I. What is an intervertebral disc? The human spine is made up of 32 vertebrae and has a very complex structure. There are only 23 intervertebral discs in the whole body because there is no intervertebral disc between the annulus and the cardinal vertebrae, and between the sacral vertebrae and the coccygeal vertebrae. They are all located between two vertebrae. The intervertebral discs in the lumbar region are the thickest, at about 9 millimeters. Lumbar discs are present from lumbar 1 to between the sacral vertebrae. What is often referred to as a herniated disc actually refers to a herniated lumbar disc. The intervertebral disc is actually a sealed container with cartilaginous plates above and below, surrounded by the annulus fibrosus, with the nucleus pulposus in the center. The nucleus pulposus is an elastic gelatinous substance containing a mucopolysaccharide protein complex, chondroitin sulfate, and a large amount of water, which surrounds the annulus fibrosus and the cartilage plate. The annulus fibrosus is composed of collagen fiber bundles of fibrocartilage, located around the nucleus pulposus. Second, what is lumbar disc herniation? Lumbar disc herniation is one of the more common clinical lumbar disorders, is a common disease of orthopedics and traumatology, frequent diseases. Lumbar disc exists in the lumbar spine between the vertebrae, for the lumbar spine joint component, by the nucleus pulposus, cartilage plate, fibrous ring three parts. When the annulus fibrosus bulges or breaks due to trauma or degeneration, the nucleus pulposus, which is like the filling of a bun, comes out, and a herniated lumbar disc is formed. Since the spinal cord passes through the back of the intervertebral disc, when the herniated disc compresses the spinal nerve or the cauda equina nerve, causing lumbar and leg pain or incontinence, or even paralysis, it is called lumbar disc herniation. Schematic diagram of lumbar disc herniation Lumbar disc herniation CT display Lumbar disc herniation MRI display Three. In patients with lumbar disc herniation, the cause of the disease is complex: induced by occupation, the main cause of the disease It is well known that the lumbar intervertebral discs are subjected to strong compressive stress in the load and movement of the spine. After about the age of 20, the intervertebral discs begin to degenerate and constitute the basic etiology of lumbar disc herniation. In addition, lumbar intervertebral disc herniation is related to the following factors: (1) trauma: observation of clinical cases shows that trauma is an important factor of intervertebral disc herniation, such as sprains when exercising, contusion when exercising, tendon strain during physical labor, lack of concentration or mental excitement due to the sudden flash of muscular incoordination, falling, hitting, and impact injuries, etc., in the spinal column during light loading and rapid rotation, which can cause fibrous ring Horizontal rupture, and compressive stress mainly makes the cartilage end plate rupture. (2) Occupation: the relationship between occupation and lumbar disc protrusion (prolapse) is very close, such as long-term work of accountants, teachers, bank clerks, secretaries, books, paintings, piano, chess, music and other artists, automobile drivers, computer operators, graphic design and other technical personnel. Engaged in heavy physical labor and due to overloading is more likely to cause disc degeneration, because in the stooping state, if you lift 20kg of heavy objects, the pressure within the disc can increase to more than 30kPa/cm2. (3) Recreational activities: such as watching TV for a long time, surfing the Internet, playing video games, playing cards, rubbing mahjong, and so on. (4) Lumbosacral congenital anomalies: malformations of lumbosacral segment can increase the incidence, including lumbar sacralization, sacral lumbarization, hemivertebral deformities, small joint deformities and asymmetry of articular eminence. Predisposing factors In addition to the main causes mentioned above, i.e. degenerative changes in the intervertebral discs, various predisposing factors also play an important role, for example, some factors that slightly increase the abdominal pressure can cause the nucleus pulposus to protrude. For example, some factors that slightly increase the abdominal pressure can cause the nucleus pulposus to protrude. The main reason is that, on the basis of degeneration of the intervertebral disc, some factors that can induce a sudden increase in the pressure of the intervertebral space can cause the nucleus pulposus to pass through the annulus fibrosus that has been denatured and thinned to enter the front of the spinal canal or pass through the vertebral plate to invade the edge of the vertebral body. Such triggering factors are as follows: (1) Increase in abdominal pressure: clinically about 1/3 of the cases before the onset of a clear increase in abdominal pressure factors, such as violent coughing, sneezing, breath-holding, straining to defecate, or even “false honor” action, which can make the abdominal pressure rise and destroy the equilibrium between vertebral segments and the vertebral canal. (2) Lumbar posture: Whether during sleep or in daily life, work, stooping to carry heavy objects in an improper posture or when the waist is in a flexed position, such as sudden rotation, it is easy to induce herniation of the nucleus pulposus. In fact, in this position, the pressure in the intervertebral space is also higher, which is easy to promote the herniation of the nucleus pulposus to the back. (3) Sudden weight-bearing: a well-trained person, more first to do preparatory activities, or start from a small weight-bearing (such as lifting weights, picking burdens, etc.) in order to prevent lumbar sprains or herniated discs, but if the sudden increase in the lumbar load, not only may cause lumbar sprains, but also prone to herniation of the nucleus pulposus. (4) pregnancy: during pregnancy, the whole ligament system is in a state of relaxation, and the laxity of the posterior longitudinal ligament is easy to make the intervertebral disc bulge. In this regard, the authors carried out relevant research studies and found that at this time, the incidence of low back pain in pregnant women is significantly higher than that of normal people. (5) lumbar trauma has degenerated the nucleus pulposus protrusion. (6) Cold and dampness. Cold or dampness can cause small blood vessel contraction and muscle spasm, which increases the pressure on the intervertebral discs, and may also cause the degenerated intervertebral discs to stretch and crack. External factors for excessive weight bearing or rapid bending, lateral flexion, rotation to form a rupture of the annulus fibrosus, or lumbar trauma, daily life and work posture is not appropriate, can also occur lumbar intervertebral disc herniation. Fourth, what are the symptoms of lumbar disc herniation? 1, lumbar pain and one side of the lower limbs radiating pain is the main symptom of the disease: lumbar pain often occurs before the leg pain, or both at the same time; most of them have a history of exertion or trauma, but also can be 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. If the lumbar 3-4 gap protrudes, due to the compression of the lumbar 4 nerve root, resulting in radiating pain to the front of the thigh. ② All actions that increase the pressure of cerebrospinal fluid, such as coughing, sneezing and defecation, can aggravate lumbar pain and radiating pain. ③ The 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 various positions are painful, can only bend the hip and knee kneeling in bed to relieve symptoms. Combined with lumbar spinal stenosis, there is often intermittent claudication. 2.Scoliosis deformity: the main curvature in the lower lumbar region, more obvious when forward bending. 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 is generally bent to the affected side; if the nucleus pulposus is located in front of the nerve root, the spine will be bent to the affected side, and the pain will be aggravated if it is bent to the healthy side; if the nucleus pulposus is located in front of the nerve root, the spine will be bent to the healthy side, and the pain will be aggravated if it is bent to the affected side. 3, limited spinal activity: the nucleus pulposus protrudes, compressing the nerve root, making the lumbar muscle protective tension, which can occur unilaterally or bilaterally. Due to the tension of lumbar muscles, the physiologic convexity of lumbar spine disappears. The spine is limited in forward flexion and backward extension, and radiating pain to one side of the lower limb may occur when forward flexion or backward extension is performed. 4. 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. 5. Positive straight leg raising test: Due to the difference of individual’s physique, there is no standardized degree of positive test, and attention should be paid to the comparison of both 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 lifted and the affected leg becomes numb, it is caused by the pulling of the nerve on the affected side, which is of great value for diagnosis. How to treat lumbar disc herniation? Regarding the treatment of lumbar disc herniation, the treatment methods in the past were relatively single, either conservative treatment or surgery to remove the nucleus pulposus. In recent years, there are some new techniques and materials involved in the treatment, such as interventional (ozone, microwave, chemical nucleus pulposus, etc.) treatment, negative pressure spinning and suction (PLD), discoscopy (MED), intervertebral foramenoscopy, artificial intervertebral disc, artificial nucleus pulposus, intervertebral fusion, vertebral body immobilization, and so on. We believe that we should adopt stepwise selection of treatment methods according to the situation and choose treatment methods scientifically and rationally. 1.Conservative treatment: most patients with lumbar disc herniation, at the early stage of the onset of most of the first to think of conservative treatment, such as massage, traction, acupuncture, plasters, sacral therapy, etc., which are the essence of China’s traditional medicine or the combination of the more advanced technology and theory with foreign products. They have significant advantages, for example, conservative treatment can eliminate the pain of surgery, and at the same time can be less expensive to get more ideal results, and conservative treatment of the course is shorter, avoiding the situation of long-term recuperation after surgery. However, conservative treatment also has certain disadvantages, for example, conservative treatment for lumbar disc herniation can not cure the lesion at root, and there is a high recurrence rate after conservative treatment, and long-term recurrence, which is easy to cause adhesion and calcification of the lesion, and bring inconvenience to the future surgical treatment. Conservative treatment is also not suitable for more serious or recurrent patients, if the patient has lower limb muscle strength, lower limb numbness and abnormal sensation, bowel function and sexual dysfunction, and the combination of lumbar spine instability patients are not suitable for conservative treatment. Interventional therapy: Interventional therapy for herniated disc refers to the use of special instruments to puncture into the nucleus pulposus in the middle of the intervertebral disc through percutaneous puncture, and then the use of physical, chemical and mechanical methods to make the nucleus pulposus of the intervertebral disc decrease in volume, so as to achieve the purposes of reducing the internal pressure of the diseased intervertebral disc, indirectly lifting the pressure on the nerve root and the annulus fibrosus, eliminating or reducing inflammatory reactions, and eliminating or alleviating the symptoms. Interventional therapy has the advantages of small trauma, fast recovery, no interference with the structure of the spinal canal, no impact on spinal stability, low complications, simple operation and so on. 3.Minimally invasive treatment: At present, minimally invasive treatment surgery mainly includes intervertebral discoscopy and intervertebral foramenoscopy. The former is via posterior lateral approach and the latter is via posterior lateral approach. The indications for minimally invasive surgery are basically the same as those for traditional open or semilaminar nucleus pulposus removal surgery. All minimally invasive techniques were selected in patients who had indications for conventional incisional surgery. Minimally invasive surgery with less trauma, less bleeding, less physiological interference, less impact on lumbar spine stability, and faster recovery is worthy of clinical promotion. For disc herniation combined with severe degeneration, slippage, calcification and various causes of instability, the fourth level of treatment can be considered. 4.Conventional surgery: When the patient’s condition is serious and cannot be treated with the help of the above methods, then conventional surgery such as interlaminar windowing, hemilaminectomy or total laminectomy will be chosen, including microsurgery or conventional surgery under direct vision. The principle of surgery is to solve the problem as small as possible and try to protect the stability of the lumbar spine. However, attention should be paid to the prophylactic enlargement of the nerve root canal, so as to ensure the long-term efficacy after surgery. 5 Non-fusion fixation and fusion fixation technology: non-fusion fixation in the “non-fusion” feature allows inter-segmental physiological movement. It is expected to restore the load transmission and normal physiological motion of the spine through the restoration of the physiological anatomy of the lumbar spine after surgery, including transforaminal, transforaminal and intervertebral fixation (artificial nucleus pulposus or artificial intervertebral disc). Non-fusion fixation techniques have their own strict indications. It is generally considered to be indicated for patients with mild lumbar instability and not for cases with combined bone deformity, severe spinal canal stenosis requiring extensive decompression, or the presence of severe slippage. Fusion fixation surgery is the ultimate treatment for severe degenerative lumbar disc pathology and is indicated in the presence of both lumbar instability and slippage. Indications are disc herniation combined with severe degeneration, spinal stenosis or severe vertebral slippage, segmental instability of the disc lesion, recurrence of the original segment after surgery for lumbar disc herniation, and so on. Spinal fusion and fixation technology is safe and effective, and has become the gold standard for the treatment of severe spinal degenerative diseases, spinal instability and spondylolisthesis, and has become the ultimate remedy for the poor efficacy or failure of the various treatment methods mentioned above. Can lumbar disc herniation be cured? Herniated disc belongs to the early pathological changes of spinal degenerative diseases. Unlike tumor diseases, it is not metastatic, malignant and fatal. Therefore, its treatment principle is different from that of oncological diseases, do not completely resect, do not cure, do not chemotherapy and radiotherapy, and give different treatments according to the patient’s age, degree, and so on. Although it is not a neoplastic lesion and does not seek a radical cure, can it pursue a complete cure? The cost of blindly pursuing a complete cure is likely to be the expansion of treatment and over-treatment, which is harmful. Just as the life span of a human being is limited no matter how long it is, human intervertebral discs also have a life span, and the length of use varies from person to person. As we age, various external factors such as overwork, trauma, overload, etc. lead to different levels of pathological changes in the discs such as degeneration, bulging, prolapse, freeing, etc. Different ages and different levels of pathological changes correspond to different levels of pathological changes. Different ages and levels of trauma correspond to different treatment methods. Interbody fusion is generally considered to be the gold standard for the treatment of spinal disorders, but this surgical standard cannot be applied to all patients with herniated discs. Let’s say a patient who is less than 20 years old is not a good candidate for such an ultimate surgery. In addition to the loss of motion in that space, early degeneration from overcompensation in other spaces is also a consideration for the surgeon. In addition the medical trauma, complications, and resulting costs are all issues that need to be evaluated in a comprehensive manner. Thus disc herniation does not seek a complete cure, only the best possible relief, and it applies a step therapy approach.