Lumbar disc herniation is one of the more common disorders, mainly because the lumbar intervertebral disc parts (nucleus pulposus, fibrous ring and cartilage plate), especially the nucleus pulposus, have different degrees of degenerative changes, under the action of external factors, the fibrous ring of the disc ruptures, and the nucleus pulposus tissue protrudes (or prolapses) from the rupture in the posterior or spinal canal, resulting in the adjacent crestal nerve root irritation or compression, thus producing lumbar pain The nerve root of the adjacent crest suffers irritation or compression, resulting in lumbar pain and a series of clinical symptoms such as numbness and pain in one or both lower extremities. Causes: 1, injury Long-term repeated external force causes minor damage, which aggravates the degree of degeneration. 2, the weakness of the disc’s own anatomical factors The intervertebral disc gradually lacks blood circulation in adulthood and has poor repair ability. On the basis of the action of the above factors, some kind of triggering factor that can lead to a sudden increase in the pressure on the intervertebral disc, i.e., may cause the less elastic nucleus pulposus to pass through the fibrous ring that has become less tough, causing the nucleus pulposus to protrude. 3, genetic factors There are reports of familial onset of lumbar disc herniation. 4, lumbosacral congenital anomalies including lumbar sacralization, sacral lumbarization, hemivertebral deformity, small joint deformity and asymmetry of joint protrusion. The above factors can cause changes in the stress on the lower lumbar spine, thus constituting an increase in the internal pressure of the intervertebral disc and making it susceptible to degeneration and injury. 5, triggering factors On the basis of intervertebral disc degeneration, certain factors that can induce a sudden increase in intervertebral disc pressure can cause nucleus pulposus protrusion. Common triggering factors include increased abdominal pressure, improper lumbar posture, sudden weight-bearing, pregnancy, cold and moisture, etc. 6, degenerative changes of the lumbar intervertebral disc is the basic factor Degeneration of the nucleus pulposus is mainly manifested by the decrease of water content, and can cause small-scale pathological changes such as vertebral joint instability and loosening due to water loss; degeneration of the fibrous ring is mainly manifested by the decrease of toughness. Clinical manifestations: (1) Signs 1. General signs (1) Lumbar scoliosis is a postural compensatory deformity to reduce pain. Depending on the relationship between the site of the herniated nucleus pulposus and the nerve root, it may appear that the crest is curved to the healthy side or curved to the affected side. If the site of the herniated nucleus pulposus is located on the medial side of the crestal nerve root, the lumbar spine bends to the affected side because the bending of the crest to the affected side reduces the tension of the crestal nerve root; conversely, if the herniated nucleus pulposus is located on the lateral side of the crestal nerve root, the lumbar spine bends to the healthy side. (2) Restriction of lumbar movement Most patients have varying degrees of restriction of lumbar movement, which is especially obvious in the acute stage, with the most obvious restriction in forward flexion, because forward flexion can further promote the nucleus pulposus to shift backward and increase the pull on the compressed nerve roots. (3) Pressure pain, percussion pain and sacral spasm The site of pressure pain and percussion pain basically corresponds to the vertebral space of the lesion, and is positive in 80%-90% of cases. The percussion pain is obvious at the spinous process and is caused by percussion vibration of the lesion. The pressure point is mainly located at 1 cm of the paravertebral area, and radiating pain along the sciatic nerve may occur. About 1/3 patients have lumbar sacrospinal muscle spasm. 2. Special signs (1) Straight leg raising test and strengthening test The patient lies supine, extends the knee and passively raises the affected limb. In normal people, the nerve root has 4mm sliding degree, and the lower limb is raised to 60°~70° before feeling discomfort in the popliteal fossa. In patients with lumbar disc herniation, nerve root compression or adhesions reduce or eliminate the sliding degree, and sciatica can occur when the elevation is within 60°, which is called a positive straight-leg elevation test. In positive patients, slowly lowering the height of the affected limb and waiting for the radiating pain to disappear, then passively flexing the affected ankle joint to induce radiating pain again is called a positive strengthening test. Sometimes, because of the large nucleus pulposus, elevation of the healthy lower limb can also pull the dural crest to induce radiating pain in the sciatic nerve on the affected side. (2) Femoral nerve pull test is performed with the patient in prone position and the knee joint of the affected limb fully extended. The examiner elevates the straightened lower limb so that the hip joint is in hyperextension, and the test is positive when the hyperextension reaches a certain level and pain occurs in the femoral nerve distribution area in front of the thigh. This test is mainly used to examine patients with lumbar 2 to 3 and lumbar 3 to 4 disc herniation. 3, neurological manifestations (1) sensory disorders depending on the location of the involved crestal nerve root and the abnormal sensation of the innervated area. The positivity rate is more than 80%. In the early stage, the symptoms are mostly skin sensation, and gradually numbness, tingling and hyperalgesia appear. However, if the cauda equina nerve is involved (central type and paracentral type), the sensory impairment will be more extensive. (2) Decreased muscle strength is seen in 70% to 75% of patients. In the case of lumbar 5 nerve root involvement, dorsal extension of ankle and toe is decreased, and in the case of sacral 1 nerve root involvement, toe and plantar flexion of foot is decreased. (3) Reflex changes are also one of the typical signs that are prone to occur in this disease. When the lumbar 4 nerve root is involved, the knee reflex may be impaired, which is active in the early stage and then rapidly becomes hyporeflexic. In sacral 1 nerve root involvement, the Achilles tendon reflex is impaired. Reflex changes are more significant for the localization of the involved nerve. (B) Symptoms 1. Low back pain is the first symptom in most patients, with an incidence of about 91%. As the outer layer of the fibrous ring and the posterior longitudinal ligament are stimulated by the nucleus pulposus, the lower lumbar sensory pain is produced by the sinus nerve, and sometimes it can be accompanied by hip pain. 2. Lower limb radiating pain Although high lumbar disc herniation (lumbar 2 to 3, lumbar 3 to 4) can cause femoral neuralgia, it is rare clinically, less than 5%. The vast majority of patients are herniated from lumbar 4 to 5 and lumbar 5 to sacral 1 gap, which manifests as sciatica. Typical sciatica is radiating pain from the lower lumbar region to the buttocks, posterior thighs, and lateral calves up to the feet, and the pain increases in response to increased abdominal pressure such as sneezing and coughing. The radiating pain is mostly on one side of the limb, and only a very few people with central or paracentral medullary herniation show symptoms in both lower limbs. There are three causes of sciatica: (1) chemical inflammation of the nerve root due to chemical stimulation and autoimmune reaction from the ruptured disc; (2) the herniated nucleus pulposus compresses or stretches the nerve root with existing inflammation, blocking its venous return and further aggravating edema, making it more sensitive to pain; and (3) ischemia of the compressed nerve root. The above three factors are interrelated and are aggravating factors for each other. 3. Cauda equina symptoms The main manifestations of cauda equina compression by protruding nucleus pulposus or prolapsed or free disc tissue are obstruction of bowel movement and urination, and abnormal perineal and perianal sensation. In severe cases, loss of control of urination and defecation and incomplete paralysis of both lower extremities may occur, which is rare in clinical practice. Treatment: Treatment 1. Non-surgical treatment Most patients with lumbar disc herniation can be relieved or cured by non-surgical treatment. The treatment principle is not to return the degenerated and herniated disc tissue to its original position, but to change the relative position of the disc tissue and the compressed nerve root or to partially retract it, so as to reduce the pressure on the nerve root, release the adhesion of the nerve root and eliminate the inflammation of the nerve root, thus relieving the symptoms. Non-surgical treatment is mainly suitable for: (1) young people, first attack or short duration of the disease; (2) people with mild symptoms that can be relieved by themselves after rest; (3) people with no obvious spinal stenosis on imaging. (1) Absolute bed rest For the first attack, bed rest should be strictly applied, emphasizing that one should not get out of bed or sit up for both bowel movement and urination, so as to have better results. After 3 weeks of bed rest, you can get up and move around under the protection of a lumbar girth, and do not bend over and hold things for 3 months. This method is simple and effective, but more difficult to adhere to. After remission, the lumbar back muscle exercise should be strengthened to reduce the chance of recurrence. (2) Traction therapy uses pelvic traction, which can increase the width of the intervertebral space, reduce the internal pressure of the intervertebral disc, the herniated part of the disc retracts, and reduce the irritation and compression of the nerve root, and needs to be carried out under the guidance of a professional doctor. (3) Physical therapy and massage can relieve muscle spasm and reduce the pressure within the disc, but note that violent massage can lead to aggravation of the disease and should be done with caution. (4) Supportive treatment can be tried with glucosamine sulfate and chondroitin sulfate. Glucosamine sulfate and chondroitin sulfate are used clinically to treat osteoarthritis in various parts of the body, and these chondroprotective agents have some degree of anti-inflammatory and anti-chondrolytic effects. Basic studies have shown that glucosamine inhibits the production of inflammatory factors by crestal myeloid cells and promotes the synthesis of glycosaminoglycans, a component of the intervertebral disc cartilage matrix. Clinical studies have found that intra-vertebral disc injections of glucosamine sulfate significantly reduce lower back pain caused by degenerative disc disease while improving crestal function. Some case reports suggest that oral administration of glucosamine sulfate and chondroitin sulfate can reverse degenerative disc changes to some extent. (5) Corticosteroids Epidural injection of corticosteroids is a long-acting anti-inflammatory agent that reduces inflammation and adhesions around the nerve roots. Generally, long-acting corticosteroid preparation + 2% lidocaine is used for epidural injection once a week, 3 times as a course of treatment, and another course of treatment can be used after 2-4 weeks. (6) Chemical lysis of the nucleus pulposus method uses collagenase or papain to inject into the intervertebral disc or between the dural crest membrane and the herniated nucleus pulposus to selectively dissolve the nucleus pulposus and the fibrous ring without damaging the nerve roots to reduce the pressure in the disc or make the herniated nucleus pulposus smaller so as to relieve the symptoms. However, this method has the risk of allergic reaction. 2.Percutaneous myelotomy/myeloplasty The nucleus pulposus will be suctioned out or laser vaporized by entering the intervertebral space under X-ray surveillance with special instruments, so as to reduce the pressure in the intervertebral disc and achieve symptomatic relief. 3.Surgical treatment (1)Indications for surgery (1)① history of more than three months, strict conservative treatment is ineffective or conservative treatment is effective, but frequent recurrence and heavy pain; (2)first attack, but the pain is severe, especially in the lower extremities, the patient has difficulty moving and sleeping, in a forced position; (3)combined with the expression of cauda equina compression; (4)single nerve root paralysis, accompanied by muscle atrophy, muscle strength loss; (5)combined with spinal canal (5) combined with spinal stenosis. (2) Surgical method: Posterior lumbar back incision, partial laminectomy and synovectomy, or laminectomy through the intervertebral space. For central disc herniation, after laminectomy, epidural or intradural discectomy is performed. In cases of combined lumbar instability and lumbar spinal stenosis, simultaneous crestal fusion is required. In recent years, minimally invasive surgical techniques such as microdiscectomy, microendoscopic discectomy, and percutaneous foraminoscopic discectomy have reduced surgical damage and achieved good results. Prevention methods: Lumbar disc herniation is caused by accumulation of injuries on the basis of degeneration, and accumulation of injuries will aggravate the degeneration of the disc, so the focus of prevention is to reduce accumulation of injuries. The bed should not be too soft when sleeping. Long-term ambulatory workers need to pay attention to the height of the table, chair, and regularly change the posture. Occupational work requires frequent bending movements, should regularly stretch, chest activities, and use a wide belt. Should strengthen the lumbar back muscle training, increase the intrinsic stability of the crest, long-term use of waist circumference, especially need to pay attention to lumbar back muscle exercise, in order to prevent the adverse consequences of disuse muscle atrophy. If you need to bend over to get something, it is best to use hip flexion, knee flexion squatting way to reduce the pressure on the back of the lumbar intervertebral disc.