In our outpatient clinics, we spine surgeons often encounter patients with lumbar disc herniation who are attracted to minimally invasive treatment and seek the best solution for their disease. It is true that patients come to the hospital seeking peace of mind and the ability to work and live peacefully through careful treatment by specialists. The actual fact is that you can find a lot of people who are not able to get a good deal on this kind of things. What is the best choice for surgical treatment of lumbar disc herniation? Combining the author’s relevant research, clinical experience and extensive review of the literature, I would like to discuss the relevant views with you. Surgery for lumbar disc herniation can be divided into open versus minimally invasive surgery (MIS), and posterior versus posterior posterolateral. For surgery of lumbar disc herniation, the first report of total laminectomy and nucleus pulposus removal for 19 cases of disc herniation was made by Mixter and Barr in 1934 in NEJM, which pioneered the surgical treatment of disc herniation. In 1955, Professor Lu Yu-po gave up his medical license and green card in the United States, returned to China with Qian Xuesen and other famous scientists, and founded the Department of Orthopedics at Xijing Hospital of the Fourth Military Medical University in Xi’an. After years of exploration and practice, he was the first to report the largest sample of lumbar disc herniation surgical treatment in China in the 1990s, and created the surgical approach of small laminectomy and nucleus pulposus removal in our department of spine group, and it has been used to this day. The specific method is described in detail in the highly clinically instructive Practical Orthopedics (1990 edition), which is familiar to our domestic colleagues. Let us review the history of discoscopic and foraminoscopic development: In 1997, Foley and Smith introduced microendoscopic discectomy (MED) and reported their experience in treating 100 patients. This is known as MED – the discoscopic technique, in which the nucleus pulposus is removed under the discoscope from the posterior median approach. In 1983, Kambin P et al, Department of Orthopaedics, University of Pennsylvania School of Medicine, reported in Clin Orthop on the percutaneous posterolateral approach. In 1990, Onik et al. of Presbyterian University Hospital, Pittsburgh, USA, reported in Neurosurgery the results of a prospective multicenter study of posterior posterolateral foraminoplasty (PELD) for lumbar disc herniation, showing a success rate of 75% in 327 patients with strict surgical indications. The success rate was 75.2% in 327 patients with strict surgical indications and 49.4% in 168 patients without control indications. It can be seen that the improvement of surgical treatment of lumbar disc herniation by domestic and foreign surgeons is almost synchronized; the difference is that domestic surgeons, led by Prof. Lu Yupu, proposed the complete removal of herniated and degenerated, loose nucleus pulposus tissue under small openings in the vertebral plate and direct vision; abroad, it is posterior-lateral, intervertebral foraminoscopic operation. In 1997, Yeung et al. of Arizona Orthopaedics in Spine reported the experience of YESS (Yeung Endoscopic Spine System) in treating 307 patients with short-term follow-up (mean 19 months) after surgery, claiming an overall success rate of 89.3%, with poor results in 10.7% and a complication rate of 3.5%, including 2 cases of deep infection The complication rate was 3.5%, including 2 cases of deep infection, 2 cases of thrombophlebitis, 6 cases of sensory retardation, and 1 case of dural rupture. In the same issue of Spine, Dr. Deen of the Mayo Clinic, USA, published a review questioning the design of the study: based on the 1990 Onik et al. study, Yeung et al. chose to report on only 307 patients, without mentioning the outcome of the other 483 patients treated with the same technique. In 1994, Hoogland et al. in Germany reported their experience with the Thomas Hoogland Endoscopic Spine System (THESSYS) system, foraminoplasty, in 280 consecutive patients. In recent years, discoscopic and foraminoscopic techniques, which lend themselves to minimal invasion, have become very popular, arguing that traditional open nucleus pulposus removal is highly invasive, with long incisions and many problems. We scientists, who meditate and think, often have a new perspective on public opinion; just as the Comparative Effectiveness Research (CER) concept proposed by the U.S. Agency for Health Care Quality and Research in 2010, for an alternative method of treatment (Alternative methods), the advantages and disadvantages are compared with classical methods. This is a necessary step before the implementation of an alternative treatment, namely CER, which compares its advantages and disadvantages with the classical method. Then, as the Lancet has published: randomized clinical trials that can change our clinical practice are the most convincing, or a technique that has been recommended by generations of physicians with a long-term follow-up of more than 10 years. Do these techniques, compared to classical open surgery, have a convincing basis? After a search, there are no randomized clinical trials published in top journals such as NEJM or Lancet, and no long-term follow-up studies over 10 years, on discoscopy or foraminoscopy that show its superiority over open nucleus pulposus removal. In 2010, Nellensteijn et al. of the Department of Orthopaedics, VU University Medical Center, The Netherlands, published a systematic review of PELD in Eur Spine J. In published studies comparing PELD with open myeloablation (clinical trials), PELD and myeloablation showed an improvement in lower extremity pain symptoms (89% vs. 87%), overall improvement (84% vs. 78%), reoperation rate (6.5% vs. ), reoperation rate (6.8% vs. 4.7%), and complication rate (1.5% vs. 1%). Therefore, it is concluded that there is no strong evidence that PELD is superior to open surgery and nucleus pulposus removal for lumbar disc herniation. In Europe and the United States, there have been few reports of large numbers of cases of intervertebral foraminoscopic techniques, and their acceptance is evident; Lee et al. of the Department of Neurosurgery, Wooridul Hospital, South Korea, in an article published this year in Neurosurgery, reviewed their experience with PELD for lumbar disc herniation in a total of 10,228 cases over a 12-year period. 436 (4.3%) of the patients failed the procedure, and failure was defined as Failure was defined as the need for reoperation within 6 weeks of PELD surgery (note: please comment on whether this definition is acceptable to the patient and whether a recurrence 2 months or 6 months after PELD would be considered a success for the authors of this article and a successful surgery for the patient). The reasons for failure included incomplete removal of the nucleus pulposus in 283 cases (2.8%), recurrence in 78 cases (0.8%), persistent pain (not relieved by complete removal of the nucleus pulposus) in 41 cases (0.4%), and incision-related pain in 21 cases (0.2%). The reasons for incomplete removal of the nucleus pulposus included improperly positioned working channel (33.6%), 91 central protrusions (33.2%), 63 axillary protrusions (22.3%), and 70 free nucleus pulposus (24.7%). With the above analysis, for experienced spine surgeons, we remove the herniated nucleus pulposus after incising the herniated annulus fibrosus and place a nucleus pulposus forceps in the intervertebral space to perceive loose, degenerated nucleus pulposus tissue in multiple directions and remove it completely by hand. In particular, the lateral area should be completely removed, as this is the area most likely to recur and fall out. This area is the blind spot of the PELD technique. Regarding the steep learning curve, the operation time is a good indication. Recently, physicians from the Department of Orthopedics at Southeast University Hospital in Nanjing, China, published in Int Orthop their experience regarding the treatment of 277 patients with lumbar disc herniation using the THESSYS system. Their surgical times have gradually decreased with the number of cases, from nearly 3 hours at the beginning to more than 80 minutes later. The average operative time was 50 minutes (30 to 90 minutes) for 10228 cases reported by 45 Korean surgeons over a 12-year period. The cost of surgery was mostly unmentioned in the study, and the average cost for THESSYS surgery patients was$15,480 for those under 45 years of age and$16,381 for those over 45 years of age, by physicians at the Department of Orthopedics, Southeast University Hospital, Nanjing. In 2014, physicians at the University of Tennessee Surgical Hospital Orthopedic Department, compared their outcomes with MED and open nucleus pulposus removal, and notably, to this day, their open surgery, surprisingly, is an 8-10 cm surgical incision with a hemi-laminectomy for nucleus pulposus removal! And, the average operative time for MED and open surgery: 98.8 minutes versus 97.3 minutes! It seems that there is a lot of misunderstanding about laminar decompression and nucleus pulposus removal, both in the spine surgery community and in patients with lumbar disc herniation, so we would like to show here the surgery and cost of a 19-year-old female patient with lumbar 4/5 and lumbar 5/sacral 1 disc herniation and ossification that we recently operated on. In this patient, our surgical team (Prof. Xinkui Li, Associate Prof. Haiqiang Wang, and Attending Physicians Jun Zhang and Fengliang Wang) performed bilateral laminar decompression (4 windows were opened, especially preserving the bone bridge between the two windows on each side, which provides an important marker for scar removal in case of recurrence and revision), nerve root exploration and release, and nucleus pulposus removal (including bone mass). The incision is 6.5 cm (in case of a segment, the incision is usually 3 cm), the operating time is 100 minutes, and the total cost is 10,000 yuan. Intraoperative fluoroscopic positioning is not required. The MED also requires fluoroscopy. The radiation risks of spine surgery have been compiled in this year’s Spine J article “Radiation risks: Who is safer, the surgeon or the patient?” by the academic editors of the Clove Orthopedic Channel. for your reference. Fluoroscopy is not required for open-heart surgery. In 2014, a systematic review of minimally invasive spinal fusion versus open fusion surgery was published in the classic orthopaedic journal Clin Orthop Relat Res. The studies reported so far do not provide a clear picture of how minimally invasive spinal fusion compares to open fusion. None of the current studies provide a credible basis for the superiority of minimally invasive spinal fusion over open fusion. The most recent foreign opinion, as reported by Canadian scholar Evaniew at the American Academy of Orthopaedic Surgeons (AAOS) annual meeting in Las Vegas this past March, is that the evidence suggests a higher risk of overall nerve root injury, dural injury, and reoperation using minimally invasive surgical techniques, and that the current evidence does not support minimally invasive surgery as a routine surgical approach to discectomy. There is no shortage of young people with lumbar disc herniation who are parents, children, husbands or wives, shouldering the expectations of their families and the responsibilities of social work. Once the disc protrudes seriously, pressing the nerves, affecting work and life, they are worried and anxious, and when they are lying on the operation bed waiting for anesthesia, their bodies and minds are restless, and their families are waiting anxiously outside the operation room. What they are looking forward to is a doctor who has excellent medical skills and has completed the learning curve, so that they can get rid of the disease and never suffer from this surgery again and never have to worry about recurrence. Spine surgeons, under the welfare of many people and their families, shoulders the expectations of many patients and families, regardless of small openings, MED or PELD, I hope that doctors with a kind heart, skilled skills, to relieve patients, as complete as possible to remove the nucleus pulposus; I also hope that the national focus on rest and relaxation, heavy manual laborers, drivers, accountants, teachers and other professionals, pay attention to the protection of the cervical spine I also hope that people with lumbar disc herniation will receive the correct knowledge of diagnosis and treatment and the most appropriate and precise treatment. Such is the original wish of this article.