I. Overview (I) Etiology 1. Degeneration Degeneration of the intervertebral disc is the basic factor of the intervertebral disc. With age, the water content of the annulus fibrosus and nucleus pulposus gradually decreases, the tension and elasticity of the nucleus pulposus decreases, and the structure of the intervertebral disc loosens, and the changes are more pronounced in the posterior lateral aspect of the annulus fibrosus that is not supported by the posterior longitudinal ligament. 2.Injury Accumulated injury is the main cause of disc degeneration. At the same time, injury is also a common cause of lumbar disc herniation. 3.Occupation People with a history of long-term bending and twisting work are susceptible to lumbar disc herniation, such as drivers and students. Genetics It is reported that the incidence of this disease is lower among people of color. 5, pregnancy During pregnancy, the pelvis and the lower lumbar tissues are relatively loose, and at the same time, the weight-bearing increases, which can easily cause intervertebral disc damage. （Bulging type The annulus fibrosus is partially ruptured and the superficial layer is intact. At this time, the nucleus pulposus bulges towards the spinal canal due to pressure, but the superficial layer is smooth. 2. Protruding type: the annulus fibrosus is completely ruptured and the nucleus pulposus protrudes into the spinal canal, which is only covered by the posterior longitudinal ligament or a layer of fibrous membrane, with an uneven or cauliflower-like surface. 3. Prolapsed type: The ruptured and protruded intervertebral disc tissue or fragments are detached into the spinal canal or completely free. Rehabilitation assessment (a) Clinical manifestations: Commonly found in young adults, more men than women, with a history of stooping labor or sitting work, the first onset of the disease is often in the process of half-bending to hold weight or sudden twisting action. 1, lumbago is the earliest symptom, mostly deep swelling and pain, from the spine to the sides of the midline extension, accompanied by unilateral lower extremity radiating pain, can also be seen bilaterally. The pain is aggravated by increased abdominal pressure such as coughing and deep breathing. 2, gait and posture, no obvious changes in the light, the more serious gait, walking slowly, often accompanied by intermittent claudication, at the same time there can be scoliosis deformity. Sciatica Most of the lower lumbar intervertebral disc herniation is accompanied by sciatica. Typical sciatica is radiating pain from the lower lumbar region to the buttocks, the back of the thighs, and the outer side of the calves until the feet. Pressure on cauda equina The nucleus pulposus protruding from the posterior region or prolapsed or free intervertebral disc tissues may compress the cauda equina, resulting in urinary and bowel obstruction and abnormal sensation in the saddle area. A few patients may have symptoms such as numbness and swelling of the limbs. （Changes in the physiological curvature of the spine and scoliosis are postural compensatory deformities formed by the passive position adopted by the patient to relieve pain. The more common ones are straightening of lumbar physiological curvature and lumbar scoliosis. When the protrusion is on the lateral side of the nerve root, the lumbar scoliosis is more convex to the affected side; while when the protrusion is on the medial side of the nerve root, the lumbar scoliosis is convex to the healthy side. 2, intermittent claudication, also known as painful claudication, its gait is characterized by small steps of the affected limb, often landing on the tip of the foot, and then quickly changing to the healthy side of the foot after landing (support phase is short, and the swing phase is long), which leads to a rapid and unsteady gait. Restriction of lumbar activities The lumbar activities will stretch the compressed nerve roots and cause pain, which is most obvious in the forward-flexed position. 4, lumbar compression pain and sacrospinous muscle spasm The lesion intervertebral space spine interspace, supraspinous and interspinous ligament, paraspinous and other areas of compression pain, and at the same time in the affected nerve trunks or branches can have compression pain, such as the buttocks, the N fossa, the back of the calf and so on. At the same time, 1/3 of the patients are accompanied by sacrospinal muscle spasm, which makes the patient’s waist fixed in a forced position. 5. Sensory abnormalities When there is nerve root involvement, patients mostly have sensory abnormalities, and the area of sensory abnormality corresponds to the affected nerve root. More than 70% of the patients have decreased muscle strength, see Table 1 for specific correspondence. (3) Special examination 1. Straight leg raising test Straight leg raising test is a valuable test for diagnosing lumbar intervertebral disc herniation. The sensitivity of diagnosing lumbar disc herniation is 76%~97%. (1) Examination method: The patient lies on his/her back with both legs straight and the affected limb is passively elevated. (2) Positive judgment Normal people do not experience discomfort in the N fossa until the lower limb is elevated to 60°-70°, so elevation within 60° of the sciatica is positive. (3) Precautions Need to exclude the effect of N cord muscle contracture and other factors, at the same time for athletes or patients with a history of long-term N cord muscle pulling need to increase the height of the appropriate or noted. (2) Straight leg raising strengthening test This test is performed only if the straight leg raising test is positive. (1) Examination method When the straight leg raising test is positive, slowly lower the height of the affected limb, wait until the radiating pain disappears, and then passively flex the ankle joint. (2) Judgment of positivity If sciatica reappears, the test is positive, otherwise it is negative. (3) Precautions Same as straight leg raising test. （X-ray film is the most commonly used and economical imaging method, which can not only provide the basis for the diagnosis of lumbar disc herniation, but also differentiate it from certain diseases with the same symptoms of lumbar and leg pain, such as bone tumors, ankylosing spondylitis, vertebral arch disintegration, and vertebral spondylolysis, etc. (1) Position of filming. (1) The position of the film: generally, the examination is performed in the orthopedic and lateral positions, and if necessary, it can be performed in the oblique position or functional position (such as hyperflexion and hyperextension position). (2) Lumbar disc herniation plain film signs are: ① lumbar vertebral physiological anterior convexity becomes shallow or disappears, or even anti-convexity, at the same time, there can be lumbar scoliosis; ② lesions of the intervertebral space narrows, before and after the width of the anterior and posterior width of the narrowing, the left and right gaps are unequal; (3) lesions of the intervertebral space of the vertebral body edges can be sclerosis and lipoacanthosis. 2.CT Electronic computed tomography (CT) can directly display the location, size, shape and relationship with the surrounding structures of the herniated disc. (1) Scanning conditions and methods: general intervertebral disc scanning window position of 80 ~ 100Hu, window width of 450 ~ 600Hu. (2) lumbar intervertebral disc herniation of common CT signs are as follows: ① block shadow, mostly formed by the intervertebral disc beyond the edge of the vertebral body; ② calcification, mostly in the posterior vertebral body edge; ③ free fragmentation, mostly protruding nucleus pulposus shadow; ④ dural sac compression, deformation, displacement; ⑤ epidural fat deformation, disappearance; ⑥ nerve roots affected by deformation, disappearance; ⑥ nerve roots. ⑤ deformation and disappearance of epidural fat; ⑥ nerve root compression, displacement and enlargement; ⑦ enlargement of lateral fossa; ⑧ Schmorl’s nodule manifested as a single or multiple occurrence in the middle and posterior 1/3 of the vertebral body’s upper or lower margins, and a bone defect with similar density to the intervertebral disc, surrounded by a hardened band of varying widths of the bone. 3.MRI Magnetic resonance imaging (MRI) has a higher resolution of soft tissue and no bone artifacts, and is mostly used for the diagnosis of cranial brain, spine, spinal cord and joint lesions. (1) Imaging types MRI imaging is mainly divided into T1-weighted image (TE) and T2-weighted image (TR). Generally, intervertebral discs show slightly low signal in T1-weighted images and high signal in T2-weighted images. When the intervertebral disc undergoes dehydration and degeneration, the signal decreases, which is more obvious in the T2-weighted image. (2) MRI can clearly distinguish different stages and types of disc herniation. (1) bulging disc: the high signal nucleus pulposus does not protrude beyond the low signal annulus fibrosus; (2) herniated disc: the high signal nucleus pulposus protrudes beyond the low signal annulus fibrosus, but the protruding part is still connected to the nucleus pulposus; (3) prolapsed disc: the high signal nucleus pulposus protrudes beyond the low signal annulus fibrosus, but the protruding part is not connected to the nucleus pulposus. 4. Others, such as myelography, epidurography and intervertebral discography, are seldom used in clinical practice at present. (a) Rest Bed rest can reduce inflammation and avoid aggravation of injury, of course, the bed should not be too soft. Generally speaking, absolute bed rest should not exceed 1 week. After the symptoms improve, some simple daily life activities should be carried out as far as possible. At the same time, attention should be paid to maintain the correct posture or movement of the activities, and a waist cuff can be worn during the activities. (ii) Comprehensive treatment Drugs can eliminate inflammation and improve symptoms, and the commonly used drugs are as follows. 1, non-steroidal anti-inflammatory analgesics (NSAIDs): more commonly used anti-inflammatory analgesics, the main mechanism is to inhibit the synthesis and release of prostaglandins. Gastrointestinal reactions and other side effects are obvious. 2, Chinese medicine acupuncture massage treatment Acupuncture massage treatment of the disease method is simple, the efficacy is accurate, in the early stage of the disease can obviously relieve the patient’s back and leg pain symptoms, improve the quality of life. 3.Traction It has been reported that traction can reduce the internal pressure of intervertebral disc, reduce nerve root irritation and compression symptoms. Traction can be divided into continuous traction and three-dimensional traction, and pelvic continuous traction is common in clinical practice. The weight of traction is generally between 7 and 15 kg, and it is performed twice a day for 1 to 2 hours each time for 2 weeks to 3 months. It is contraindicated for pregnant women and patients with severe cardiovascular diseases. Lumbar disc herniation patients with CT or MRI examination suggesting lumbar disc bulge without complete rupture, lateral saphenous fossa stenosis not exceeding 2/3 of the original, herniated disc extrusion of the spinal canal not exceeding 1/2 of the original volume or the anterior-posterior diameter of the spinal canal not less than 0.8cm, the left and right diameters of the spinal canal not less than 1.0cm, the position of the protruding disc calcification is not located in the lateral saphenous fossa, there is no obvious osteoporosis or proliferation of the bypass bridge, slippage, and patients with serious heart disease are suitable for this method. Patients with heart disease are suitable for this approach. Central disc herniation with saddle area numbness, diaphragmatic incontinence; lumbar disc herniation with obvious nerve damage, such as lower limb muscle weakness, drop foot, bunion dorsiflexion or metatarsophalangeal flexion muscle strength disappears; intervertebral disc herniation makes the spinal canal stenosis or and the spinal canal bony stenosis, spinal canal anterior-posterior diameter is less than 0.6cm, the left and right diameter is less than 0.75cm, walking not more than 500 meters; ruptured intervertebral disc herniation makes the lateral saphenous fossa completely disappeared, The volume of the spinal canal is less than 1/2 of the original or the anterior-posterior diameter is less than 0.8cm and the left-right diameter is less than 1.0cm, the fragments of ruptured type are free in the spinal canal and cause compression, and the disc herniation of lateral type (neurogenic foramen) directly compresses the neurogenic foramen, and the protruded disc calcifies and narrows at the lateral fossa, and there is no significant improvement in the symptom in 3 weeks of conservative treatment, or there is no obvious cause of relapse in one year; those who have been treated in the first and second stage for 6 weeks without significant improvement in the symptoms; those who have been treated in the first and second stage for 6 weeks without significant improvement in the symptom. Physical therapy Physical therapy has the functions of analgesia, anti-inflammatory, excitation of neuromuscular and loosening adhesion. Short-wave and ultrashort-wave therapy: in the early stage of the disease, in order to improve the blood circulation of the affected area, eliminate the inflammatory reactions such as oozing and edema, and reduce the pain caused by the compression or stimulation of the nerve root. 5. Injection therapy Sacral fissure injection block therapy is often used to inject the medication into the epidural cavity through the sacral fissure, and the medication will travel up the vertebral canal to the affected nerve root, in order to reduce the local inflammation and adhesion. Corticosteroid solution is usually used, once a week, 3 times for a course of treatment. It is suitable for those who have obvious pain and the effect of general treatment is not good. Local regional closure: it can be divided into superficial and deep closure: 1. Superficial closure: the scope of closure includes the lumbar dorsal fascia, psoas muscle starting and ending points and supraspinatus and interspinous ligaments. Generally require the combination of pressure and pain points and precise anatomical sites. 6.Exercise training The role of exercise training is to maintain the patient’s normal spinal form, improve the strength of the lumbar back muscles, and enhance the elasticity of the ligaments around the vertebral body. 1. Acute period Within 1 week, bed rest is the mainstay, and the lower limbs can be appropriately elevated to reduce spinal stress. 2.Relief period Gradually start the lumbar and abdominal muscle training, pay attention to avoid excessive lumbar flexion or hyperextension. Daily 2 to 3 groups, each group 10 to 15 times, each lasting 5 to 10 seconds. (1) Half-bridge training: lie on your back, use your head and feet as a support point to lift your hips off the bed. When the strength is not enough, it can also be supplemented with two-handed support. (2) Back fly training: prone position, with the abdomen as the support point, upper limbs back and behind, chest and lower limbs lifted off the bed at the same time, shaped like a flying swallow, also known as the “flying swallow”. (3) Back extension training: lying down, both lower limbs are naturally straightened, alternately lifting upwards as far as possible.