Lumbar disc herniation is a common disease, according to the current medical conditions and level, the diagnosis of this disease is not difficult, and there are many effective treatments, and even in the township hospitals can implement surgical treatment. However, in the tide of the market economy of reform and opening up, the diagnosis and treatment of lumbar disc herniation have many misunderstandings, and some people have raised the question, “Is it good or bad that lumbar disc herniation surgery is ‘going to the countryside’?” Some people also ask the question, “Is it good or bad that lumbar herniated disc surgery is going to the countryside? Now, some problems exist in the diagnosis and treatment of lumbar intervertebral disc herniation are discussed. 1, the understanding of clinical symptoms, signs and symptoms of patients complaining of chronic low back pain, such as doctors do not further detailed understanding of the condition, only think of lumbar disc herniation, is very easy to cause misdiagnosis or underdiagnosis. Clinical experience tells us that the key to the diagnosis of lumbar intervertebral disc herniation is the unique performance of symptoms and signs. (1) Age of onset Lumbar disc herniation occurs in young adults, especially in 30-40 years old, if more than 50 years old, or even 60 years old, unless the past often have back and leg pain, otherwise the diagnosis should be cautious, and the scope of consideration should be broader. (2) The site of pain Most patients have lumbar pain with unilateral or bilateral lower limbs to below the knee radiating pain, numbness, a few patients with L3 ~ 4 protrusion of lumbar pain with radiating pain in front of the thighs, but if only lumbar pain without leg pain or only accompanied by the buttocks or the back of the thighs, it is mostly not this syndrome; only leg pain without lumbar pain, may also be inter disc herniation. However, other lesions such as tumors, inflammation and nerve roots also have low back pain, but not disc herniation. (3) The nature of the pain In addition to a small number of ruptured discs, nucleus pulposus prolapse or free in the spinal canal and adhesions, the low back pain can be persistent, most patients are intermittent pain. Therefore, persistent pain should first be excluded from inflammation, tuberculosis or tumors. (4) Degree of pain Most patients’ pain can be tolerated or relieved by oral anti-inflammatory painkillers. For the pain time up to 1 week or more, it is difficult to relieve the diagnosis of the disease should be cautious. (5) the regularity of pain Most patients have regularity of pain, pain aggravated by activity, reduced at rest; turn over, standing aggravated, reduced lying down; afternoon heavier than the morning, daytime heavier than the evening; coughing and urination and defecation pain aggravated by the increase in intra-abdominal pressure. (6) Episodes of pain: The history of lumbar and leg pain is long, weeks, months or years, repeated episodes, sometimes severe, sometimes light, and for long time pain does not reduce or progressive aggravation of the patient should be considered for other diseases, especially lumbar spine bone tumor. (7) Lumbar shape and mobility Most of the patients show flat back or with side bending to reduce the pressure or tension of the protruding nucleus pulposus of the intervertebral discs on the nerve roots, so the lumbar spine is mostly restricted in a certain direction when they move. If the lumbar spine is limited in all directions and painful, acute lumbar sprain, lumbar spine tuberculosis, ankylosing spondylitis, tumors, etc. should be considered; such as increased lumbar lordosis in the standing position, lumbar vertebrae have a step-like depression deformity, for the isthmic fracture and slip. (8) Straight leg raising test 95% of patients have positive straight leg raising test, but acute lumbar sprain, ankylosing spondylitis, lumbosacral spine tumor, sacroiliac joint and hip joint lesion can also be positive. The strengthening test is an effective way to differentiate between true and false radicular sciatica. On the contrary, a negative straight leg raising test is not the majority of this disease; but L3 ~ 4 or more or mild central type, or extreme lateral type, or nerve root atrophy of long-term compression, or the central lumbar disc herniation with a wide spinal canal lumen can also be a negative manifestation of the disease, and attention should be paid to differentiate. (9) Muscle atrophy If the nerve root is compressed for a long time, limited muscle atrophy of the lower limbs may occur, which generally corresponds to the level of intervertebral disc herniation, such as quadriceps muscle caused by L3-4 herniation, extensor digitorum longus muscle caused by L4-5 herniation, and the huge centralized lumbar disc herniation caused by L4-5 herniation. Long muscle atrophy, huge central herniation or prolapse can cause cauda equina damage causing atrophy of the anterolateral calf muscle group or foot drop, but if there is generalized muscle atrophy, it is not necessarily disc herniation. With the introduction of CT, MRI and other imaging devices, not only does the diagnosis of lumbar intervertebral disc herniation provide direct imaging signs, but also the three-dimensional observation can be made to determine the herniated size, type and location. These advantages make some orthopedic surgeons easy to ignore or lack of understanding of their shortcomings, and enter the only imaging diagnosis and clinical disconnection of the misunderstanding. (1) X-rays Because X-rays cannot provide direct imaging signs, they are mistakenly thought to be omitted. In fact, X-rays can provide an overall understanding of the spine, observe the lumbosacral spine for bony deformities (such as lumbarization of the sacral vertebrae or sacralization of the lumbar vertebrae), inflammation, tumors and so on, to avoid omission of diagnosis and misdiagnosis. (2) Myelography The current iodine water contrast agent has very little toxic side effects, and lumbar spinal myelography is inexpensive, intuitive, and has the advantages of a wide range of observation, with an accuracy rate of more than 90%. However, negative performance can be seen in the case of wide lumen of the spinal canal and small herniation. (3) CT provides direct and detailed imaging signs for the diagnosis of intervertebral disc herniation, and its accuracy varies greatly among reports, generally about 70%. False positives and false negatives are not uncommon, and are related to the performance and quality of the machine, the scanning technique and the experience of the reader. A common misunderstanding is that there is no X-ray film, only CT examination, there is a leakage of diagnosis, misdiagnosis, especially common is to diagnose the bulging as herniation, so the treatment is ineffective is not uncommon. (4) MRI has a diagnostic accuracy of more than 90% for disc herniation, but it is difficult to popularize due to its high price. Lumbar deformity or poor machine performance diagnostic accuracy is often affected. 3, the problem of diagnosis Diagnosis of some basic concepts should be clear. (1) disc bulge is not equal to the protrusion of bulging is the disc nucleus pulposus and fibrous ring tension, elasticity began to degenerate, its morphology and structure is still normal. Imaging performance: the disc anterior or posterior, lateral side of the uniform expansion, 40 years old began to appear, the older the more obvious, there can be no clinical symptoms, also do not need any treatment, unless combined with bony stenosis of the spinal canal or ligamentum flavum hypertrophy, hyperplasia of the small joints, only to appear in spinal stenosis of the clinical manifestations. Some patients who still have lower back pain after surgery in primary hospitals, review their CT films only see disc bulging, and there is no radicular sciatica symptoms, it is not surprising that the surgical effect is poor. Therefore, do not take the disc bulge as herniation and surgical treatment. (2) Herniation is not the same as herniation The pathology of disc herniation is that part or most of the fibrous ring in a certain area is ruptured, and the nucleus pulposus is degenerated and protrudes. Imaging manifestations: the edge of the disc in a position of peak-like protrusion, generally in the posterior edge of the disc is the most common; such as the corresponding radicular sciatica symptoms, signs, in order to diagnose the disc herniation. Orthopedic surgeons should not diagnose asymptomatic, symptomatic imaging herniation as disc herniation, nor should they generalize the symptoms of low back pain subjectively associated with imaging herniation. (1) Conservative treatment is unchanged In primary hospitals, clinics or non-surgical departments without surgical conditions, patients’ fear of surgery is utilized to promote the effectiveness of a conservative treatment method in the unit, regardless of the efficacy of the patient to use it in the end. For example, long time and heavy weight pelvic traction, frequent and repeated epidural (sacral tube) hormone injection therapy, or repeated gravity massage under anesthesia, etc., resulting in delayed diagnosis and treatment or complications. Conservative treatment is suitable for people with short history, mild clinical symptoms and signs, mildly positive performance of imaging tests such as myelography or CT, and once the treatment is ineffective, it should be given up or changed to other treatment methods as soon as possible. (2) Interventional therapy “once you try it, it works” Currently, there are two types of interventional therapy: percutaneous disc aspiration and percutaneous disc aspiration nucleus pulposus dissolution (papaya curd protease or collagenase injection). The mechanism of action of the former is to cut and suction through the disc, and the latter is to degrade the nucleus pulposus through the dissolving enzyme drug, so as to achieve the purpose of lowering the internal pressure of the disc. Both have the advantages of small trauma, satisfactory efficacy (generally 70%), and short hospitalization time. Because of the simple operation of this method, many small and medium-sized hospitals can be carried out. However, cases should be strictly selected, preoperative examination and preparation should be done, and the therapeutic effect should not be over-exaggerated. In fact, it is not uncommon for interventional therapy to cause nerve or blood vessel injury, discitis, or even anaphylactic shock caused by nucleus pulposus dissolution. The indications for interventional therapy should be: early disc herniation with obvious clinical symptoms and signs, ineffective conservative treatment, and no spinal stenosis, cauda equina injury syndrome, and no disc calcification, adhesion or nucleus pulposus prolapse confirmed by CT or MRI. (3) improper selection of surgical indications Commonly: ① only imaging of the protruding signs and symptoms without corresponding signs of disc surgery; ② first-onset patients, the symptoms are not serious, without formal conservative treatment that is hastily to do the operation; ③ only clinical symptoms, imaging atypical disc surgery; ④ due to wrong diagnosis led to the selection of indications for the wrong, such as lumbosacral malignancy, metastatic carcinoma, ankylosing spondylitis or lumbar spondylolisthesis. For example, lumbosacral malignant tumor, metastatic cancer, ankylosing spondylitis, or lumbar spondylolisthesis were misdiagnosed as herniated discs, and disc surgery was performed. (4) Intervertebral disc surgery “to the countryside” In recent years, lumbar intervertebral disc surgery “to the countryside” phenomenon in the ascendant, is it good or bad? Joy is that the level of spinal surgery in recent years has really made a leap in development and improvement, “rural” surgery is not only convenient for patients, but also improve the level of medical care in grassroots hospitals, which is of course indisputable; worry is that, ignoring the selection of the indications for the expansion of the indications for surgery arbitrarily, the above phenomenon are serious; or in hospitals that do not have the conditions for lumbar intervertebral disc surgery. Or in hospitals that do not have the conditions for lumbar intervertebral disc surgery, surgery is reluctantly carried out, and as a result, surgical complications occur repeatedly, and even medical disputes are common, which is a very noteworthy problem. 5. Problems related to surgery (1) Positioning error It is not uncommon for errors to occur during surgery, such as L4-5 intervertebral disc herniation and surgery for L5-S1 or L3-4, or even L2-3. This may be due to the absence of radiographs, or even if they are taken, the lumbar spine sequence is misjudged due to 12th rib deformity (too small) or lumbar sacralization, or sacral lumbarization. Some people use preoperative positioning with photographs or injections of methylene blue, which may be accurate in most cases, but may also be wrong. Preoperative localization plus intraoperative localization is the most accurate, that is, reveal L5, S1, sacral vertebrae are shaken, L5 can be shaken, between the movement and immobility that is L5 ~ S1 gap, of course, must be excluded from the lumbosacral vertebrae of the congenital deformity. (2) the size of the skin incision Some physicians believe that the incision is easier to reveal; some believe that the incision is small, indicating that the technology is “smart”. In fact, the size of the incision should not become a sign of high and low surgical techniques. If the incision is small to meet the needs of surgery, small than large. But should not be small and small, but should be based on the actual needs. For example, obese people, intervertebral disc protrusion huge, combined with spinal stenosis or free prolapse, the incision should be larger; on the other hand, intervertebral disc protrusion on the side of the outward, but not too large, the patient is young and not obese, the incision can be smaller, especially L5 ~ S1. (3) how much of the laminar plate should be resected This is also often heard of the argument. Some doctors believe that total laminectomy is clean and clear. Some doctors believe that laminectomy is rarely or even not necessary to cut the laminae, resulting in less damage, better spinal stability, and easier recurrence. How much laminectomy should depend on the specific circumstances, if the disc protrusion, adhesions or combined with spinal stenosis, the laminectomy should be cut more, and vice versa, less can be less. (4) Length of operation time No matter what kind of operation, the shorter the operation can be completed within a short period of time, the better, but it should not be short for the sake of short. Surgery is complex, the operation time should be long; surgery is simple, less difficult, the time should be short. It should be noted that: do not think that the intervertebral disc is a “small surgery” to seek fast, but should seek good. (5) How much of the intervertebral disc is appropriate to remove This is not an easy question to answer. Theoretically, it is impossible to perform a “complete” resection. We believe that there are the following cases: ① young people with a lot of water in the nucleus pulposus, see the nucleus pulposus, nucleus pulposus is difficult to remove cleanly, should be patient and repeated scraping, clamping; ② middle-aged people nucleus pulposus mature into a block, the block should be taken out of the nucleus pulposus, and then scrape the intervertebral space; ③ old patients with degeneration of the nucleus pulposus with osteophytes, the spinal space is narrow, only to the protruding nucleus pulposus can be removed cleanly because the intervertebral space is very little; ④ out or free nucleus pulposus, will be in the intervertebral space, the intervertebral space is very small; ⑤ the nucleus pulposus, will be in the intervertebral space of the intervertebral disk. If the nucleus pulposus is detached or free, the part of the nucleus pulposus in the spinal canal should be removed, and then the residual annulus fibrosus and nucleus pulposus should be resected at the exit. In short, to remove the nucleus pulposus, we should be patient and repeatedly sweep, and should not think that clamping out a large piece of nucleus pulposus tissue is the completion of the task, and no longer continue to try to find and scratch. (6) the use of ring drill, sharp knife and instrument into the depth of the problem Some people like to use the ring drill, clean, fast. Some people also advocate the use of a sharp knife, safety and insurance, exposure is small. If the scope of exposure is large, the ring drill can be used; sharp knife in the exposure of small safety, not easy to accidentally injure the nerve tissue. As for drilling, cutting, pliers into the intervertebral space how deep, must be calm, accurate estimation, but generally no more than 1.5cm is safe, otherwise accidental injury to the abdominal blood vessels is not alarmist. (7) Intervertebral disc fusion or reconstruction For intervertebral disc herniation accompanied by lumbar pseudo or real slip instability, some people advocate autologous or allogeneic bone, BAK, TFC and other intervertebral disc implantation and fusion, which is beneficial; some people also advocate artificial disc implantation, which is not yet mature and controversial. (8) Postoperative drainage: The benefits are more than the drawbacks, and there is nothing wrong with no drainage, but it is better not to drain if there is dural rupture. (9) Post-operative rehabilitation After surgery, the low back muscles can be actively practiced, and the patient can go down to the ground within 1 to 2 weeks. Three months after the operation can participate in the work, within six months exempt from bending to carry heavy objects. However, the specific rehabilitation should be based on the patient’s age and the specific circumstances of the operation.