The anatomy and physiology of the intervertebral disc and the diagnosis and treatment of the intervertebral disc mainly consist of the external fibrous ring and the central nucleus pulposus, the nucleus pulposus mainly consists of a colloid matrix, the fibrous ring mainly consists of fibrocartilage bundles forming the inner ring part, the water content reaches 85% and 75% respectively before the age of 10 years, after the age of 10 years the nucleus pulposus starts to fibrosis from its ventral dorsal edge and gradually develops towards the center, after the age of 30 years the water content further decreases. Pathological types of lumbar disc herniation: LDH is divided into degenerative, bulging, herniated (under the posterior longitudinal ligament), prolapsed (behind the posterior longitudinal ligament) and free types. Degeneration: Mostly no clinical symptoms and signs. Decreased water content in the disc is seen on MRI scan, and deformation or calcification is seen on CT. The degeneration type is an early change and is not usually confused with the protrusion type. Bulging: Bulging is a physiologic degeneration with a relaxed but intact annulus fibrosus and a crinkled nucleus pulposus that appears as the annulus fibrosus uniformly extending beyond the edge of the vertebral body endplate. There are no clinical symptoms, but sometimes recurrent back pain may occur due to narrowing of the spinal space, instability of the vertebral segments, and secondary changes in the articular eminence, and rarely radicular symptoms. If combined with developmental spinal stenosis, it is manifested as spinal stenosis and spinal decompression should be performed. A bulging disc is a degenerative disc that decreases in height, with the peripheral annulus fibrosus symmetrically exceeding the normal physiological limits of the vertebral endplate edge. Theoretically, a bulging disc is a physiological degenerative process, and in the absence of other pathological factors, bulging may not produce symptoms. The majority of patients with LDH can recover with non-surgical treatment. Protrusion: The nucleus pulposus protrudes into the spinal canal through the fibrous annulus fissure without rupture of the posterior longitudinal ligament, and the imaging shows a limited protrusion of the disc into the spinal canal, which may be asymptomatic. This type can be relieved by conservative methods such as traction and bed rest, but the recurrence rate is high due to the poor healing ability of the fibrous annular fissure. Minimally invasive intervention is required when necessary. Extrusion: complete rupture of the annulus fibrosus and posterior longitudinal ligament and protrusion of the nucleus pulposus into the spinal canal, with obvious symptoms and signs, which are difficult to heal spontaneously. Free type (seqestration): The prolapsed nucleus pulposus is not connected to the corresponding disc, and can be free into the upper or lower segments of the spinal canal or the intervertebral foramen, etc. Its clinical manifestations are persistent nerve root symptoms or spinal stenosis symptoms, and a small number of them may appear cauda equina syndrome, which often requires surgery. Discogenic pain Lower back pain caused by disc degeneration can be broadly classified into discogenic etiology and myogenic or neurogenic etiology according to the mechanism of its occurrence, and the difference lies in whether the pain is confined to the lower back or involves The latter indicates nerve root damage, mostly due to disc herniation and prolapse. Discogenic pain is defined as degeneration of the fibrous annulus forming an internal fissure without superficial rupture, without signs of nerve root damage, and with predominantly lumbosacral pain. The diagnosis depends on MRI showing degenerative manifestations of the intervertebral disc, and T2-weighted image showing a high signal area in the posterior part of the disc, suggesting a fissure in the posterior part of the fibrous ring, as the fissure contains fluid from the disc and local inflammatory reaction, and signal enhancement in the corresponding area is seen by intravenous injection of iodine contrast agent. Discography may induce corresponding pain, and the disc fissure is seen to extend into the outer 1/3 of the annulus fibrosus, usually a marginal tear connected to the nucleus pulposus. The diagnosis of discogenic pain is made only if there is no degeneration of other adjacent discs and no similar pain on imaging. After the diagnosis of discogenic pain is confirmed, non-surgical treatment is mainly applied, and in recent years, minimally invasive interventional intradiscal thermal therapy, such as percutaneous laser disc decompression (PLDD), radiofrequency intradiscal electrothermal coagulation (IDET) or intradiscal annuloplasty (IDET), is mostly used. The puncture catheter of IDETA can be circumferentially curved to reach the posterior fibrous annulus rupture along the fibrous annulus tissue and gradually heated to cause collagen fibers to contract, degenerate, polymerize, and destroy local nerve endings. This method has been developed rapidly recently, but the long-term efficacy remains to be observed. Conservative treatment of lumbar disc herniation: Conservative treatment is the basic treatment for LDH, and about 80% of LDH can be relieved or cured by conservative treatment. Conservative treatment is aimed at accelerating the decompression of inflammatory edema in the lumbar disc herniation lesion and the irritated nerve roots, thereby reducing or relieving their irritation and compression on the nerve roots. Conservative treatment is mainly indicated for: 1. young people, first attack or short duration of disease; 2. people whose symptoms can be relieved by themselves after rest; 3. people without spinal stenosis on X-ray examination. Conservative treatment of herniated disc: specific methods include absolute bed rest, continuous traction, physical therapy, massage, massage, oral anti-inflammatory and pain-relieving drugs, focal injection therapy, etc. The role of focal injection therapy is to reduce the inflammatory response of the nerve root, with an efficiency of 76% for the herniated type and only 26% for the bulging type. Generally, the regular conservative treatment for 6-8 weeks has no effect on the consideration of other methods. 1, absolute bed rest, the most important. 2, can traction, but the initial traction can aggravate the clinical discomfort, to correctly understand it. 3.Local physiotherapy and hot compress. 4.Non-steroidal pain medication, hormonal drugs can be added appropriately in the acute stage, the effect is better, usually 3 days, but now many people do not advocate the application of hormones. 5.If the above methods are not effective, epidural closure or sacral canal treatment can be done. 6.Avoid physical labor during the recovery period. Chinese medicine conservative treatment First, correct the cause of the patient (such as: poor sitting posture), then, orthopedic massage > acupuncture (available nerve root electro-acupuncture) > the usual patient practice (lumbar back muscle training) serious epidural anesthesia + hormone after the large pushing water Chinese medicine internal and external application. Surgical treatment of lumbar disc herniation: Indications for surgery: LDH diagnosed by symptoms, signs, imaging and neurolocalization, no relief after 6-8 weeks of regular conservative treatment, sensory-motor dysfunction, cauda equina syndrome, intolerable pain or recurrent attacks affecting work and life. Contraindications to surgery: severe heart, lung, liver and kidney diseases, infected lesions, severe neurasthenia, psychiatric patients, and patients with effective conservative treatment. Choice of surgical methods: 1.Open decompression: low back pain with unilateral lower limb pain, accumulating one gap. 2.Half laminectomy: low back pain with unilateral limb pain, cumulative two interstitial patients or those who were originally diagnosed with protrusion of a certain interstitial space and the intraoperative pathological changes of that interstitial space were found to be insufficient to explain the preoperative symptoms and the adjacent interstitial space needed to be explored. 3.Total laminectomy: Huge central type lumbar disc herniation with symptoms of acute cauda equina injury. Those whose recurrence after nucleus pulposus removal is ineffective by conservative treatment and require secondary surgery. 4.Partial arthrodesis or arthrodesis: those with extreme lateral type or combined with spinal stenosis. Treatment of LDH with standard procedures still leaves a few people with residual back pain or worsening symptoms after surgery, and people often attribute these manifestations to pathological changes after discectomy. The pain of many such patients has been addressed by methods such as segmental fusion, including posterior intertransverse fusion, interbody fusion, and the interbody fusion device technique (BAK, Cage) developed in the 1990s, and the fusion rate is now considered to be positively correlated with the clinical satisfaction rate. However, it has also been observed that despite a fusion rate of 89%, the clinical satisfaction rate is only 60%. Therefore, some authors believe that a solid fusion does not necessarily predict a satisfactory clinical outcome, and that there may be other reasons for residual symptoms after conventional disc surgery. Minimally invasive interventions for lumbar disc herniation: 1. Chemonucleolysis: Chemonucleolysis is the application of collagenase hydrolysis to dissolve the nucleus pulposus or herniated material, thus relieving the irritation and compression of the nerve root for therapeutic purposes. This technique is mainly used for herniated and prolapsed LDH. 2. percutaneous lumbar discectomy (PLD): The mechanism of PLD is to reduce the disc pressure by removing the disc tissue, thus weakening or eliminating the tension mechanism of nerve root damage. Randomized controlled studies have reported an excellent rate of less than 70%, and the surgical operation is blind, with a high recurrence rate, and less efficacy and reliability than chemical lysis and endoscopic disc removal, so this technique is not used alone. 3, percutaneous laser disc decompression (PLDD): operation is similar to PLD, using the laser to generate heat energy to vaporize the disc tissue, dry and dehydrate it, reduce the tension and pressure of the nucleus pulposus tissue on the nerve root, and relieve the radicular symptoms. Most authors have shown that the efficacy is significantly lower than that of chemolysis. The procedure is also a non-direct vision minimally invasive procedure with expensive equipment, and its safety, efficacy and cost-effectiveness ratio need to be further observed. Endoscopic discectomy (microendoscopic discectomy, MED): there are three types of endoscopic approaches: (1) posterior-lateral transvertebral foramen approach discoscopy; (2) anterior laparoscopy; (3) posterior discoscopy, i.e., standard interlaminar disc approach, which is suitable for single-segment paracentral herniation, prolapse, and free discs in the spinal canal, and can simultaneous decompression of the spinal canal such as lateral fossa enlargement. Due to good monitoring of the imaging system, blindness is avoided, and precise localization, appropriate amount of resection and effective decompression can be performed with minimal trauma, rapid recovery, and high recent excellent rates. However, due to the limitation of exposure, high technical requirements, difficulty, difficulty in complete surgery, and long-term efficacy need further observation. At present, in addition to conventional open surgery, minimally invasive interventional techniques have been an important means of treating LDH, and the effect is better than conservative treatment for those with more severe symptoms. Reconstruction techniques for lumbar disc herniation: Accelerated disc degeneration in adjacent segments after lumbar fusion and formation of pseudo-joints in fused segments leading to recalcitrant postoperative lumbar pain have raised concerns. Attempts at allogeneic disc transplantation, artificial disc replacement, and artificial nucleus pulposus techniques aimed at reconstructing the physiological function of the disc, and gene therapy strategies for delaying and reversing disc degeneration are new topics in the treatment of intervertebral disc disease. Attachment: the route of the spinal nerve out of the intervertebral foramen The cervical nerve emanates from the upper intervertebral foramen, such as the C3 nerve from the C2/3 intervertebral foramen, and the thoracic and lumbar nerves emanate from the next intervertebral foramen, such as the L4 nerve from the L4/5 intervertebral foramen. So which nerve is being compressed by the lumbar disc herniation? Is it the L4 nerve that emanates from the L4/5 intervertebral foramen that is being compressed by a herniated L4/5 disc? No, because the L4 nerve has gone out of the intervertebral foramen, so the nerve that is being compressed is the L5 nerve. 1, lumbar 3/4 disc prolapse (lumbar 4 nerve root damage) [muscle strength test] (1) Anterior lumbar muscle is involved. Therefore, the dorsal extension and inversion of the foot is weakened into a complete loss of strength, (2) toe extensor and peroneal muscles are not involved, so toe extension and foot extensor activities are not impaired. [Reflex test] (1) The quadriceps muscle is mainly innervated by the lumbar 4 nerve root, so the knee tendon reflex is weakened or disappeared due to its involvement. (2) The triceps calf muscle is not involved, so the heel reflex exists. [Sensory test] The medial skin sensation of the calf and foot is impaired. 2. lumbar 4/5 disc prolapse (lumbar 5 nerve root damage) [Muscle test] (1) the toe extensor muscle is involved, so the toe extension movement is weak or completely impaired; (2) the anterior tibial muscle and peroneal muscle are not involved, so the dorsal extension, inversion and valgus activities of the foot are not impaired. [Reflex test] The quadriceps and triceps are not involved, so the knee tendon and Achilles tendon reflexes are present. [Sensory test] The skin sensation of the lateral calf and dorsal foot was impaired. 3, lumbar 5 sacral 1 disc prolapse (sacral l nerve root damage) [muscle strength test] (1) peroneal long and short muscles are involved, so the power of foot external rotation is reduced or completely lost; (2) tibialis anterior and toe extensor muscles are not involved, so there is no obstacle to foot dorsal extension, internal rotation and toe dorsal extension. [Reflex test] (1) The triceps calf muscle is involved, so the Achilles tendon reflex is weakened or disappeared; (2) the quadriceps muscle is not involved, so the knee tendon reflex exists. (2) The knee tendon reflex is present. Clinical manifestations (1) 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 may occur simultaneously; most of them have a history of trauma, or may have no clear cause. The pain has the following characteristics: a. The radiating pain is transmitted along the sciatic nerve and reaches the lateral calf, dorsum of the foot or toes. In case of lumbar 3-4 interstitial herniation, radiating pain to the front of the thigh is produced due to the compression of the lumbar 4 nerve root. b. All actions that increase the pressure of cerebrospinal fluid, such as coughing, sneezing and defecation, can aggravate the lumbago and radiating pain. c. The pain increases with activity and decreases with rest. Bed position: Most patients are in lateral recumbency with flexion of the affected limb; individual severe cases have pain in all positions and can only bend the hip and knee*** in bed to relieve symptoms. Combined with lumbar spinal stenosis, there is often intermittent claudication. (2) 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 generally bent to the affected side. Left: the herniated nucleus pulposus is located in front of the nerve root, the spine bends to the affected side, and the pain increases if the bend is to the healthy side Right: the herniated nucleus pulposus is located in front of the nerve root, the spine bends to the healthy side, and the pain increases if the bend is to the affected side (3) Restriction of spinal movement The herniated nucleus pulposus compresses the nerve root and causes protective tension in the lumbar muscles, which can occur unilaterally or bilaterally. Due to the tension of the lumbar muscle, the physiological lumbar convexity 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. The restriction of lateral bending is often only on one side, according to which it can be differentiated from lumbar spine tuberculosis or tumor. (4) Lumbar pressure pain with radiating pain There is a limited pressure pain point next to the spinous process on the affected side of the herniated disc, and it is accompanied by radiating pain to the calf or foot, which is important for diagnosis. (5) Positive straight leg raise test Due to the difference of individual physique, there is no uniform degree standard for this test to be positive, and attention should be paid to the comparison of both sides. A positive test is when the affected side is limited in raising the leg and feels radiating pain to the calf or foot. Sometimes numbness occurs in the affected leg while lifting the healthy limb, which is caused by the pulling of the nerve on the affected side, and this is of great value for diagnosis. (6) Neurological examination When lumbar 3-4 herniation (lumbar 4 nerve root compression) is present, there may be decreased or absent knee reflex and decreased sensation in the medial calf. In the case of lumbar 4-5 herniation (lumbar 5 nerve root compression), the dorsal sensation of the anterolateral foot of the lower leg is reduced, and the extension and 2-toe muscle strength is often reduced. In the case of lumbar 5-sacral 1 herniation (sacral 1 nerve root compression), the posterior posterior calf and lateral foot sensation is decreased, the muscle strength of the 3rd, 4th and 5th toes is decreased, and the Achilles tendon reflex is decreased or disappeared. In severe cases of nerve compression, the affected limb may have muscle atrophy. If the herniation is large, or if it is central, or if the nucleus pulposus fragments protrude into the spinal canal, there may be more extensive nerve root or cauda equina damage symptoms, and the numbness area on the affected side is often more extensive, including the affected hip, lateral femur, calf and foot below the plane of nucleus pulposus protrusion. Central type protrusion often has nerve damage symptoms in both lower extremities, but one side is more severe; attention should be paid to check the sensation in the saddle area, which is often diminished on one side and sometimes on both sides, often with loss of control of urination, wet pants and bedwetting, constipation, sexual dysfunction, and even partial or major paralysis of both lower extremities. Differential diagnosis (1) posterior lumbar joint disorder The upper and lower synapses 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 may arise from synovial imbrication in the acute stage, and traumatic arthritis of the posterior joint may arise 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. (2) 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 they can continue walking. 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. (3) 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. CT scan is unique for early limited tuberculosis lesions of the vertebral body that cannot be shown on X-ray. (4) Vertebral metastases Increased pain, aggravated at night, debilitated patient, primary tumor can be detected. osteolytic destruction of vertebral body can be seen on X-ray plain film. (5) Spinal meningioma and cauda equina neuroma are chronic progressive disorders without intermittent improvement or self-healing, often with incontinence. Cerebrospinal fluid protein is elevated, and the Quay test shows obstruction. Myelography may be used to confirm the diagnosis. CT manifestations: (1) The posterior edge of the normal lumbar disc does not exceed the posterior edge of the bony endplate of the vertebral body and is slightly depressed in the middle in a kidney shape. A prolapsed disc manifests as a curved soft tissue shadow protruding locally from the posterior edge of the vertebral body, usually connected to the intervertebral disc and with a more consistent density, and the epidural free nucleus pulposus is visible. The nucleus pulposus is above or below the disc plane, and its density is lower than that of the vertebrae but higher than that of the dura and paravertebral soft tissues, and the protruding disc may calcify. (2) The epidural fat is compressed, displaced, or even disappears, and the anterior or lateral edge of the subdural space is compressed and deformed. (3) A laterally and posteriorly protruding disc may shorten the anterior and posterior diameters of the lateral saphenous fossa, compressing the corresponding spinal nerve roots and displacing them posteriorly; the spinal nerve roots may also be thickened due to edema. CT scan after iodine hydrography of the spinal canal can help to show changes in the spinal nerve root sheath and the dural cavity. (4) Posterior vertebral sclerosis and sometimes Schmorl’s nodes can be seen on the upper and lower edges of adjacent vertebral bodies. CT manifestations of disc bulge: (1) In mild bulge, the normal kidney-shaped depression at the posterior edge of the disc disappears, and the rounding is full. (2) In severe cases, the edge of the diffusely bulging disc widens uniformly in all directions, beyond the edge of the upper and lower vertebral bodies, but the disc remains symmetrical, without local protrusion, and maintains an oval shape, which can be accompanied by vacuum degeneration. In severe cases, it can cause dural sac compression stenosis and cauda equina compression. CT disc herniation is divided into four types according to the direction of disc herniation, namely central, lateral, distal lateral and lateral anterior, the first two being intradural and the last two extradural. The central type disc herniation is located in the middle of the spinal canal and mainly compresses the epidural fat space and the dural sac; the lateral type disc herniation is located in the inner side of the spinal canal and does not exceed the inner mouth of the intervertebral foramen, and mainly compresses the epidural fat space, the dural sac and the nerve roots; the distal lateral type disc herniation is located outside the spinal canal and mainly causes narrowing of the intervertebral foramen and compression of a lateral root nerve; the lateral anterior type disc herniation itself does not cause compression symptoms. The lateral anterior disc herniation itself does not cause compression symptoms, but because the outer 1/3 of the disc has nerve distribution, it is also a cause of low back pain, so it should be given sufficient attention. The degree of disc herniation is not directly proportional to the degree of spinal stenosis, but the degree of spinal stenosis is influenced by the size of the herniated material, the size of the dural sac, the thickness of the ligament, joint hypertrophy and disc bulge. Intravertebral tumor and lumbar keyboard herniation symptoms differentiation: 1, herniated disc pain at night without obvious plus sharp pain, position change, walking pain increased, examination: lasegue disease is mostly positive, herniated intervertebral space or next to the pressure pain. Intradural imaging can be seen as nerve root compression, lateral film can have a partial defect of contrast, cerebrospinal fluid examination is not abnormal. 2, the onset of intradural extramedullary tumor has pain as the main manifestation, pain and position also have a relationship, but the pain is more intense, like acute disc herniation symptoms, night pain is more obvious, there may be spinal cord hemisection, physical examination: lasegue can be negative, no obvious pressure pain in the intervertebral space. Intravertebral imaging reveals a significantly larger contrast defect and a marked increase in cerebrospinal fluid protein. Postoperative disc herniation is more common clinically and is not easily distinguished from postoperative epidural tissue fibrosis CT scan of the herniated disc and epidural scar isointensity, MRI both signal equal. Differentiation: CT AND MRI enhancement scans: no enhancement of the herniated disc tissue and enhancement of the surrounding scar tissue, as evidenced by low-density CT and low-signal MRI non-enhanced areas within the enhanced scar tissue and surrounding tissue!