Clinical manifestations (1) Lumbar pain Most patients have a history of lumbar pain for several weeks or months, or a history of recurrent lumbar pain episodes. The degree of lumbar pain varies, and in severe cases, it may affect the ability to turn over and sit up. Generally after resting the symptoms are reduced, coughing, sneezing or bowel movements, can make the pain worse. (2) Lower extremity radiating pain on one side of the lower extremity sciatic nerve area radiating pain is the main symptom of this disease, often in the disappearance of low back pain or reduce the appearance. The pain starts from the buttocks and gradually radiates to the back of the thigh, the outside of the calf, and in some cases to the outside of the dorsum of the foot, the heel or the ball of the foot, affecting standing and walking. If the protrusion is in the center, it is in the cauda equina symptoms, bilateral protrusion, the radiation may be bilateral or alternating. (3) Lumbar mobility disorders Lumbar mobility is affected in all aspects, especially in posterior extension disorders. In a few patients, forward flexion is obviously limited. (4) Scoliosis Most patients have varying degrees of lumbar scoliosis. The direction of scoliosis can indicate the location of the protrusion and the relationship of the nerve root. (5) Observational numbness: those with a long course of the disease often have subjective numbness. It is mostly limited to the posterior-lateral calf, dorsum of the foot, heel or sole. (6) The temperature of the affected limbs decreased, many patients feel cold in the affected limbs, objective examination, the temperature of the affected limbs is lower than that of the healthy side; some dorsal arterial pulsation is also weaker, which is due to the sympathetic nerve stimulation. This is due to sympathetic nerve stimulation. It must be differentiated from embolic arteritis. Symptoms and diagnosis (a) Low back pain and radiating pain to one side of the lower limb are the main symptoms of the disease. Lumbago often occurs before leg pain, or both can occur at the same time; most of them have a history of trauma, or there may be no clear cause. The pain has the following characteristics: 1, radiating pain along the sciatic nerve conduction, directly to the lateral calf, the dorsum of the foot or the toes. In the case of lumbar 3-4 interspace herniation, radiating pain to the anterior thigh is produced due to compression of the lumbar 4 nerve root. 2.All actions that increase the pressure of cerebrospinal fluid, such as coughing, sneezing and defecation, can aggravate low back pain and radiating pain. 3.Pain is aggravated during activities and relieved after rest. Bed position: most patients adopt the lateral position and flex the affected limbs; individual severe cases in various positions are painful, and can only flex the hip and knee kneeling on the bed to relieve the symptoms. In combination with lumbar spinal stenosis, intermittent claudication is common. (ii) Scoliotic deformity The main curvature is in the lower lumbar region, which is more obvious when the spine is bent forward. The direction of scoliosis 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 bends to the affected side. Left: If the nucleus pulposus is located anteriorly within the nerve root, the spine bends toward the affected side, and the pain is increased if the bend is toward the healthy side. Right: the nucleus pulposus protrudes in front of the nerve root, the spine bends toward the healthy side, and the pain increases if the spine bends toward the affected side. (C) Restriction of spinal movement The herniated nucleus pulposus compresses the nerve root, causing protective tension in the lumbar muscles, 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. (D) Lumbar pressure pain with radiating pain There is a limited pressure point next to the spinous process on the affected side of the herniated disc, accompanied by radiating pain to the calf or foot, which is important for diagnosis. (e) Positive straight leg raising test There is no standardized degree of positivity in this test due to the difference in physical fitness of individuals, and attention should be paid to the comparison between the two sides. It is positive if the affected side is limited in raising the leg and feels radiating pain to the calf or foot. Sometimes, when the healthy limb is raised, the affected leg becomes numb and painful, which is caused by the pulling of the nerves on the affected side, which is of great value to the diagnosis. (F) Neurological examination: In case of lumbar 3-4 herniation (lumbar 4 nerve root compression), there may be decreased or lost knee reflexes and decreased sensation in the inner calf. Lumbar 4-5 herniation (lumbar 5 nerve root compression), the anterolateral dorsal sensation of the calf is reduced, and the extension and the second toe muscle strength is often reduced. In case of lumbar 5-sacral 1 herniation (sacral 1 nerve root compression), there is hypesthesia in the posterior aspect of the calf and lateral aspect of the foot, hypesthesia in the muscles of the 3rd, 4th and 5th toes, and hyporeflexia or disappearance of the Achilles tendon reflex. If the nerve compression symptoms are severe, there may be muscle atrophy in the affected limb. If the herniation is large, or is central herniation, or if the fibrous ring ruptures and the nucleus pulposus fragments protrude into the spinal canal, there may be more extensive nerve root or cauda equina damage, and the numbness area on the affected side is usually more extensive, which may include the buttocks, the lateral femur, the calf, and the foot below the plane of the nucleus pulposus herniation. Central type herniation often have nerve damage symptoms in both lower limbs, but one side is more serious; attention should be paid to check the saddle area sensation, there is often one side of the decrease, sometimes both sides of the decrease, there is often a loss of control of urination, wet pants, bedwetting, constipation, sexual dysfunction, and even partial or partial paralysis of the two lower limbs. Auxiliary examination: Frontal and lateral radiographs of lumbosacral vertebrae should be taken, and left and right oblique radiographs should be taken if necessary. 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 and so on. 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 are not completely excluded from lumbar disc herniation. Most patients with lumbar disc herniation can be correctly diagnosed based on clinical symptoms or signs. The main symptoms and signs are: ① lumbar pain combined with “sciatica”, radiating to the calf or foot, positive straight leg raising test; ② in the lumbar 4-5 or lumbar 5 sacral 1 interspinous ligament side of the obvious pressure points, and at the same time to the calf or foot radiating pain; ③ calf anterior or posterior lateral skin sensory loss, toe muscle strength, the affected side of the Achilles tendon reflex decreased or disappeared. X-ray can exclude other bony lesions. Diagnostic points: Herniated lumbar disc is common in young adults, especially in manual laborers or long-time sitting and standing workers, and there is no significant difference in the incidence rate between men and women. When the following symptoms occur, lumbar disc herniation can be suspected, and it is not difficult to make a diagnosis with imaging examination. 1.There is lumbar pain above the waist after trauma or unilateral lower limb pain. 2.The lumbar pain is mostly located in the lower lumbar region on one side, and the leg pain is mostly radiating from the buttock to the distal end on one side, which may be accompanied by numbness. 3.Unilateral saddle area (riding a bicycle and the part of the seat contact) or one side (bilateral) lateral calf, dorsum of the foot lateral or medial pain or numbness, or pain and numbness at the same time. 4. Pain in the waist or leg, which can be relieved after bed rest, and then appears again after getting out of bed for a period of time.