Etiology of lumbar disc herniation The basic factor of lumbar disc herniation is disc degeneration, but the predisposing factors leading to disc herniation have not been clearly established, but some factors are related to it. (i) Structural factors of the spine Spinal deformities, including symmetrical or asymmetrical displaced vertebrae of the spine, scoliosis; straightening of the physiological curvature of the spine induced by physiological curvature of the spine. Physiological curvature straightening is common in young people who are sedentary for long periods of time. (B) physiological factors 1, age The incidence of lumbar disc herniation is highest in middle age 30-50 years. Qingdao Medical College 209 patients aged 20-40 years accounted for 64.46%, over 40 years accounted for 34.92%, in recent years there is a trend of continuous rejuvenation, we have seen 9-year-old patients in the clinic. 2.Height The incidence of lumbar disc herniation is high when the male exceeds 1.8m, the female exceeds 1.7m and the lumbar spine index and obesity are large. The incidence of lumbar disc herniation is more in men than in women, about 2:1. The incidence of disc in the United States is 3.1% in men and 1.3% in women; the incidence in Finland is 1.9% in men and 1.3% in women. (C) race and genetic factors 1, race Indians, Eskimos, black Africans incidence rate is significantly lower than other ethnic groups 2, genetics Wuhan Medical College Second Affiliated Hospital has reported that within 15 years found that there are two or more people in the same family with blood relations suffer from lumbar disc herniation, statistics have 20 households 24 columns, there is a positive family history of patients, the relative risk of lumbar disc herniation occurred before the age of 21 years. The risk was estimated to be approximately five times higher among patients with a positive family history. (iv) Occupational factors A group of 57,000 occupational surveys, the following occupations have a high incidence rate: long-term sitting office desk workers drivers engaged in long-term bending labor long-term weight-bearing long-term standing (v) Traumatic factors 1, acute injuries such as lumbar sprain, vertebral slippage, spinal fracture, vertebral compression, etc., can cause the rupture of the disc cartilage plate, so that the disc nucleus pulposus protrudes. Traumatic factors usually do not cause pain immediately, and pain occurs when edema and aseptic inflammation occur with nerve compression. Disc herniation in children and adolescents is associated with acute trauma. 2. Exercise It is usually believed that exercise in general is beneficial to the nutritional supply of the lumbar discs, and it is now recognized that strenuous exercise is associated with degeneration of the lumbar discs. But some sports such as playing tennis, swimming, jogging, cycling, etc. are beneficial to the lumbar intervertebral disc. 3, to wear As early as 1935 pease first reported the discovery of disc stenosis after lumbar puncture. Lumbar puncture, a medical treatment, often due to surgical anesthesia, extraction of cerebrospinal fluid examination, intravertebral angiography, etc. (vi) Smoking factors The nutrition of the lumbar intervertebral disc depends on the blood vessels around the disc to provide, the disc is a tissue lacking blood supply, the blood vessels leading to the disc are extremely small, nicotine within the cigarette will cause the blood vessels to constrict, reducing the blood supply to the lumbar intervertebral disc and causing the disc to degenerate. (vii) disease Some diseases can lead to increased atherosclerosis, which affects the lumbar intervertebral disc and causes disc degeneration, most commonly diabetes. (viii) Pregnancy is one of the common causes of lumbar disc herniation, and Laban investigated 49,760 women after delivery with an incidence of 10,000. And it is more frequent in women with multiple pregnancies. The increased load on the lower back during pregnancy is the main cause. Pathogenesis of lumbar disc herniation Disc herniation is a multifaceted and common disease, which is mainly caused by a series of symptoms caused by disc strain and degeneration, rupture of the annulus fibrosus or prolapse of the nucleus pulposus, which stimulates or compresses the spinal nerve and spinal cord. In adults, degenerative changes occur in the intervertebral disc, and the fibers in the annulus fibrosus become thicker, more brittle and finally fracture, so that the intervertebral disc loses its original elasticity and cannot bear the original pressure. Under overstrain, sudden change in position, violent action or violent impact, the annulus fibrosus can bulge outward, so that the nucleus pulposus can also protrude outward through the fissure of the ruptured annulus fibrosus, which is called disc herniation. Clinical manifestations of lumbar disc herniation (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 can 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. In the case of lumbar 3-4 interstitial herniation, radiating pain to the front of the thigh is produced because of the 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.The pain increases with activity and decreases after rest. Bed position: Most patients adopt lateral recumbency 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 protruding nucleus pulposus and the nerve root: if the protrusion 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 (c) Restricted 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 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 only one side, according to which it can be differentiated from lumbar spine tuberculosis or tumor. (iv) Lumbar pressure pain with radiating pain There is a limited pressure pain point next to the spinous process on the affected side of the disc herniation site, accompanied by radiating pain to the calf or foot, which is important for diagnosis. (e) 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. A positive test is when the leg elevation is limited on the affected side and radiating pain is felt 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. (F) Neurological examination In lumbar 3-4 herniation (lumbar 4 nerve root compression), the knee reflex may be decreased or disappeared, and the medial calf sensation may be decreased. In the case of lumbar 4-5 herniation (lumbar 5 nerve root compression), there is hypoesthesia of the anterolateral dorsalis pedis of the lower leg, and there is often hypoesthesia of the extension and 2-toe muscle strength. In the case of lumbar 5-sacral 1 herniation (sacral 1 nerve root compression), there is hypoesthesia of the posterior and lateral calf, hypotonia of the 3rd, 4th and 5th toe muscles, and hypotonia or disappearance of the Achilles tendon reflex. If the nerve compression symptoms are severe, 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 herniation often has symptoms of nerve damage in both lower extremities, but one side is heavier; attention should be paid to checking 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. Lumbar disc herniation treatment is divided into three main categories: a. Non-surgical treatment includes: 1, bed rest 2, drug therapy 3, traction therapy 4, physical therapy 5, massage therapy 6, acupuncture treatment 7, instead of therapy 8, closed therapy 9, small needle knife therapy 10, reset method 2, surgical treatment includes conventional open surgery (including: half laminectomy, total laminectomy, transabdominal intervertebral disc surgery) 3, intervention Treatment includes: 1, collagenase chemolysis therapy 2, ozone injection therapy 3, radiofrequency thermal coagulation target puncture technology (a) drug therapy Drug therapy, including therapeutic drugs and symptom relief drugs. Due to the special structure of the lumbar intervertebral disc determines many general drugs difficult to have a therapeutic effect, so the general Western medicine only pain relief function, relieve clinical symptoms mainly, there are some therapeutic drugs in Chinese medicine, most of the drugs still can not achieve the purpose of radical cure lumbar disc herniation. (B) Traction therapy We all know that lumbar disc herniation is divided into three types: bulge, protrusion and prolapse by the size of the protrusion. Patients with lumbar disc herniation, at the first onset, are generally advised to use traction therapy. Traction mainly pulls the intervertebral space with mechanical force to reduce the internal pressure of the disc, so that the compression of the herniated material on the nerve is slightly reduced. This is mainly due to the strength of traction varies from person to person, it is difficult to hold; another is the selection of indications is difficult to accurately distinguish; and then the patient’s cooperation problem. For patients with lumbar disc bulge, the pressure in the disc is very high at this time and can be cured by traction, but it is ideal to be absolutely bedridden when traction is applied. If the traction immediately after walking, sitting in a car, etc. will restore the high pressure state within the disc, resulting in traction ineffective. Traction is only applicable to patients with bulging discs. If the disc has caused herniation and prolapse, traction is completely ineffective and may aggravate the patient’s symptoms. Traction is contraindicated in patients with acute lumbar disc herniation. Because the patient in the acute stage, due to edema and inflammatory stimulation of the nerve root, will cause tension and spasm of the lumbar back muscles, if then traction will strain the lumbar muscle fibers, causing back pain and aggravating the clinical symptoms. In summary, traction is only suitable for patients with simple lumbar disc bulge, and must be used when the symptoms are not heavy, in order to relieve clinical symptoms, and is prohibited for patients with lumbar disc herniation, prolapse, accompanied by spinal stenosis, and patients in the acute phase of lumbar synostosis. (c) Physiotherapy, massage therapy, acupuncture therapy Physiotherapy includes electric therapy, infrared irradiation, heat therapy and other methods, and the purpose of treatment is basically the same as that of massage and acupuncture. The main purpose of physiotherapy is to relieve the clinical symptoms of patients, not to cure them. As most patients with lumbar synostosis are accompanied by chronic lumbar muscle strain, pear-shaped muscle tension, and muscle spasm in the area where the nerve travels with the lumbar disc herniation, general hospitals will use physiotherapy, massage, acupuncture and other treatments to relieve muscle tension and spasm. So patients who have had physical therapy know that they will be more comfortable when doing physical therapy, and will be the same as before after not doing it. Therefore, physiotherapy, massage, acupuncture and other treatments are only used for lumbar synostosis with treatment. (iv) Closure therapy Closure therapy is divided into two application methods, one for intraspinal closure and one for nerve root closure. As the name implies, intradural closure is to inject drugs directly into the spinal canal, and nerve root closure is to inject drugs around the nerve roots. The injected drug is mainly adrenal glucocorticoid plus local anesthesia. The hormones reduce and eliminate sterile inflammation and edema of the nerve roots; the anesthetic drugs provide pain relief and anesthetize the nerves to make them less sensitive. We all know why lumbar synostosis leads to back and leg pain, mainly because the nucleus pulposus of the lumbar intervertebral disc compresses the nerve after leading to edema and sterile inflammation of the nerve root, so the effect of closure is pain relief, protrusion compression can not be resolved, when the closure of the drug effect after the lumbar leg pain symptoms immediately recovered again. (E) small needle knife therapy small needle knife therapy is a new treatment method developed on the basis of acupuncture and closed therapy, and in recent years it has gradually “deified” its therapeutic effect. Small acupuncture is a surgical instrument with a needle knife, in the pain points of patients with back and leg pain to carry out extensive peeling loosening, and then injected into the local anesthetic drugs plus hormonal drugs, to play the role of anti-inflammatory pain, the purpose of small acupuncture is to create conditions for the expansion of the closed range, therefore, small acupuncture treatment is actually a closed therapy improvement, its therapeutic effect is equivalent to closed. Because of the use of adrenal glucocorticoids in the treatment process, it should not be used more than once. The side effects of hormones can cause such as osteoporosis, gastrointestinal reactions, acne hirsutism, centripetal obesity, etc., and are also prohibited for patients with concomitant diabetes and hypertension. (F) Alternative therapy for lumbar disc herniation: The use of pure natural sawtooth shark cartilage powder to restore the regeneration of the cartilage fiber ring of the human lumbar spine has become a brand new medical attempt for lumbar disc herniation in various advanced countries after the 80s. Because the protrusion of the lumbar disc is caused by the breakage of the fibrous ring (a kind of cartilage). The Sawtooth Mackerel cartilage powder has been clinically proven to regenerate cartilage. In the United States, the OAM (Office of Alternative Medical Services) has also studied and popularized shark cartilage as an alternative to medical treatment, and in Japan, shark cartilage powder is used directly as an alternative to medical treatment for lumbar disc herniation, and is popular because it is natural and has no side effects, and the 7.5g/day dosage is the most popular shark cartilage in Japan. The amount of 7.5g/day is also a statistic of the Japan Shark Cartilage Popularization Association. The new research brings a bright light for mankind to completely conquer lumbar disc herniation. (VII) Surgery Conventional open surgery includes: total laminectomy, hemi-laminectomy, transabdominal disc surgery, and vertebral fusion. The purpose of surgery is to directly remove the nucleus pulposus of the diseased lumbar intervertebral disc and achieve the treatment purpose by releasing the nerve root compression. Because of the special physiological position of the lumbar spine, surgery destroys the normal physiological structure of the lumbar vertebrae, resulting in large surgical damage, easily causing postoperative instability of the lumbar spine, postoperative scar tissue adhesions, intraoperative accidental injury to nerve roots and a series of adverse reactions, so most patients are afraid of surgery, how to avoid the above adverse reactions caused by surgery? This has been a major problem in the medical field. (H) collagenase chemolysis therapy human intervertebral disc nucleus pulposus tissue, composed of water, fibrous tissue, proteoglycans, collagenase full name: collagenolytic enzyme, can dissolve the nucleus pulposus proteoglycans. Currently, collagenase intervertebral disc lysis can be considered when one of the following conditions is met: 1. unilateral lumbar and leg pain with significant nerve root compression symptoms. 2.Meets the indications for surgical resection. 3.After 3 months of regular conservative treatment is ineffective. (ix) Ozone (triple oxygen) injection therapy: High concentration of ozone has astringent and vaporizing effects, with the help of which many hospitals have adopted the treatment of lumbar synostosis in recent years. After the injection of ozone can be vaporized to concentrate the nucleus pulposus of the lumbar intervertebral disc. Medical ozone therapy for herniated disc indications 1, clinical manifestations of low back pain or (and) sciatica, nerve root compression signs are obvious, mild neurological loss, conservative treatment for more than 8-12 weeks is ineffective; 2, CT or MRI examination shows a mild or moderate herniated disc, consistent with clinical localization symptoms, and clinical symptoms and degenerative changes in the lumbar spine is not related; 3, surgical treatment 3.Patients with failure of lumbar spine surgery syndrome (FBSS) after surgical treatment; 4.Patients who voluntarily try this operation to reduce symptoms and signs.