Lumbar disc herniation (LDH), also known as lumbar disc rupture, is one of the common diseases in middle-aged and elderly people. It is caused by degenerative changes in the lumbar spine or external forces that lead to the imbalance of the internal and external pressure in the lumbar disc, resulting in the rupture of the lumbar disc rupture and the protrusion of the nucleus pulposus, thus compressing the nerve roots, blood vessels, spinal cord or cauda equina in the lumbar spine. In 1934, Mixter and Barr reported the success of surgical removal of the prolapsed lumbar disc and achieved good results. Subsequently, scholars at home and abroad have carried out lumbar disc removal and conducted in-depth research on lumbar disc herniation. Etiology】 Degenerative changes occur in various tissues of human body after puberty, among which the changes of intervertebral disc occur earlier, the main change is dehydration of the nucleus pulposus, after dehydration the disc loses its normal elasticity and tension, on the basis of which the nucleus pulposus protrudes from the place due to the weakening or rupture of the fibrous ring caused by heavier trauma or repeated inconspicuous injuries. The nucleus pulposus mostly protrudes into the spinal canal from the lateral posterior side (a few can be on both sides at the same time), compressing the nerve root and producing signs of nerve root injury; it can also protrude from the center to the posterior, compressing the cauda equina and causing urinary and fecal disorders. If the fibrous ring is completely ruptured, the broken nucleus pulposus enters the spinal canal and can cause extensive damage to the cauda equina. Because of the heavy load and activities in the lower back, the protrusion mostly occurs in the lumbar 4-5 and lumbar 5-sacral 1 spaces. Clinical manifestations】 (a) Low back pain and radiating pain of one lower limb are the main symptoms of the disease. Low back pain often occurs before leg pain, or both can occur at the same time; most of them have a history of trauma, and there can be no clear cause. The pain has the following characteristics: 1. The radiating pain is transmitted along the sciatic nerve and reaches the lateral calf, dorsum of the foot or toes. 2. All actions that increase the pressure of cerebrospinal fluid, such as coughing, sneezing and defecation, can aggravate the low back pain and radiating pain. 3. The pain increases with activity and decreases after rest. Bed position: Most patients adopt the lateral position and flex the affected limb; individual severe cases have pain in all positions and can only bend the hip and knee in bed to relieve the symptoms. In combination with lumbar spinal stenosis, there is often intermittent claudication. (B) Scoliosis deformity: the main bend in the lower back, more obvious when forward flexion. The direction of scoliosis depends on the relationship between the herniated nucleus pulposus and the nerve root: if the herniation is located in front of the nerve root, the trunk is usually bent to the affected side. (iii) Restricted spinal movement: the herniated nucleus pulposus compresses the nerve roots, causing protective tension in the lumbar muscles, which can occur unilaterally or bilaterally. As a result of lumbar muscle tension, the physiological anterior convexity of the lumbar spine disappears. The anterior flexion and posterior extension of the spine is restricted, and radiating pain to one lower limb may occur during anterior flexion or posterior extension. Lateral bending is often restricted on one side only, which can be differentiated from lumbar spine tuberculosis or tumor. Auxiliary examination]: Frontal and lateral radiographs of the lumbosacral spine should be taken, and if necessary, left and right oblique radiographs should be added. Although the X-ray signs cannot be used as a basis for the diagnosis of lumbar disc herniation, they can be used to exclude some disorders such as lumbar tuberculosis, osteoarthritis, fracture, tumor and spondylolisthesis. In severe cases or atypical cases, special examinations such as spinal iodography, CT scan and MRI can be considered to clarify the diagnosis and the site of herniation when there is difficulty in diagnosis. Patients with no obvious abnormalities in the above examinations are not completely excluded from lumbar disc herniation. Differential diagnosis] (a) Posterior lumbar joint disorder: The upper and lower articular protrusions of adjacent vertebrae constitute the posterior lumbar joint, which is a synovial joint with nerve distribution. When the relationship between the upper and lower synapses of the posterior joint is abnormal, pain can be produced by synovial imbrication in the acute phase, and traumatic arthritis of the posterior joint can be produced in chronic cases, resulting in lumbago. This pain mostly occurs at 1.5 cm next to the spinous process, and there may be radiating pain to the ipsilateral hip or behind the thigh, which is easily confused with lumbar disc herniation. The radiating pain usually does not exceed the knee joint and is not accompanied by signs of nerve root damage such as sensation, muscle weakness and loss of reflexes. In cases where identification is difficult, 2% procaine 5 ml can be injected near the small articular eminence of the lesion, and if the symptoms disappear, lumbar disc herniation can be excluded. (b) Lumbar spinal stenosis: intermittent claudication is the most prominent symptom. Patients complain of soreness, numbness and weakness of the lower limbs after walking for a certain distance, and must squat down to rest before continuing to walk. Cycling may be asymptomatic. Patients complaining of many symptoms but few signs are also important features. A small number of patients show signs of radicular nerve injury. Severe central stenosis may present with urinary and fecal incontinence, and special tests such as myelography and CT scan may further confirm the diagnosis. (iii) Lumbar spine tuberculosis: Early limited lumbar spine tuberculosis can stimulate the adjacent nerve roots, causing low back pain and radiating pain in the lower extremities. Lumbar spine tuberculosis has the systemic reaction of tuberculosis with more severe lumbar pain and destruction of vertebral body or pedicle visible on X-ray. CT scan has a unique role in early limited tuberculosis lesions of the vertebral body that cannot be shown on X-ray. (iv) vertebral metastases: pain is increased, aggravated at night, the patient is debilitated, and the primary tumor can be detected. osteolytic destruction of the vertebral body is seen on X-ray plain film. (v) Spinal meningioma and cauda equina neuroma: chronic progressive disease without intermittent improvement or self-healing, often with urinary and fecal incontinence. Myelography, CT, or MRI can clarify the diagnosis. Most patients can be relieved by non-surgical treatment. Only a small number of patients require surgical treatment. There is not enough evidence to conclude whether non-surgical treatment can retract the herniated disc and heal the ruptured annulus fibrosus. However, at least aseptic inflammation of the nerve root may subside, adhesions may be loosened, and compression may be partially or completely relieved, resulting in symptomatic relief or complete disappearance. However, in some severe cases, because of the large protruding nucleus pulposus and severe nerve compression, early surgery is required to release the nerve compression, otherwise the nerve will have irreversible changes. (A) Non-surgical treatment Non-surgical treatment are: (1) First of all, complete absolute bed rest, early acute period including urination and defecation do not get out of bed, which can release the pressure of weight, muscle strength and external load on the intervertebral disc, is the basic treatment of disc herniation. It is necessary to lie on a hard bed, and can be combined with lumbar traction, hot compresses, physiotherapy, acupuncture, massage and other treatments. Acute patients can generally be significantly improved after 3 weeks of bed rest. At this time, they should start to exercise their lumbar back muscles and get up under the protection of lumbar girth. After getting up, continue to strengthen the low back muscle exercise, and cancel the waist brace one by one. Do not use the lumbar girth for a long time without strengthening the back muscle exercise, otherwise it will make the lumbar back muscle atrophy, and it will be more impossible to get rid of the lumbar girth in the future. (2) pelvic traction: traction can further reduce the pressure within the intervertebral discs, the efficacy is better, especially for early patients. (3) Tui-na massage: the technique should be gentle and should not be violent. (4) Drugs: The use of dehydrating drugs and hormonal drugs is mainly to make the edema of the compressed nerve root subside and reduce the inflammatory response. Some symptomatic pain medications can also be used. (2) Surgery Indications for surgery: (1) history of lumbar disc herniation for more than six months, after strict conservative treatment is ineffective, or conservative treatment is effective, but frequent recurrence and heavy pain; (2) the first episode of lumbar disc herniation pain is severe, especially in the lower limbs, the patient is difficult to move and sleep due to pain, forced to be in the lateral lying position of flexed hip and knee, or even kneeling position; (3) the presence of single nerve paralysis or cauda equina nerve (4) the patient is middle-aged, with a long medical history, affecting work and life; (5) although the medical history is atypical, the myelogram or epidural and vertebral venogram shows obvious filling defects and signs of compression, or the discogram shows total disc degeneration with huge protrusion; (6) the disc protrudes and has other causes of lumbar spinal stenosis. 1.Conventional lumbar disc removal This surgical procedure is a recognized, widely used and reliable surgical procedure, and is still widely used. The herniated nucleus pulposus is directly removed and the nerve root canal is enlarged to relieve the compression and achieve the purpose of treatment. The procedure involves cutting the skin, stripping the sacrospinous muscle, pulling it apart to fully expose it, and biting off the ligamentum flavum and the vertebral plate. According to the amount of occluded lamina, the procedure is divided into: 1) total laminectomy with removal of both laminae and spinous processes, with full exposure and complete decompression; 2) hemi-laminectomy with removal of one lamina and preservation of the opposite lamina and spinous processes; and 3) “open window” with removal of the nucleus pulposus. The difference between limited lumbar disc removal and conventional surgery is that only the free and herniated part of the disc is removed during surgery, but not the central and lateral areas of the intervertebral nucleus pulposus. However, limited lumbar disc removal surgery has been the subject of considerable debate. It is debatable whether there will be re-protrusion of unprojected nucleus pulposus tissue along the original nucleus pulposus protrusion site and what the long-term effect will be. 3. Minimally invasive treatment of lumbar disc herniation 3.1 Chemical myelolysis; 3.2 Percutaneous puncture myelotomy; 3.3 Percutaneous laser discectomy;; 3.4 Posterior translaminar hiatus fiber endoscopic discectomy (MED); 3.5 Microscopic discectomy.