Lumbar disc herniation is very common in clinical practice, however, issues related to it, such as the choice of treatment measures, the timing of surgery, surgical indications, surgical methods, etc., have a greater controversy, today let us talk about which patients with lumbar disc herniation need surgical treatment. Lumbar disc herniation is a disease in which the disc misalignment exceeds the normal disc boundary range and compresses the nerves, resulting in pain, weakness, paralysis of muscle joints, or abnormal distribution of dermatomal sensation. Low back pain and a herniated disc alone is not a lumbar disc herniation. Most people with lumbar herniated disc radiculopathy improve with or without treatment. The herniated disc tissue usually atrophies/degenerates over time. Many studies have shown a gradual improvement in clinical function as the herniated disc decreases in size. 1. Is a herniated disc the same thing as a herniated lumbar disc? No. A herniated disc is a disc in which the annulus fibrosus ruptures and the nucleus pulposus tissue protrudes (or prolapses) from the rupture into the posterior or spinal canal. This is really just a pathologic change, or imaging presentation. It is not a disease. In addition there are long-term follow-up studies that have found no correlation between the presence of a herniated disc in these volunteers and the subsequent presence and duration of low back pain. Lumbar disc herniation, on the other hand, is a clinical syndrome in which a herniated lumbar disc results in irritation or compression of the adjacent spinal nerve roots, resulting in a range of symptoms such as low back pain, numbness, and pain in one or both lower extremities. The diagnostic criteria proposed by Prof. McCulloch 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 dermatomal sensory abnormality; ③ a positive straight leg raise test, the angle is less than 50% of the normal angle, or the healthy side of the straight leg raise test is positive; ④ with muscle atrophy, weakness, hyperalgesia, and tendon reflexes and other two out of the four items; ⑤ with clinical symptoms consistent with the imaging characteristics. (5) Imaging features consistent with the clinical presentation. According to the above diagnostic criteria and the pathological characteristics of lumbar disc herniation, lumbar disc herniation must not only have the pathological changes of lumbar disc herniation (imaging manifestations), but also have the clinical manifestations of damage to the corresponding neural structures, and pain and numbness with the characteristics of rhizomatic distribution. Therefore, even if there is obvious lumbar disc herniation on the imaging, and there is also regional pain in the lumbar region, buttocks or thighs, etc., such as there is no pattern of radicular distribution of nerves, the diagnosis of lumbar disc herniation is questionable. 2, lumbar disc herniation examination preferred CT? Wrong: MRI is better than CT in terms of diagnostic accuracy and false-positive rate, and is non-invasive, multi-dimensional and radiation-free. Therefore, for patients with a diagnosis of lumbar disc herniation and a corresponding history and positive findings on physical examination, MRI is preferred as the imaging test of choice, with CT, myelography, or CT myelography as alternatives. 3. Do I have to stay in bed for conservative treatment of lumbar disc herniation? Wrong Bed rest is recommended for patients with acute low back pain to gain less benefit (pain, functional rehabilitation) than continuing with daily activities; and for patients with lumbar disc herniation, there is little difference in bed rest compared to remaining active. There is a large body of literature that agrees with the above, and few studies have been reported that advocate strict bed rest. It is clear that bed rest is not necessary, and if the patient’s pain and dysfunction are not so severe that it is difficult to walk, it is not necessary to artificially restrict his or her activities and strictly require bed rest. 4. Is enhanced myelography-guided epidural hormone injections (ESIs) necessary for the treatment of lumbar disc herniation? Yes. Compared with medication, transforaminal ESI has a better utility ratio and is effective in short-term pain control, which improves the clinical functional prognosis of most patients with lumbar disc herniation. Moreover, there is no statistically significant difference in the prognosis of ESI for different types of lumbar disc herniation. 5. Is conservative treatment preferred for 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. For radicular pain with positive signs of nerve root compression or neurologic dysfunction, with imaging confirmation that the herniated disc matches the clinical symptoms, and with symptoms lasting longer than 6 weeks, surgery is more effective than non-surgery. It should be noted that for patients with mental depression, the functional prognosis after surgical treatment is poorer and worse. 6, lumbar disc herniation surgery, the earlier the better? No. The longer the symptoms of lumbar disc herniation last, the worse the final treatment result will be, no matter surgical treatment or non-surgical treatment, but it has nothing to do with the duration of the disease before treatment. Surgery is recommended within 6 months for patients with lumbar disc herniated 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 a better long-term neurologic prognosis. Therefore, both patients and orthopedic surgeons should recognize that the treatment of lumbar disc herniation should involve early intervention, whether surgical or nonsurgical. 7. Is the efficacy of intervertebral foraminoscopy necessarily better than traditional surgery? No. For patients with strictly selected indications, intervertebral discoscopy can achieve the same results as open disc surgery. With the exception of discectomy, there is no significant difference in outcomes between percutaneous discectomy and traditional open discectomy. In addition, there is no clinical evidence that medial synovectomy for lumbar disc herniated radiculopathy improves functional prognosis. 8. Is spinal fusion necessary for specific patients with lumbar disc herniation radiculopathy? No. Only 45% of patients return to work within 1 year after fusion compared to 70% of patients who return to work within 1 year after discectomy. Although the results of fusion surgery at 6-7 years are somewhat better than those of nucleotomy, the difference is not significant, and fusion surgery is difficult and associated with many complications. Fusion surgery may be considered in younger patients. 9.Medullary herniation – is surgery better in patients with small fibrous ring breaches? 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 and small annulus have the best outcome, the lowest recurrence rate (1%), and the lowest reoperation rate (1%). Patients with a herniated nucleus pulposus and an intact annulus had the next best outcome, with recurrence and reoperation rates of 10% and 5%, respectively. Patients with a herniated nucleus pulposus and a large fibrous ring rupture had a poorer outcome, with a recurrence rate of 27% and a reoperation rate of 21%, while patients with an unruptured nucleus pulposus and an intact fibrous ring had the worst outcome. Can glucocorticoids and/or fentanyl be used after lumbar decompression surgery to improve postoperative pain in patients? No. Glucocorticosteroids and/or fentanyl can significantly improve low back pain in the short-term postoperative period; however, at 1 year postoperatively, there is no statistically significant difference in the degree of improvement in leg pain between patients taking glucocorticosteroids and/or fentanyl and those who are not taking glucocorticosteroids or fentanyl. Therefore, the application of glucocorticoids or / and fentanyl after lumbar decompression is not recommended to improve patients’ postoperative pain in the long term.