Lumbar disc herniation (LDH) is caused by degeneration of the lumbar disc or rupture of the annulus fibrosus due to external forces, resulting in protrusion of the nucleus pulposus of the disc and compression of the nerve roots or/and cauda equina nerve, resulting in the corresponding clinical symptoms. The most common symptoms of lumbar disc herniation are low back pain and radiating pain in the lower extremities. Lumbar disc herniation accounts for 18% of patients with low back and leg pain. It occurs between the ages of 20 and 40, accounting for 65% to 80% of lumbar disc herniation, and about 20% to 35% of patients over the age of 40. Clinically, lumbar 4/5 and lumbar 5/sacral 1 intervertebral disc herniation is the most common. This disease belongs to the category of “lumbar and leg pain” and “paralysis” in Chinese medicine. Etiology Chinese medicine believes that the occurrence of lumbar intervertebral disc herniation is mainly related to the deficiency of kidney essence and loss of nourishment of tendons and bones, fall and flash, stagnation of qi and blood, and invasion of external evil. The pathogenesis is due to the weak endowment of the body, coupled with overwork or excessive room strain, or old age and physical decline, resulting in the loss of kidney essence to moisten the tendons and bones, resulting in intervertebral disc degeneration, or improper force or strong weight-bearing at the waist, damage to the tendons and bones, stagnation of qi and blood in the meridians in the waist and the development of lumbago. The key to lumbar intervertebral disc herniation is the deficiency of kidney energy and loss of nourishment of tendons and bones. The cause of herniated lumbar disc is the deficiency of kidney qi and the loss of nourishment of tendons and bones. The blockage of meridians and veins and the poor flow of qi and blood are the pathogenesis of pain. Modern medicine believes that lumbar intervertebral disc degeneration is an irreversible process that occurs under the influence of many factors. Degenerated intervertebral discs have a reduced ability to resist pressure due to the degradation of proteoglycans in the nucleus pulposus, and a weakened ability to buffer pressure and resist tension due to changes in collagen composition, both of which together reduce the mechanical function of the disc to absorb load and disperse stress. In daily life, the intervertebral disc is constantly subjected to the extrusion and tension of the longitudinal axis of the spine, and the lower lumbar spine in particular is subjected to the greatest force. When the lumbar disc is suddenly or continuously subjected to unbalanced external forces, rupture of the annulus fibrosus and protrusion of the nucleus pulposus may occur. It is currently believed that the main mechanism causing lumbar pain is caused by direct pressure or excessive stretching of the involved spinal nerve, and by biochemical stimulation of the nerve root by the herniated nucleus pulposus material, causing aseptic inflammation of the nerve root. In contrast, some herniated discs may have no clinical symptoms such as pain. The International Society for the Study of the Lumbar Spine (ISSLS) and the American Academy of Orthopaedic Surgery (AAOS) classify LDH as degenerative, bulging, herniated (under the posterior longitudinal ligament), prolapsed (behind the posterior longitudinal ligament), and free. The degenerative type is the early change and the bulging type is mostly asymptomatic. Asymptomatic herniated discs by CT are found in up to 30% of the population, symptomatic ones in about 2%, and those requiring surgery account for about 10 to 20% of those with symptoms. Most patients with herniated discs can recover with non-surgical treatment. When the nucleus pulposus is herniated, it can dissipate and be absorbed, and the neuralgia is reduced or disappears. If the nucleus pulposus has degenerated or calcified, it may compress the nerve root for a long time, causing obvious and persistent neuralgia, and this pathological tissue tends to adhere to the nerve root and dura. In the process of resorption, there is an increase in local connective tissue with retained blood vessels that invade the intervertebral space to repair the defective fibrous ring and absorb the degenerated nucleus pulposus. After herniation of the nucleus pulposus, the supporting role of the intervertebral disc is weakened, and in addition to the gradual narrowing of the intervertebral space and reactive sclerosis of the relative edges of the vertebral body, secondary pathological changes such as intervertebral instability, joint protrusion and vertebral body hyperplasia, degenerative thickening of the ligamentum flavum, and spinal stenosis may occur. The pathological process of lumbar disc herniation can occur in multiple segments or all segments of the lumbar spine at the same time, and the rate of progression may vary in different segments. It is uncommon for the disc to herniate in more than two segments and not necessarily in adjacent or ipsilateral segments. Herniations of more than two segments are reported in the literature to account for 10% to 20% of all lumbar disc herniations. Based on the proximity of nerve root emanation points and rows to the disc, herniated lumbar discs at lumbar 3, 4 and above are compressing the previous nerve and cauda equina that will emanate through the dura. The postero-lateral type of lumbar 4/5 disc herniation compresses the lumbar 5 nerve root, and the lumbar 5/sacral 1 disc herniation damages the sacral 1 nerve root. In the case of a partial-central or central type, it may affect one or more cauda equina nerves further down; in the case of a very lateral herniation, it may compress the superior nerve of the same segment. Clinical manifestations and diagnosis I. Symptoms (a) Low back pain Most patients have this symptom, with persistent dull pain in the low back being the most common. (2) Leg pain The pain is manifested as a series of pain from the buttocks to the thighs and calves. In mild cases, it does not affect walking, but in severe cases, the pain is unbearable and limping, and even the lower limbs cannot be straightened when lying in bed, and the pain needs to be relieved by bending the hip and knee in the lateral position. If coughing, sneezing and other actions that increase abdominal pressure can make the leg pain worse. Mostly one side of the leg pain, a few central or huge free type herniations show pain in both lower limbs. In high-grade disc herniation, the lumbar 2, 3, and 4 nerve roots are involved, and pain in the ventral groove area or anterior medial thigh in the area of nerve root innervation occurs. (iii) Numbness When the disc herniation stimulates the proprioceptive and tactile fibers, numbness of the limb appears, and the site of numbness is related to the location of the herniation, such as numbness of the lateral calf and medial dorsum of the foot when the lumbar 4/5 herniation compresses the lumbar 5 nerve root; numbness of the posterior aspect of the calf, lateral dorsum of the foot, heel and sole when the lumbar 5/sacral 1 disc herniation compresses the sacral 1 nerve root, and numbness of the lumbar 3/4 disc herniation compresses the lumbar 4 nerve root numbness in the anterolateral thigh. Numbness mostly occurs at the same time as pain, and the pain is more intense at the beginning of the disease, while the pain is lighter and the numbness gets heavier over time. The cauda equina syndrome occurs in central lumbar disc herniation, and there is also numbness in the perineum. (iv) Cauda equina syndrome When cauda equina syndrome occurs in central lumbar disc herniation, the patient may have weak or uncontrollable defecation and urination, numbness in the saddle area, male patients may develop impotence, female patients may develop urinary retention and pseudo-incontinence, and severe cases may develop bilateral lower limb incomplete paralysis. (v) Muscle paralysis Muscle paralysis by nerve paralysis when the nerve root is severely compressed. If the lumbar 4/5 intervertebral disc herniates and compresses the lumbar 5 nerve root, the anterior tibialis, long and short peroneal muscles, extensor digitorum longus and extensor digitorum longus are paralyzed, resulting in foot drop, with extensor digitorum longus paralysis being the most common. (F) coldness of the affected limb The pain reflex of the affected limb causes sympathetic vasoconstriction, or because of stimulation of the sympathetic nerve fibers next to the vertebrae, causing sciatica and lowering of the skin temperature of the lower leg and toes, especially the toes are obvious. (2) Signs (a) Gait The more obvious symptoms are unnatural posture when walking, and the heavier ones walk with a forward leaning body and a limp with the hips tilted to one side. (ii) Change of lumbar physiological curvature The physiological curve of lumbar vertebrae disappears or flat lumbar in the lighter cases; the deformity of lateral and posterior protrusion of lumbar vertebrae in the heavier cases appears or worsens after walking and decreases when lying down. The lateral bending posture of the lumbar region is a protective posture of the body. When the protrusion is located in the inner and lower part of the compressed nerve root (axillary type), the lumbar spine is bent to the healthy side; when the protrusion is located in the nerve (shoulder type), the lumbar spine is bent to the affected side (c) Pressure pain and percussion pain next to the lumbar spine The pressure pain point basically coincides with the diseased vertebral segment; heavy pressure or percussion on the diseased lumbar spine may cause radiating pain in the lower limbs. (d) Lumbar mobility is limited in all directions in the acute stage, especially in the direction of lateral protrusion when there is lumbar lateral deformity. When the lumbar spine activity causes the protrusion to close to the nerve root, it can cause the leg pain to increase. (v) Muscle strength changes and muscle atrophy Muscle atrophy and muscle strength decrease in the area innervated by the affected nerve roots. （Weak or absent knee reflex indicates the involvement of L3-4 nerve root; weak or absent Achilles reflex indicates the involvement of S1 nerve root. (vii) Sensory examination of the lower extremities Abnormal sensation in the area innervated by the affected spinal nerve roots, mostly manifesting as skin hypersensitivity in the early stage, and gradually appearing as numbness, tingling and hyperalgesia. Patients may have a positive flexion test, a positive straight leg raise test and a positive strengthening test, and a positive femoral nerve pull test if the L3 and 4 nerve roots are involved. In addition to serving as a reference for the diagnosis of lumbar disc herniation, it is more important to provide a differential diagnosis of various diseases such as septic inflammation of the lumbar spine, primary tumor and metastatic cancer. (ii) CT At present, CT examination has become an important method for diagnosing this disease, and the accuracy rate of CT diagnosis is 83%~100%. The direct signs are mound-like protrusion of the disc into the spinal canal, deformation or displacement of the dural sac and nerve root sheath by compression, and the ability to diagnose extreme lateral herniation. Secondary signs such as hypertrophy of the ligamentum flavum, stenosis of the spinal canal, stenosis of the lateral saphenous fossa, and hyperplasia of the small joints and thickening of the vertebral plates can be clearly demonstrated. （MRI can clearly observe the bright spots formed by inflammatory edema tissue at the edge of the disc and changes in nerve root compression. （The basic imaging sign of disc herniation is an indentation or filling defect of the anterior dural space and posterior displacement of the structures in the spinal canal by compression. In the orthostatic position, abnormal filling of the spinal canal on one side or symmetrical narrowing on both sides is seen, along with poor or interrupted visualization of the nerve root sheath on one or both sides. Because of the invasive nature of this test, it is generally not done when CT or MR examinations are available. In 1988, the North American Spine Society established the indications for discography: severe lower back pain lasting more than 4 months, with or without lower extremity radiation pain, and unresponsive to any conservative treatment methods. Discography should provide information on four aspects: (1) morphologic changes in the disc, (2) subjective pain response, (3) disc pressure or amount of contrast injected, and (4) adjacent segment control. A normal disc can accommodate 1.5 ml to 2.5 ml of contrast medium. More than 3 ml indicates the possibility of rupture of the annulus fibrosus. (v) Electromyography The damaged nerve root and its degree of influence on the muscle can be determined according to the distribution of abnormal electromyography. The diagnosis of lumbar intervertebral disc must be integrated with clinical history, physical signs and imaging examination. Generally speaking, the diagnosis is based on the following: 1. leg pain heavier than lumbar pain, leg pain according to the area of distribution of the sciatic or femoral nerve; 2. skin sensory disturbance according to the area of distribution of the nerve; 3. positive pull test of the sciatic or femoral nerve; 4. two signs of the four nerve injury signs (muscle atrophy, muscle weakness, sensory disturbance and diminished reflexes); 5. imaging at a level consistent with the clinical examination examination findings, including spinal canalography, CT or MRI, etc. The disease needs to be differentiated from lumbar spinal stenosis, lumbar dorsal fasciitis, spinal tumor, radiculitis, pear-shaped muscle syndrome, arachnoiditis and visceral reflex lumbar pain. Treatment Treatment of lumbar disc herniation is divided into two categories: non-surgical treatment and surgical treatment. Non-surgical treatment is advocated for young patients with herniated discs who have had their first attack or a short course of disease without systematic conservative treatment, or for patients with herniated discs whose symptoms are mainly lumbar pain. The effect is more certain through the comprehensive treatment of Chinese medicine such as evidence-based medicine, manual tui-na, traction, bed rest, physical therapy and acupuncture. For some patients with severe pain, oral administration of non-steroidal anti-inflammatory painkillers or epidural closure can also achieve the purpose of pain relief. Some patients with recurrent attacks, non-surgical treatment is ineffective, affecting life and work, or free type prolapse, serious clinical symptoms, or obvious nerve parenchymal damage (obvious muscle atrophy, muscle weakness), or damage to the cauda equina nerve, should choose surgical treatment. I. Identification and treatment The disease is mostly caused by the evidence of deficiency of the origin and the symptoms of the symptoms. The internal deficiency is blamed on the liver and kidney, while the external reality is blamed on wind, cold, dampness and trauma to blood stasis. The acute attack of pain is severe, the treatment of the symptoms is the main, remission period of its paralysis and pain, repeatedly does not heal, the main treatment of the root, or with the deficiency of the real and the symptoms of both. (A) wind-damp paralysis paralysis of the lower back and legs heavy, turn side unfavorable, repeated attacks, rainy days aggravated, pain wandering uncertain, evil wind, warmth is reduced, the tongue is light red or dull, the moss is thin white or white greasy, pulse moist. The treatment is to remove wind and dampness, remit paralysis and relieve pain. The formula is Douwuxiaosheng Tang plus or minus. (2) Cold and dampness paralysis. Cold pain in the waist and legs is heavy, with unfavorable rotation, pain at a fixed place, not reduced or aggravated by lying down, light day and heavy night, increased pain in case of cold, reduced by heat, loose urine and stool, fat and light tongue, white greasy moss, tight, slow or sunken tight pulse. The treatment is to warm the meridians and disperse cold, dispel dampness and clear the channels. The formula is P.E.C.T. plus or minus. (3) Damp-heat paralysis Pain in the waist, hip and leg, with heat and heaviness in the painful area, or with redness and swelling of the limbs, thirst without desire to drink, boredom and restlessness, short and red urine, or urgent and heavy stools, with red tongue, yellow and greasy moss, and moist or slippery pulse. The treatment is to clear dampness and heat, clear the channels and stop pain. The formula is San Ren Tang with addition and subtraction. (4) Qi stagnation and blood stasis Recent history of trauma to the lumbar region, severe pain in the lumbar region, stabbing pain, stiffness in the lumbar region, difficulty in moving up and down, refusal to press the painful area, dark purple tongue, or petechiae, thin white or thin yellow tongue coating, sunken and astringent pulse. The treatment is to move Qi and invigorate Blood, promote circulation and relieve pain. The formula is Fuyuan Revitalizing Blood Soup with addition and subtraction. (5) Weakness of kidney yang. Recurrent attacks of lumbar and leg pain, coldness of the lumbar and leg, warmth and fear of coldness, pressing and rubbing, aggravated by exertion, little breath and lazy speech, white and fat body, spontaneous sweating, pale mouth without thirst, loss of hair or early white, loose or falling teeth, frequent urination, impotence in men, low volume of derivatives in women after menstruation, pale fat and tender tongue, white smooth coating, weak pulse. The treatment is to warm the kidney yang and warm the yang to promote paralysis. The formula is chosen from Right Return Pill. (6) Yin deficiency of liver and kidney. Soreness and pain in the waist and legs, weakness, intolerance of labor, aggravated by labor and relieved by lying down, thinness of the body, flushing of the face, distress and insomnia, dry mouth, heat in the heart of the hands and feet, flushing of the face, yellow urine, red tongue with little fluid, thin pulse. The treatment is to nourish Yin, tonify the kidney and strengthen the tendons and bones. The formula is Zuo Gui Wan. In the treatment of lumbar intervertebral disc herniation, it can improve local blood flow, reduce the internal pressure of the intervertebral disc, induce the herniated object to retract or change the position with the nerve root, so as to relieve pain. The techniques for treating lumbar disc herniation can be divided into two categories, one is the lumbar fixed-point oblique wrenching technique, and the other is the three eight methods of large massage. It is suitable for young people with untreated herniated discs of first attack or short duration, or herniated discs with mainly lumbar pain symptoms, or patients with mainly bulging and no clear signs of nerve damage. Lumbar traction therapy (a) electric pelvic traction is one of the main methods of conservative treatment for lumbar disc herniation. Position requirements such as supine traction, the hip joint in a flexed position is better, can apply a small stool placed under both knees. In principle, the traction force should be comfortable to the patient, and the traction force of the lumbar spine should be at least >25% of the body weight. Traction time: 20 to 40 minutes, average 30 minutes. The frequency of treatment should be at least five or six times a week. (ii) Continuous traction method The patient lies on a hard bed, with the end of the bed raised at an angle of 15°, with a pelvic traction belt, with a weight of 15-30 kg, and a thin pillow under the waist, the longer the continuous traction time, the better, and the traction time is about 3 weeks. (Figure 6-4-2) (Figure 6-4-2) Continuous traction method IV. Acupuncture and moxibustion The meridians closely related to low back pain are the foot solar bladder meridian, foot Yangming stomach meridian, foot Shaoyin meridian, foot Shaoyang gall bladder meridian, the Governor’s Vessel and the Belt Vessel. Main points: Kidney Yu, Wei Zhong, Yang Ling and Cheng Shan. The acupuncture points should be matched with the evidence, and the acute stage should be treated with diarrhea, while the chronic stage should be treated with flat tonics, flat diarrhea or tonic methods, or with moxibustion. V. Western medicine treatment On the basis of Chinese medicine therapy, for obvious pain, give appropriate non-steroidal anti-inflammatory and analgesic and nerve-nourishing drugs, or use a small amount of glucocorticoid intravenous drip (prohibited for hypertension and peptic ulcer) to promote the inflammation of the nerve root to subside, in order to achieve pain relief. The local anesthetic and steroid drugs are injected into the painful point or epidural cavity to directly treat the aseptic inflammation of the nerve root, which can play a better anti-inflammatory and analgesic role. Commonly used closure therapy there are two kinds: (a) vertebral plate closure for the diseased vertebral spine next to the obvious pressure point, commonly used 1% ~ 2% lidocaine 1 ~ 3ml plus compound betamethasone injection 1ml, every 5 ~ 7 days injection. (B) Epidural cavity closure method The drug is injected into the epidural cavity, commonly used 1%-2% lidocaine 5-10ml, compound betamethasone injection 1ml, mixed and injected into the epidural cavity of the lumbar spinal canal, 7-14 days injection, the whole course of treatment does not exceed 3 times. The drugs used in closure therapy contain steroids and are prohibited for people with hypertension and peptic ulcers. Surgery can remove the protruding disc and release the cauda equina and nerve root compression, thus achieving significant therapeutic effects; however, surgery cannot repair the degenerated disc or immediately repair the injured nerve tissue, and at the same time, surgery may further damage the stability of the spine, so the indications for surgery should be strictly controlled. The use of TCM treatment for patients during the perioperative period can help reduce inflammation of the nerve roots, promote the recovery of blood flow, and provide nutrients for nerve repair. (1) Indications for surgery (1) patients with severe symptoms that affect life and work and who have been treated ineffectively by non-surgical therapy for more than three months; (2) patients with extensive muscle paralysis, sensory loss and damage to the cauda equina nerve (such as sensory loss in the saddle area and dysfunction of urination and defecation), and those with complete or partial paraplegia. (3) Patients with severe intermittent claudication and spinal stenosis, or those whose X-ray and CT images show spinal stenosis, should undergo surgery as early as possible because non-surgical treatment is not effective. (2) Commonly used surgical methods 1, “window” type lumbar disc nucleus pulposus removal “window” type removal of the nucleus pulposus is the most common surgical method for the treatment of lumbar intervertebral disc herniation. Its advantage is that it has less damage to the bone of the spine; it has little effect on the stability of the spine and is beneficial to the functional recovery after surgery. 2.Hemilaminectomy to remove the nucleus pulposus The surgical indications, anesthesia and surgical methods of hemilaminectomy are basically the same as the “open window” type, with the difference that the affected side of the vertebral plate is bitten off and the scope of exposure is larger. However, care should be taken to preserve the small joints in order to maintain the stability of the spine. It is only used when the open-window surgery does not reveal well. 3.Bilateral “window” removal of the nucleus pulposus Bilateral windowing is used when the lumbar disc herniation has bilateral lower extremity symptoms and it is estimated that the nerve roots are compressed bilaterally, and one side of the windowing surgery cannot release the opposing side of the compression. 4. discoscopic nucleus pulposus removal The surgical method of discoscopic operating system (MED) is used. A small incision (1.5 cm) is made next to the spinous process and the operating trocar is inserted posteriorly, a light source and an imaging system are connected, and the operator sees the magnified tissue in the spinal canal on the screen and removes the nucleus pulposus using fine instruments. The advantages are less trauma, less interference with the spinal canal and nerve roots, and faster patient recovery. In addition, there are also paracentral access disc nucleus pulposus aspiration, ultrasonic or laser nucleus pulposus pneumatization, etc., all of which are used to reduce the volume of the nucleus pulposus by reaching the disc through a catheter to reduce the internal pressure of the disc and indirectly reduce the tension of the nerve roots for the purpose of pain relief. Prevention and conditioning Although the etiology of lumbar disc herniation is not completely clear, degeneration of the disc itself and trauma undoubtedly play an important role in the pathogenesis, so the prevention of lumbar disc herniation focuses on how to avoid disc injury. Prevention should start from the following aspects: First, health examination and prevention education, health examination should be carried out regularly for adolescents or staff, especially adolescents, workers engaged in long-term lumbar sports and athletes, etc. Second, improve the labor posture and poor weight-bearing habits. Third, strengthen muscle exercise. Fourth, prevention in family life. Prognosis and regression If lumbar disc herniation can be diagnosed and treated early, for patients with short duration, mild symptoms and no nerve damage, most of them can be cured after systematic conservative treatment while paying attention to health care and strengthening suitable physical exercise. For some patients with serious disease, or those who have lost treatment or misdiagnosis, or those who have no or poor effect of conservative treatment, and whose disease affects patients’ life and working ability and shows nerve damage, surgery should be performed. The principle of surgery is to completely remove the nucleus pulposus tissue that is protruding and compressing the nerve, and to remove the factors around the nerve that are causing the nerve compression. The long-term results of surgery are positive, but some patients require reoperation due to recurrence of disc herniation caused by re-trauma, nerve root adhesions, adjacent disc herniation, or lumbar instability.