptoms is called cervical disc herniation. The incidence of cervical disc herniation is high among various cervical spine disorders, mostly seen after middle age, and the symptoms vary depending on the direction of the disc protrusion. The symptoms vary depending on the direction of the herniated disc. Generally, it is more to one side, when the nerve root, a branch of the spinal cord, is compressed, causing pain and numbness on one side of the neck, from the shoulder to the scapula, and dispersion pain and muscle weakness to the upper limbs. If there is a large herniated disc right in the center, it can compress the spinal cord itself and cause symptoms such as clumsy fine finger movements, unstable walking, and bladder and rectal dysfunction (frequent urination, dysuria, urinary incontinence and constipation). Although the principle of treatment is mainly conservative, when nerve damage is caused by spinal cord compression, early surgery is required; long delays make recovery difficult and may also lead to paralysis. If the symptoms described above occur, it is recommended to seek consultation with a spinal specialist as soon as possible. 9, cervical spondylosis As the cervical spine (cervical spine) itself or intervertebral discs degenerate and age, causing bone and cartilage proliferation to form bone spurs, compression or stimulation of surrounding nerves, blood vessels, or neck, shoulder and arm pain, or numbness of the hands and feet walking unstable, or headache, dizziness, panic and nausea and other different symptoms, this condition is called cervical spondylosis. MRI is necessary to observe the site and size of the bone spur and to observe the degree and location of deformation and degeneration of the spinal cord under pressure. If it is only a stiff neck and dull scapular pain, symptomatic physical therapy and gentle exercise therapy are usually sufficient. If this state progresses and neck, shoulder and arm pain, or numbness in the hands and feet, especially with dyskinesia and difficulty urinating, a visit to a spine specialist is necessary. Most cervical spondylosis (nerve root type) with mainly neck and shoulder upper limb pain (neck, shoulder and arm pain) has good results with conservative treatment, but most patients have at least one more symptom recurrence in their lifetime; if symptoms are repeatedly prolonged or a few with severe pain that conservative treatment is ineffective, surgery is required. In cervical spondylosis (spinal cord type) with symptoms such as weakness and numbness of the limbs, inflexibility of the hands, and unstable walking, most of them (60-80%) will have progressive aggravation of the natural course of the disease, and the final result will be paralysis; therefore, it is generally advocated that surgery should be the main treatment once the diagnosis is made; the lighter the disease, the earlier the surgery, the better the result. For cervical spondylosis (sympathetic nerve type, vertebral artery type) with symptoms such as dizziness and headache, panic and chest tightness, nausea and vomiting, conservative treatment is generally the main treatment. Such patients have complicated subjective symptoms and are prone to delay, so they need to be treated with great care and endurance. Most patients can be treated conservatively for a long time; a few patients with severe recurrent symptoms can be operated, and most of them can obtain miraculous results. 10, cervical posterior longitudinal ligament ossification – OPLL OPLL is a disease in which the posterior longitudinal ligament located behind the cervical vertebral body and immediately adjacent to the spinal cord is abnormally ossified, compressing the spinal cord. As the ossification develops and spinal cord compression increases, pain in the neck and shoulders, numbness in the hands and feet, impaired finger movement, and difficulty walking can occur, and is most common in men between the ages of 40 and 50. Diagnosis can sometimes rely solely on X-rays, but CT examinations are the most sensitive, and MRI examinations are the most effective for observing the degree of compression on the spinal cord. When symptoms are mild, conservative treatment is used, such as bracing to maintain rest and medication. When finger movement disorders and difficulty walking occur, surgery is necessary. Surgery is broadly divided into anterior surgery (anterior osteotomy and decompression implantation) and posterior surgery (single- or double-opening cervical spinal canalplasty), which requires 1-2 weeks of hospitalization. It is also important to emphasize that even if there are no symptoms or mild symptoms, OPLL is a high-risk cervical spine and care should be taken not to fall to prevent spinal cord injury. 11, thoracic medullary compression The spinal cord nerves are divided into cervical medulla, thoracic medulla and lumbar medulla (cauda equina) depending on the location. The state of neurological dysfunction due to compression of the thoracic medulla for some reason is called thoracic medullary compression. The main causes of thoracic medullary compression are disc herniation, degenerative lesions of the thoracic spine (degenerative bone spurs that increase with age), ossification of the posterior longitudinal ligament, and ossification of the ligamentum flavum, which together are characterized by lesions compressing the thoracic spinal cord and forming symptoms of bilateral lower limb paralysis. Thoracic medullary compression is less common. The reason for this is that the thoracic vertebrae surrounding the thoracic medulla are less stable and less mobile due to the fixation of the thorax. Because of this, the thoracic spine is different from the cervical and lumbar spine, and generally develops after middle age, with symptoms starting with numbness and weakness in the lower extremities common, and slowly can appear as band pain in the trunk (abdomen or chest), and further aggravation will result in symptoms such as unstable walking, bladder and rectal dysfunction (urinary frequency, urinary closure, urinary incontinence and constipation). When early symptoms are only in the lower extremities, diagnosis is difficult and misdiagnosis as a lumbar spine disorder or even surgery may occur. If you have persistent lower extremity symptoms, you must visit a spine specialist.