Overview】 Lumbar intervertebral disc herniation refers to the degenerative lesion of the lumbar intervertebral disc, after which the fibrous ring ruptures partially or completely under the action of external force, and protrudes outward alone or together with the nucleus pulposus and cartilage end plate, stimulating or compressing the sinus nerve and nerve root, causing a lesion with lumbar pain as the main symptom. The main change is the dehydration of the nucleus pulposus, which loses its normal elasticity and tension. On this basis, the nucleus pulposus is protruded due to the weakening or rupture of the fibrous ring caused by heavy 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 posteriorly from the center, compressing the cauda equina and causing urinary and fecal disorders. If the annulus fibrosus ruptures completely, 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] I. Symptoms and signs The high incidence of lumbar disc herniation is in the age group of 30 to 40 years. The history is often of recurrent lower back pain and hip pain, relieved by short-term rest. The pain may be suddenly aggravated by bending over, manifesting as sudden onset of leg pain that is more intense than lumbar pain. The pain often begins in the lower back and dissipates into the sciatic innervation area and the buttocks. The pain is usually intermittent, worsening with activity, especially in the sitting position, relieving after rest, especially in the semi-abdominal position, and worsening with exertion, sneezing, and coughing. Other symptoms of lumbar disc herniation include muscle weakness and sensory abnormalities. In most patients, muscle weakness is intermittent, varies with activity, and is limited to the innervation zone of the involved nerve root. Sensory abnormalities also vary and are limited to the innervation area of the involved nerve root. Numbness, decreased muscle strength, and occasional pain in the groin area or testicles in the involved leg may be associated with a central or high disc herniation. If the herniated disc is large or the disc protrudes high, symptoms of total cauda equina compression may occur, namely numbness, decreased muscle strength, perianal pain, numbness in the perineal area and paralysis of the extensor muscles in both lower extremities. This diagnosis should be considered first when the patient is suddenly incontinent. Physical examination The physical examination of a patient with a herniated lumbar disc may show a variety of findings. Usually, the acute onset of pain is characterized by significant spasm of the paravertebral muscles, which persists during walking activities. The lumbar spine may appear lateralized or tilted, and in many patients the normal physiologic anterior lumbar convexity disappears. After the acute phase, the muscle spasm is significantly reduced. Loss of lumbar anterior lordosis may be the only sign. Pressure points may appear on the spinous processes of the diseased disc segments, and in some patients the pain may involve the lateral aspect. If there are signs of nerve root irritation, they are usually centered on the course of the sciatic nerve and are seen in the proximal sciatic notch and the distal N fossa. In addition to this, pulling the sciatic nerve at the knee can produce pain in the buttocks and thighs and calves. The Lasegue test on the affected side is often positive. If there is persistent pain in the leg, regardless of its duration, there may be atrophy of the affected limb, manifested as asymmetry in the circumference of the thigh or calf. Neurologic examination varies depending on the plane of the involved nerve root. Massive disc herniations or large central herniations that invade the entire lumbar spinal canal may cause low back pain, leg pain, and occasionally perineal pain, manifesting as cauda equina syndrome, i.e., with saddle area numbness, loss of bilateral ankle reflexes, and urinary incontinence. In these cases, intravesical manometry may show loss of bladder innervation. more than 95% of lumbar disc herniations occur in the L4 or L5 interspace. In many cases of high lumbar disc herniation, the straight leg raise test is negative, but then a positive femoral nerve pull test is helpful for diagnosis. [Differential diagnosis] (a) Posterior lumbar joint disorder. The upper and lower synapses of adjacent vertebrae constitute the posterior lumbar joints, which are synovial joints 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. (ii) Lumbar spinal stenosis. Intermittent claudication is the most prominent symptom. Patients complain of soreness, numbness and weakness of the lower limbs after walking 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 crestal myelography and CT scan may further confirm the diagnosis. (iii) Lumbar spine tuberculosis. Early limited lumbar spine tuberculosis may irritate the adjacent nerve roots, causing low back pain and radiating pain in the lower extremities. CT scan is unique for early limited tuberculosis lesions of the vertebral body that cannot be shown on X-ray. (iv) Vertebral metastases. The primary tumor can be detected with increased pain, which is aggravated at night, and the patient is debilitated. osteolytic destruction of the vertebral body is seen on X-ray plain radiographs. (v) Crestal meningioma and cauda equina neuroma. They are chronic progressive disorders without intermittent improvement or self-healing, often with urinary and fecal incontinence. Crestal myelography, CT or MRI can clarify the diagnosis. Imaging 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 diseases such as lumbar tuberculosis, osteoarthritis, fracture, tumor and crestal spondylolisthesis. In severe cases or atypical cases, special examinations such as crestal myelography, CT scan and MRI can be considered when there is difficulty in diagnosis to clarify the diagnosis and the site of herniation. Patients with no obvious abnormalities in the above examinations are not completely excluded from lumbar disc herniation. [Typing] The lesioned nucleus pulposus can be divided into the following four types according to the degree of protrusion: 1. bulging type: with intact fibrous ring and posterior longitudinal ligament, the nucleus pulposus is diffusely bulging out; 2. protruding type: the nucleus pulposus penetrates the fibrous ring, but the posterior longitudinal ligament is still intact, and the protruding nucleus pulposus with irregular morphology can be seen intraoperatively, confined under the thinned posterior longitudinal ligament, and the protruding nucleus pulposus with high tension can emerge by itself when the posterior longitudinal ligament is cut; 3. The nucleus pulposus penetrates the posterior longitudinal ligament in the shape of cauliflower, but its roots are still in the intervertebral space; 4. free: a large piece of nucleus pulposus tissue penetrates the fibrous ring and posterior longitudinal ligament and completely protrudes into the spinal canal. This type is further divided into two types: Type I: the free nucleus pulposus is located between the nerve root and the fibrous ring; Type II: the free nucleus pulposus migrates to the upper or lower part of the vertebral space and is located in the posterior part of the vertebral body. The treatment of lumbar disc herniation can be summarized into three categories: conservative treatment, minimally invasive surgical intervention and surgical treatment. Based on the principle of “simple not complicated, conservative not minimally invasive, minimally invasive not surgical”. The specific treatment method depends on the patient’s condition and conditions: patients with small protrusions and mild symptoms can be treated conservatively first. Patients with large protrusions, free protrusions, bony spinal stenosis, lower limb movement disorders and cauda equina syndrome (urinary and fecal dysfunction) should receive surgery as soon as possible. Patients who do not respond to conservative treatment and are unwilling to undergo surgery can be treated with minimally invasive interventions. Over the decades, people have made many attempts to treat lumbar spondylosis, and have created and developed many treatment methods. However, these conservative treatment methods mainly focus on symptomatic treatment of neuritis caused by compression of nerve roots by lumbar intervertebral discs, which can often only eliminate or alleviate symptoms, but not cure lumbar disc herniation, and therefore have the shortage of slow recovery and easy recurrence. For cases with large disc protrusions and obvious compression of the crestal medulla and nerves, there is often nothing that can be done, and some treatments can even aggravate the disease if used improperly, so care should be taken and used with caution. According to the characteristics of its pathogenesis, our department breaks through the shortcomings of the current single method of other hospitals, combining Chinese and Western medicine, incorporating the strengths of various schools, combining traditional and modern, and has achieved very good results. (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, this can release the weight, muscle strength and external load on the pressure of the disc, is the basic treatment method of disc herniation. Acute patients can generally improve significantly after 3 weeks of bed rest. At this time, the lumbar and back muscle exercise should be started on a case-by-case basis, and can get up and move under the protection of the lumbar girth. After getting up, continue to strengthen the low back muscle exercise, and eliminate the waist brace one by one. Do not use the waist circumference for a long time without strengthening the back muscle exercise, otherwise it will make the low back muscle atrophy, and later it will be more impossible to get rid of the waist circumference. (2) Computerized traction method. According to different diseases and conditions, the computer set traction mode, so that the vertebral space increases, the internal pressure of the intervertebral disc decreases, forming a negative pressure to facilitate the return of the intervertebral disc. (3) acupuncture and massage physiotherapy cupping method. This method has the function of unblocking the meridians, relieving muscle spasm, improving blood circulation, and restoring the balance inside and outside the spinal canal. (4) Chinese medicine fumigation method. Chinese medicine to activate blood circulation, dispel wind and cold, reduce swelling and pain, strengthen the waist and kidneys; Chinese medicine fumigation of heat and Chinese medicine factors acting on the waist and legs, to achieve synergistic consolidation of treatment, not easy to relapse. (5) Computerized three-dimensional traction method. Through the computer set inclined plate, rotation reset, traction three-dimensional whole crest, correct the joint disorder caused by protrusion and restore the balance of its bony structure. It reduces and eliminates the irritation and compression of nerve roots, so that the back and leg pain and clinical symptoms and signs disappear. (6) Drugs: The main purpose of using dehydrating drugs and hormonal drugs is to make the edema of the compressed nerve root subside and reduce the inflammatory reaction. Some symptomatic pain relief drugs can also be used. Chinese medicine is used to treat the pain. (7) Sacral canal epidural drip method. Commonly known as “liquid knife”. This method acts on the intervertebral disc through the three principles of pressure impact, suspension reset and nutrition repair to loosen the adhesions in the spinal canal, and at the same time has the therapeutic effects of inhibiting the inflammatory reaction, relieving spasm, improving local microcirculation and nourishing nerves. (8) Combination of dynamic and static method. It means that during the acute period of the disease and the treatment period, the patient is required to rest in bed more often, while cooperating with functional exercises. In particular, the recovery period should be strengthened by exercising the lumbar back and abdominal muscles, which not only helps the recovery of disc herniation, normalizes the lumbar muscle strength and maintains the balance inside and outside the spinal canal, but also prevents the recurrence of lumbar disc herniation. （In recent years, minimally invasive interventional treatment for disc herniation has been accepted by scholars at home and abroad, and the main methods include: percutaneous paraspinal ozone nucleus oxidation, collagenase lysis, percutaneous discotomy and suction, laser disc decompression, radiofrequency thermal coagulation target therapy, and discoscopy. Methods carried out in our department: (1) Collagenase nucleus pulposus ablation method. Under the guidance of CT, collagenase is injected directly into the herniated disc inside and outside through a puncture needle to dissolve the herniated material and cure it. (2) Ozone nucleus pulposus oxidation method. Ozone of different concentrations is injected into and around the herniated disc through a puncture needle under CT guidance to strongly oxidize the herniated material and the surrounding sterile inflammation, causing dehydration and atrophy of the nucleus pulposus cells, thus shrinking the herniated material and reducing the compression and healing. This method of treating lumbar disc herniation can generally solve the problem only once, treating both the symptoms and the root cause with definite results. Principle: 1. Chemical nucleolysis of the disc nucleus pulposus is the injection of lysis enzymes into the nucleus pulposus of the disc to depolymerize the proteoglycans, the main component of the nucleus pulposus, so as to dissolve the nucleus pulposus, reduce the internal pressure of the disc and relieve the compression of the nerve roots. The available lysing enzymes are papain, collagenase, polysaccharidase, chymotrypsin, hyaluronidase and chondroitinase ABC, etc. The most commonly used enzyme in China is collagenase (collagen hydrolase, an enzyme that can hydrolyze the specific three-dimensional structure of natural collagen molecules under physiological conditions). Since collagenase can specifically degrade collagen, whether the protruding tissue is the nucleus pulposus or the fibrous ring wrapped around the nucleus pulposus protruding outward, its basic component is collagen, and collagenase can have a dissolving effect on it, thus reducing the internal pressure of the disc and playing a therapeutic role. 2, ozone lysis ozone is a strong oxidizing agent, it causes the nucleus pulposus to lose water and atrophy by destroying the nucleus pulposus cells and proteoglycans in its matrix, so as to release the nerve root compression of the herniated nucleus pulposus; ozone can also promote the dissipation of the inflammatory process and activate the pain sensation inhibition mechanism, so as to stimulate the inhibitory interneurons to release enkephalin and analgesia. Operation and use: All methods are best performed under CT guidance. The operation of various methods of puncture within the intervertebral disc is basically the same, and the approach depends on the patient’s specific situation and the physician’s personal experience, with lateral posterior approach, medial approach to the small joint, small joint space approach and lateral saphenous approach being feasible. The patient is positioned prone on the CT scan bed with a pillow on the abdomen and the level of the protrusion is determined on the preoperative CT film. A metal wire was used as a marker on the back and a 2 mm thin layer scan was made vertically in the gap of the prominence. The optimal puncture point, puncture angle and depth were selected and designed on the CT image, and the needle entry point on the body surface was determined under CT. The needle was inserted along the designed route, and there was a sense of dehiscence when penetrating the ligamentum flavum, or after reaching the vicinity of the prominence according to the design of the depth during the lateral approach, 1 ml of filtered air was injected, and the CT scan was performed to observe whether the needle tip reached the pre-designed position of the prominence. Afterwards, 8-10ml of 40ug/ml of oxygen and ozone mixture is extracted from the ozone generator with a disposable syringe, and slowly injected under pressure after pumping back no ooze, and 5ml of 1.6%-1.2% lidocaine solution and 5ml of Depo-Provera mixture is injected outside the disc, and then the needle is inserted through the puncture needle to reach the prominence and CT scan again to determine whether the tip of the needle is inside the prominence, and then extracted After that, 3-5ml of 60ug/ml of oxygen and ozone mixture is slowly injected into the protrusion, that is, into the disc, while communicating with the patient, and again CT scan to observe the distribution of ozone inside and outside the disc, observe for about 15min-20min, and then inject 600-1200u of collagenase into the protrusion quickly after confirming complete crestal anesthesia, dilute it into about 3-4ml with saline, 1ml inside the disc and 2-3ml outside the disc. After pulling the needle, local pressure was applied and sterile dressing was applied and pushed into the ward, and supine position was changed to 72 hours after 6 hours of prone position. Evaluation of efficacy: The evaluation of collagenase lysis of the disc should be performed 2-3 weeks after treatment. This is because the duration of action of collagenase is 18-24H and the absorption of the lysate takes approximately 2 weeks. The general condition of the patient after treatment is characterized by an improvement in crestal scoliosis. The recovery of neurological function is slower and generally takes 3-10 months, with some patients having a longer duration of disease. Patients with degeneration of nerve tissue due to prolonged compression may have sequelae such as superficial sensory paralysis to varying degrees. In patients with no significant change in symptoms after 6 weeks of collagenase lysis, lysis can be judged as a failure. In China, Yu Zhijian et al. reported that the efficiency of ozone treatment for lumbar disc herniation was 76.6%, DErne et al. reported that the efficiency of medical ozone treatment for lumbar disc herniation was 68%, while Muto and Andreula et al. reported a higher efficiency of 78% and 76%, respectively, while the efficiency reported by He et al. was 80.2%. Analysis of advantages and disadvantages: collagenase nucleolysis is a minimally invasive interventional therapy using collagenase injection to selectively dissolve collagen fibers in the nucleus pulposus, which is one of the effective means to eliminate open surgery for lumbar disc herniation that is unanimously recognized at home and abroad. Its characteristics of small trauma, simple operation and few complications once made it the preferred minimally invasive treatment for disc herniation, but as the treatment research progresses, its shortcomings become more and more obvious. Here are four points worthy of attention: (1) the puncture must be accurate, i.e., the puncture must be made into the disc or around the herniated disc (the puncture needle is close to the herniation), which raises the requirements for the puncture technique; (2) the concentration of collagenase must be locally saturated in the herniated disc to effectively dissolve the herniation. If collagenase is only injected into the anterior/posterior epidural space, it is difficult to ensure that collagenase aggregates or reaches sufficient concentration locally or around the herniated disc, and the effect of these factors on the lysis of the herniated disc is conceivable; (3) collagenase, as a protein, can only be active at the appropriate pH and temperature, and the loss of these two basic conditions will result in the loss of most or all of the enzyme activity. (4) In addition, it should be emphasized that collagenase is a lyophilized preparation because the aqueous solution of collagenase is extremely unstable at room temperature and must be stored at low temperature. If it is left at room temperature for 2 hours, its activity will be reduced by 40%. If it is left for 6 hours, the activity will be reduced by 75%. Therefore, it cannot be prepared in advance, which will prolong the procedure to some extent. In the choice of treatment precision, because collagenase is highly mobile, it is impossible to control or predict the extent of its diffusion when injected into the disc, thus causing inevitable damage to the normal nucleus pulposus tissue as well. If the dose or concentration is not mastered accurately enough, it may result in the loss of a large amount of normal nucleus pulposus tissue, thus seriously affecting the stability of the crestal column. In addition, collagenase nucleolysis has its own side effects and complications that cannot be ignored: Side effects of collagenase nucleolysis: (1) Pain reaction. The pain is usually worse than before treatment 3-10 days after treatment, because the injection of collagenase increases the volume of the disc, while the degradation of collagen fibers occurs under the action of collagenase, resulting in an increase in the disc contents, which increases the intradiscal pressure and the chemical irritation during the degradation process, which occurs after the sinus spinal nerve is provoked. (2) Urinary retention and intestinal paralysis. It is caused by the agitation of the sinus nerve after the increase of the intradiscal pressure and causes vegetative nerve dysfunction. (3) Crestal instability low back pain. After disc lysis, the intervertebral space becomes narrower and the small joints will overlap, resulting in reflex low back discomfort and pain due to irritation of the sinus reflex nerve. Complications of collagenase nucleolysis : (1) Allergic reaction: collagenase as a biological agent, there is a possibility of allergic reaction. (2) Intervertebral infection: manifested as lumbar muscle spasm, increased lumbar pain with deep pressure pain, normal or elevated white blood cell count and classification, and increased blood sedimentation. (3) Nerve injury: Mostly the puncture needle pierces the crestal nerve root or accidentally injures the crestal membrane or the outer nerve membrane during puncture. High concentration of collagenase dehydrates and degenerates the nerve root, and once it accidentally enters the subarachnoid space, chemical meningitis occurs in mild cases, and paraplegia may occur in severe cases. The incidence of collagenase complications is very low, but if they do occur, they can all lead to irreversible consequences. Therefore, we can see that collagenase has more safety hazards in the puncture process, chemical nature, preservation methods, and treatment results, which has a non-negligible constraint on its application and is difficult to carry out. Analysis of the advantages and disadvantages of medical ozone therapy for lumbar disc herniation: ozone therapy for lumbar disc herniation is a new treatment method that has emerged in the past two years. Ozone is a strong oxidizing agent. It can cause the nucleus pulposus to lose water and shrink by destroying the proteoglycans in the nucleus pulposus matrix, and release the nerve root compression by the herniated nucleus pulposus. Ozone also destroys the nucleus pulposus cells, causing a decrease in proteoglycan production and secretion in the nucleus pulposus. In addition, it has been demonstrated that ozone promotes the dissipation of the inflammatory process, mainly by: affecting the release of cytokine antagonists and/or self-exempt inhibitory cytokines such as IL10 and TGFβ1; causing the overexpression of antioxidant enzymes to neutralize excess reactive products; and stimulating vascular endothelial cells to produce no and PDGF causing vasodilation, which leads to the dissipation of inflammation. For the resolution of postoperative infections, the chance of infection is greatly reduced by the disinfecting effect of ozone itself. However, ozone therapy has a narrow scope of application, with a single injection of no more than 20 ml, and is effective for mild disc herniation, while it is not effective for moderate to severe herniation, nor does it directly eliminate the nucleus pulposus tissue that compresses the nerve. One treatment is not effective and often requires 2-5 treatments to obtain a more satisfactory result. In addition, patients may experience increased symptoms after ozone injection due to the increased pressure within the disc. Ozone is more effective in relieving the symptoms of a herniated disc, but less effective in treating a herniated disc. All of the above minimally invasive interventions have the following advantages: ① small operation cost and low cost: ② no removal of the disc, which does not affect the stability of the crest; ③ multiple disc lesions can be treated at the same time: ④ short operation time, little trauma and fast recovery; ⑤ no intra-vertebral canal operation, few postoperative complications or sequelae: ⑥ no damage to the bony disc, which does not affect the balance and weight-bearing capacity: ⑧ only local anesthesia is required, the operation is simple and easy for the surgeon to master. It is easy to grasp and other advantages. The operation method is also very similar, and even the treatment principle and efficacy are basically the same. Relatively speaking, ozone treatment for disc herniation is the simplest, almost non-invasive, and does not require expensive equipment and drugs, and can be performed on an outpatient basis, which greatly reduces the cost for patients; the antibacterial and antiviral functions of ozone can greatly reduce the chance of postoperative disc infection. (iii) Surgical treatment For a long time, orthopedic surgeons have insisted on the principles of removal and decompression, such as full lamina, half lamina, intervertebral openings and other accesses to perform disc removal to achieve the purpose of decomposable nerve roots and decompression. At present, only 10-20% of patients need surgery. However, surgical treatment is very traumatic, risky, long recovery time, postoperative complications such as crestal spine stability, postoperative neuralgia due to adhesions and scarring, and high cost. And make patients afraid of surgical treatment. Patients are often not easy to accept, and some of them live with pain because of the fear of surgery. Therefore, many medical workers and patients with low back pain are eager to have an ideal method that is non-invasive, less invasive, less painful, faster recovery, more effective, safe and simple. One of the important trends of modern surgery is the limited and minimally invasive surgery. With the rapid development of medical technology, the research of minimally invasive crestal surgery has become the crestal surgery today.