Lumbar disc herniation is a common and frequent disease in orthopaedic clinics, which is characterized by low back pain, leg pain, or both. However, there are many causes of low back pain, and Lewis has listed 158 factors that can cause low back pain, which should be considered comprehensively in diagnosis. 1. Pelvic outlet syndrome Pelvic outlet syndrome is a symptom group caused by the irritation or compression of the sciatic nerve passing through the pelvic outlet, and it was only named in the 80’s. Its full name is “sciatic nerve pelvic outlet stenosis syndrome”. In the past, it was often confused with “pear-shaped muscle syndrome”, but research has shown that pear-shaped muscle lesion is only one of the causes of this disease, and only a small part of it, according to statistics, only about 10%. (The pelvic outlet of the sciatic nerve is a bony fibrous canal composed of multiple layers of muscles, ligaments and connective tissues in the posterior pelvic wall; it starts from the pelvic mouth and ends at the lower edge of the internal muscle of the foramen ovale. The sciatic nerve passes through it from the posterior pelvic wall into the gluteal region. The pear-shaped muscle starts at the anterior edge of the sacrum and crosses the foramen magnum transversely to end at the superior trochanteric fossa, dividing the pelvic outlet into two segments; the superior gluteal nerve and artery pass through the upper segment; the lower segment is the inferior foramen of the pear-shaped muscle, which is composed of the inferior edge of the pear-shaped muscle and the superior edge of the superior I muscle with a width of only 2 . 7 + O . The lower segment is the inferior foramen of the paretic muscle, which is a triangular slit of only 2.7 + O.6 cm in width formed by the inferior border of the paretic muscle and the superior border of the superior I muscle. Injury or lesion of the soft tissues here and mutation of the pear-shaped muscle can cause irritation or compression of the sciatic nerve, resulting in a series of clinical symptoms. (2) Clinical manifestations The main clinical manifestation is irritation of the sciatic nerve trunk, starting with radiating pain along the sciatic nerve in the buttock, accompanied by motor, sensory or reflex disorders in its innervated area. The onset of the disease may be gradual or acute, with a history of trauma, exertion, exposure to cold or moisture. The onset of the disease may be slow, with a history of trauma, exertion, cold or dampness. The onset is mostly unilateral, with an initial dull, aching or heavy sensation in the buttocks, or sometimes a severe sharp pain. The pain radiates to the posterior thigh and lateral calf, but rarely reaches the heel and the bottom of the foot, and there is no clear radical boundary. The pain may be aggravated by walking, or intermittent claudication may occur. On examination, there is significant pressure pain at the surface projection of the sciatic nerve outlet in the buttock, which is about 2.5 cm above the middle and inner 1/3 of the line between the sciatic tuberosity and the greater trochanter. On examination, there is obvious pressure pain at the surface projection of the sciatic nerve outlet in the buttock, which is about 2.5 cm above the middle and inner 1/3 of the sciatic tuberosity and the greater trochanter. Sometimes painful nodules or spasmodic pear-shaped muscles can be found locally. (3) Physical examination Feibeng’s sign: passive internal rotation of the lower limb in the extended hip position Thiele’s test: internal retraction, flexion and internal rotation of the hip joint Prone position hip extension and knee flexion, the doctor holding the heel and strong internal rotation of the hip can induce the reappearance of symptoms Straight leg raising test, flexion and neck test are mostly atypical. No positive signs in the lumbar region (4) Treatment Local closure can identify lumbar disc herniation. If the local closure does not heal, consider sciatic nerve release or pear-shaped muscle cut (needle knife treatment). 2. gluteal epicutaneous nerve entrapment syndrome The gluteal epicutaneous nerve originates from the lateral branch of the posterior branch of the L1-3 spinal nerve, and when it crosses the iliac crest into the buttocks, it passes through the lumbar dorsal fascia to form a bony fiber canal at the upper edge of the iliac crest and penetrates into the subcutis, distributing in the buttocks and the posterior lateral skin of the femur. The gluteal epicutaneous nerve can produce a series of symptoms when it is irritated or compressed at the deep fascial foramen. Clinical manifestations include low back pain and gluteal pain that may spread to the thighs and N fossa, but rarely involves the lower legs; there are obvious pressure points under the edge of the iliac crest above the posterior superior iliac spine, and sometimes striated nodes or small lipomas can be found; it may be accompanied by gluteal muscle spasm. Local closure or acupuncture treatment can eliminate the pain immediately. No signs in the lumbar region, negative straight leg raise and strengthening test can exclude lumbar disc herniation. 3, third lumbar transverse process syndrome The third lumbar vertebra is located in the middle of the lumbar vertebra, its transverse process is the longest and has a large posterior extension curvature, and many muscles and fascia of the lumbar back and abdomen are attached to it, forming the lumbar vertebra activity hub and stress center. Therefore, it is susceptible to musculofascial strain injury. The tip of the third lumbar transverse process is immediately behind the posterior branch of the second lumbar nerve root, and when the waist is bent forward and to the opposite side, it is easily stretched and worn to cause pain and numbness in its innervated area; it can also involve the anterior branch to cause radioactive pain, spreading to the hip and anterior thigh, and a few radiating to the perineum. The lateral femoral cutaneous nerve trunk of the lumbar plexus nerve passes in front of the transverse process of the third lumbar vertebra and is distributed to the outer thighs and knees, where the lesion may also produce symptoms of lateral femoral cutaneous neuralgia. The onset of the third lumbar transverse process syndrome may be slow or acute, and there may be a history of trauma. In addition to the above symptoms, examination may reveal significant pressure pain at the tip of the third lumbar transverse process and local muscle spasm or muscle tension. In lean and long patients, the third lumbar transverse process can be found to be too long. When local closure, when the needle tip reaches the lesion area, the original symptoms can be induced to reappear; local closure or acupuncture treatment can immediately relieve pain, and the long-term efficacy of acupuncture treatment is better. 4, gluteus maximus strain The gluteus maximus is the largest superficial muscle in the body, its covering fascia is thin, and its starting part is vulnerable to strain injury. The innervated nerves of the gluteus maximus come from L5 to S2, and the pain can be involved in the lower limbs and produce symptoms similar to those of lumbar disc herniation. Acute gluteus injury can cause muscle spasm, but the pressure point is lateral to the posterior superior iliac spine. 5.Interspinous ligament strain is one of the common causes of lumbar pain, which generally manifests as soreness and weakness in the lower back when bending, difficulty in straightening and local pain after bending, etc. 6.Posterior branch of spinal nerve syndrome The posterior branch of spinal nerve is issued by the spinal nerve and is about O.5-1cm long. The posterior branch of the spinal nerve emanates from the spinal nerve and is about O.5 to 1 cm long, and travels posteriorly and inferiorly at the inferior edge of the transverse process of the lower vertebral body and lateral to the superior articular process, and is divided into medial and lateral branches with an angle of about 60 degrees. The medial branch travels through the transverse root of the inferior vertebral body and the lateral aspect of the superior articular process downward through the osteofibrous canal for 3 vertebral bodies, crossing the deep fascia near the midline to the subcutaneous level. Along the way, it branches to the small articular processes, fascia and ligaments one or two segments below. The lateral branch travels inferiorly and divides into muscular branches that innervate the paravertebral muscles. The dermatomes branch descends through the lumbodorsal fascia to the subcutaneous level in three vertebrae and continues inferiorly: L1 lateral branch to below the iliac crest; L2, L3 lateral branch through the buttocks to the posterior femur; L4, L5 across the iliac crest through the buttocks to the posterior sacrum. The endings of the medial branches are generally distributed between the posterior midline and the line of the lesser trochanter; the endings of the lateral branches are distributed beyond the line of the lesser trochanter. There are anastomosing branches between the medial and lateral branches, and the innervation of the same structure is polygenic. For example, the L4-5 tuberosity is innervated by the medial branches of the posterior spinal nerve of L2, L3, and L4. Thus, stimulation of a posterior branch of a spinal nerve can cause referred pain in the distal compartment below, and all symptoms disappear when this nerve trunk is closed. Because the posterior branch of the spinal nerve is more fixed at its origin and bifurcation, it is susceptible to strain during spinal motion. Spinal fracture. Changes in the relative position of the vertebral bodies due to disc degeneration or postoperative changes can pull on the posterior branch of the spinal nerve and produce symptoms. Clinical manifestations are acute or chronic low back pain, which may be accompanied by thigh pain, but not the knee joint, without abnormal sensation, movement and reflexes; complaints of pressure pain at the root of the ipsilateral transverse process in the 2 to 3 segments above the painful area. 7, N cord muscle and gastrocnemius muscle strain generally should not be confused with lumbar disc herniation, and misdiagnosis is caused by a positive straight leg elevation test when the local symptoms are aggravated by straight leg elevation. This indicates that it is important for the clinician to correctly understand the straight leg raise test and other signs related to nerve root stimulation. Patiently searching for local pressure points for closure can both clarify the diagnosis and achieve the purpose of treatment. 8, lumbar spine small joint degeneration In recent years, the failure of lumbar spine surgery has increased, and the interrelationship between small joints and intervertebral discs and their status in the etiology of lumbar pain has received increasing attention. substance P (SP) and calcitonin gene-related peptide (CGRP) as the main peptide-ergic neurotransmitters are a very active research area in recent years. Studies have shown that SP and CGRP nerves are damage receptors that transmit nociception, have strong vasodilatory capacity, and can also contribute to bone reconstruction. These peptidergic nerves located in the joint capsule, especially in the synovial folds, may be the neural basis for chronic low back pain. The increased stress on the small joints during spinal degeneration can squeeze the synovial folds between the articular cartilage and pull on the small joint capsule, thus stimulating the SP and CGRP nerve fibers in them to release SP and CGRP and cause low back pain. This finding suggests that mechanical stimulation of sensory nerves on the small joint capsule may be an important cause of chronic low back pain.