Lumbar intervertebral disc herniation: It is one of the more common disorders, mainly because the lumbar intervertebral disc parts (nucleus pulposus, fibrous ring and cartilage plate) degenerative changes in the role of external factors, the intervertebral disc fibrous ring rupture, the nucleus pulposus tissue from the rupture protrusion (or prolapse) in the posterior or spinal canal, resulting in the adjacent spinal nerve roots suffer from stimulation or compression, resulting in lumbar pain, one lower limb or both lower limbs numbness This results in a series of clinical symptoms such as lumbar pain, numbness and pain in one or both lower limbs. The incidence of lumbar disc herniation is highest in lumbar 4/5 and lumbar 5 sacral 1, accounting for about 95%. I. Etiology (a) basic etiology 1, degenerative changes in the lumbar intervertebral disc is the basic factor: degeneration of the nucleus pulposus is mainly manifested as a decrease in water content, and can cause small-scale pathological changes such as vertebral joint instability and loosening due to water loss; degeneration of the fibrous ring is mainly manifested as a decrease in the degree of toughness. 2, injury: long-term repeated external forces cause minor damage, aggravating the degree of degeneration. 3, the weakness of the intervertebral disc’s own anatomical factors: the disc gradually lacks blood circulation in adulthood and has poor repair ability. On the basis of the action of the above factors, some kind of triggering factor that can lead to a sudden increase in the pressure on the intervertebral disc, i.e., may cause the less elastic nucleus pulposus to pass through the fibrous ring that has become less tough, causing the nucleus pulposus to protrude. 4, genetic factors: lumbar disc herniation has been reported to have familial onset, the incidence of this disease in people of color is low. 5, lumbosacral congenital anomalies: including lumbar sacralization, sacral lumbarization, hemivertebral deformity, small joint deformity and joint protrusion asymmetry, etc.. The above-mentioned factors can make the stress on the lower lumbar spine change, thus constituting an increase in the internal pressure of the intervertebral disc and susceptible to degeneration and injury. (ii) Predisposing factors On the basis of degenerative disc degeneration, a certain factor that can induce a sudden increase in intervertebral disc pressure can cause nucleus pulposus herniation. Common predisposing factors include increased abdominal pressure, lumbar malposition, sudden weight bearing, pregnancy, exposure to cold and moisture, etc. Clinical typing and pathology: The following typing can be made from the pathological changes and CT and MRI manifestations, combined with treatment methods. 1, bulging type: partial rupture of the fibrous ring, while the surface layer is still intact, at this time, the nucleus pulposus is confined to the vertebral canal due to pressure, but the surface is smooth. Most of this type can be relieved or cured by conservative treatment. 2, protrusion type: complete rupture of the annulus fibrosus, 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 of the protruding disc tissue or fragments off 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 node: the nucleus pulposus enters the cancellous bone of the vertebral body through the fissure of the upper and lower end plate cartilage, generally only have low back pain, no nerve root symptoms, most do not need surgery. Clinical manifestations (a) Clinical symptoms 1. Low back pain: It is the first symptom in most patients, with an incidence of about 91%. Due to the stimulation of the outer layer of the fibrous ring and the posterior longitudinal ligament by the nucleus pulposus, the lower lumbar induction pain is produced by the sinus nerve, and sometimes it can be accompanied by pain in the buttocks. 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 lumbar 4 to 5 and lumbar 5 to sacral 1 interval herniation, 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 small number of people with central or paracentral herniated nucleus pulposus 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 mutually aggravating factors. 3, cauda equina symptoms: the protruding nucleus pulposus or prolapsed, free disc tissue presses the cauda equina nerve, the main manifestations of which are large and small bowel obstruction, perineum and perianal sensation abnormalities. 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 lordosis is a postural compensatory deformity for pain relief. 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 forward flexion can further promote the nucleus pulposus to shift backward 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 25px of the paravertebral area, and radiating pain along the sciatic nerve may occur. About 1/3 of patients have lumbar sacral spasm. 2. Special signs (1) Straight leg raise 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 elevated 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, elevating the lower limb on the healthy side can also pull the dura mater to induce radiating pain on the affected sciatic nerve. (2) Femoral nerve pull test is performed with the patient in prone position and the knee joint of the affected limb fully extended. The examiner elevates the straightened lower limb so that the hip joint is in hyperextension, and when the hyperextension reaches a certain level and there is pain in the femoral nerve distribution area in front of the thigh, it is positive. 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 affected spinal nerve roots and the abnormal sensation in the area of innervation. The positivity rate is more than 80%. In the early stage, the symptoms are mostly skin sensation, and gradually numbness, tingling and hyperalgesia appear. Because the affected nerve roots are mostly single-jointed and unilateral, the scope of sensory impairment is small; however, if the cauda equina is involved (central type and paracentral type), the scope of sensory impairment is more extensive. (2) Decreased muscle strength 70% to 75% of patients showed decreased muscle strength. In case of lumbar 5 nerve root involvement, the ankle and toe dorsiflexion strength decreased, and in case of sacral 1 nerve root involvement, the toe and foot plantarflexion strength 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 for the localization of the involved nerve. Auxiliary examinations: (a) X-ray plain film of lumbar spine: X-ray plain film alone cannot directly respond to the presence of disc herniation, but degenerative changes such as narrowing of the intervertebral space and hyperplasia of the vertebral body edge are sometimes seen on X-ray film, which is an indirect indication, and some patients can have spinal deflection and scoliosis. In addition, X-ray plain film can detect the presence of tuberculosis, tumors and other bone diseases, which has important differential diagnostic significance. (B) CT examination: It can clearly show the site, size, morphology and displacement of the nerve roots and dural sac of the herniated disc, 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. (iii) Magnetic resonance imaging (MRI): MRI has no radiological damage and is of great significance in the diagnosis of lumbar disc herniation. MRI can comprehensively observe whether the lumbar intervertebral disc is diseased and clearly show the morphology of the disc herniation and its relationship with the dural sac, nerve roots and other surrounding tissues through sagittal images at different levels and transverse images of the involved disc. The presence of other occupying lesions in the spinal canal can be identified. However, the display of whether the herniated disc is calcified or not is not as good as CT examination. (iv) Other: electrophysiological examinations (electromyography, nerve conduction velocity and evoked potentials) can assist in determining the extent and degree of nerve damage and in observing the effects of treatment. Laboratory tests are mainly used to exclude some diseases and play a role in differential diagnosis. Fourth, the treatment system of herniated disc: (a) step treatment plan Non-invasive treatment: traction, physical therapy, Chinese medicine, Western medicine massage and massage Minimally invasive treatment: 1, radiofrequency, ozone, chemical dissolution of the nucleus pulposus and intraspinal injection, etc. 2.Posterior discoscopy and intervertebral foraminoscopy. Discectomy (fusion) surgical treatment. Traction therapy: Traction therapy principle: According to the study, the lumbar spinal space is widened by 1.5~2.5mm after traction compared with before traction, and the widening of the spinal space can make it become negative pressure, plus the tension of the posterior longitudinal ligament, which is conducive to the partial rejection of the herniated nucleus pulposus or change its relationship with the nerve root. The increase in the vertebral space and the pulling apart of the synovial joints restore the normal shape of the intervertebral foramen, thus releasing the compression of the nerve roots. Traction can also make the lumbar spine get sufficient rest and reduce the stimulation of movement, which is conducive to the absorption and decompensation of tissue congestion and edema, and can also relieve muscle spasm and reduce intervertebral pressure. (B) radiofrequency ablation of herniated discs Radiofrequency (radiofrequencyRF) treatment technology is a technology that treats herniated discs by precisely outputting ultra-high frequency electric waves through specific puncture guide needles to produce local high temperature in local tissues, which can play the role of thermal coagulation or ablation and atrophy of the nucleus pulposus of the intervertebral disc, and is therefore also called “herniated discs Radiofrequency thermal coagulation” or “radiofrequency ablation of herniated discs. Radiofrequency treatment process is precisely positioned under C-arm guidance, time detection under digital subtraction, directly acting on the diseased disc, the data is accurate to less than 1mm, the whole operation is visible, will not hurt the surrounding normal tissues and organs and nerves, radiofrequency temperature can be controlled to ensure the safety of the treatment before and after, generally not infected, there is no thermal injury. The puncture needle is only 0.7mm (as thin as an infusion needle), no incision, no bleeding, no postoperative effect on the stability of the spine, little danger and fast recovery. (C) Discoscopy (posterior discoscopy) Discoscopy (MicroEndoDiscSystem) is one of the more advanced minimally invasive spinal surgery methods in the international arena. The system combines advanced technology with clinical excellence, providing patients with a low-injury, short-course, safe and reliable treatment method. It can remove the prominent nucleus pulposus, hypertrophic ligamentum flavum and hyperplastic synapses and other neurogenic factors, thus achieving a radical cure. The system has a highly clear observation performance, flexible and stable fixation device and well-designed surgical instruments, which facilitate the smooth and efficient treatment. Now, it can treat not only lumbar disc herniation, but also lumbar spinal canal narrowing such as lateral saphenous fossa stenosis and central canal stenosis. (iv) Intervertebral foramoscopy technique Intervertebral foramoscopy technique is the application of medical endoscopy to establish a working channel for the extraction of the nucleus pulposus through the lateral route via the intervertebral foramen safety triangle with the use of the ring to polish the small articular protrusion and break through the fibrous ring into the intervertebral disc under local anesthesia and consciousness of the patient, and then use the tiny nucleus pulposus forceps and bipolar radiofrequency bendable electrodes to perform intra-disc and herniated nucleus pulposus under visualization. Extraction and ablation (lumbar 5 sacral 1 central type, paracentral type protrusion, must be through the posterior bite to remove the plate and the yellow ligament through the intervertebral plate gap into the disc extraction of the nucleus pulposus) so as to achieve the purpose of treatment of herniated disc, the emergence of this technology makes the substantial treatment of herniated disc into the minimally invasive era. V. Intervertebral foraminoscopy technology – the least invasive means of substantive treatment: (a) high safety local anesthesia, the ability to interact with the patient during surgery, no injury to nerves and blood vessels, basically no bleeding, clear surgical field of view, effectively avoiding the risk of misoperation. (ii) Ultra-minimally invasive The skin incision is only about 6mm, with minimal bleeding, short operation time and almost no scar after surgery, in line with the aesthetic point of view. (III) Precise Lateral approach avoids interference with the spinal canal and nerves by posterior surgery, does not bite off the vertebral plate, does not destroy the paravertebral muscles and ligaments, and has almost no effect on the stability of the spine. (4) Visualization The herniated nucleus pulposus and nerve roots, dural sac and hyperplastic bone tissue can be clearly seen under direct endoscopic view. (E) Fast recovery The operation time is short, and the patient can go down to the ground after the operation, and the hospital stay is about 3-5 days. (6) Wide range of indications It can remove most types of disc herniation and prolapse, and can deal with intervertebral foraminal stenosis and partial spinal stenosis. (vii) High satisfaction of efficacy Immediate postoperative relief of pain and other symptoms, self-care of urine and stool, simple care. The internationalized concept guides the rehabilitation and the early return to normal life and work after surgery. Prevention of disc herniation: Lumbar disc herniation is caused by accumulation of injury on the basis of degeneration, and accumulation of injury will aggravate the degeneration of disc, so the focus of prevention is to reduce accumulation of injury. Usually have a good sitting posture, 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 to 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.