Lumbar disc herniation is a disease in which the disc is misaligned beyond the normal disc boundary, compressing the nerves and causing pain, weakness, ganglion paralysis or abnormal distribution of sensation in the dermatome. Lumbar disc herniation is common in clinical practice, and back pain and lumbar disc herniation alone are not lumbar disc herniation. However, issues related to it, such as the choice of treatment measures, the timing of surgery, indications for surgery, and surgical methods, are more controversial. Let’s talk about the 10 problems about lumbar disc herniation today. First, is a herniated disc the same thing as a lumbar disc herniation? No. A herniated disc is a rupture of the intervertebral disc’s annulus fibrosus, and the nucleus pulposus tissue protrudes (or prolapses) from the rupture into the posterior or spinal canal. This is really just a pathological change, or imaging presentation. It is not a disease. There are also long-term follow-up studies that have found no correlation between the presence of a herniated disc in these volunteers and the subsequent presence or absence of low back pain and the duration of low back pain. Lumbar disc herniation, on the other hand, is a clinical syndrome in which a herniated lumbar disc causes irritation or compression of the adjacent spinal nerve roots, resulting in a series of symptoms such as low back pain, numbness and pain in one or both lower extremities. The diagnostic criteria proposed by the professor have been used until now: ①, leg pain is greater than lumbar pain, mainly confined to the sciatic nerve or femoral nerve innervation area; ②, abnormal sensation in the dermatomes; ③, positive straight leg raise test with an angle less than 50% of normal, or positive straight leg raise test on the healthy side; ④, two of the four items such as muscle atrophy, weakness, hypoesthesia and weakened tendon reflexes; ⑤, imaging features consistent with clinical manifestations. ⑤. Imaging features consistent with clinical manifestations. According to the above diagnostic criteria and the pathological features of lumbar disc herniation, lumbar disc herniation must not only have pathological changes of lumbar disc herniation (imaging manifestations), but must also have clinical manifestations of damage to the corresponding nerve structures, and pain and numbness with radicular distribution. Therefore, even if there is an obvious lumbar disc herniation on imaging, and there is also regional pain in the lumbar region, buttocks or thighs, etc., the diagnosis of lumbar disc herniation is questionable if there is no pattern of radicular distribution of nerves. 2. Is CT preferred for the examination of lumbar disc herniation? No. It is better than CT examination in terms of diagnostic accuracy and false positive rate, and has the characteristics of non-invasive, multi-dimensional and radiation-free. Therefore, MRI is preferred as the imaging test of choice for patients with a diagnosis of lumbar disc herniation and the presence of a corresponding history and positive physical examination findings, with CT, myelography, or CT myelography as an alternative. 3. Is bed rest mandatory for conservative treatment of lumbar disc herniation? No. Less benefit (pain, functional recovery) is recommended for bed rest in patients with acute low back pain than for continued maintenance of daily activities, and there is little difference between bed rest and maintenance of activity in patients with lumbar disc herniation. There is a large body of literature that is consistent with these views and few studies have been reported that advocate strict bed rest. This shows that bed rest is not necessary, and if the patient’s pain and dysfunction are not so severe as to make it difficult to walk, there is no need to artificially restrict their activities and strictly require bed rest. 4. Is enhanced myelography-guided dural hormonal injections (ESIs) necessary for the treatment of lumbar disc herniation? Yes. Compared with pharmacological treatment, transforaminal ESI has a better utility ratio and is significantly more effective in short-term pain control, improving the clinical prognosis of most patients with lumbar disc herniation. Moreover, there is no statistically significant difference in the treatment prognosis of ESI for different types of lumbar disc herniation. 5. Is conservative treatment preferred for patients with symptomatic lumbar disc herniation? Yes Lumbar disc herniation is self-limiting to some extent. For patients with mild symptoms, surgery or conservative treatment can achieve better functional improvement, and conservative treatment can avoid the risk of surgery for patients. In cases of neurogenic pain with positive signs of nerve root compression or neurological dysfunction, where the herniated disc is confirmed by imaging to be compatible with clinical symptoms and where the duration of symptoms exceeds 6 weeks, surgery is more effective than non-surgery. It should be noted that in patients with psychiatric depression, the functional prognosis is worse and poorer after surgical treatment. 6. Is the earlier the surgical treatment for lumbar disc herniation, the better? No. The longer the duration of symptoms of lumbar disc herniation, the worse the final treatment outcome, whether surgical or non-surgical, but independent of the duration of the disease before treatment. Surgery within 6 months is recommended for patients with lumbar herniated disc radiculopathy whose symptoms are severe enough to require surgical treatment. Available evidence suggests that patients with early surgical intervention (6 months – 1 year) have faster postoperative recovery and better long-term neurological prognosis. Therefore, it is important for both patients and orthopedic surgeons to recognize that treatment of lumbar disc herniation should involve early intervention, whether surgical or non-surgical. 7. Is the efficacy of intervertebral foraminoscopy necessarily better than that of conventional surgery? No. In patients with strictly selected indications, discoscopic treatment can achieve the same results as open disc surgery. In addition to laminectomy, there is no significant difference in outcomes between percutaneous discectomy and traditional open discectomy. In addition, there is no clinical evidence to support that medial synovectomy for lumbar herniated disc radiculopathy improves functional prognosis. 8. Is spinal fusion necessary for specific patients with lumbar herniated disc radiculopathy? No. Only 45% of patients return to work within 1 year after fusion compared with 70% of patients who return to work within 1 year after discectomy. Although the results of fusion surgery are somewhat better than nucleotomy after 6-7 years, the difference is not significant, and the fusion procedure is difficult and has many complications. For young patients, fusion surgery can be considered. 9. Is the surgical outcome better in patients with a herniated nucleus pulposus – smaller fibrous ring rupture? Yes. Studies with evidence level I confirm that intraoperative findings are most closely related to the final outcome. Patients with a small herniated nucleus pulposus – small fibrous annulus have the best outcome, the lowest recurrence rate (1%), and the lowest reoperation rate (1%). Patients with herniated nucleus pulposus – intact annulus had the next best outcome, with recurrence and reoperation rates of 10% and 5%, respectively. Patients with herniated nucleus pulposus – large fibrous ring rupture had a worse outcome, with a recurrence rate of 27% and a reoperation rate of 21%, while patients with unruptured nucleus pulposus – intact fibrous ring had the worst outcome. 10. Is spinal fusion necessary for specific patients with herniated lumbar disc radiculopathy? No. In patients taking glucocorticoids and fentanyl, there is a statistically significant improvement in low back pain in the short term after surgery, however, 1 year after surgery, there is no statistically significant difference in the degree of improvement in leg pain compared to those not taking them. Therefore, the use of glucocorticoids or/and fentanyl after lumbar decompression is not recommended to improve long-term postoperative pain in patients.