“Lumbar herniation” is the abbreviation of lumbar disc herniation. Lumbar disc herniation is a series of clinical symptoms and signs caused by degeneration of the lumbar disc, rupture of the fibrous ring, and protrusion of the nucleus pulposus to stimulate or compress the nerve roots and cauda equina nerve, commonly known as “lumbar herniation”. It often causes a lot of pain in life and work, and even disability and loss of working ability. Lumbar disc herniation is the main cause of low back pain and is one of the most common orthopedic clinical disorders, accounting for 10%-15% of patients with low back pain in orthopedic outpatient clinics and 25%-40% of inpatient cases for low back pain. Lumbar disc herniation is a common disease today and is difficult to rehabilitate, requiring changes in unreasonable lifestyles. Symptoms The most common symptom in patients with lumbar disc herniation is pain, which can manifest as low back pain, sciatica, and typically sciatica manifests as radiating pain from the buttocks, back of the thigh, lateral calf to the heel or back of the foot. Lumbar intervertebral disc – construction diagram 5% of patients with lumbar synostosis have varying degrees of lumbar pain, and 80% have lower limb pain. Lumbar pain, in particular, is not only the most common symptom of a herniated lumbar disc, but also one of the first symptoms to appear. The pain occurs mainly due to the stimulation and compression of adjacent tissues (mainly sinus nerve and spinal nerve root) by the herniated and degenerated nucleus pulposus, as well as the overflow of biological substances such as glycoproteins in the nucleus pulposus, the release of histamine and other local chemical inflammation caused by chemical and mechanical radiculitis, resulting in mild or severe chronic back and leg pain. Moreover, degeneration of the lumbar spine also often occurs simultaneously in other tissues of the lumbar region, such as small intervertebral joints, ligaments, and lumbar muscles, causing local chronic inflammation of these tissues and causing pain. The two factors interact with each other and aggravate each other, causing progressive development of lumbar and leg pain. Complications Osteomalacia Patients with recurrent lumbar pain and prolonged lumbar pain with lumbar disc herniation will have a combination of joint degeneration and osteomalacia. On the one hand, the degeneration causes relaxation of the intervertebral disc and narrowing of the lumbar interval. On the other hand, osteophytes of the articular processes can lead to further narrowing of the intervertebral foramina, thereby increasing the pressure on the nerve roots. Lumbar vertebral bone flab. Osteomalacia is mostly found at the edge of the degenerated disc. If the bulge is in the intervertebral foramen and the larger bulge in the posterior longitudinal ligament, it can compress the nerve roots and lead to symptoms of lumbar disc herniation. Lumbar spondylolisthesis The degeneration of a herniated lumbar disc can lead to lumbar instability and osteoarthritis of the articular processes. Both of these are major causes of lumbar spondylolisthesis. Lumbar instability The posterior joint of the disc in the three-joint complex of the lumbar spine degenerates and cannot maintain the stability of the spine, while both the vertebrae and joints become hyperplastic and eventually lead to fibrous or bony ankylosis. Therefore, it is a stage of degeneration when the lumbar spine is unstable. Lumbar spinal stenosis The narrowing of the intervertebral space caused by a lumbar disc herniation, the relaxation and protrusion of the annulus fibrosus, the hypertrophy of the ligamentum flavum, and the osteophytes of the posterior edge of the vertebral body and the intervertebral joints can cause the spinal canal to become smaller, which will continue to narrow the original smaller spinal canal. Patients then experience chronic low back pain, low back pain, and consequently intermittent claudication. Disease Status Lumbar disc herniation is one of the common orthopedic diseases, and about 1/5 of patients with low back pain are caused by a herniated lumbar disc. It has been more than seventy years since Mixterher and Barr proposed this disease in 1934. From the epidemiological analysis at home and abroad, the population rate and absolute value of its incidence are on the rise. The age of onset varies from a few to several tens of years, and we have seen patients with lumbar disc prolapse as young as 9 years old. The rising incidence of the disease is related to the environment in which we live, the change of habits in life and work, and the long-term bad habits of using the back are the main cause. Patients with lumbar disc herniation should remain rational in their choice of shoes to avoid unnecessary injuries. Fashion and health are often opposed, and are most prominent in shoes and health, and some unscientific statements can be discerned by virtue of logic. Disease definition Lumbar disc herniation, the full medical name should be “lumbar disc herniation” due to the name varies, the Society of Orthopedic Surgeons on the naming of lumbar disc lesions are defined as follows: 1, intervertebral disc: normal disc without degeneration, all intervertebral disc tissue are in the disc. 2.Disc bulge: the annulus fibrosus of the intervertebral disc is uniformly beyond the intervertebral space and the disc tissue does not protrude in a restricted manner. 3, disc herniation: the disc tissue is confinedly displaced beyond the intervertebral space. The displaced disc tissue is still connected to the original disc tissue, and its basal continuum is larger in diameter than the displaced disc portion beyond the intervertebral space. 4. Disc prolapse: The diameter of the displaced disc tissue is greater than the basal contiguous portion and is displaced beyond the intervertebral space. The prolapsed disc tissue mass is larger than the ruptured disc space and lies within the spinal canal through this fissure. Typology Example The domestic term for lumbar disc herniation is also called lumbar disc rupture, lumbar disc prolapse, lumbar intervertebral cartilage disc herniation, and lumbar cartilage plate rupture. Although the names and meanings of the above diseases differ, the current unified term is: “lumbar disc herniation”. The onset of lumbar disc herniation is due to the degeneration and proliferation of the lumbar spine, and the degeneration of the lumbar spine is a gradually progressing physiological or pathological process, so age is an influencing factor. Experts say that in the degeneration process of the lumbar spine, in addition to the manifestation of intervertebral disc degeneration, narrowing of the vertebral space, osteophytes of the anterior and posterior edges of the vertebral body and joint protrusions, the surrounding joint capsule and ligaments also undergo a series of changes such as congestion, swelling, fibrosis, calcification or ossification, thus stimulating and compressing the cervical and lumbar nerve roots, spinal cord or cervical sympathetic nerve, vertebral artery and other tissues, which can lead to a variety of different clinical manifestations This can lead to a variety of clinical manifestations. [The nucleus pulposus that protrudes from a lumbar disc herniation and ends in front of the posterior longitudinal ligament is called “protrusion”, while the nucleus pulposus that crosses the posterior longitudinal ligament into the spinal canal is called “prolapse”. The nucleus pulposus is divided into 3 types according to the posterior protrusion site: 1. Posterior lateral protrusion type: The weakest posterior part of the fibrous ring is on both sides of the midline of the disc, which is weak in itself and lacks the support of the strong central fibers of the posterior longitudinal ligament, so it is the most common site of lumbar disc protrusion. Clinically most common, accounting for about 80%. 2.Central protrusion type: The nucleus pulposus protrudes through the posterior central part of the fibrous ring and reaches under the posterior longitudinal ligament. In addition to causing sciatic nerve symptoms, it can also stimulate or compress the cauda equina nerve, manifesting as perineal palsy and urinary and fecal disorders. 3. Intravertebral foraminal protrusion: The nucleus pulposus protrudes posteriorly through the posterior annulus fibrosus and posterior longitudinal ligament into the spinal canal and into the intervertebral foramen, which is easily missed, but fortunately its incidence is low, only about 1%. Etiology I. Degenerative changes: At present, it is believed that the basic etiology is degenerative changes of the lumbar intervertebral disc. Degeneration is the objective law of birth, growth, decay and death of all living things, and because of the special physiological function of the lumbar spine, the degeneration of the lumbar intervertebral disc is earlier than other tissues and organs, and the progress is relatively fast. This process is a long-term, complex process. The so-called lumbar disc degenerative changes: that is, due to the compression of the disc by weight, coupled with the lumbar and often bending, back extension and other activities, easy to cause extrusion and wear of the disc, especially the lower lumbar intervertebral disc, thus producing degenerative changes. Degenerative changes in the lumbar intervertebral disc is the basis for the occurrence of this disease. Second, other factors: 1, the role of external forces: in daily life and work, some people tend to have long-term lumbar improper force, excessive force posture or incorrect body position, etc.. For example, long-term bending work of coal miners and construction workers need to often bend over to lift heavy objects. These long-term repeated external force caused by the injury of the intervertebral disc over time, aggravating the degree of degeneration. 2, the weakness of the disc’s own anatomical factors: (1) intervertebral disc in adults gradually lack of blood circulation, repair ability is also poor, especially after the degeneration, repair ability is even weaker. (2) The posterior lateral fibrous ring of the disc is weak, and the posterior longitudinal ligament is significantly reduced in width in the plane of lumbar 5 and sacral 1, and the strengthening effect on the fibrous ring is significantly weakened. (3) congenital anomalies of lumbosacral segment: deformities of lumbosacral segment can increase the incidence, and these anomalies cause unequal width of vertebral space and often cause joint protrusion and more rotational strain on the joints, so that the fibrous ring is subjected to different pressure and accelerates degeneration. 3, race, genetic factors: the incidence of people of color is lower, for example, the incidence of Indians and black Africans, etc. is significantly lower than other ethnic groups. Pathology The pathological process of lumbar disc herniation can be roughly divided into three stages: 1. Pre-herniation: the nucleus pulposus may become fragmented or scar-like connective tissue due to degeneration and injury, and the degenerated fibrous ring may become thin and soft or produce fissures due to repeated injury. Patients at this stage may have low back discomfort or pain, but no radiating lower extremity pain. There are also people with no original lesion, which can be caused by a large violence to cause the nucleus pulposus to protrude. 2.Protrusion stage: When the pressure of the disc increases due to trauma or normal activities, the nucleus pulposus protrudes from the weakness or rupture of the fibrous ring. The herniated material irritates or compresses the nerve roots, which means that radioactive lower limb pain occurs, or compression of the cauda equina nerve causes urinary and fecal dysfunction. In elderly patients, the entire fibrous ring becomes weak and flaccid due to disc degeneration, and the disc may be diffusely bulging out to the periphery. 3.Late stage of protrusion: After lumbar disc protrusion, the disc itself and other adjacent structures can undergo various secondary pathological changes after a long course of disease. Pathogenesis It is generally believed that there are three mechanisms for lumbar disc herniation causing back and leg pain: the cause of lumbar disc herniation is also implicated with occupation, lumbar disc herniation is seen in people in various industries, often engaged in bending labor, driver’s lumbar bumps and right hand and foot strain heavy, all prone to damage to the lumbar intervertebral disc. What is the cause of lumbar disc herniation, it is generally believed that those engaged in heavy physical labor have heavy disc degeneration. However, the incidence of brain workers is not very low, which may be related to the fact that brain workers are in a sitting position for a long time and have relatively little activity. Most lumbar disc herniations are caused by long-term unreasonable posture. The initial manifestation is just improper posture stooping back, local excessive force, over time will cause chronic damage to soft tissue, forming chronic low back pain such as lumbar muscle strain, so also called postural low back pain, and lumbar disc herniation is the result of further accumulation on this basis. Mechanical compression mechanism The herniated disc produces compression on the nerve roots, cauda equina, and dura mater, blocking their venous return and reducing capillary blood flow, affecting the nutrition of the nerve roots and further increasing edema, thus increasing the sensitivity of the nerve roots to pain, which is the main cause of lumbar pain. However, as research has progressed, it has been found that this concept does not explain all clinical manifestations Some patients have severe disc herniation and significant compression visible on imaging data with mild clinical symptoms. Numerous studies have shown that mechanical compression of nerve roots is not the only cause of low back pain. Lumbar disc herniation in the elderly is mainly caused by the aging of the human body, and causes such as osteoporosis in the elderly can also cause lumbar disc herniation. There are also many young adults who also suffer from lumbar disc herniation, whose causes are mainly, due to usual poor sitting posture, trauma and other reasons. Inflammatory response mechanism Inflammatory congestion and edema of the nerve root is often found during surgery. The reason for this is that the ruptured disc releases many chemical irritants that cause an inflammatory response in the affected nerve root or spinal ganglion. At this time, the nerve roots become more sensitive to pain and symptoms of low back pain may occur even without direct compression by the herniated nucleus pulposus. Neurohumoral mechanisms Biochemicals and neuropeptides play an important role in pain perception. The dorsal root ganglion is a manufacturing site and delivery station for many neuropeptides in the body, and the intervertebral disc annulus fibrosus, posterior longitudinal ligament, and joint capsule sites are rich in neuropeptides. The release of neuropeptides during injury can directly stimulate the surrounding receptors and trigger pain. Disease Triggers The basic factor in lumbar disc herniation is disc degeneration, but certain triggers can increase the intervertebral space pressure and cause the nucleus pulposus to herniate. This predisposing factor is often related to the following factors: 1. age factor: the age of onset of lumbar disc herniation is 30-50 years old, and the average age of surgery is 40 years old, so degeneration may be an important factor. 2. Height and gender: It is believed that being too tall also predisposes to lumbar herniation, and the incidence is five times higher in men than in women. 3, increased abdominal pressure: about 1/3 of patients clinically have clear factors that increase abdominal pressure before the onset of the disease, such as violent coughing, sneezing, breath holding, forceful defecation, etc.. Make the abdominal pressure increase, disrupting the equilibrium between the vertebral joint and the spinal canal. 4, bad posture: people in a variety of work, the need to constantly replace a variety of positions to relieve lumbar pressure, such as long-term in a position unchanged, can lead to cumulative local injury. Especially in long-term bad posture is more likely to induce this disease. 5, occupational factors: heavy manual workers have the highest incidence, white-collar workers have the lowest. Car drivers due to long-term bumps and vibration state, the disc under pressure and repeated changes, also prone to induce disc protrusion. 6, cold and damp: cold or damp can cause small blood vessel contraction, muscle spasm, so that the pressure on the intervertebral disc increases, which may cause the rupture of the degenerated intervertebral disc. Clinical manifestations Low back pain Low back pain is the first symptom in most patients, with an incidence of about 91%. A small number of patients have only leg pain without low back pain, so that not every patient will necessarily have low back pain. There are also some patients who have low back pain first and then leg pain after a period of time, while the low back pain reduces or disappears on its own and only complains of leg pain when they come to the clinic. The pain is mostly tingling, often accompanied by numbness and soreness in the legs and feet. Lower limb radiating pain Low back and leg pain is easy to attack after trauma, exertion and cold, each time for about 2 to 3 weeks, and can be gradually relieved. The pain is often relieved if you rest in bed during the attack. People who engage in heavy physical labor, especially those who repeatedly bend over, have a high chance of having low back pain. People who lack exercise and have poor muscle strength in the low back are prone to low back pain even if they occasionally bend over to lift heavy objects or sprain their back. Any factors that increase abdominal pressure, such as coughing, straining to defecate, laughing, sneezing, lifting heavy objects, chronic coughing, etc., are likely to trigger low back pain or aggravate the existing low back pain. Restricted lumbar activities The forward flexion and backward extension activities of the lumbar spine in patients with lumbar disc herniation are closely related to the degree of disc herniation. If the annulus fibrosus is not completely ruptured, the lumbar spine takes an anterior flexion position and posterior extension is limited. The reason for this is that when the lumbar spine is flexed forward, the ligamentum flavum between the vertebral plates is tensed, increasing the volume of the spinal canal and the posterior space of the intervertebral space, and the corresponding increase in tension of the posterior longitudinal ligament allows the herniated nucleus pulposus to be partially returned, thus reducing the symptoms of nerve root compression. Scoliosis This is a postural compensatory deformity adopted by patients with lumbar disc herniation to reduce pain. The lumbar spine is bent to the left or right and the spinous process can be distorted by touching the spinous process in the middle of the back, but this is not a unique sign of lumbar disc herniation, as about 50% of normal people also have a distorted spinous process. Intermittent claudication The claudication that occurs in lumbar disc herniation is mostly intermittent, i.e., pain and weakness in the lower extremities after walking a certain distance, and the symptoms can be relieved after bending down or squatting to rest and continue walking. With the passage of time, the symptoms gradually worsen slowly, and the shorter the standing time or walking distance before the appearance of the above symptoms, the more serious the condition. Sensory numbness Some patients with lumbar disc herniation do not experience pain in the lower extremities, but only numbness in the extremities, mostly due to compression of the proprioceptive and tactile fibers of the nerves by the disc tissue. The lateral thigh is a common area of numbness and can have a burning sensation when in contact with clothing and pants, and prolonged standing can aggravate the numbness. The cause of lateral thigh sensory disturbance is mostly due to fibular ring bulge or joint degeneration and not due to disc herniation. Diagnosis and differentiation Symptom diagnosis 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 can occur at the same time, mostly with a history of trauma, or without a clear cause. The pain has the following characteristics: (1) The radiating pain is transmitted along the sciatic nerve and goes straight to the lateral calf, dorsum of the foot or toes. In the case of lumbar 3-4 interval herniation, radiating pain to the front of the thigh is produced due to compression of the lumbar 4 nerve root. (2) All actions that increase the pressure of cerebrospinal fluid, such as coughing, sneezing and defecation, can aggravate the lumbago and radiating pain. (3) Pain increases with activity and decreases with rest. In bed position, most patients adopt lateral recumbency and flex the affected limbs, individual severe cases have pain in all positions and can only bend the hips and knees in bed to relieve the symptoms, and those with combined lumbar spinal stenosis often have intermittent claudication. 2, scoliosis deformity: the main bend in the lower back, more obvious when forward bending, the direction of scoliosis depends on the relationship between the protruding nucleus pulposus and the nerve root, such as the protrusion is located in front of the nerve root, the trunk is generally bent to the affected side. Left: If the 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 nucleus pulposus is located in front of the nerve root, and the spine is bent to the healthy side, and the pain is increased if the bend is to the affected side. 3. Restricted spinal activity: the nucleus pulposus protrudes and compresses the nerve root, 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. The restriction of lateral bending is often only on one side, according to which it can be distinguished 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, accompanied by radiating pain to the calf or foot, and this point is important for diagnosis. 5. Positive straight leg raising 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. Sometimes numbness occurs in the affected leg while raising the healthy limb, which is caused by the nerve pull 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), there may be hypoesthesia or disappearance of knee reflex and hypoesthesia of 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, there may be muscle atrophy in the affected limb. The incidence of lumbar disc herniation is common in young and strong people, especially in manual laborers or long-time sitting and standing workers, and there is no significant difference between men and women. When the following symptoms appear, lumbar disc herniation can be suspected, and with imaging examination, it is not difficult to make a diagnosis. 1. There is lumbar pain above the lumbar region after trauma or unilateral lower limb pain. 2, the site of lumbar pain is mostly located on one side of the lower back, and leg pain is mostly radiating pain from the hip to the distal end on one side, which may be accompanied by numbness. 3.Unilateral pain or numbness in the saddle area (the area in contact with the seat of the bicycle) or on one side (both sides) of the lateral calf, the lateral or medial dorsum of the foot, or pain and numbness at the same time. 4, low back or leg pain, can be relieved after bed rest, and pain again after getting out of bed and moving around for a while. Auxiliary examination 1, X-ray: The density of the nucleus pulposus, fibrous ring and cartilage plate included in the lumbar intervertebral disc is low and does not show up under X-ray, so clinically the lumbar spine X-ray plain film of patients with lumbar synostosis can have only some non-specific changes or even no abnormal changes. However, X-rays can detect degenerative changes and structural abnormalities in the lumbar spine, which is important for suggesting disc degeneration and can exclude other lumbar spine disorders, such as lumbar tuberculosis, tumors and lumbar spondylolisthesis. A typical patient with lumbar disc herniation can make a preliminary diagnosis through history, physical signs and X-ray plain film. 2.CT examination: CT of the lumbar spine can clearly show the site, size, morphology and nerve root and dural pressure of the herniated disc, as well as the hypertrophy of the ligamentum flavum, small joint hyperplasia, narrowing of the spinal canal and lateral saphenous fossa. The accuracy rate of the diagnosis of lumbar disc herniation reaches 80%-92%. 3, magnetic resonance imaging (MRI): MRI has no radiation, can be multi-directional imaging (cross-sectional, coronal, sagittal and oblique), shows better anatomical details, is more sensitive to subtle pathological changes in tissue structures (such as infiltration of bone marrow), and can exclude nerves and spinal tumors, etc. For some fall into the spinal canal of the nucleus pulposus tissue will not be missed. 4, myelography: myelography uses the space in the subarachnoid space of the spinal canal, injects the contrast agent and then takes a picture under X-ray to show the internal structure of the spinal canal. At present, water-soluble contrast agent is commonly used, which can show the dural cavity, cauda equina and nerve root sheath more clearly, and the diagnosis of lumbar disc herniation can reach about 90%, and the main X-ray manifestations are the signs of dural sac compression and the signs of nerve root sheath compression. However, due to the widespread clinical application of CT and MRI, which are non-invasive and have a higher diagnostic rate, the clinical application of myelography has been greatly reduced, and because of its large side effects, which may even cause serious conditions such as paraplegia, it is now advocated that it should be used with caution. Electromyography: Electromyography is a method of electrophysiological examination of peripheral nerves and muscles, which can be used to observe and record the electrical activity of muscles at rest, active contraction and stimulation of the peripheral nerves innervating them, and can also be used to measure the conduction velocity of peripheral nerves. In lumbar disc herniation, electromyography reflects the status of the corresponding nerve root by examining the excitability of the muscles in both lower extremities and determines the segment of the disc herniation and nerve root compression based on the distribution of abnormal electrical activity. In patients with spinal nerve root and cauda equina nerve compression, the positive rate of EMG can reach 80%-90%, but it is not the first choice compared with CT and MRI. It can be used to assist in the diagnosis and determination of nerve root compression, and it can also be used as one of the indicators to determine the recovery of nerve roots after treatment.