The lumbar disc herniation (LDH), also known as lumbar fibrous annulus 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 internal and external pressure in the lumbar disc, resulting in the rupture of the lumbar fibrous annulus and 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. Zhang Yafeng, Department of Spinal Orthopedics, Wuxi Chinese Hospital [Etiology] Degenerative changes occur in various tissues of the human body after puberty, among which changes in the intervertebral disc occur earlier, and the main change is dehydration of the nucleus pulposus, after which the disc loses its normal elasticity and tension, and on this basis the nucleus pulposus is protruded from the place due to the weakening or rupture of the fibrous ring caused by heavier trauma or many 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, causing 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 space. 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 may 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) Restriction of spinal movement The herniated nucleus pulposus compresses the nerve roots, causing protective tension in the lumbar muscles, which can occur unilaterally or bilaterally. Due to the tension of the lumbar muscles, 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 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. (ii) 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 they must squat down and 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. (iii) Lumbar spine tuberculosis Early confined lumbar spine tuberculosis may 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. (iv) 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. (v) Spinal meningioma and cauda equina neuroma are chronic progressive disorders with no 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. (i) Non-surgical treatment Non-surgical treatment includes: (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 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 improve significantly after 3 weeks of bed rest. At this time, the lumbar back muscle exercise should be started on a case-by-case basis, and the patient can get up and move 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 later it will be more impossible to get rid of the lumbar girth. (2) pelvic traction: traction can further reduce the pressure within the intervertebral discs, the efficacy is better, especially for early patients. (3) massage: the technique should be gentle and should not be violent. (4) drugs: the use of dehydrating drugs, 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) 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 attack 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 the hip and knee, or even kneeling position; (3) the presence of single nerve palsy or cauda equina nerve (4) the patient is middle-aged and has a long medical history, which affects work and life; ○5 although the medical history is atypical, myelography or epidural and vertebral venography shows obvious filling defects with signs of compression, or discography shows total disc degeneration with huge protrusion; ○6 herniated disc with other causes of lumbar spinal stenosis. 1, conventional lumbar disc removal This surgical procedure is a recognized, This surgical procedure is a well-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 goal 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 laminae removed, the procedure is divided into the following categories: ○1 total laminectomy with removal of the nucleus pulposus, which involves removal of both laminae and spinous process, with full exposure and complete decompression. ○2 half laminectomy with removal of the nucleus pulposus, where one side of the lamina is removed and the opposite side of the lamina and spinous process are preserved. 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, and the nucleus pulposus in the central and lateral areas of the intervertebral space is not removed. 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 results 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 transforaminal fibrous endoscopic discectomy (MED); 3.5 Prosthesis of the intervertebral disc 3.6 Radiofrequency ablation of the nucleus pulposus (Nucleoplasty).