At present, any of the domestic and foreign treatments for lumbar disc herniation (including conservative and surgical treatments) only relieve symptoms, not cure them. It can neither interrupt the pathological process of the herniated disc nor restore the lumbar spine to normal. Patients still need to pay attention to posture and functional exercises for the muscles of the low back after surgery. The success of lumbar spine surgery is critical with the appropriate case selection. The appropriate surgical approach should be taken for the different pathological changes of the herniated disc. For patients with lumbar disc herniation without progressive aggravation of neurological symptoms and without cauda equina syndrome, which of the following treatment modalities is preferred for this patient?A , conservative treatmentB , surgical treatment I. Overview of staging of disc herniation: With the progressive understanding of the degenerative process of the disc and the development of new materials and technologies, there have been more changes in the diagnosis and treatment of lumbar disc herniation in recent years. Currently, the degeneration of lumbar discs is divided into three periods: dysfunction. Instability. Stability. These three periods are continuous and the degeneration varies from segment to segment. One segment can be the dysfunctional phase, while the adjacent segment has entered the restabilization phase, which is the staging and characteristics of lumbar disc degeneration. The progress of the diagnosis of lumbar disc herniation: 1, the progress of imaging examination of lumbar disc herniation: doctors can determine the segment instability by dynamic X-ray examination (hyperextension and hyperflexion position); CT is widely used with its price advantage; and MRI is the best method because of its wide display range and clear nerve structure. General myelography has largely been replaced by magnetic myelography (MRM). Dynamic open MRI can reflect changes in the intervertebral disc during spinal motion (flexion and extension, lateral bending, rotation) and can be useful in some specific cases. Various lumbar injections of anesthetics or contrast agents are diagnostic for low back pain of unknown diagnosis and have localization implications for cases with extensive degeneration that is difficult to localize. For example, discography can confirm the diagnosis of discogenic low back pain. MRI enhancement can differentiate postoperative scar tissue from recurrent discs. When the symptoms and signs do not match the segments on imaging, attention should be paid to the possibility of nerve root deformity and lateral or very lateral disc herniation. 2, psychological examination of lumbar disc herniation: In addition to medical history, physical examination and imaging examination, doctors in Europe and the United States pay more attention to the examination of psychosocial factors of patients before treating lumbar spine disorders, especially before fusion surgery. Psychological examinations commonly used before surgery are MMPI (Minnesota Multiphasic Personality Inventory) or DRAM to estimate whether the patient’s symptoms are somatic or psychogenic and to speculate the chance of treatment failure. In MMPI scores such as dysthymia (hysteria) and depression (hypochondriasis) with scores greater than 75, only 16% of patients can achieve satisfactory treatment (conservative and surgical) outcomes. Progress in the treatment of lumbar disc herniation: (a) Conservative treatment of lumbar disc herniation : From simple bed rest to complex traction, conservative treatment methods are still varied. Many methods report “miraculous” results, but no scientific studies have been conducted to confirm them. The natural course of disc disorders is characterized by alternating deterioration and remission, with most patients eventually improving, independent of the treatment method, so that the results are “mixed”. The majority of symptomatic patients are satisfied with conservative treatment. The efficacy of surgery is generally most pronounced in the first postoperative year, but the difference in efficacy between surgery and conservative treatment decreases over time with longer follow-up. Except for patients with cauda equina syndrome, conservative treatment remains the treatment of choice for patients without progressive worsening of neurological symptoms. Even for patients who decide to undergo surgery, it is advisable to give 6-12 weeks of conservative treatment to give them another chance to improve their neurological function. If conservative treatment is not effective, surgical treatment needs to be considered. In the past, surgery was recommended when conservative treatment was ineffective for more than 6 months; there is now a trend to reduce this time to 6 weeks or 3 months. It is important for both the operator and the patient to realize that any treatment (both conservative and surgical) is only symptom relief, not a cure. It neither interrupts the pathological process of the herniated disc nor restores the lumbar spine to normal. Patients still need to pay attention to posture and low back muscle exercises after surgery. The success of lumbar spine surgery is critical with the appropriate case selection. The appropriate surgical approach should be adopted for the different pathological changes of the herniated disc. (B) Surgical treatment of lumbar disc herniation: Surgical treatment of lumbar disc herniation, especially the traditional classical surgery, has been carried out for nearly 70 years, and has been carried out in China for more than half a century, and has now been popularized to city, county, factory, mine and township hospitals. 1, the traditional surgery of lumbar disc herniation: the traditional classical surgery includes open window method, half laminectomy and total laminectomy. There are several reports of long-term follow-up for more than 10 years for these three procedures, with excellent rates of about 85%, 75% and 45% respectively, and the orthopedic community has reached a consensus on their understanding. Open-window surgery is the most widely used because it is less invasive, causes less structural damage, and has good long-term results, with a complication rate of about 4%. The open approach is suitable for symptomatic, single-gap disc herniations on one side; hemilaryngectomy is suitable for symptomatic, adjacent double-gap disc herniations on one side. For bilaterally symptomatic disc herniation, open window or bilateral open window nucleus pulposus removal surgery can be performed on the major herniated side according to the imaging changes. Total laminectomy should be avoided except for huge central intradural disc herniations. In the vast majority of cases, open surgery can be used to treat the central type of herniation. Prophylactic intervertebral fusion is not necessary after removal of the nucleus pulposus, except in cases where there are clear signs of instability in the herniated space preoperatively or where too many articular processes have been removed intraoperatively. During surgery, care should be taken to maintain maximum stability of the spine based on adequate decompression, which is the key to obtaining good long-term results. Nearly 30% of patients with soft lumbar disc herniation with lateral saphenous fossa stenosis should undergo additional foraminoplasty. Minimally invasive surgery for lumbar disc herniation: It is believed that the extensive muscle trauma and the muscle atrophy and muscle weakness caused by traditional open surgery are the main causes of postoperative low back pain. With the development of minimally invasive spine surgery (MISS) and less invasives spine surgery (LISS) concepts and techniques, new disc removal modalities have emerged. In North America, the microlumbar disc excision has largely replaced the traditional discectomy. The incision is approximately 3 cm and requires good illumination and retractors and precise intraoperative positioning (image intensifier), often with magnification. This procedure is similar to conventional surgery, with the advantages of less trauma, less postoperative pain, and shorter hospital stay, and in some foreign units, even routine postoperative hospitalization. At present, many units at home and abroad carry out various minimally invasive procedures, such as myelolysis, radiofrequency discectomy (intradiscal electrothermal therapy (IDET), percutaneous lumbar diskectomy (PLD), automated percutaneous lumbar disc removal, percutaneous laser disk decompression (PLDD) and posterolateral percutaneous endoscopic laser discectomy, arthroscopic microdiscectomy, microendoscopic discectomy (MED), etc. Intradiscal electrotherapy (IDET). Mochia and Arime suggest that the general indications for minimally invasive surgery are: age under 40 years, nucleus pulposus not free to the dorsal aspect of the posterior longitudinal ligament, absence of degenerative spinal stenosis on imaging, and no neurological degeneration. Myelolysis emerged in the 1960s and is now abandoned by most orthopedic surgeons due to complications such as transverse myelitis and severe allergic reactions. It is still used by some radiologists and neurosurgeons in China and Europe. Some physicians have experimented with CT-guided injection of collagenase into the disc herniation versus the surface of the herniation to increase efficacy. In recent years, MED has emerged to combine traditional open surgery with microsurgical techniques and modern endoscopic technology to clearly observe deep structures on a monitor, allowing direct visualization of the disc and decompression. Some units have attempted to use MED surgery to remove ossified discs, free discs, the posterior wall of the lateral saphenous fossa with osteophytes, and the entire vertebral plate. However, this procedure requires the operator to have both open surgery experience and mastery of microsurgery techniques, which is difficult and expensive, and has no significant advantage in efficacy over small incision discectomy. The complications of minimally invasive surgery are relatively slightly higher, at least in the operator’s primary segment. 3. Intervertebral fusion for lumbar disc herniation: It relies on the strength and diameter of the intervertebral fusion device itself to effectively restore and maintain the height of the affected intervertebral space, restore the size of the intervertebral foramen, relieve the nerve root compression, provide immediate postoperative stability, and facilitate fusion. However, the cost of fusion is the loss of intervertebral motion, which sacrifices spinal function and can lead to accelerated disc degeneration in adjacent segments. Therefore, intervertebral fusion is only a remedy for a small number of patients who have severe disc degeneration, combined lumbar instability or recurrence despite repeated lumbar discectomy. 4, lumbar disc herniation replacement surgery: the excellent postoperative rate of nucleus pulposus removal is 70-85%, and 3-14% of patients require reoperation after nucleus pulposus removal. (1) Narrowing of the intervertebral space, relaxation of the fibrous ring, instability of the lumbar intervertebral joints (100-150% reduction in stiffness in all directions of motion), and degenerative slipped vertebrae may occur after removal of the nucleus pulposus, causing back pain. (2) Narrowing of the intervertebral space will result in a smaller intervertebral foramen height, which may compress the nerve roots and produce neurogenic symptoms. (3) The local stresses applied will increase and the osteophytes at the posterior edge of the vertebral body will increase, leading to recurrence of lumbar pain from spinal stenosis. Because the long-term efficacy of nucleus pulposus removal is still unsatisfactory, artificial nucleus pulposus replacement, artificial disc replacement, and allogeneic disc transplantation have emerged one after another. These treatments originated in Europe in the 1980s and were widely performed in North America in the mid- to late-1990s, and a few units in China have already performed these procedures. Allogeneic disc transplantation is mostly reported on a case-by-case basis due to the high surgical trauma and limited donor source. (1) Artificial pulp nucleus (PDN): consists of a polymer polyethylene jacket and a semimobile hydrogel (polyacrylonitrile-polyacrylamide copolymer) inside it, which can absorb water equivalent to 80% of its own weight when fully expanded, and its volume can vary with load. The procedure is similar to the open discectomy method. This procedure requires a more complete structure of the annulus fibrosus, a more rigorous removal of the nucleus pulposus and protection of the upper and lower endplates, followed by implantation of an artificial nucleus pulposus. Whether discogenic pain is also a strict indication for lumbar disc herniation is still under intense debate at home and abroad; and postoperative complications can be as high as 30%, with the most serious complication being displacement of the artificial nucleus pulposus. (2) Artificial disc replacement: Artificial disc replacement (ADR): is a hot topic in the past two years. The principle is similar to that of mature knee and hip replacements, but the biomechanical characteristics of the disc are more complex. The SB Charité III artificial disc prosthesis has a sliding nucleus made of high molecular polyethylene in the center and metal plates on the top and bottom. The surgical approach is anterior or anterolateral. It can be lowered to the floor the day after surgery and requires a lumbar brace to be worn for 6 weeks. Hochschduler considers the indications for ADR to be: (1) symptomatic disc rupture. (2) Symptomatic disc degeneration. (3) adjacent segmental instability due to spinal fusion. Contraindications include: (1) spinal deformity of the operated segment. (2) Severe osteoporosis. (3) Lumbar spondylolisthesis above II°. (4) Bony spinal stenosis. (5) Back pain caused by surgical scar adhesions. Intraoperative complications are large vessel injury, postoperative as prosthesis displacement or entrapment in the vertebral body and retrograde ejection. The disadvantage of ADR is that the surgery is more traumatic and has more complications; it requires large excision of the fibular ring and nucleus pulposus tissue which are still relatively normal, further destroying the local stability; ADR properly props up the vertebral space during surgery, although restoring the height of the vertebral space and the volume of the intervertebral foramen, but the joint space of the synovial joint is abnormally enlarged, making the three joints of the spine The existing prosthesis is designed to have a service life of 5-10 years, but the artificial joint wears out and ages rapidly, and the mobility of the artificial disc decreases significantly after 1-2 years, which does not yet meet the original design requirements. The ideal method of treating disc degeneration should be to simulate the structure and physiology of the human disc as much as possible, restore the function of the spinal joints, and maintain the normal stress distribution in the adjacent segments. Removing and reconstructing the entire disc is still a challenge for current materials science and biomechanics. Artificial nucleus pulposus and artificial disc replacement, with their novel design concepts, are far from mature, with only a few thousand cases in total worldwide, lacking certification of large numbers of cases, long-term follow-up, and high treatment costs. Although these procedures have made some advances in principle, it is difficult to determine whether they can end or delay lumbar spine degeneration. The biggest problem with the replacement approach is that only part of the nucleus pulposus or annulus fibrosus degenerates in a degenerating disc, whereas replacement surgery requires removal of the entire disc or nucleus pulposus. Skeptics believe that: (1) the lumbar spine has a strong compensatory and repair capacity, and that the loss of intervertebral height after nucleus pulposus removal is likely to be accompanied by the re-establishment of a new stable relationship between the local tissues during the healing process and the maintenance of normal physiological function; (2) there is no clear correspondence between the clinical symptoms of the patient and the abnormal signs in the imaging examination, and the loss of surgical gap height does not necessarily lead to low back pain or localized spinal pain. (2) there is no clear correspondence between the clinical symptoms of the patient and the abnormal signs in the imaging examination, and the loss of the surgical gap height does not necessarily lead to low back pain, nor does it necessarily cause local structural instability of the spine. 5, cellular and gene therapy: cellular and gene level therapy has the potential to become a new direction in the treatment of spinal disorders in the 21st century. Some scholars have attempted to culture nucleus pulposus cells, and others are searching for genes that determine degenerative changes in the lumbar spine. In conclusion, there are numerous surgical treatments for lumbar disc herniation, all of which have achieved certain or encouraging therapeutic results under the premise of strict control of surgical indications. However, these new techniques have been carried out in China for a relatively short period of time, some for only one year and many for less than ten years. The exact evaluation of a treatment method should be based on a rigorous, objective and scientific approach to the evaluation criteria, as well as on the results of long-term follow-up. Domestic should be limited to try in conditional low back pain treatment centers and compare the results of the efficacy and complications of different treatment methods, at present, it seems inappropriate to rapidly promote the clinical application of the above new technology in China.