What is an intervertebral disc and what does it do? The intervertebral disc is located between two neighboring vertebrae and is the main connection and support structure between the vertebrae. It is also the main structure that absorbs shock when the spine moves, and acts as an “elastic cushion” that protects and controls the spine’s activities while bearing the body’s gravitational force, balancing and cushioning the external forces. The intervertebral disc consists of two parts: the nucleus pulposus (Nucleus pulposus) and the annulus fibrosus (annulus fibrosus). Yang Cao, Orthopedic Department, Wuhan Union Hospital What is lumbar disc herniation? Lumbar disc herniation is a common disease in orthopedics, it is mainly due to degenerative changes in adult intervertebral discs (aging) to lose the original elasticity, can not bear the original pressure. In overstrain, sudden change of body position, violent movement or violent impact, the disc protrudes outward, stimulating or compressing the spinal nerve and spinal cord, causing a series of symptoms. Lumbar disc herniation will lead to lumbar distension, sciatic nerve radiating pain, lower limb numbness and distension, loss of sensation or pain allergy, muscle atrophy, thinning of the affected leg, difficulty in walking and so on. In serious cases, it will produce dysfunction of urinary and defecation, paralysis of the lower limbs, long-term bed-ridden leading to a decline in the quality of life, loss of work and labor capacity. Why do people get lumbar disc herniation? The underlying factor of lumbar disc herniation is degenerative disc changes associated with the following factors. (i) Structural factors of the spine Spinal deformity, straightening of the physiological curvature of the spine (ii) Physiological factors Age: The incidence of lumbar disc herniation is highest in the middle-aged 30-50 years of age Sex: Lumbar disc herniation occurs more often in males than in females (iii) Hereditary factors The relative risk of lumbar disc herniation occurring before the age of 21 is about five times higher than that of the general population in people with a positive family history. (d) Occupational factors The following occupations have a high incidence of herniated discs: long-term office workers, drivers, long-term stooping laborers, long-term weight-bearing workers, long-term standing workers (e) Traumatic factors Herniated discs in children and adolescents are often associated with acute traumatic injuries, such as lumbar sprains, spinal fractures, and compression of the vertebral bodies, etc. The incidence of herniated discs in children and adolescents is also higher than in women. (vi) Smoking factors Nicotine in cigarettes will cause blood vessels to constrict, reducing the blood supply to the lumbar intervertebral discs and making them susceptible to degenerative changes. (vii) Diseases Some diseases, such as diabetes mellitus, may lead to aggravation of arteriosclerosis, which may affect the lumbar intervertebral discs and lead to degeneration of the intervertebral discs. (viii) Pregnancy The increased load on the lower back during pregnancy can easily trigger lumbar disc herniation. Am I susceptible to lumbar disc herniation? The following is a list of people who are susceptible to lumbar disc herniation, so you can check for yourself. ● Age: Lumbar disc herniation occurs in young adults ● Gender: Lumbar disc herniation occurs more often in men, and the incidence rate of men is higher than that of women, and it is generally believed that the ratio of men to women is 4 to 12:1 ● Physical appearance: Generally, people who are too obese or too thin are susceptible to lumbar disc herniation ● Occupation: Industrial workers who work more intensively, white-collar workers who work long hours in offices, and workers who often stand up, such as salespersons, are prone to lumbar disc herniation. Occupationally: industrial workers with high labor intensity, white-collar workers who sit in the office for a long period of time and work at the desk, and workers who stand a lot, such as salespersons, textile workers, teachers, and surgeons. ● From the living and working environment: often in the cold or wet environment, all to a certain extent, become the conditions to induce lumbar disc herniation. ● From different periods of time of women: prenatal, postpartum and menopause are the risk periods for lumbar disc herniation in women. ● Congenital lumbar spine dysplasia or deformity, smokers and even people who are too nervous are prone to lumbar disc herniation. The symptoms are: ● Lumbar pain, lower lumbar region and the bottom of the lumbar region with persistent dull pain is common, when lying down to reduce, after standing for a long time to aggravate. ● Radioactive tingling along the buttocks, thighs and backs of the calves to the heels or backs of the feet. ● Decreased muscle strength or paralysis of the lower limbs, foot drop. ● Intermittent claudication: This refers to unilateral or bilateral lower back pain, numbness and weakness of the lower limbs, or even claudication after walking or walking for a certain distance (usually a few hundred meters). However, the symptoms can be relieved or disappear after squatting or sitting down and resting for a few moments, and then reappear after walking for a certain period of time. ● Cauda equina symptoms, common perineal numbness, tingling, weakness in defecation and urination, urinary incontinence in women and impotence in men. ● Numbness of the lower limbs with radiating pain in the lower limbs, feeling cold and clammy. What practices are beneficial to the health of the lumbar spine? Three kinds of exercises that are good for the lumbar spine: ● Stretching: It is best to get up in the morning and move the lumbar region, do back and forth stretching, left and right rotation, “stretching” and other actions, so that the lumbar region does not change from a static state immediately to increase the lumbar loading of the action ● Swallowing: Lie on your stomach on the bed, go to the pillow, hands behind the back, and force your chest to lift up your head and chest out of the bed, and at the same time Straighten the knee joints, the two thighs force backward also leave the bed, for 3 to 5 seconds, and then muscle relaxation and rest, 3 to 5 seconds for a cycle, this method is commonly known as “Yan Fei”. This action can well exercise the muscles of the lower back. ● Swimming: Swimming, especially breaststroke can exercise the muscle groups of the lower body, so that it can effectively share the burden of the lower back, to prevent and alleviate the formation of low back pain Precautions in daily life: ● Coughing, sneezing, it is best to take a straight back, straighten the chest, the hands on the waist posture. ● When lifting heavy objects, pay attention to the amount of strength, if you think it can be moved, do not exert too much force, first move the waist and limbs, transportation of good qi, and then slowly lift the heavy objects, gently put them down after moving into place. ● Seats should be of the right height and size, do not sit on small benches or low sofas, and the height of the seat should be greater than 90 degrees between the thighs and the upper body. The correct sitting posture should be straight back, chest and back, and it is best to put a soft cushion under the backrest to help maintain the physiological curvature of the lumbar spine. ● Watching TV or doing other things, don’t stay in one position for too long, stand up and move around every hour or so to relax the tense lumbar muscles, which can effectively prevent lumbar pain ● Pay attention to rest, combine work and rest to prevent excessive fatigue; prevent the lumbar region from being stimulated by trauma and cold and other undesirable factors. What are the non-surgical treatments for lumbar disc herniation? ● Bed rest: Bed rest is a very simple but effective measure that can be used by patients with lumbar disc herniation, and bed rest is the basis of all non-surgical treatments. Lumbar support and support belt: The main purpose of lumbar support and support belt for patients with lumbar disc herniation is braking, which can make the damaged lumbar disc get sufficient local rest and create good conditions for the patient’s body to recover. ● Tuina massage: Tuina massage is one of the common therapies for patients with lumbar intervertebral disc herniation ● Closure therapy: it includes pain point closure therapy, epidural cavity closure therapy, intervertebral foraminal nerve root closure therapy and other methods. ● Medication: (1) Lumbar intervertebral disc nucleus pulposus herniation causes local inflammatory reaction, releasing inflammatory factors to stimulate the nerves is one of the main causes of lumbar and leg pain. Anti-inflammatory and analgesic drugs can be taken orally to relieve the local inflammatory reaction and relieve pain. Chinese medicine that activates blood circulation and removes blood stasis can increase local microcirculation, which is also helpful to reduce the local inflammatory reaction and relieve pain symptoms. (2) In the acute stage of lumbar disc herniation, edema at the spinal nerve root is more obvious, which is not only one of the main causes of severe pain, but also can cause secondary arachnoid adhesion. In order to eliminate the local reactive edema, intravenous steroids, oral diuretics such as dihydroclonidine, and dehydration such as mannitol can be administered by intravenous pressure drip. (3) If the herniated nucleus pulposus of lumbar intervertebral disc compresses or irritates the nerve root, nutritive nerve drugs can be applied to improve the neurological symptoms. Surgical treatments and indications for surgery for lumbar disc herniation When do I need surgical treatment? When non-surgical treatments are ineffective, when the patient’s quality of life decreases and when the pain is intolerable and conservative treatments are ineffective, the patient should give up and consider surgical treatments as soon as possible, as blind and prolonged conservative treatments tend to delay the diagnosis and treatment or lead to complications. Surgery must be considered in the following cases: ● Ineffective non-surgical treatment or recurrence of severe symptoms, affecting work and life ● Significant and widespread symptoms of neurological damage, or even continue to deteriorate, with suspected complete rupture of the annulus fibrosus of the intervertebral disc and protrusion of the nucleus pulposus into the spinal canal ● Centralized lumbar disc protrusion with dysfunction of urinary and faecal function ● Combined with obvious lumbar stenosis lumbar lumbar disc protrusion what are the surgical therapies? Depending on your condition, your doctor will choose the appropriate surgery for you. Conventional open surgery: At present, most of the surgical treatments for lumbar disc herniation still use conventional open surgery, including total laminectomy, hemilaminectomy, transabdominal disc surgery, vertebral fusion, etc. The purpose of the surgery is to directly remove the lesion. The purpose of surgery is to directly remove the nucleus pulposus of the diseased lumbar intervertebral disc and relieve nerve root compression to achieve the therapeutic purpose. ● Minimally invasive intervertebral discoscopic surgery: In order to avoid the problem of high damage of conventional open surgery and to reduce the risks and complications of surgery, lumbar disc surgery is performed with the assistance of a microscope and intervertebral discoscope. ● Minimally invasive intervertebral discoscopic surgery: Based on the traditional nucleus pulposus removal surgery, it perfectly combines the micro-injury of percutaneous puncture technology and spinal endoscopic technology to maximize the maintenance of the normal anatomical structure of the spinal column under the premise of minimally invasive operation, and it is currently the most commonly used technique for minimally invasive surgical treatment of lumbar disc herniation. What should I do before the surgery? Cooperate with the doctor to do a good job of preoperative preparation, not only is conducive to the smooth progress of the operation, but also can reduce the occurrence of postoperative complications, so that you can faster return to a healthy body, normal life. ● Sign for anesthesia and sign before surgery, these will inform you of the possible risks of anesthesia and surgery, please read them carefully. ● Eliminate nervousness and fear and keep a positive outlook. ● Train to urinate and defecate in bed to prevent postoperative urinary retention from occurring. ● Laxation the day before surgery and fasting after 10:00 pm. It should be reminded that lumbar disc herniation surgery is a common surgical procedure, so there is no need to be overly anxious about the surgery. If you have difficulty sleeping the night before surgery, ask your doctor for sleeping pills. What are the steps involved in lumbar herniated disc surgery? Here is the main focus on conventional open surgical treatment First, an anesthesiologist will give you anesthesia. Lumbar herniated disc surgery is usually performed with an epidural, and you will remain awake throughout the procedure. However, we recommend that you get a good night’s sleep and rest. Rest assured that your heart function, blood pressure, fluid status and depth of anesthesia will be closely monitored by the anesthesiologist throughout the procedure. Next, the surgeon will cut through the skin, muscles, and ligaments layer by layer until the herniated disc is revealed, and carefully remove the herniated portion. Finally, the wound is irrigated to stop the bleeding completely and then sutured layer by layer. Before closing the wound, the surgeon will place a drain in the wound to prevent infection. The entire surgery takes about 1 hour. What are the possible complications after the surgery? Possible complications include: ● Infection: Wound infection and intervertebral space infection may occur after the surgery. ● Nerve damage: There is a risk of nerve root damage during surgery, either epidural or intradural. ● Macrovascular injury: Most commonly, the large blood vessels around the spine are injured during posterior surgery. ● Adhesions and eschar: Adhesions and eschar occur between the nerve roots at the surgical site and the exposed portion of the dura after laminectomy, resulting in low back pain or radicular nerve root pain. ● Spinal instability: In some patients, leg pain disappears but low back pain persists after surgery. ● Organ damage: vascular injury may be accompanied by other organ damage. It is worth mentioning that the probability of the above complications occurring is very low with the precise operation of the lumbar disc herniation surgery by the surgeon, prior prevention (e.g., routine use of antibiotics to prevent infection), and your active cooperation. Even if they do occur, they can be minimized with timely treatment. How can I recover as quickly as possible after surgery? After surgery, you should strictly follow the doctor’s instructions and actively carry out rehabilitation exercises, so as to achieve the goal of recovering health as soon as possible and improving the quality of life. Training in the acute stage: ● Strict bed rest is required after surgery, and the bed should preferably be a hard board bed for about 4-5 weeks. ● Turning over in the early postoperative period should be assisted by other people, and it is not advisable to turn over forcefully on your own to ensure that the lumbar fascia, muscles and ligaments are healing well. ● Lower limb elevation training should be done from 24 hours after surgery, which can prevent nerve root adhesion. 2 weeks later, lumbar back muscle training should be done to promote strength recovery. ● After sufficient bed rest, you can get out of bed and do light activities appropriately. Exercises during the recovery period: ● Gradually strengthen the strength of the muscles of the low back and pay attention to correcting bad postures, and pay attention to self-protection of the low back to prevent recurrence of the disease. ● After surgery, mental laborers should gradually return to work after 2-3 months, and manual laborers can only start working after 3-4 months. Work should be light to heavy and short to long, and avoid strong bending and weight bearing. ● Review the examination once every 3-6 months. What tests can diagnose a herniated lumbar disc? Lumbar disc herniation is diagnosed by clinical symptoms, physical signs, and imaging tests. Imaging tests include X-rays, CT, MRI, and intravertebral imaging. Intravertebral imaging is less commonly used because it is invasive. Why does my doctor want me to have X-rays, CT and MRI? Different imaging methods have their own advantages and disadvantages, and cannot be replaced by each other. x-ray examination is mainly to have a general view of the lumbar spine, to know whether there is any damage to the bone quality of the lumbar spine, whether there is any deformity of the lumbar spine, such as slippage, lateral curvature, posterior convexity, etc., and whether there is any change of the spinal interval. MRI can understand the soft tissue of the spine, including disc degeneration, the degree and direction of disc herniation, the compression of the nerves in the spinal canal, and can exclude tumor lesions in the spinal canal. Can the diagnosis of lumbar herniation be confirmed after taking the radiographs only? The diagnosis of lumbar disc herniation depends on the combination of clinical symptoms, physical examination, and imaging tests. Imaging alone cannot confirm the diagnosis of lumbar disc herniation, because many normal people can also be found to have lumbar disc herniation on CT or MRI, and if there are no corresponding clinical symptoms, the diagnosis of lumbar disc herniation cannot be made. Clinically, there are often other diseases that cause back and leg pain in patients, the doctor did not ask a detailed history and physical examination, only rely on CT or MRI films easily diagnosed as lumbar disc herniation, resulting in misdiagnosis and mistreatment. For example, I have encountered femoral head necrosis, sacral tumor, lumbar muscle strain and other diseases treated as lumbar disc herniation. Can a normal imaging test rule out lumbar herniation? A normal imaging test can usually rule out lumbar disc herniation. However, at present, domestic imaging instruments are of different quality and there is a big difference in the level of imaging doctors, some instruments are very blurred, which can also miss the diagnosis of herniated lumbar intervertebral disc. What diseases are easily confused with lumbar herniation? How to identify? Clinical diseases that cause low back and leg pain are easily confused with lumbar disc herniation, and there are many diseases that cause low back and leg pain. Common clinical diseases include lumbar muscle strain, lumbar spinal stenosis, lumbar spondylolisthesis, spinal tumor, intravertebral canal tumor, spinal tuberculosis, intervertebral space infection, femoral head necrosis, pelvic tumors, and abdominal tumors. Some of these diseases can cause low back pain, some can cause leg pain, and some can be accompanied by both low back and leg pain. Lumbar muscle strain usually manifests as soreness and pain in the lumbar muscles on both sides of the waist, without leg pain, which can be relieved after rest. Typical lumbar spinal stenosis usually manifests as intermittent claudication, low back and leg pain after walking for a certain distance, relieved by squatting and resting, and able to continue walking again. The pain is not obvious or painless when lying down or sitting. Lumbar spondylolisthesis mainly manifests as lower back pain in the early stage, and manifests as lumbar spinal stenosis in the later stage after compression of nerves. Spinal tumors usually have severe and progressive lumbar pain, which cannot be relieved even with painkillers. Tumors in the spinal canal often have decreased muscle strength and difficulty in urination and defecation. Spinal tuberculosis mainly manifests as lumbar pain, and if the tuberculosis lesion protrudes into the vertebral canal and compresses the nerves, leg pain, loss of muscle strength, and difficulty in urination and defecation may occur. There may be symptoms of tuberculosis poisoning such as hot flashes in the afternoon and night sweats at night. Infection in the intervertebral space often has fever, elevated blood count, rapid blood sedimentation and so on. The pain of femoral head necrosis is mainly in the hip, and the abduction and external rotation of the hip joint is limited. Tumors in the pelvis or abdomen can also cause low back pain, or leg pain if they compress the lumbar or sacral plexus nerves. Both diseases are often accompanied by abdominal or lower abdominal pain. The above descriptions are typical symptoms of these diseases, clinically there are many patients with atypical symptoms, easy to be confused with lumbar disc herniation, even if the professional doctors are sometimes easy to miss or misdiagnosis. Therefore, patients suspected of having lumbar disc herniation should go to a regular hospital to find a specialist to avoid misdiagnosis and misdiagnosis. Do I need to treat my herniated disc even if I don’t have symptoms? A herniated lumbar disc found on imaging without symptoms does not require treatment. What are the treatment options for lumbar herniation? There are two types of treatment for lumbar disc herniation: conservative treatment and surgery. Conservative treatment includes bed rest, physical therapy, massage and medication. Surgical treatment includes various minimally invasive surgeries, such as intervertebral foramenoscopic nucleus pulposus removal, intervertebral discoscopic nucleus pulposus removal, microscopic nucleus pulposus removal, and so on. The traditional open surgery disc nucleus pulposus removal, artificial disc replacement, etc.. Various lumbar herniation therapies, are they effective? Conservative treatment of lumbar disc herniation is mainly through eliminating the local inflammatory reaction caused by the herniated disc, and then eliminating the stimulation of the nerve root by the inflammatory factor produced by the inflammatory reaction, so as to eliminate the pain and achieve the therapeutic effect. The main treatment methods are bed rest, oral anti-inflammatory and analgesic drugs and Chinese medicines or proprietary Chinese medicines that activate blood circulation and eliminate blood stasis, and various kinds of physical therapy, massage and acupuncture that can promote local blood circulation and achieve therapeutic effects. Some physical therapy devices can promote local blood circulation and have a therapeutic effect, but do not believe in some therapeutic devices advocating that the herniated disc will be reset. Herniated disc is first of all a degeneration of the disc, the whole disc organization has undergone a fundamental change, can not play its normal function, even if the surgery under direct vision is not possible to reset it, and even more unlikely to be reset through the instrument or manipulation. Is there any secret prescription for lumbar herniation? Chinese medicine is a treasure trove in China, and there are many medicines that have the ability to promote local blood circulation and eliminate local inflammatory reactions, thus achieving therapeutic effects. Some of the drugs have been explored and some may not have been explored yet. The therapeutic mechanism of these drugs is the same, while different people react differently to different drugs, thus different people feel different effects to different drugs. There is no absolute secret formula or recipe that works well for all people.