Lumbar disc herniation is one of the more common disorders, mainly because the lumbar intervertebral disc parts (nucleus pulposus, fibrous ring and cartilage plate), especially the nucleus pulposus, have different degrees of degenerative changes, under the action of external factors, the fibrous ring of the disc ruptures, and the nucleus pulposus tissue protrudes (or prolapses) from the rupture in the posterior or vertebral canal, resulting in the adjacent spinal nerve roots suffer from irritation or compression, thus producing lumbar pain This results in a series of clinical symptoms, such as numbness and pain in one or both lower extremities. The incidence of lumbar disc herniation is highest in lumbar 4-5 and lumbar 5-sacral 1, accounting for about 95%. Etiology I. Basic etiology: 1. Degenerative changes of the lumbar intervertebral disc are the basic factors; 2. Long-term repeated external forces cause slight damage and aggravate the degree of degeneration; 3. Weakness of the disc’s own anatomical factors; 4. Familial onset of lumbar disc herniation has been reported, and the incidence of this disease in people of color is low; 5. Lumbosacral congenital anomalies. These include lumbar sacralization, sacral lumbarization, hemivertebral deformity, small joint deformity and joint protrusion asymmetry. The above factors can cause changes in the stress on the lower lumbar spine, which constitutes an increase in the internal pressure of the intervertebral disc and predisposes to degeneration and injury. Second, triggering factors On the basis of degenerative changes in the intervertebral disc, a certain factor that can induce a sudden increase in intervertebral disc pressure can cause the nucleus pulposus to protrude. Common predisposing factors include increased abdominal pressure, improper lumbar posture, sudden weight bearing, pregnancy, exposure to cold and moisture, etc. Clinical typing The following typing can be made from the pathological changes and CT and MRI performance, combined with the treatment methods. The nucleus pulposus is confined to the spinal canal due to pressure, but the surface is smooth. Most of this type can be relieved or cured by conservative treatment. 2.Protruding type The fiber ring is completely ruptured, the nucleus pulposus protrudes into the spinal canal, covered only by the posterior longitudinal ligament or a layer of fibrous membrane, the surface is uneven or cauliflower-shaped, often requiring surgical treatment. 3, prolapse free type rupture protruding disc tissue or fragments into the spinal canal or completely free. This type can not only cause nerve root symptoms, but also easily lead to cauda equina symptoms, and non-surgical treatment is often ineffective. 4.Schmorl’s node The nucleus pulposus enters the cancellous bone of the vertebral body through the fissure of the cartilage of the upper and lower end plates, and generally there is only low back pain without nerve root symptoms, and surgery is not required. Clinical manifestations (a) Clinical symptoms 1. Low back pain is the first symptom in most patients, with an incidence of about 91%. As the outer layer of the fibrous ring and the posterior longitudinal ligament are stimulated by the nucleus pulposus, the induction pain in the lower back is produced by the sinus nerve, and sometimes it can be accompanied by hip pain. 2. Lower limb radiating pain Although high lumbar disc herniation (lumbar 2 to 3, lumbar 3 to 4) can cause femoral neuralgia, it is rare clinically, less than 5%. The vast majority of patients are herniated from lumbar 4 to 5 and lumbar 5 to sacral 1 gap, which manifests as sciatica. Typical sciatica is radiating pain from the lower lumbar region to the buttocks, posterior thighs, and lateral calves up to the feet, and the pain increases in response to increased abdominal pressure such as sneezing and coughing. The radiating pain is mostly on one side of the limb, and only a very few people with central or paracentral medullary herniation show symptoms in both lower limbs. There are three causes of sciatica: (1) chemical inflammation of the nerve root due to chemical stimulation and autoimmune reaction from the ruptured disc; (2) the herniated nucleus pulposus compresses or stretches the nerve root with inflammation, blocking its venous return and further aggravating edema, making it more sensitive to pain; and (3) ischemia of the compressed nerve root. The above three factors are interrelated and are aggravating factors for each other. 3. Cauda equina symptoms The protruding nucleus pulposus or prolapsed, free intervertebral disc tissue presses the cauda equina nerve, which mainly manifests as obstruction of bowel movement and urination, abnormal perineum and perianal sensation. In severe cases, symptoms such as loss of control of urination and defecation and incomplete paralysis of both lower limbs may occur, which are rare in clinical practice. (2) Signs of lumbar disc herniation 1. General signs (1) Lumbar scoliosis is a postural compensatory deformity to reduce pain. Depending on the relationship between the site of the herniated nucleus pulposus and the nerve root, the spine is bent to the healthy side or to the affected side. If the site of the herniated nucleus pulposus is located on the medial side of the spinal nerve root, the lumbar spine bends to the affected side because the spine bends to the affected side to reduce the tension of the spinal nerve root; conversely, if the herniated nucleus pulposus is located on the lateral side of the spinal nerve root, the lumbar spine bends to the healthy side. (2) Restriction of lumbar movement Most patients have varying degrees of restriction of lumbar movement, which is especially obvious in the acute stage, with the most obvious restriction in forward flexion, because the nucleus pulposus can be further displaced backward in forward flexion and increase the pull on the compressed nerve roots. (3) Pressure pain, percussion pain and sacral spasm The site of pressure pain and percussion pain basically corresponds to the vertebral space of the lesion, and is positive in 80% to 90% of cases. The percussion pain was obvious at the spinous process, which was caused by percussion vibration of the lesion. The pressure point is mainly located at 1 cm of the paravertebral area, and radiating pain along the sciatic nerve may occur. About 1/3 patients have lumbar sacrospinal muscle spasm. 2. Special signs (1) Straight leg raising test and strengthening test The patient lies supine, extends the knee and passively raises the affected limb. In normal people, the nerve root has 4mm sliding degree, and the lower limb is raised to 60°~70° before feeling discomfort in the N fossa. In patients with lumbar disc herniation, the nerve root compression or adhesion reduces or disappears the sliding degree, and sciatica can occur within 60° of elevation, which is called a positive straight leg elevation test. In positive patients, slowly lowering the height of the affected limb and waiting for the radiating pain to disappear, then passively flexing the affected ankle joint to induce radiating pain again is called a positive strengthening test. Sometimes, because of the large nucleus pulposus, elevation of the healthy lower limb can also pull the dura mater to induce radiating pain in the sciatic nerve on the affected side. (2) Femoral nerve pull test The patient is placed in a prone position with the knee joint of the affected limb fully extended. The examiner elevates the straightened lower extremity so that the hip joint is in hyperextension, and the test is positive when the hyperextension reaches a certain level and pain occurs in the femoral nerve distribution area in front of the thigh. This test is mainly used to examine patients with lumbar 2 to 3 and lumbar 3 to 4 disc herniation. 3, neurological manifestations (1) sensory disorders Depending on the location of the involved spinal nerve roots, abnormal sensation in the innervated area may occur. The positivity rate is more than 80%. In the early stage, the symptoms are mostly skin sensitization, and gradually numbness, tingling and hyperalgesia appear. However, if the cauda equina nerve is involved (central type and paracentral type), the sensory impairment will be more extensive. (2) Decreased muscle strength 70% to 75% of patients have decreased muscle strength. In the case of lumbar 5 nerve root involvement, the dorsal extension of ankle and toe is decreased, and in the case of sacral 1 nerve root involvement, the toe and plantarflexion of foot is decreased. (3) Reflex changes are also one of the typical signs that are prone to occur in this disease. When the lumbar 4 nerve root is involved, the knee reflex may be impaired, which is active in the early stage and then rapidly becomes hyporeflexic. In sacral 1 nerve root involvement, the Achilles tendon reflex is impaired. Reflex changes are more significant to the localization of the involved nerve. The X-ray plain film alone cannot directly reflect the presence of disc herniation, but degenerative changes such as narrowing of the intervertebral space and vertebral body edge hyperplasia are sometimes seen on the X-ray film, which is an indirect indication that some patients can have spinal deflection and scoliosis. In addition, X-ray plain film can find the presence of tuberculosis, tumors and other bone disease, has important differential diagnostic significance. 2.CT examination can clearly show the site, size, shape and nerve roots of the herniated disc and the displacement of the dural sac under pressure, as well as the hypertrophy of the vertebral plate and ligamentum flavum, hyperplasia of the small joints, narrowing of the spinal canal and lateral saphenous fossa, etc. It has a greater diagnostic value for this disease and is now commonly used. MRI is of great significance in the diagnosis of lumbar disc herniation, as it can comprehensively observe whether the lumbar disc is diseased and clearly show the morphology of the herniated disc and its relationship with the dural sac, nerve roots and other surrounding tissues through sagittal images at different levels and cross-sectional images of the involved discs, in addition to identifying the presence of other occupying lesions in the spinal canal. Other occupying lesions can be identified. However, the display of whether the herniated disc is calcified or not is not as good as CT examination. Other electrophysiological examinations (electromyography, nerve conduction velocity and evoked potentials) can help determine the extent and degree of nerve damage and observe the effect of treatment. Laboratory tests are mainly used to exclude some diseases and play a role in differential diagnosis. Diagnosis The diagnosis of a typical case, combined with medical history, physical examination and imaging, is usually not difficult, especially today when CT and MRI techniques are widely used. If there are only CT and MRI manifestations without clinical symptoms, the disease should not be diagnosed. Treatment 1. Non-surgical treatment Most patients with lumbar disc herniation can be relieved or cured by non-surgical treatment. The treatment principle is not to return the degenerated and herniated disc tissue to its original position, but to change the relative position of the disc tissue and the compressed nerve root or partially retract it, so as to reduce the pressure on the nerve root, release the adhesion of the nerve root and eliminate the inflammation of the nerve root, thus relieving the symptoms. Non-surgical treatment is mainly suitable for: (1) young people, first attack or short duration of the disease; (2) people with mild symptoms that can be relieved by themselves after rest; (3) people with no obvious spinal stenosis on imaging. (1) Absolute bed rest For the first attack, bed rest should be strictly applied, emphasizing that neither bowel movements nor urination should be performed in bed or sitting up, so as to have better results. After 3 weeks of bed rest, you can get up and move around under the protection of a lumbar girth, and do not bend over and hold things for 3 months. This method is simple and effective, but more difficult to adhere to. After remission, the lumbar back muscle exercise should be strengthened to reduce the chance of recurrence. (2) Traction therapy The use of pelvic traction can increase the width of the intervertebral space, reduce the internal pressure of the intervertebral disc, the protruding part of the disc retracts, and reduce the irritation and compression of the nerve root, which needs to be carried out under the guidance of a professional doctor. (3) Physiotherapy, massage and tui-na can relieve muscle spasm and reduce the pressure within the intervertebral disc, but note that violent massage and tui-na can lead to aggravation of the disease and should be done with caution. (4) Corticosteroid epidural injection Corticosteroid is a long-acting anti-inflammatory agent, which can reduce inflammation and adhesions around the nerve root. Generally, long-acting corticosteroid preparation + 2% lidocaine is used for epidural injection once a week, 3 times as a course of treatment, and another course of treatment can be used after 2-4 weeks. (5) Chemical lysis of the nucleus pulposus Using collagenase or papain, injected into the intervertebral disc or between the dura and the herniated nucleus pulposus, selectively dissolve the nucleus pulposus and the fibrous ring without damaging the nerve roots, in order to reduce the pressure in the disc or make the herniated nucleus pulposus smaller so as to relieve the symptoms. However, there is a risk of allergic reaction to this method. 2.Percutaneous myelotomy/myeloplasty The nucleus pulposus will be suctioned out or laser vaporized by entering the intervertebral space under X-ray surveillance with special instruments, so as to reduce the pressure in the intervertebral disc and achieve symptomatic relief. 3.Surgical treatment (1) Indications for surgery ① history of more than three months, strict conservative treatment is ineffective or conservative treatment is effective, but frequent recurrence and heavy pain; ② first attack, but the pain is severe, especially in the lower extremities, the patient has difficulty moving and sleeping, in a forced position; ③ combined with the expression of cauda equina compression; ④ single nerve root paralysis, accompanied by muscle atrophy, muscle strength loss; ⑤ combined with spinal canal (5) combined with spinal stenosis. (2) Surgical methods ①In recent years, minimally invasive surgical techniques such as microdiscectomy, microendoscopic discectomy and percutaneous foraminoscopic discectomy have reduced surgical injuries and achieved better treatment results in the near future, but they require high operator skills, otherwise the surgical risks are extremely high, the nerves are easily damaged, the discects are not completely removed, and the postoperative recurrence rate is slightly higher compared with traditional surgery; ② Posterior lumbar back incision, partial removal of the lamina and articular processes In the case of central type disc herniation, a partial resection of the lamina and articular eminence, or disc removal through the intervertebral space is performed. For central disc herniation, after laminectomy, epidural or intradural discectomy is performed; ③In cases of combined lumbar instability, lumbar spondylolisthesis, and lumbar spinal stenosis, simultaneous spinal fusion is required. In addition, for patients with high disc herniation and heavy weight are also classified as within the treatment of lumbar fusion by a wide range of scholars. Lumbar fusion can be the ultimate surgery for lumbar disc herniation because the disc tissue can be completely removed and will not recur after surgery. After lumbar fusion, the patient can completely resume a normal life without recurrence. Although the surgery is slightly traumatic, it can improve the quality of life and solve the worries. Prevention Lumbar disc herniation is caused by accumulation of injury on the basis of degeneration, and accumulation of injury will aggravate the degeneration of the disc, so the focus of prevention is to reduce accumulation of injury. The bed should not be too soft when sleeping. Long-term ambulatory workers need to pay attention to the height of the table, chair, and regularly change the posture. Occupational work requires frequent bending movements, should regularly stretch, chest activities, and use a wide belt. Should strengthen the lumbar back muscle training, increase the intrinsic stability of the spine, long-term use of waist circumference, especially need to pay attention to lumbar back muscle exercise to prevent the adverse consequences of disuse muscle atrophy. If you need to bend over to get something, it is best to use hip flexion, knee flexion squatting way to reduce the pressure on the back of the lumbar intervertebral disc.