Lumbar disc herniation is one of the more common lumbar disorders in clinical practice and is the most common cause of back pain and leg pain and numbness. Are you also suffering from it? Do you want to know what are the treatment options for lumbar disc herniation? The human intervertebral disc begins to degenerate and age after adulthood, and with the addition of occupational strain or spinal instability, the degeneration and aging will occur even faster. The degenerated discs are less resistant to injury, which can cause pain and numbness in the back and legs due to rupture of the disc annulus fibrosus, herniation of the nucleus pulposus and compression of the adjacent nerves. Conservative therapy such as analgesic drugs, traction, physiotherapy, massage, and rehabilitation should be preferred at the first onset. If conservative treatment is ineffective for 3 months or if the herniation is large, it is necessary to solve the problem through surgery. There are many surgical methods, just like the “18 martial arts”, each with its own indications, which are roughly divided into two categories: traditional and minimally invasive: I. What are the traditional surgical treatments? 1.Total laminectomy In 1934, Dr. Mixter and Dr. Barr in the United States first confirmed and cured sciatica caused by lumbar disc herniation through surgery, and this medical contribution created the so-called disc surgery era. This medical contribution ushered in the era of so-called disc surgery, which was followed by disc surgery in various countries. Early lumbar disc surgery used a total laminectomy approach to remove the nucleus pulposus. As shown in the figure below, total laminectomy causes the most damage to normal tissues and is most likely to cause complications such as lumbar instability and recurrent back and leg pain. Currently, this procedure is no longer used for simple lumbar disc herniation, but only in cases with extensive spinal stenosis and spinal instability, but requires internal fixation and fusion to ensure the stability of the spine. In 1939, Love improved this method by replacing it with a hemi-laminectomy approach. The damage to normal tissue is reduced, but there is still a high incidence of lumbar instability. At present, this procedure is no longer used for simple lumbar disc herniation, except in cases of unilateral spinal stenosis, which also requires additional internal fixation and fusion. 3, interlaminar openings, small incision interlaminar openings for disc nucleus pulposus removal became popular in the middle and later part of the last century and is still used even today. It is characterized by biting off a little of the upper and lower lamina, removing the ligamentum flavum, and removing the herniated disc. This method further reduces the damage to normal tissues, has little effect on spinal stability, and facilitates postoperative functional recovery, but its incision is not substantially improved compared with the previous two, still about 5 cm, and still requires stripping the paravertebral muscles and biting off part of the articular eminence. The ten-year recurrence rate is reported by various families between 3% and 15%. All of the above are traditional posterior surgeries, which are less commonly used for simple lumbar disc herniation due to the effect on spinal stability; except when the lesion is extensive, accompanied by spinal stenosis, isthmic fissure and other factors, which are used for complete decompression, but often require fixation with titanium nail rods. Minimally invasive techniques are increasingly being used for simple lumbar disc herniation. II. What are the minimally invasive techniques? This is a type of method in which a sleeve needle is punctured into the intervertebral disc under the guidance of C-arm X-ray machine or CT, and then physical or chemical principles are used to reduce the volume of the nucleus pulposus. These include nucleus pulposus aspiration techniques, collagenase, papain, ozone (super) oxygen, laser, plasma, and radiofrequency ablation techniques. 1) aspiration technique 2) plasma, 3) radiofrequency, 4) hyperoxia ablation 5) collagenase ablation The above techniques have little damage and basically no bleeding, and are suitable for inclusive disc herniation. However, because it acts on the disc, it is not effective for the case of large herniation, prolapse and accompanied by calcification. 2, microsurgery method Using a head-mounted or tabletop microscope and a microdrawing hook, the skin incision is shortened to 3 cm, with less soft tissue damage, good spinal stability and fast recovery, but the lumbar nerve root diameter is 5-8 mm, which is completely discernible to the naked eye, and the microscope appears superfluous, so it is only applied when the dura needs to be cut. 3, expandable canal system Actually, it is an advanced pull hook system with its own light source, which is not a substantial improvement over the small incision opening. It can be operated under direct vision, with an incision of about 3-5 cm, and can complete posterior decompression and internal fixation. It can also be used for internal fixation of the lumbar spine in the lateral and lateral-anterior approaches. 4.Posterior discoscopic MED (Micro Endoscopic Discectomy) This technique changes the direct view of posterior surgery to screen display, shortens the incision to 1.8cm, further reduces the damage to normal tissues, and decompresses adequately. The approach is the same as that of conventional open surgery, but the change from direct view to indirect view on the screen requires a learning and adaptation process and a long learning curve for the surgeon. Currently there is a trend of being replaced by intervertebral foraminoscopy. 5, intervertebral foramoscopy Professor Anthony Yeung, Phoenix, USA, began to combine visualization technology with percutaneous puncture technology at the end of last century, and commissioned Wolf of Germany to develop the first generation of intervertebral foramoscopy, known as YESS (Yeung’s Endoscopic Spine Surgery) technology. Because it concentrated the advantages of minimally invasive, high efficiency and safety, the technology quickly spread all over the world. Professor Hoogland from Germany added the TESYS (Transforaminal Endoscopic Spine Surgery System) technique. The accompanying instruments have also developed rapidly, and the indications have expanded from simple lumbar disc herniation to spinal stenosis, cervical disc herniation and spinal instability, and now spinal fusion surgery can be done under the scope. The contemporary foraminoscopic approach is no longer limited to the intervertebral foramen, and both anterior and posterior approaches can reach the lesion, so it is also called a full-function spine scope. A typical foraminoscope is a tube equipped with a pinhole camera and a light source that enters the foramen from the lateral or posterior muscular space of the patient’s body and provides a clear view (60x magnification) of the herniated nucleus pulposus, nerve roots, dural sac and hyperplastic bone tissue through a screen. The herniated tissue is then removed using various types of grasping forceps, the bone is removed microscopically, and the radiofrequency electrodes are used to stop the bleeding and repair the broken fibrous ring. The surgical trauma is small: the skin incision is only 7mm, bleeding is less than 20ml, and only one stitch or no stitch is required after surgery. It is the minimally invasive treatment for disc herniation with the least trauma and the best effect among similar surgeries. The disadvantage is that it is difficult to operate, and the doctor needs to master the technique based on proficiency in open surgery, systematic training and long-term research to truly master the technique. Third, how to choose Which type of surgery to choose should be based on the type of lesion and develop a personalized plan. Minimally invasive should be preferred for simple lumbar disc herniation. Of course, the doctor’s mastery of various methods should also be considered for comprehensive judgment. In some elderly people who plan to use open surgery but cannot tolerate major surgery due to accompanying heart and lung diseases, foraminoscopy can achieve better results with less risk and is a good choice.