Lumbar disc herniation is very common in clinical practice, however, there is a great controversy on issues related to it, such as the choice of treatment measures, timing of surgery, indications for surgery, and surgical methods. How should the surgical option be selected? Lumbar disc herniation is a disease in which the disc is misaligned beyond the normal disc boundary, compressing the nerves and causing pain, weakness, myofascial paralysis or abnormal distribution of sensation in the dermatome. Low back pain and lumbar disc herniation alone are not lumbar disc herniation. Most patients with lumbar disc herniation radiculopathy improve with or without treatment. The herniated disc tissue usually atrophies and degenerates over time. Many studies have shown gradual improvement in clinical function as the herniated disc decreases in size. 1. Is a herniated disc the same thing as a lumbar disc herniation? A herniated disc is a rupture of the intervertebral disc’s annulus fibrosus, with the nucleus pulposus protruding (or prolapsing) from the rupture into the posterior or spinal canal. This is really just a pathological change, or imaging presentation. It is not a disease. There are also long-term follow-up studies that have found no correlation between the presence of a herniated disc in these volunteers and the subsequent presence or absence of low back pain and the duration of low back pain. Lumbar disc herniation, on the other hand, is a clinical syndrome in which a herniated lumbar disc causes irritation or compression of adjacent spinal nerve roots, resulting in a range of symptoms such as low back pain, numbness and pain in one or both lower extremities. The diagnostic criteria proposed by Professor McCulloch have been used to date: ① leg pain is greater than lumbar pain, mainly confined to the sciatic or femoral nerve innervation area; ② abnormal sensation in the dermatomes; ③ positive straight leg raise test with an angle less than 50% of normal, or positive straight leg raise test on the healthy side; ④ two of the four items such as muscle atrophy, weakness, hypoesthesia and weakened tendon reflexes; ⑤ consistent with the clinical presentation ⑤ Imaging features consistent with clinical manifestations. According to the above diagnostic criteria and the pathological features of lumbar disc herniation, lumbar disc herniation must not only have pathological changes of lumbar disc herniation (imaging manifestations), but must also have clinical manifestations of damage to the corresponding nerve structures, pain and numbness, etc. with radicular distribution. Therefore, even if there is an obvious lumbar disc herniation on imaging, and there is also regional pain in the lumbar region, buttocks or thighs, etc., the diagnosis of lumbar disc herniation is questionable if there is no pattern of radicular distribution of nerves. 2. Is CT preferred for lumbar disc herniation examination? MRI is better than CT examination in terms of diagnostic accuracy and false positive rate, and has the characteristics of non-invasive, multi-dimensional and radiation-free. Therefore, MRI is preferred as the imaging test of choice for patients with a diagnosis of lumbar disc herniation and a corresponding positive history and physical examination, with CT, myelography, or CT myelography as alternatives. 3. Is bed rest mandatory for conservative treatment of lumbar disc herniation? Less benefit (pain, functional recovery) is recommended for bed rest in patients with acute low back pain than for continued daily activity, and there is little difference between bed rest and maintenance of activity in patients with lumbar disc herniation. There is a large body of literature that is consistent with these views and few studies have been reported that advocate strict bed rest. This shows that bed rest is not necessary, and if the patient’s pain and dysfunction are not so severe as to make it difficult to walk, there is no need to artificially restrict their activities and strictly require bed rest. 4. Is enhanced myelography-guided dural hormonal injections (ESIs) necessary for the treatment of lumbar disc herniation? Compared to pharmacological treatment, transforaminal ESIs have a better utility ratio and are significantly more effective in short-term pain control, improving the clinical prognosis of most patients with lumbar disc herniation. Moreover, there is no statistically significant difference in the treatment prognosis of ESI for different types of lumbar disc herniation. 5. For patients with symptomatic lumbar disc herniation, is conservative treatment preferred? Lumbar disc herniation is self-limiting to some extent. For patients with mild symptoms, surgery or conservative treatment can achieve better functional improvement, and conservative treatment can avoid the risk of surgery for patients. In cases of neurogenic pain with positive signs of nerve root compression or neurological dysfunction, where the herniated disc is confirmed by imaging to be compatible with clinical symptoms, and where the duration of symptoms exceeds 6 weeks, surgery is more effective than non-surgery. It should be noted that in patients with psychiatric depression, the functional prognosis is worse and poorer after surgical treatment. 6. Is surgery for lumbar disc herniation better as soon as possible? The longer the duration of the symptoms of lumbar disc herniation, the worse the final outcome of treatment, whether surgical or non-surgical, but independent of the duration of the disease before treatment. Surgery within 6 months is recommended for patients with lumbar herniated disc radiculopathy whose symptoms are severe enough to require surgical treatment. Available evidence suggests that patients with early surgical intervention (6 months – 1 year) have faster postoperative recovery and better long-term neurological prognosis. Therefore, it is important for both patients and orthopedic surgeons to recognize that the treatment of lumbar disc herniation should involve early intervention, whether surgical or non-surgical. 7. Is the efficacy of intervertebral foraminoscopy necessarily better than that of conventional surgery? For patients with strictly selected indications, foraminoscopic treatment can achieve the same results as open disc surgery. In addition to laminectomy, there is no significant difference in the outcomes of percutaneous discectomy versus traditional open discectomy. In addition, there is no clinical evidence to support that medial synovectomy for lumbar herniated disc radiculopathy improves functional prognosis. However, the advantages of laminectomy include the advantages of less trauma, less bleeding, faster recovery, and shorter hospital stay. 8. Is spinal fusion necessary for specific patients with lumbar herniated disc radiculopathy? Only 45% of patients return to work within 1 year after fusion compared to 70% of patients who return to work within 1 year after discectomy. Although the results of fusion surgery are somewhat better than nucleotomy after 6-7 years, the difference is not significant and is compounded by the difficulty and complications of fusion surgery. Indications for fusion surgery are massive disc nucleus pulposus prolapse, removal of the nucleus pulposus that may lead to intervertebral instability, or pre-existing lumbar instability. 9. Is the surgical outcome better in patients with a herniated nucleus pulposus – smaller fibrous annulus rupture? Studies with Level I evidence confirm that what is seen intraoperatively is most closely related to the final outcome. Patients with a small herniated nucleus pulposus – small fibrous annulus have the best outcome, the lowest recurrence rate (1%), and the lowest reoperation rate (1%). Patients with herniated nucleus pulposus – intact annulus had the next best outcome, with recurrence and reoperation rates of 10% and 5%, respectively. Patients with herniated nucleus pulposus and large fibrous ring rupture had a worse outcome, with a recurrence rate of 27% and a reoperation rate of 21%, while patients with unruptured nucleus pulposus and intact fibrous ring had the worst outcome. 10. Can glucocorticoids and/or fentanyl after lumbar decompression improve postoperative pain in patients? In patients taking glucocorticoids and/or fentanyl, there is a statistically significant improvement in low back pain in the short-term postoperative period, however, 1 year after surgery, there is no statistically significant difference in the degree of improvement in leg pain between patients taking glucocorticoids and/or fentanyl and those not taking them. Therefore, the use of glucocorticoids or , and fentanyl after lumbar decompression is not recommended to improve long-term postoperative pain in patients.