After the correct clinical diagnostic procedure, the diagnosis of low back pain is clear, and pain due to extreme conditions in the thoracolumbar spinal canal or idiopathic lesions (tumors, vascular malformations, spinal cord lesions, etc.) is excluded. Then it is necessary to make the appropriate and rational treatment of the various pathologies. First of all, to determine whether there is an indication for surgery, which is extremely important, otherwise the condition will be delayed, the choice of various non-surgical treatment methods and cooperation should be based on the changes in the condition, that is, different diseases at different stages of the onset of the treatment provided by different means and methods of treatment, treatment procedures are also different. To achieve strong targeting, short course of treatment, good efficacy, safety and reliability; cause and symptomatic and to achieve the repair of damaged tissue and limb function restoration purposes. Ma Songhe, Department of Pain, Henan Provincial People’s Hospital I. Theoretical Basis of Clinical Treatment (I) Pathophysiology of Tissue Damage in Lumbar Vertebral Tubes The primary morbidity factors in lumbar vertebral tubes are mainly divided into two categories: (1) Mechanical factors. Mechanical compression or irritation due to herniation of intervertebral discs, hypertrophy and degeneration of ligamentum flavum, thickening of posterior longitudinal ligament, hypertrophy of small joints, and stenosis of the spinal canal can constitute compressive damage to the nerve root, dural sac, or cauda equina. (2) Biological factors. Neurogenic transmitters (substance P, vasoactive intestinal peptide, calcitonin gene-related peptide, etc.) and inflammatory mediators (bradykinin, prostaglandin E1, leukotriene B4, acetylcholine, etc.) produced by medullary protrusions and inflammatory mediators (bradykinin, prostaglandin E1, leukotriene B4, acetylcholine, etc.) generated by immune responses produce a more intense aseptic inflammatory response of fatty connective tissues in the spinal canal before mechanical compression damage to the nerve root and the dural sac occurs. This leads to pathological changes such as inflammatory swelling ischemic stasis, fibrosis, and demyelination of the epidural tissue, and thus the nerve tissue is stimulated and agitated. Clinically, it manifests as two syndromes:(1) Pain. The nerves are hyper-sensitive and ectopic impulses are generated, manifesting as lumbago, lumbar hip pain, or lumbar leg pain. (2) Numbness or/and paralysis of the lower extremities. Sensory deficit or motor loss, such as muscle weakness, muscle atrophy, and loss of tendon reflexes. It may even lead to cauda equina damage (dysfunction of urinary and defecation, paralysis of the lower limbs, perineal sensory disturbances). For mechanical morbidity factors, spinal manipulation (non-surgical) or surgical decompression is mainly used to mechanically loosen the dural sac and nerve roots, improve blood supply and restore function. For biological pathogenic factors, epidural nerve block therapy or nucleus pulposus chemolysis (e.g. collagenase injection) is mainly used to eliminate the pathological changes of aseptic inflammatory reaction and block the development of lesions. Symptomatic treatment can be used as appropriate, such as the use of anti-inflammatory and analgesic drugs, peripheral percutaneous electrical stimulation and other kinds of physical therapy can relieve pain and restore muscle strength and nerve function. (II) Pathogenesis of soft tissue damage outside lumbar spine tube The soft tissue pain caused by acute injury sequelae or chronic strain injury is the primary factor, and its preferred site is mainly in the skeletal muscle and fascia at the periosteal attachment. Due to the inflammatory swelling, stasis, and decomposition of necrotic tissues in the damaged tissues, the nerve endings at the attachments are chemically stimulated by aseptic inflammation and cause pain. Regular soft-tissue pressure points are formed locally in a three-dimensional pain-causing area, which is also characterized by distal involvement. Pain can be induced by external stimuli such as episodes of sensation, infection, fatigue, or minor trauma, wind, cold, and dampness in these diseased tissues. Pain-induced muscle spasms and myoclonus can be reciprocal. Chronic and long-lasting muscle degeneration contracture can mechanically compress or pull the peripheral vascular nerves, clinically there can be a radioactive numbness of the limbs, or even atrophy and weakness, blood flow disorders, such as cold distal limbs, hematoma, dark ze, weak pulse and other symptoms. In the case of prolonged lesions, spinal and pelvic dynamic balance disorders may occur. The human body will cause corresponding compensatory regulation (left-right, front-back) and series of compensatory regulation (upward and downward), once the loss of compensatory regulation, one side of the lumbar pain can be followed by the opposite side of the lumbar pain or abdominal pain, but also upward to follow the back, neck, scapula, upper limb pain or headache and so on, and downward to follow the sacro-coccygeal, sacro-iliac, buttocks and hips, knees and ankles, the soles of the feet pain symptoms. For early soft tissue damage, massage, drug injection and various physical therapy can be performed; for middle stage cases, spinal release manipulation, silver needle release therapy, supplemented by traditional Chinese medicine and various physical therapy; for late soft tissue damage, degeneration and contracture are serious, and various parts of the soft tissue can be performed release surgery. Clinically, most patients have both internal and external tissue damage in the spinal canal, and the treatment should generally eliminate the intra-vertebral pathogenic factors first, and then lift the extra-vertebral pathogenic factors. If only the elimination of intra-vertebral pathogenic factors without solving the extra-vertebral pathogenic factors, it will even aggravate the extra-vertebral soft tissue pain. Experiments have proved that stimulation of the anterior root of the spinal cord produces impulses that conduct retrogradely along the motor neurons, which can reduce the excitability of the motor neurons, a phenomenon known as return inhibition. This phenomenon is called return inhibition. The mechanism is caused by the excitation of motor neuron axon side branch discharges to the inhibitory interneurons (Renshaw cells) in layer VII of the ventral horn of the gray matter of the spinal cord, which in turn inhibit motor neurons. Therefore, elimination of aseptic inflammatory stimuli by epidural nerve block alone, on the contrary, weakened or disappeared the above mentioned return inhibitory process, which enhanced the muscle spasm caused by extra-vertebral soft tissue damage and aggravated the pain. On the other hand, modern electrophysiology suggests that stimulation of low-threshold myelinated primary afferent fibers such as muscle Ia and Ib afferent fibers attenuates the response of pain-sensitive neurons in the dorsal horn of the spinal cord, and on the contrary, blockade of conduction of myelinated fibers enhances the response of pain-sensitive neurons in the dorsal horn. Therefore, this inhibition of dorsal horn injury messaging by coarse fibers occurs mainly in the dorsal horn glial region (SG). Epidural nerve block alone cannot be used for mixed damaging lesions inside and outside the lumbar spinal canal. Second, clinical treatment ideas (a) Thoracolumbar spinal canal internal tissue damage. In addition to various tumors, vascular malformations, demyelinating diseases, spinal cord cavities and other specialty diseases, the main treatment is for disc herniation, spinal stenosis and cauda equina damage. Indications for surgery: (1) Intervertebral disk herniation. Giant, ruptured or multi-segmental lesions; (2) Severe stenosis of the spinal canal. The sagittal diameter of the main spinal canal is less than 10 mm or the anterior-posterior diameter of the nerve root canal is less than 2 mm; (3) Cauda equina damage. Perineal or perianal sensory loss, vesico-rectal dysfunction and lower limb paralysis. Surgical methods: (1) Conventional laminectomy decompression. Enlarged opening, hemilaminectomy, total laminectomy (2) Laminectomy. Plus internal fixation or plus implant fusion (3) Multi-segment soft tissue release in the spinal canal (4) Discoscopic disc removal (4) Percutaneous percutaneous discectomy and suction or high-power laser resection. Non-surgical treatments for lumbar spinal canal lesions: epidural space drug injections, spinal release maneuvers, collagenase injections. Intravenous drips of mannitol or β-heptapodophylloside sodium for dehydration and swelling, dexamethasone or leupeptin for anti-inflammation and analgesia, and cytidine or neurotropin for nerve nutrition can be used as adjunctive treatments. (ii) Extravertebral soft tissue damage. Generally, non-surgical treatment should be used, because the vast majority of patients can be cured. Commonly used and effective treatment methods include (1) nerve block therapy (2) soft tissue pressure point massage (3) silver needle therapy (4) various physical therapy. Indications for surgical treatment: (1) persistent symptoms (serious condition, long duration) (2) recurrent attacks (without obvious triggers) (3) prolonged treatment (various non-surgical therapies fail to work) (4) serious impact on work and life (loss of self-care ability). Surgical methods: (1) lumbar soft-tissue release, (2) hip soft-tissue release, (3) soft-tissue release of the superior border of the pubic symphysis, (4) femoral intramuscular release, (5) inferior inferior fat pad release, (6) tarsal sinus soft-tissue release, and (7) posterior soft-tissue release of the internal (external) ankle. Clinically, mixed lesions inside and outside the spinal canal are more common, and the treatment generally focuses on the intravertebral canal lesions first, especially to grasp the surgical indications, which can eliminate the pathogenic factors in time without delaying the condition, and then actively deal with the soft tissue damaging lesions outside the spinal canal, and both of them should not be neglected. For the majority of patients, it is appropriate to use targeted, highly effective and safer non-surgical methods to form a coherent treatment program. Only by doing both internal and external treatment, and emphasizing both muscles and bones, can a cure be obtained. The following clinical treatment program only provides non-surgical treatment options based on the development of lumbar and leg pain disease and different conditions. (I) Damage to tissues in the thoracolumbar spinal canal. (1) Acute onset of patients, because the spinal canal nerve root sheath membrane and the fat connective tissue outside the dural sac aseptic inflammatory reaction is strong, the tissue of inflammatory swelling, ischemia and stasis is obvious, the role of a variety of pain-causing substances, with pain as the main symptom, the nerve compression of the mechanics is not the main factor, so in bed or wearing a waist cuff should be used with the assistance of the epidural lumen injection, or the addition of the spinal column to relaxation of the manipulation. For patients with severe pain who cannot walk, intravenous drip dehydration and swelling, anti-inflammatory and analgesic, nutritive nerve and other drugs can also be added. (2) In chronic patients, the mechanical factor of nerve compression becomes the main link, the nerve root, dural sac can be extruded from the herniated disc or due to the fat connective tissue degeneration contracture, fibrosis, the role of the cord and damage occurs. Therefore, spinal release maneuver should be taken first, followed by epidural space drug injection, assisted by intravenous drip neurotrophic drugs, traction therapy, or collagenase nucleolysis plus epidural space drug injection can also be used. (B) Thoracolumbar extravertebral soft tissue damage. (1) Acute onset of patients, nerve block or pressure point injection of drugs; more serious, severe pain can be used to nerve block and spinal release maneuver, rapid relief of pain, release muscle spasm; milder patients choose a variety of physical therapy, such as: intermediate frequency electrotherapy, thermal magnetic therapy, semiconductor laser or ultrashort wave and so on. (2) Patients in the chronic stage are characterized by heavy tissue lesions, multiple sites of disease, low muscle mechanics compensation function, often coexisting with intravertebral lesions, so the treatment should focus on relieving myospasm and myoclonus. Clinically, spinal release manipulation or/and silver needle acupuncture therapy is adopted, supplemented by external application of traditional Chinese medicine and thermal magnetic therapy to achieve the purpose of soft tissue release and repair. Exercise therapy can also be carried out at a later stage to enhance muscle strength and physical fitness in order to promote disease recovery. For the elderly or adolescent patients, those who are physically weak and have more serious cardiovascular and cerebrovascular diseases, they should be treated with caution, and differ in the selection of manipulation, choice of drugs, and layout of silver needles, which should be used to determine the treatment program for individual differences. Fourth, commonly used non-surgical treatment (a) manipulation through the mechanics of the human spine, limbs, bones and joints and soft tissues in specific parts of the body, regulating the body’s anatomical position and functional status to achieve the purpose of pain management. Most of the human low back pain belongs to the soft tissue pain, manipulation has a unique therapeutic effect, for the disc herniation and due to the epidural fat connective tissue chronic inflammatory adhesion caused by the dural sac and nerve root stimulation and compression also has a better role in the relaxation. However, due to the basic research is not deep enough, some osteopathic treatment still has a certain degree of risk, clinical application must be used in accordance with the principles of human spinal biomechanics, standardized techniques. 1. spinal release maneuver. For intervertebral disc herniation, spinal stenosis (part). (1) Drawing plate manipulation. Applicable to lateral or central paracentral type of disc herniation, this technique by biomechanical experimental results show that the lumbar spine flexion, stretching and torsion composite stress makes the disc protrusion away from the nerve root displacement, the main mechanism is to loosen the disc protrusion and the nerve root of the two inflammatory adhesion, so as to reduce or eliminate the nucleus pulposus protrusion of the nerve root and the dural sac of the nerve root and the irritation and compression. Operation method: the patient is lying in prone position, with arms placed on both sides of the torso. A long and wide cloth belt of folded style is pulled out from the patient’s back to the axilla, and crossed in front of the chest and fixed at the head of the bed (or fixed with a special chest traction belt). The assistant uses both hands to hold the affected side of the lower limb above the ankle for confrontation traction (or on the traction bed by the calf fixed sleeve to start traction). The doctor stands on the affected side, with a finger pressure in the lesion of intervertebral spinous processes next to the small joints, this is both the paraspinal pressure and pain points and scoliosis bulge, the other hand on the healthy side of the lower limb above the knee wrenching to make the hip hyperextension. Ask the assistant to gradually stretch the affected side of the lower limb, when the operator’s fingers feel a sense of joint pulling open, lift the hand of the healthy leg to the affected side of the diagonal wrench to make the lumbar hyperextension and twisting, pressing the joint of the thumb under the thumb there is a sense of bony throbbing and accompanied by a continuous “ka-ka” sound, which is the soft tissue relaxation of the popping and adhesion of separation sound. Quickly flatten the healthy limb in the original position, let the patient rest in bed for a while after the operation, turn over and stay in the supine position for 4 hours. Each lesion segment can be manipulated only once, and after each treatment, the patient must stay in bed for three days and wear a waist cuff for three weeks. (2) Lumbar lumbar compression manipulation: suitable for centralized herniation of intervertebral disk. The patient is lying in the abdominal position, with shoulders abducted and elbows flexed, both arms naturally flat, and the chest belt and lower limb fixation belt are used for traction. The operator stands on the affected side of the patient’s torso, and when the assistant starts the traction machine to gradually stretch the patient’s lumbar spine, the operator’s thumbs of both hands are respectively along the spinal spinous process on both sides of the spondylolisthesis about (2cm) from the upper lumbar section to the lumbosacral section of the gliding push line, when the thumb pushes the pressure to the lesion interspace, the traction force must reach about 1.5 times of the patient’s weight, usually 90-120 kilograms, and the operator quickly applies the pressure to the spinal column in the anterior part. The operator quickly applies pressure to the anterior aspect of the spine, at this moment, the bony joints can be felt to be obviously throbbing and emitting a clicking sound, and then slowly make the traction force decrease to disappear, and repeat the operation again if there is no bony joints throbbing. After the operation, the patient is asked to lie down for 4 hours, absolutely bedridden for three days, and wear a waist cuff within three weeks. (The following figure) 2. Sacroiliac joint restoration maneuver ① anterior malposition. The patient lies supine. The operator stands on the injured side, presses the distal side of the big fishbone with one hand on the front of the ilium, with the tiger’s mouth facing downward, puts 4 fingers in the groin, and puts the thumb on the lateral side of the femur, and supports the lower part of the knee with the other hand, and naturally bends the knee so that the hip flexion is at an angle of 90°. Operate according to the following steps: (1) both hands with a steady force vertical to the iliac posterior impact of the push; (2) then support the hand of the knee so that the hip is fully flexed, press the hand of the ilium at the same time to push back hard, at this moment often feel the iliac bone to move or accompanied by a “click” sound; (3) the hand of the ilium to the healthy side of the palm, the muzzle of the tiger close to the iliac bone anteriorly, in the hip valgus position inward above the ilium several intermittent push. Intermittently push the ilium several times. (Figure below) ② Posterior malposition. The patient lies on the healthy side or prone position. The operator to palm the root of the palm of the hand forward to hold the injured side of the posterior superior iliac spine, the other palm to take the ankle, gradually extend the hip to the maximum, and then hold the iliac bone of the hand to push the iliac bone forward and downward quickly, so that the hip is extended, feel the iliac bone to move, the end of the maneuver. (As shown below) (B) Nerve block therapy 1. Sacral cleft epidural anterior gap nerve block. It is suitable for nerve root and epidural inflammation. The patient takes the prone position, the lower abdomen is padded with a thin pillow, and both lower limbs are slightly abducted, which is convenient for the patient to relax the buttock muscles and the operator to touch the upper edge of the sacral fissure, and a piece of gauze is stuffed under the tip of the coccyx to prevent the disinfectant solution from flowing to the perineum. The upper edge of the sacral fissure is touched downward along the mid-spine line, or the depression of the sacral fissure is touched 4-5 cm upward from the caudal tip. After routine sterilization, a local anesthesia skin mound was made slightly above the line joining the two sacral horns. A 4-cm, 7.5- or 8-gauge syringe with liquid is used at an angle of about 20° (30° for women) to the skin to directly pierce the sacral fissure. When the needle penetrates the sacrococcygeal ligament, the operator feels a sense of emptiness, that is, the puncture is successful, and then the beveled surface of the needle body is tightly attached to the anterior wall of the sacral canal fissure into the needle 3-4cm, suction bloodless cerebrospinal fluid, and then slowly injected into the therapeutic liquid, no resistance to the injection of medication, about 1-2 minutes to complete the injection, the needle is taken to the supine position, and the patient is observed to pulse and breathing and other reactions. The patient’s pulse, respiration and other reactions will be observed. Drug composition: 2% lidocaine 5ml, cytidine diphosphate choline 0.5g, vitamin B121mg, dexamethasone 5mg (or lepirin 0 .9g); dosage: 25-30ml for those with high segmental (L1-3) lesions, 16-20ml for those with low segmental (L4-S1), with severe diabetes mellitus When using collagenase treatment, it must be carried out under imaging surveillance (CT or C-arm X-ray machine), and after successful puncture with a 16cm long, 18-gauge special disk puncture needle, the depth of the epidural catheter with a steel wire core is 12-14cm from the skin in the lumbar 5-sacral 1 space, 12-14cm from the skin in the lumbar 4-5 space, and 12-14cm from the skin in the lumbar 5-sacral 1 space. 14cm, lumbar 4-5 gap from the skin 16-18cm. exit the wire in the catheter, no blood or cerebrospinal fluid through the catheter suction, injection of contrast agent 1-2ml in the imaging monitor to observe the results of the positive and lateral contrast agent display, especially the lateral contrast agent in the anterior interstices of the dural sac was a line-like distribution, it is indicated that the intubation is successful or in the anterior interstices of the dural sac, or in the anterior interstices of the dural sac. This indicates successful intubation, or the tip of the wire in the catheter is located behind the nucleus pulposus to be blocked or dissolved, as confirmed on the CT imaging monitor. The first injection of 1% lidocaine 4-5 ml, after 20 min without spinal numbness signs, that is, can be injected with collagenase 1200-2400 u (1200 u per gap injection, each time no more than 2400 u), the affected side downward side lying (central nucleus pulposus prolapse prone) after 8-10 h Get out of bed. This treatment can also be performed by lumbar foraminal injection under the supervision of an imaging monitor. Other nerve blocks, such as lumbar paravertebral nerve block, lumbar lateral saphenous fossa nerve block, gluteal epiphyseal nerve block, gluteal sciatic nerve block, etc., combined with drug injection in the area of the pressure point, can be used as appropriate according to the condition and the site of pain. (C) Silver Needle Acupuncture Therapy The silver needle made of silver as the main material, the length of the needle body for 6-15cm different specifications, needle thickness (diameter of 1.1mm), characterized by a softer texture, fast heat transfer, deep treatment site, the scope is larger, is the treatment of a variety of soft tissue pain in the treatment of the special effect of the treatment. 1. Operational procedures (1). According to the acupuncture treatment needs to take prone position (waist, lower limb posterior side), lateral position (hip), supine position (lower limb anterior side). (2). Determine the site and range of needling according to the needs of the condition. In the soft tissue pain in the specific lesion tissue to select the pressure point, generally between the pressure point of the needle distance of 1.0-2.0 cm. so called “intensive” acupuncture method. The pressure points are mostly the connection between muscle or myofascia and periosteum, with strict anatomical distribution, consistent with the site and scope of surgical release. (3). Under aseptic operation, 0.5% lidocaine was injected intradermally at each entry point, forming a dermal mound with a diameter of about 5 mm, so that the burning of the moxa ball during the injection would not produce stinging and burning pain in the skin. For larger parts of the pressure pain area such as the waist, buttocks or back of the neck has been used to en sodium emulsion topical application of the needle point, two hours after the anesthesia effect that is produced, the needle area of the skin, the subcutaneous muscles can be achieved painless. (4). Choose high-pressure sterilized silver needles of appropriate length to pierce the dermal mound, respectively, aligned with the direction of the deep lesion area for straight or oblique stabbing. Through the subcutaneous muscle or fascia directly to the periosteal attachment (pressure point), leading to a strong acidity and swelling numbness until the needle feeling. (5). Into the needle is completed, in each silver needle on the end of the ball-shaped needle installed a diameter of about 1.5cm of the ball of moxa, ignited after burning slowly. At this moment, the patient is conscious of the treatment site of the deep soft tissues appear comfortable warmth, pain all drive away. (6). Ai fire extinguished after the residual heat of the needle body still has a therapeutic effect, must be cooled before starting the needle. Apply 2% iodine to each needle eye. Allow it to be exposed (summer and fall) or covered with gauze (winter and spring) and keep it away from water for three days, so as to avoid infection at the point of needle entry. 2. Precautions (1). In the same lesion area usually only one acupuncture treatment, multiple lesion area treatment, the interval of 2-3 weeks is appropriate. Because of the silver needle acupuncture human soft tissue will carry out a stress adjustment, especially the neighboring parts of the manifestation of obvious muscle tension, while the acupuncture site is often in a state of muscle relaxation. (2). Silver needle treatment does not require needling techniques to produce tonic effects, nor does it require strong stimulation techniques to produce analgesic effects. This is because intensive needling methods can produce significant analgesic and muscle relaxation effects. (3). If the peak of the heating value of the combustion of moxa ball, because the needle body selection is not long enough to make the skin around the eye of the needle to produce burning pain intolerable, at this time, available ready to fill the cool water 20ml syringe will be sprayed with water from the needle until the high heat of the needle handle to moderate cooling.