Lumbar disc herniation is a common and frequent disease in neurosurgery and spine surgery, and is one of the most common causes of lower back pain and low back pain. Its pathogenesis is a syndrome caused by degeneration of the lumbar disc, rupture of the annulus fibrosus, and protrusion of the nucleus pulposus, which stimulates and compresses the nerve roots and cauda equina. Most patients with lumbar disc herniation can have their symptoms relieved with conservative treatment such as traction and strengthening of the lumbar muscles, but about 15% of patients with lumbar disc herniation eventually require surgery. Mixter and Barr at Harvard Medical School in the United States first used surgery to cure lumbar disc herniation in 1934, and to date, the history of surgical treatment of lumbar disc herniation has reached more than 70 years. After a lot of experiments and clinical research, the diagnostic technique of this disease has been gradually improved, and the surgical method has also been greatly developed and innovated. I. Posterior lumbar disc herniation removal under direct vision Traditional posterior lumbar disc removal is still a commonly used surgical method with reliable efficacy, especially a more common treatment method in primary hospitals. (3) central type herniated disc or suspected free block prolapsing into the spinal canal to produce cauda equina symptoms, should be operated as soon as possible; (4) lumbar disc herniation with lumbar spinal stenosis or combined with lumbosacral “migrated vertebrae” or spinal slippage, need to do lumbosacral fusion at the same time. Posterior lumbar disc herniation removal is a classic surgical procedure for the treatment of lumbar disc herniation. According to the amount of occluded discs, the traditional surgery for lumbar disc herniation includes three types of procedures: total laminectomy, hemilartebral resection lumbar disc herniation removal, and interlaminar window lumbar disc herniation removal. Total and hemi-laminectomy lumbar disc herniation removal is easy to access, has a wide surgical field of view, can directly remove the nucleus pulposus, has sufficient decompression on the nerve roots, and has a positive postoperative effect; however, the decompression range of this surgical method is too large, which can cause damage to the posterior column structure of the spine and affect the stability of the spine; there is a potential risk of injury to the nerve roots and large peritoneal vessels during the operation; after the operation, some patients form a large amount of fibrous scar tissue or regular neoplastic tissue in the defective area of the vertebral plate. In some patients, a large amount of fibrous scar tissue or irregular new bone is formed in the defective area of the vertebral plate, which adheres to the dura mater or nerve roots, resulting in medically induced spinal stenosis. Open disc nucleus pulposus is the most commonly used surgical method. It has the advantages of less injury, faster recovery, better efficacy and fewer complications, but the disadvantage is the small exposure area. For patients with disc herniation with narrow plate space, a small incision is used for subtle decompressive nucleus pulposus removal, and for patients with calcified lumbar disc herniation of central type and wide basal type, a double-opening enlarged decompressive disc removal is used, which can fully expose the herniated disc, nerve roots and lateral saphenous fossa, with accurate surgical positioning, little trauma, less bleeding, maximum preservation of the integrity of the posterior lumbar structures and minimization of dural sac adhesions The operation time is short and recovery is fast. If the herniated disc is combined with obvious degenerative changes and requires more extensive exploration or decompression, hemilaryngectomy can be used; if the herniated disc is bilaterally herniated in the same space or the central type herniated adhesions are not easily removed from one side, or if it is combined with obvious degenerative changes in the spine or combined with central type disc stenosis requiring bilateral exploration and decompression, total laminectomy can be used. Anterior lumbar disc removal under direct vision Anterior lumbar disc removal was first reported by Halt in 1950. The success rate of the operation is about 82%-95%. However, it requires a high level of operator skill. The advantages of this procedure are: it does not expose the spinal canal, does not touch the dura and nerve roots, and avoids inflammatory injury; it avoids hematoma, scarring and adhesions around the epidural and nerve roots; it does not destroy the posterior structure of the spine, which reduces postoperative lumbar instability and lumbar spine slippage, and allows early functional exercise and movement to the floor. However, it is impossible to judge the protrusion of the disc and the specific situation of the spinal canal, nerve root canal and nerve root under direct vision, and it is impossible to remove the disc that has prolapsed into the posterior edge of the vertebral body: there is a possibility of causing damage to the peritoneum, ureter, blood vessels of the posterior abdominal wall and sympathetic plexus. Microscopic lumbar disc removal Traditional posterior full and half laminectomy to remove the nucleus pulposus of the lumbar disc has different degrees of damage to the integrity of the three lumbar structures and has a certain impact on the stability of the lumbar spine, and has disadvantages such as long incision, large damage, patient needs to tolerate greater pain, slow postoperative recovery and greater psychological pressure on the patient. Minimally invasive lumbar disc technology refers to techniques and methods that are less invasive than traditional incision surgery, and currently refers to those that use non-traditional surgical methods and treat with certain special surgical instruments or tools. The advantages of microscopic lumbar disc removal are: small incision, clear field, short hospital stay and quick postoperative recovery. At present, microscopic subtotal lumbar discectomy is commonly performed under X-ray fluoroscopy, with a 1.5-cm-long posterior median paracentral incision by inserting a guide needle. The nerve roots are retracted, the posterior longitudinal ligament is dissected, and the intervertebral disc is subtotally removed, keeping the cartilage plate intact during surgery. The epidural space and intervertebral foramen are explored for the presence of free intervertebral discs. The dura is covered with a fat graft. The advantages are: small surgical incision, less bleeding, unaffected spinal stability, and fast postoperative recovery. Chemical nucleolysis (CN) In 1964, Smith first reported the treatment of lumbar disc herniation by chemical nucleolysis with percutaneous posterior lateral disc puncture and injection of papaya rennet, which pioneered minimally invasive spinal surgery. At present, more lysis agents are used at home and abroad as collagenase, which can dissolve collagen in the nucleus pulposus and fibrous ring without damaging the enzymes in the adjacent structures and with lower allergic reactions, and has replaced papaya rennet protease. Clinically, there are mainly five methods as follows: (1) percutaneous oblique or posterior direct puncture of the intervertebral disc (intradiscal) injection method; (2) percutaneous epidural lateral crypt protrusion local (extradiscal) injection method; (3) epidural lateral crypt puncture method through the external incision of the vertebral plate or the inner edge of the small joint; (4) percutaneous paraspinal epidural injection method; (5) combined method of percutaneous cut and aspiration and collagenase injection. CT-guided and C-arm X-ray surveillance is also the only means of safety assurance. The main complications include inadvertent introduction of collagenase into the subarachnoid space, nerve root injury, epidural space infection, increased abdominal pressure during the lysis period leading to re-detachment of the nucleus pulposus causing cauda equina syndrome and paraplegia. Therefore, correct selection of indications and standardized operation can reduce the occurrence of serious complications. V. Percutaneous lumbar discectomy (PLD) In 1975, Hijikata first reported the use of percutaneous puncture technique for the treatment of lumbar disc herniation, which opened up a new pathway between open surgery and conservative treatment, and its superior performance and improved operation have led to its rapid promotion worldwide, with It has the advantages of less trauma, faster recovery, no interference with the internal structure of the spinal canal, no influence on the stability of the spine, fewer complications, and simpler operation. However, the procedure is performed under x-ray fluoroscopy and not under direct vision. The herniated disc tissue cannot be removed during surgery, and it is difficult to achieve complete decompression. Therefore, its indications are limited to simple and acute disc herniation. Arthroscopic discectomy (arthroscopy microdiscectomy, AMD) From the late 1980s to the early 1990s, after Schreiber pioneered the introduction of endoscopic techniques into percutaneous nucleus pulposus removal in 1982, many scholars introduced arthroscopy into the field, using a modified arthroscope called a discoscope, in order to more The nucleus pulposus can be removed more accurately and effectively, reducing its blindness. This procedure has the advantages of less trauma, faster recovery, positive outcome, no effect on the intervertebral space height, and helps maintain spinal stability. However, the surgical equipment and instruments are more expensive. The endoscopic surgical technique is difficult to master and requires rigorous training, which is not easy to popularize. Percutaneous laser disc decompression (PLDD) In 1987, Daniel was the first to report the success of laser treatment of lumbar disc herniation. Percutaneous laser disc decompression is developed on the basis of percutaneous disc removal. This procedure has the advantages of being easy to perform, safe and effective with a low complication rate. However, because the technique is not performed under direct vision, its bed treatment results are not significantly different from other techniques. And need more expensive laser equipment, at present the domestic carry out less. Eight, radiofrequency ablation myeloplasty (nueleoplasty) radiofrequency ablation myeloplasty was first used in the United States in July 2000 for clinical treatment of lumbar disc herniation, is an advanced minimally invasive technology for the treatment of disc herniation. It is characterized by the ability to remove a large amount of diseased tissue without causing irreversible damage to the surrounding normal tissue (bleeding, necrosis, etc.). The procedure has the advantages of simple operation, safety and minimal trauma, but the disadvantage is that it requires high investment in equipment. At present, the introduction of this technology in China is still short, and long-term follow-up is needed to observe the long-term efficacy and complications. Intradiscal Electrothermal Therapy (IDET) Intradiscal Electrothermal Therapy (IDET) is a technique in which the triple helix structure of collagen fibers within the annulus fibrosus is disintegrated, denatured and contracted by local heating, resulting in the retraction of the IDET disc tissue and a reduction in pressure. The degree of intradiscal pressure reduction after IDET treatment has been reported to be inconsistent, but all have significant effects. During surgery, a guide needle is punctured through the center of the intervertebral disc under fluoroscopy, and a heat-resistant wire is placed into the guide needle. The heat-resistant wire passes through the nucleus pulposus and bends along the medial wall of the annulus fibrosus, and continues to advance so that it is distributed throughout the posterior and posterior lateral parts of the annulus fibrosus, and the wire is slowly heated and heated to 80°C and 90°C, and the needle is withdrawn after maintaining for 4-5 rains. The treatment mechanism is: (1) local heat therapy causes contraction of collagen fibers in the fissured fibrous ring tissue and re-browns the tears to heal; (2) heating inactivates inflammatory factors and degrading enzymes in the disc, thus eliminating chemical pain-causing factors; (3) heat inactivates the nociceptive nerve endings distributed in the outer layer of the fibrous ring and loses the ability to receive and transmit pain signals; (4) deep heat therapy acts to improve IDET treatment is still in its initial stage, with few studies reported, and its application value needs to be further verified. In 1997, Foley and Smith pioneered the use of microendosectomy in LDH surgery. In 1999, the American company SOFAMORDANEK improved on the original MED technology and introduced the second generation of M E T R x discoscopy system. This surgical system consists of three parts: optical system, image acquisition system and surgical instruments, and there are significant improvements in image quality, instrument type and operating space. Under X-ray fluoroscopy, the endoscope and surgical instruments are introduced directly through the 16-18m m working tube after C-arm positioning to clean the soft tissue outside the spinal canal, open the window between the vertebral plates, distract the nerve roots, and remove the herniated nucleus pulposus. The indications for the M E D technique are basically similar to those for open spine surgery. The best indication is a unilateral single-segment lateral herniation with significant nerve root compression. M E D surgery may also be considered in cases of combined limited spinal stenosis, lateral saphenous or nerve root canal stenosis, and disc calcification. MED has unique advantages and definite efficacy not only for simple single-segment lumbar disc herniation, but also for complex lumbar disc herniation such as lumbar spinal stenosis, lumbar instability and lumbar tuberculosis. Its advantages are high treatment excellence rate, wide range of indications and small trauma, fast postoperative recovery and low treatment cost. The disadvantages include preoperative positioning error, intervertebral space infection, cerebrospinal fluid leakage, nerve root and cauda equina injury, and postoperative lumbar instability and other complications, but this does not affect its excellent application prospects in minimally invasive treatment of lumbar spine system diseases. Percutaneous endoscopic discectomy (PELD) Percutaneous endoscopic discectomy is a more advanced minimally invasive spine technique that was gradually perfected in the mid to late 1990s. It is an arthroscopic or endoscopic visualization procedure that uses a set of special equipment and instruments to remove the herniated disc tissue directly through the posterior-lateral approach and through the intervertebral foramen “safety triangle” to achieve decompression and release of the spinal cord and nerve roots. When dealing with saphenous fossa stenosis and spinal stenosis, maximum removal of the herniated nucleus pulposus can be performed under direct vision. The nerve roots at the internal and external exits of the foramen and the downstream nerve roots in the spinal canal can be fully decompressed and released. Since the procedure is performed under local anesthesia and the patient remains awake, the patient experiences an immediate electrical sensation when the nerve root is touched, and this response is fed back to the operator in a timely manner, thus avoiding damage to the nerve root. Intervertebral foraminoscopic and endoscopic microdiscectomy is fundamentally different from intradiscal decompression techniques. XII. Artificial lumbar disc replacement (ADR) Artificial lumbar disc replacement is a new technique in spine surgery. It can restore the height of the intervertebral space, stress transmission and distribution, maintain the limited motion of the intervertebral joints, restore the kinematics and loading function of the diseased disc, and achieve the purpose of load sharing, segmental stability and segmental motion. At the same time ADR removes discs that have damaged, inflammatory degeneration. Reduces sources of autoimmunity and inflammation-inducing substances in degenerated discs. This results in pain relief. The current artificial lumbar discs are materially and kinematically different from the normal lumbar discs, and the ADR procedure is technically demanding and surgically invasive. The high technical requirements of ADR, the high surgical trauma, and the high price limit the widespread use of this technology. In summary, although the surgical treatment of lumbar disc herniation has a history of more than 70 years. The surgical approach has gone through the stages of classical lumbar disc removal, open lumbar disc removal, minimally invasive lumbar discectomy, artificial disc replacement, artificial prosthesis implantation and gene therapy. Classical surgical procedures have been followed for a long and ultra-long time though. However, the efficacy is still unsatisfactory. Decompression and nucleolysis lead to structural, morphological and functional abnormalities and instability of intervertebral joints, which become the main reasons for unsatisfactory treatment results and recurrence of lumbar pain. The main goal of minimally invasive spine technology is to minimize the invasiveness of spinal surgery, which has become a new trend in the treatment of L D H because of its advantages of less trauma, exact efficacy, fewer complications, no destruction of spinal stability, less patient pain, and faster recovery. However, it does not necessarily mean that the application of minimally invasive techniques will achieve the purpose of “minimally invasive”. Minimally invasive techniques should include percutaneous puncture techniques, endoscopic techniques and physical therapy techniques such as laser and electrothermal. Therefore, minimally invasive endoscopic spine surgery is crucial to the surgeon’s clinical experience, skill level and minimally invasive potential. In clinical work, we need to effectively grasp the indications for surgery and do a good preoperative evaluation. We also follow the principle of selecting surgical indications in stages from superficial to deep and from easy to difficult. We firmly believe that with the continuous updating of high precision medical imaging, microendoscopic instruments and advances in clinical surgical techniques, more and more microscopic, digital and artificially intelligent minimally invasive techniques will be used in the field of spinal surgery.