Step 1: Questioning (1) Where exactly is the discomfort and the right or wrong course of the disease. (2) The nature of the pain, whether it is localized or radiating, the area of radiation, and whether there are other accompanying symptoms. The area of radiation: ①. Posterior thigh to N fossa – L3/L4 segment. ②. Posterior lateral thigh – L3/L4 segment. ③. Radiated to the lower leg – L5/S1 segment. ④. Single lower back gluteus to transverse gluteus – supraspinatus, interspinous, sacroiliac joint, iliac crest labrum, pear-shaped muscle, gluteus maximus, gluteus minimus of L5/S1. (3). Causes of the onset of the disease include the working environment, living habits, and geographical characteristics. Geographical characteristics: ①. Southerners – the muscles are looser and the manipulation amplitude should be smaller. ②. Northerners – the muscles are more compact and the manipulation amplitude can be large. (4). Overall assessment of any history of trauma, malignant disease, serious skin disease, etc. Step 2: Look at the diagnosis (1). Walking posture. Whether there is a sloping neck, whether the shoulders are level, whether there is a scoliosis of the spine, whether there is a limp in the gait, and whether the toes are facing forward. (2). Observation of facial appearance More painful, emaciated, anxious face. Poor elasticity of the dark circles of the eyes. (3). Sitting posture Look at the spine for scoliosis, retroflexion, depression, and tense contracture of the muscles on both sides. Step 3: Specialist examination (a). Standing position examination Ask the patient to do forward and backward motion: ①. Increased symptoms of anterior tilt – lesions outside the spinal canal. ②. Backward tilting symptom aggravation – lesions in the spinal canal. (b) Sitting examination Tap on the joint capsule between the transverse processes to see if there is pain and radiating pain, paying attention to the elderly and patients with severe radiating pain. (c) Supine position examination 1. Comparison of the form and length of both lower limbs. (1). Morphological comparison. The patient’s lower limbs are naturally straightened and the operator stands in front of the patient’s heels. The operator held the patient’s ankle joints with both hands and lifted them up 30~40cm, then let them fall naturally and observed the morphology of both feet after they landed on the bed. ①. Normal: ↑ ⊙ ↑ – both feet are slightly abducted upward in unison ②. J⊙I or J⊙↑ – suggesting spasm and tension of the anterior medial thigh adductor muscle. ③. Adduction: I⊙J or I⊙↑ – suggesting spasm and tension of the posterior lateral thigh adductor muscle. (2). Length comparison The operator rests the palms of both hands under the patient’s ankle joint and holds both thumbs in front of the ankle joint. The operator squats while pulling the patient’s ankle joint downward to straighten the heel and compare the right and wrong of the two heels. ①. Normal: equal length ②. Abnormal: unequal length – suggesting displacement and tilt of the lumbosacral segment and pelvis 2. Straight leg raise test ①. 10~30° start to increase radioactive pain – positive sign ②. 40~60° start to increase radioactive pain – weak positive sign ③. 70~90° start to increase radioactive pain – negative sign 3. 4 word test The ankle joint is placed on the opposite knee joint, and the outer part of the knee of a normal person can be pressed against the bed. To the bed surface, if you can not contact or can be contacted but the hip discomfort – suggests that the femoral internal muscle group tension, the hip joint problems. 4.Ankle joint on the opposite knee, the operator presses one hand on the patient’s shoulder, and presses the knee to the opposite side with one hand, such as hip and lower back pulling discomfort – suggesting sacroiliac joint, iliac crest lip, gluteus medius, pear-shaped muscle problems (d), prone position examination 1, chest and abdomen pillow test (1). 30cm high pillow under the chest, hands naturally placed on both sides, so that the lumbar segment downward depression – such as increased pain in the lumbar region, suggesting intra-vertebral canal lesions, true protrusion, mostly accompanied by radiological symptoms. (Mechanism): After the chest pillow, the gap in the lumbar segment of the spinal canal narrows, the ligamentum flavum accumulates, the small joints overlap, squeezing to the small joint capsule and nerve roots, causing the nerve roots to collide with the protrusion and the dural sac, and the distal nerve radiation symptoms appear (2). 30cm high pillow under the abdomen, hands naturally placed on both sides, so that the lumbar segment protrudes backward – such as increased pain in the lumbar region, suggesting extra-vertebral canal lesions, pseudo-protrusion, not accompanied by radiological symptoms (mechanism): after the chest pillow, the lumbar segment vertebral gap increases, the muscles of the lumbar back are stretched and tensed and sore and uncomfortable, less neuroradiological symptoms 2, lower abdominal pillow examination abdominal pad 15cm pillow, thin pillow in front of the chest, so that the lumbar region is fully Backward elevation (1). Observation ①. Observe the general outline of the thoracolumbosacral spine to see if there are changes in curvature such as scoliosis, concavity, and retroflexion ②. Observe the muscles on both sides of the spine for tautness, elevation, and clear stripes along the edges a. elevation on both sides and depression in the middle b. elevation on one side and depression on the other c. elevation in the thoracolumbar segment and depression in the lumbosacral segment d. obvious muscle accumulation or too flat in the lumbosacral segment ③. Observe whether the highest point of the iliac crest on both sides is at the same level ④. Observe whether the lumbar eye, gluteus medius and pear-shaped muscles on both sides are in line. There is no atrophy or contracture. Clinically, one side is high and the other is low – suggesting: lumbosacroiliac and pelvic problems (2). Palpation ①. Check for scoliosis of the spine – middle and index fingers are placed separately on both sides of the spinous process of the thoracic vertebrae, and the lumbosacral region is palpated from top to bottom, from light to heavy ②. Check for scoliosis of the spinous process – place the thumb on the superior segment of the thoracic spine and slowly slide down against one side of the spinous process and then the opposite side. ③. Tap on the false fist to look for painful areas a. Spinous process line – L5/S1 segment, L5/L4 segment, L4/L3 segment, to see if there is pain in the spinous process, interspinous and supraspinous, clinically more common in L5/S1 segment b. Both transverse processes – L5/S1 transverse process part, L5/L4 transverse process part, L4/L3 transverse process part, to see if the pain is local or radiating ④. Thumb pressure to look for painful points a. Press the top and top and bottom of the spinous process b. Press the joint capsule 2 cm next to the spinous process c. Press the tip of the transverse processes of L3, L4, L5, S1 d. Press the lumbosacral and sacroiliac joints, iliac crest lip e. Press the pear-shaped muscle and exit, the starting and ending points of the gluteus medius, the distribution area of the superior gluteal nerve, the iliotibial bundle, the sciatic tuberosity, the exit of the transverse gluteal process Look for deep pressure pain and radiating pain, contracture points . If the thumb belly does not find a positive point, the fingertips can be used to search with slight force ⑤ look at the degree of muscle denseness a. Dense – indicates that there is a problem in the superficial layer, manipulation in the middle layer plus fan release b. Relaxation – prohibit large area manipulation, disable dial needle Attachment: true and pseudo lumbar disc herniation identification 1, true herniation (intra-vertebral canal lesion) – nerve root compression location of compression: the inner and outer mouth of the spinal canal symptoms: distal radioactive 2. Pseudo-herniation (extradural lesion) (1). Nerve trunk compression Location of compression: pear-shaped muscle outlet, gluteus medius, gluteus minimus, sacroiliac joint, iliac crest labrum Compression of sciatic nerve trunk Symptoms: radioactive pain area second only to radicular (2). Plexus compression Location of compression: the outlet of the transverse gluteal muscle compresses the posterior femoral cutaneous nerve; the medial cutaneous nerve jam of the gastrocnemius muscle medial to the N fossa; the posterior lateral 2 cm of the fibular tuberosity compresses the common peroneal nerve Symptoms: associated radiological regional symptoms Lumbar disc herniation is one of the common orthopedic diseases, and about 1/5 of patients with low back pain are caused by lumbar disc herniation. It has been more than seventy years since Mixterher and Barr proposed this disease in 1934. From the epidemiological analysis at home and abroad, the population rate of its incidence and the value of exhaustive pairs are on the rise. The age of onset varies from a few years to several tens of years, and we have seen patients with lumbar disc prolapse as young as 9 years old. The increase in the incidence of this disease is related to the environment we live in and the changes in our living and working habits. Long-term bad habits with the back are the main cause. In the past seventy years, the majority of medical workers have been working hard on research and have made great progress in both the familiarity of the disease and the treatment methods. From folk recipes, herbal medicine, to traction, massage, physical therapy, reset to participation, minimally invasive, surgical treatment, treatment methods are endless and varied. How can we choose among the many treatment methods for individual patients? Patients are headless, more many doctors are also unaware of, full of confusion. In fact, the choice of indications is the key to treating the disease. That is, in a sea of treatment methods, understand the extent of their own condition, choose the most targeted treatment methods, lumbar disc herniation can be completely quickly cured. The actual fact is that you can find a lot of people who have been in the business for many years. The actual fact that I’m not very knowledgeable, especially compared to the authoritative experts at home and abroad, the comments that are suitable for the following consultation are just for reference and not final. The pathology of lumbar disc herniation The intervertebral disc tissue itself lacks blood supply and has very poor repair ability, coupled with a lot of weight-bearing activities. Generally, after the age of 20, the intervertebral disc begins to undergo degenerative changes, and the toughness and elasticity of the fibrous ring are gradually decreasing. At this time, if trauma is encountered, especially cumulative strain injury, it becomes the cause of rupture of the annulus fibrosus. There are also many cases where there is no history of trauma, but where the tension in the muscles and ligaments increases after exposure to cold, which increases the internal pressure of the disc and promotes the rupture of the atrophied annulus fibrosus. The intervertebral disc is a special structure made of connective tissue that is burdened with unique functions. Any alteration of the disc affects its normal mechanical performance or interferes with its normal balance function, absorption and redistribution of its forces to the spine. The intervertebral disc includes the nucleus pulposus, the annulus fibrosus and the cartilage plate. The nucleus pulposus of the intervertebral disc contains a small amount of collagen fibers in addition to a soft matrix of mainly mucopolysaccharide. The nucleus pulposus accounts for more than half of the volume of the intervertebral disc and, because of its deformability, is able to properly transmit the load force. The reason why the disc can maintain proper function is closely related to its water content water content, which in turn is stabilized by the polysaccharide content. The difference between the fibrous ring and the nucleus pulposus is certainly still evident, but the collagen fibers of the fibrous ring are in the form of dense laminae, with the fibers of each layer interlocking at right angles to each other and at an angle of 45° to the spine, and this laminae structure can accommodate the pressure and tension and the flexion and rotational stresses caused by the spine. The cartilage plate is glassy cartilage, which is scarfed between the vascularized vertebral spongiosa and the avascular nucleus pulposus. On the surface of the vitreous cartilage, the collagen fibers are parallel to each other on the surface, and at the deeper level near the bone, the collagen fibers are perpendicular. The proteoglycan ground intervertebral disc matrix is an important component of the intervertebral disc matrix and is an important structure for the mechanical and chemical functions of the disc. Proteoglycan molecules are large, extremely viscous, and very hydrophilic. Under normal conditions, the nucleus pulposus is highly compressible and has a strong loading capacity due to the properties of proteoglycans. If the glycan chains of the proteoglycans break down, they lose their ability to retain extracellular water. The biochemical integrity of the intervertebral amphibian nucleus pulposus is determined by its water content volume. Under normal conditions the intervertebral disc is subject to pressure and redistributes its forces to the spine and is an important part of accomplishing normal function. The formation of disc herniation is a normal excess of proteoglycans, which will cause the nucleus pulposus to become fluid and increase, and the pressure within the nucleus pulposus to rise and predispose to disc herniation. However, mucopolysaccharides in the nucleus pulposus can produce a new balance through reduction and re-integration. The progressive reduction of proteoglycan can promote the fibrosis of collagen, and the nucleus pulposus gradually loses its original compressibility and loading capacity due to the deposition of collagen and the increase of fibrosis, which will not be able to perform the function of absorbing and redistributing the stress of the nucleus pulposus to the spine under load at any time, thus causing damage to the intervertebral disc. If there is external trauma or excessive stress is placed on the damaged disc, it is more likely to cause disc herniation. It is thought that the glycoprotein and β-protein in the nucleus pulposus matrix form an antigen in autoimmunity, and that this antigen is released (referring to the release of β-protein in degenerated discs and herniated discs, which is normally encapsulated in the nucleus pulposus), which continuously stimulates the body, resulting in an immune response, and also causes an inflammatory response in the nerves, resulting in pain.