【Overview】 Lumbar disc herniation, also known as lumbar annulus fibrosus rupture, is one of the common diseases in middle-aged and old-aged people, is caused by degenerative changes in lumbar vertebrae or external force lumbar intervertebral discs, internal and external pressure imbalance caused by the lumbar intervertebral discs, lumbar intervertebral annulus fibrosus rupture, nucleus pulposus protrudes, which compression of lumbar vertebral nerve roots, blood vessels, spinal cord or cauda equina due to a series of clinical symptoms. In 1934, Mixter and Barr reported that surgery to remove the prolapsed lumbar intervertebral disc was successful and achieved good results. Since then, scholars at home and abroad have carried out lumbar disc removal surgery and conducted in-depth research on lumbar disc herniation. [Etiology] After puberty, various tissues of the human body appear degenerative changes, in which the changes in the intervertebral discs occur earlier, the main change is the dehydration of the nucleus pulposus, the dehydration of the intervertebral disc loses its normal elasticity and tension, and on this basis, due to the heavier trauma or repeated repeated inconspicuous injuries, resulting in the fibrous annulus is weak or ruptured, and the nucleus pulposus is protruded from the place. The nucleus pulposus mostly protrudes into the spinal canal from one side (a few can be on both sides at the same time), compressing the nerve root and producing signs of nerve root injury; it can also protrude backward from the center, compressing the cauda equina and causing urinary and defecation disorders. If the annulus fibrosus is completely ruptured, the broken nucleus pulposus tissue enters the spinal canal, which can cause extensive cauda equina damage. Due to the heavy burden on the lower lumbar region and the many activities, the herniation occurs mostly in the lumbar 4-5 and lumbar 5-sacral 1 interspace. Clinical manifestations] (a) lumbar pain and one side of the lower extremity radiating pain is the main symptom of the disease. Lumbago often occurs before leg pain, or both at the same time; most have a history of trauma, but also no clear cause. The pain has the following characteristics: 1, radiating pain along the sciatic nerve conduction, directly to the lateral calf, dorsum of the foot or toes. 2.All actions that increase cerebrospinal fluid pressure, such as coughing, sneezing and defecation, can aggravate low back pain and radiating pain. 3.Pain increases with activity and decreases with rest. Bed position: most patients adopt the lateral position, and flexion of the affected limbs; individual severe cases in a variety of positions are painful, can only flexion of the hip and knee kneeling on the bed to alleviate the symptoms. Combined with lumbar spinal stenosis, there is often intermittent claudication. (ii) Scoliosis: the main curvature is in the lower back, which is more obvious when bending forward. The direction of lateral curvature depends on the relationship between the protruding nucleus pulposus and the nerve root: if the protrusion is located in front of the nerve root, the trunk usually curves to the affected side. (C) Restricted spinal activity The protruding nucleus pulposus compresses the nerve root, making the lumbar muscles tense in a protective manner, which may occur unilaterally or bilaterally. Due to the tension of lumbar muscles, the physiologic lordosis of lumbar spine disappears. Spinal forward flexion and backward extension activities are restricted, and radiating pain to one side of the lower limb may occur during forward flexion or backward extension. Lateral bending restriction is often only on one side, according to which can be identified with lumbar spine tuberculosis or tumor. Auxiliary examination] The lumbosacral spine should be photographed in front and side view, and if necessary, the left and right oblique view should be added. There is often scoliosis, sometimes see the narrowing of the intervertebral space, the edge of the vertebral body lip hyperplasia. x-ray signs can not be used as a basis for the diagnosis of lumbar intervertebral disc herniation, but it can be used to exclude a number of disorders, such as lumbar spine tuberculosis, osteoarthritis, bone fracture, tumors, and vertebral spine slippage, etc.. In severe cases or atypical cases, when there are difficulties in diagnosis, special tests such as iodine oil imaging of the spinal cord, CT scanning and magnetic resonance imaging can be considered to clarify the diagnosis and the location of the herniation. Patients with no obvious abnormality in the above examinations cannot completely exclude lumbar disc herniation. Differential diagnosis] (1) Lumbar posterior joint disorder The upper and lower articular processes of adjacent vertebrae constitute the lumbar posterior joint, which is a synovial joint with nerve distribution. When the relationship between the upper and lower articular processes of the posterior joints is abnormal, pain can be produced by synovial inlay in the acute stage, and traumatic arthritis of the posterior joints can be produced in chronic cases, resulting in low back pain. This pain mostly occurs at 1.5 centimeters adjacent to the spinous process, and may have radiating pain to the ipsilateral buttock or posterior thigh, which is easily confused with lumbar disc herniation. The radiating pain of this disease usually does not exceed the knee joint and is not accompanied by signs of nerve root damage such as decreased sensation, muscle strength and loss of reflexes. In cases where identification is difficult, 5 ml of 2% procaine can be injected near the small articular eminence of the lesion, and if the symptoms disappear, lumbar disc herniation can be excluded. (Intermittent claudication is the most prominent symptom of lumbar spinal stenosis. Patients complain that after walking for a certain distance, their lower limbs become sore, numb and weak, and they have to squat down to rest before they can continue walking. Bicycling may be asymptomatic. Patients with many complaints and few physical signs are also important features. A few patients have manifestations of radicular nerve injury. Severe central stenosis can be incontinence, and the diagnosis can be further confirmed by special examinations such as spinal cord iodine oil imaging and CT scan. (C) Lumbar spine tuberculosis Early limited lumbar spine tuberculosis can irritate the neighboring nerve roots, resulting in lumbago and radiating pain in the lower limbs. Lumbar spine tuberculosis has the systemic reaction of tuberculosis, the lumbar pain is more severe, and the destruction of vertebral body or vertebral arch root can be seen on X-ray film.CT scan has a unique role in the early confined tuberculosis foci of vertebral body which cannot be shown on X-ray film. (iv)Vertebral metastasis Pain is aggravated, worsened at night, the patient’s physique is debilitated, and the primary tumor can be detected.The vertebral body can be seen as osteolytic destruction on X-ray flat film. (E) chordoma and cauda equina neuroma: chronic progressive disease, without intermittent improvement or self-healing phenomenon, often with urinary and fecal incontinence. The diagnosis can be clarified by myelography, CT examination or magnetic resonance examination. Most patients can be relieved by non-surgical treatment. Only a few patients need surgery. Whether non-surgical treatment can make the herniated disc retract and the ruptured annulus fibrosus heal, there is not enough evidence to make a conclusion. However, at least it can make the aseptic inflammation of the nerve root subside, the adhesion loosen, and the compression partially or completely release, thus relieving or completely disappearing the symptoms. However, in some severe cases, due to the large protruding nucleus pulposus and severe nerve compression, early surgery is needed to relieve the nerve compression, otherwise the nerve will be irreversibly altered. (I) Non-surgical treatment Non-surgical treatments are: (1) First of all, it is necessary to be completely and absolutely bedridden, and do not get out of bed in the early acute stage, including urination and defecation, so as to relieve the pressure of body weight, muscle strength and external loads on the intervertebral discs, and it is the basic treatment of herniated discs. Need to lie on a hard board bed, can be accompanied by lumbar traction, heat, physical therapy, acupuncture, massage and other treatments. Acute patients generally in bed after 3 weeks can be significantly improved. At this time that should be ashamed to start the lumbar and dorsal muscles exercise, and can get up under the protection of the waist circumference activities. After getting up, continue to strengthen the lumbar back muscle exercise, cancel the waist circumference by shame. Can not be long-term use of the waist without strengthening the back muscle exercise, otherwise it will make the waist and back muscle atrophy, and later will be more unable to get out of the waist circumference. (2) Pelvic traction: traction can further reduce the pressure in the intervertebral disc, and the therapeutic effect is better, especially for early patients. (3) Tui na massage: the technique should be gentle and should not be used with violence. (4) Drugs: the use of dehydrating drugs, hormonal drugs is mainly to make the compressed nerve root edema subside and reduce the inflammatory reaction. Some symptomatic analgesic drugs can also be used. (B) surgical treatment indications for surgery: ① lumbar disc herniation history of more than six months, after strict conservative treatment is ineffective, or conservative treatment is effective, but often recurring and heavier pain; ② the first episode of lumbar disc herniation pain is severe, especially in the lower limbs, the patient because of the pain is difficult to act and sleep, forced to be in the hip and knee lateral position, or even kneeling position; ③ the emergence of a single nerve paralysis or the cauda equina nerve compression paralysis; ③ the emergence of a single nerve or the cauda equina nerve compression paralysis; ④ the emergence of a single nerve or the cauda equina nerve compression paralysis (iii) single nerve palsy or cauda equina palsy; (iv) middle-aged patients with a long history of the disease, which affects their work and life; although the medical history is not typical, but through the myelography or epidural and vertebral vein angiography, it shows obvious filling defect and signs of compression, or through the intervertebral disc angiography, it shows total disc degeneration and huge protrusion; intervertebral disc protrusion and lumbar stenosis caused by other reasons. 1.Conventional lumbar intervertebral disc removal This surgical method is a recognized, widely used and reliable surgical method, which is still widely used. Through the surgery, the protruding nucleus pulposus tissue is directly removed, and the nerve root canal is enlarged to relieve the compression, so as to achieve the therapeutic purpose. The procedure involves incision of the skin, stripping of the sacrospinous muscle, retraction for full exposure, and occlusion of the ligamentum flavum and the vertebral plate. According to the number of laminae to be removed, it is divided into: 1. Total laminectomy with nucleus pulposus removal, removing both laminae and spinous processes, with sufficient exposure and complete decompression. 2. Semi-laminectomy with removal of the nucleus pulposus, removing one side of the plate and preserving the opposite side of the plate and spinous process. 3.”Open window” type nucleus pulposus removal. The difference between limited lumbar disc removal and conventional surgery is that only the free and herniated portion of the disc is removed during the surgery, but not the nucleus pulposus in the central and lateral areas of the intervertebral space. However, limited lumbar disc removal surgery has been the subject of considerable debate. It is debatable whether the herniated nucleus pulposus tissue will re-herniate along the original nucleus pulposus herniation site and what the long-term results will be.