Lumbar intervertebral disc herniation diagnosis and treatment standard 【Overview】 It is a syndrome caused by degeneration of intervertebral disc, rupture of the annulus fibrosus, and protrusion of the nucleus pulposus that irritates or oppresses the nerve root and the cauda equina, and causes lumbar and leg pain as the main manifestation, and it is one of the most common causes of lumbar and leg pain. It is one of the most common causes of low back pain. The incidence is highest in L4-5 and L5-S1 interspace. It belongs to the category of lumbago and paralysis in traditional Chinese medicine. Etiology] I. Traditional medicine: Chinese medicine believes that: qi and blood, meridians and internal organs dysfunction and the occurrence of low back pain has a close relationship, the causes of this disease are: l, trauma; 2, strain; 3, kidney qi deficiency, essence weakening, tendon and vein loss of nourishment; 4, wind, cold, dampness, heat of the evil flow of the meridians, so that meridians and channels blocked, stagnation of qi and blood stasis, do not pass is painful. The Spiritual Pivot? The beginning of all diseases”: “is why the evil of deficiency in the people also …… stay and do not go is transmitted to the loss, in the loss of time, six meridians can not be, the limbs are limb pain waist and spine is strong.” The origin of all diseases? Waist and foot pain wait”: “the kidney gas is insufficient, by the wind evil for also, labor injury is kidney deficiency, the virtual is subject to wind cold, wind cold and positive qi fight, so waist and foot pain.” Second, modern medicine: 1, internal causes: ①, congenital developmental abnormalities of the intervertebral disc. Degeneration of intervertebral disc, reduction of water content of nucleus pulposus, decrease of elasticity and resistance to load. 2. External causes: ①, a heavy trauma. Repeated mild trauma and cumulative injuries such as exertion. Cold stimulation. Pathological changes] l. Pre-prominent: nucleus pulposus scar-like connective tissue, degeneration of fibrous ring repeated injury, thinning, fissure, the patient may have lumbar discomfort or pain, no radiating lower limb pain. 2. Protruding period: acute traumatic inflammatory reaction occurs in the nerve root, congestion, edema, thickening and extreme sensitivity. 3, late protrusion: ①, protrusion fibrosis, calcification. (2) The whole disc is degenerated, the annulus fibrosus is crumpled, the vertebral body is sclerotic, the edge of the bone proliferation, and the formation of bony cumbersome. (iii) Adhesion, degeneration and atrophy of the nerve root, and loss of movement and sensation in its innervated area. (iv) Hypertrophy of ligamentum flavum as secondary lesion. (5) Degeneration and hyperplasia of intervertebral joints, due to the narrowing of the intervertebral space after intervertebral disk herniation and the increase of compensatory load on the intervertebral joints. 6.Secondary spinal stenosis. Classification] According to the direction and location of the herniation: 1. Lateral herniation The herniation is located at the posterior lateral side of the intervertebral disc, compressing the nerve root and causing radiating leg pain. 2. ①, root-shoulder type: the protrusion is located in the outer front of the nerve root (shoulder), the nerve root to the back of the medial extrusion, the spine is more to the healthy side of the curvature, to the affected side of the protrusion. (ii) Root-ventral type: the protrusion is located in front of the inner part of the nerve root (axilla), and the nerve root is extruded laterally, and the spine bends to the affected side and protrudes to the healthy side. ③, anterior root type: the protrusion is located in front of the nerve root, squeezing the nerve root to the posterior side, the physiological anterior protrusion of the spine disappears, and the anterior and posterior activities are restricted, mostly without lateral curvature deformity. Central type of herniation ①. Central type: located in the center, compressing the nerve roots and cauda equina on both sides. It is located in the center, compressing the nerve roots and cauda equina on both sides. ②, partial central type: favoring one side, mainly compression of one side of the nerve root and cauda equina or both sides of the pressure, but one side is lighter, one side is heavier. Clinical manifestations] I. Symptoms and signs 1. Lumbago and radiating leg pain Characteristics: ①, radicular radiating pain. The pain is related to abdominal pressure. The pain is related to abdominal pressure. ③ The pain is obviously related to activity and body position. Claudication The affected limb cannot take normal steps and bear weight, and often needs to walk with the help of crutches. 3. Lumbar muscle spasm, spinal deformity and activity limitation. 4, interspinous paraspinal tenderness and radiating pain. 5. Nerve function damage. Motor: atrophy of the muscles innervated by the involved nerves. Sensation: sensory hypersensitivity, hyperalgesia or loss of sensation in the distribution area of the involved nerve roots. Weakness or disappearance of reflexes. Commonly used examination methods and signs: 1) Straight leg raising test (lasegue sign) 2) Straight leg raising strengthening test 3) Flexion test 3) Auxiliary examination: 1) X-ray examination: lumbar vertebrae front and side view film 2) CT 3) MRI 【Diagnosis】 Refer to Diagnostic and Efficacy Criteria of Traditional Chinese Medicine (TCM) published by the State Administration of Traditional Chinese Medicine (SATCM) in 2004. 1) History of trauma to the lumbar region, chronic strain injury or exposure to cold and dampness, and most patients have a history of chronic injury prior to the onset of the disease. 2) Diagnosis of lumbar trauma, chronic strain injury or cold and dampness. Patients have a history of chronic strain injury or cold and dampness before the onset of the disease; most of them have a history of chronic strain injury or cold and dampness before the onset of the disease; 2. often occurring in young and middle-aged people; 3. lumbar pain radiating to the buttocks and lower limbs, and aggravated by increased abdominal pressure (e.g. coughing and sneezing); 4. scoliosis, loss of lumbar lordosis, pressure pain in the paravertebral region of the lesion site and radiating to the lower limbs, and the activities of the lumbar region are affected by 5. sensory hypersensitivity or retardation of the innervated areas of the lower limbs involved, and in cases with a long course of the disease, there may be muscular atrophy, and the positive test of straight-leg elevation or strengthening. Knee and Achilles tendon reflexes are weakened or disappeared, and bunion extension is weakened; 6. X-ray examination: scoliosis, lumbar physiological curvature straightening, the lesion intervertebral space can be narrowed, and there is osteophyte hyperplasia on the adjacent edge; CT or MRI examination can show the site of intervertebral disc herniation and the degree of protrusion (bulging). Modern medicine must consider and analyze the symptoms, signs and imaging data together to ensure the consistency of the three. 1, lateral consistency: the vast majority of lumbar vertebrae protruding on the side of the image and symptoms and signs are consistent; 2, level consistency: CT shows the level of herniated discs (interspace), the affected nerve and the complaint area and signs reflecting the lesion of the nerve is the same; 3, the degree of consistency: the greater the general image shows the greater the protrusion, the more severe the clinical manifestations and signs. The more the herniation is shown on the image, the heavier the clinical signs are, but it is not absolute, it is also affected by the positional relationship between the herniated disc and the compressed nerve root. Zhang Xiong, Department of Geriatrics, Guangyuan Hospital of Traditional Chinese Medicine 【Differential Diagnosis】 1, lumbar spine tuberculosis: the lower lumbar spine tuberculosis foci spread to the spinal canal or nerve root, appearing similar to lumbar intervertebral disc protrusion symptoms, the patient has symptoms of tuberculosis toxicity such as fatigue, low fever, accelerated sedimentation rate, the vertebral body destruction, narrowing of the intervertebral space, and cold abscess, etc.. 2. Ankylosing spondylitis: manifesting lumbar pain, lumbar back stiffness and limitation of lumbar activities, X-ray examination can see blurring of sacroiliac joint space, narrowing and ankylosis signs, calcification of spinal peripheral ligaments, vertebral body showing bamboo-like changes, HLA-B27 positive. 3. Tumor in lumbar spine canal: there may be signs of nerve root and cauda equina syndrome, and a few of them have unilateral lower limb symptoms, which can be easily confused with lumbar disc herniation, and the diagnosis can be confirmed by MRI examination. 4. Vertebral tumor: lumbar spine is the most common site of metastatic tumor, and middle-aged and old-aged patients need to pay attention to the severe lumbar back pain. Different from lumbar disc herniation, primary or secondary tumors can be found in the vertebral body and accessories with osteolytic destruction, and the intervertebral space is often unchanged, and ECT can show the abnormal concentration of nucleus pulposus, and MRI can show the low signal. 5. Osteoporosis: it can cause low back pain, and the pain is obvious in pathological fracture, and the pain range is wide, which can involve the whole low back and legs, and the severe cases are bedridden. The compression of spinal cord or nerve root can show corresponding signs, X-ray, CT and bone density examination can confirm the diagnosis. 6, Sacroiliac joint syndrome: no obvious radiating pain, no muscle strength, sensation and reflex changes, the pressure point is in the sacroiliac joint, not in the spinous process. 7. Piriformis syndrome: gluteal tenderness, gluteal muscle atrophy, pyriformis muscle tension, no spinous process tenderness. 8. Lumbar spinal stenosis: intermittent claudication, slow bending pain, many symptoms and few signs. Classification of TCM symptoms: Refer to “Diagnostic and therapeutic efficacy standards of TCM” published by the State Administration of Traditional Chinese Medicine in 1994: 1. Blood stasis: lumbar and leg pains are like pins and needles, the pains have a fixed place, light day and heavy night, the lumbar region is stiff, the rotation of the back is limited, and the pains are refusing to be pressed. The tongue is dark purple, or there are petechiae, and the pulse is tight or astringent. 2. Cold-dampness syndrome: Cold pain in the lower back and legs, with unfavorable rotation, unabated pain when lying down, aggravated by cold and rain, and cold limbs. The tongue is pale, the moss is white or greasy, and the pulse is dull and tight or moist. 3. Damp-heat syndrome: pain in the lower back, weakness of the legs, pain accompanied by a feeling of heat, pain increases in hot or rainy days, pain decreases after activity, malignant heat and thirst, short and red urine. Yellow and greasy moss, moist or stringy pulse. Deficiency of liver and kidney: lumbago, weakness of legs and knees, worse with exertion, relieved by lying down. In Yang deficiency, the color of the face is white, the hands and feet are not warm, the breath is lazy, the waist and legs are cold, or there is impotence, premature ejaculation, the women’s belt is clear and thin, the tongue is pale, the pulse is thin. Yin deficiency, dry throat and thirst, flushing, tiredness and fatigue, heartburn and insomnia, dreams or spermatorrhea, women’s yellowish odor, red tongue with little moss, fine pulse. Treatment: I. Conservative treatment 1, indications: ①, the first attack, or short duration of the disease. ②, longer duration of the disease, but the symptoms and signs of mild. (iii) Smaller protrusions by imaging. Those who cannot perform or do not agree with surgery. 2.Methods: ①, rest in hard bed ②, needle knife closed loosening treatment according to “Guangyuan Hospital of Traditional Chinese Medicine needle knife treatment technical operation procedures” on the supraspinatus, interspinous, transverse interosseous muscle, the nerve root outside the mouth and the exit of the compressed dermal nerves for the closed loosening of the needle knife, once a week, generally not more than three times. (iii) Nerve block treatment (iv) Anti-inflammatory, analgesic, nutritive and other symptomatic treatments based on the dialectical use of traditional Chinese medicines such as Tongluo lumbar and leg pain capsule and proprietary Chinese medicines. (5) Acupuncture, massage, local drug penetration and traction should be used to further loosen the adhesion. After the acute stage, bridge exercise and swallow function exercise should be given. Surgical treatment 1. Those who have not been treated with strict non-surgical treatment for at least three months. 2. 2. Those with incomplete paraplegia. 3. 3. Combined with severe spinal slippage. 4. Those who cannot be treated non-operatively for other reasons, but there must be a definite protruding object compressing the nerve root as confirmed by imaging. Nursing precautions: 1. Observe the basic vital signs, especially the sensation of the lower limbs; 2. Pay attention to the blood seepage around the incision, edema, and prevention of infection; 3. 3-5 days of bed rest, and wear a waist girdle when getting out of bed; 4. Strengthen the lumbar spine muscle exercise in the later stage to prevent recurrence. Cure: the original symptoms disappear, muscle strength and sensation are normal, and the patient can participate in normal labor and work. 2, good: the original symptoms reduced, limb function improved. 3. No cure: no improvement of symptoms. Overview] It is a syndrome caused by degeneration of intervertebral disc, rupture of annulus fibrosus, and protrusion of nucleus pulposus that stimulates or compresses nerve root and cauda equina, and causes lumbar and leg pain as the main manifestation, which is one of the most common causes of lumbar and leg pain. It is one of the most common causes of low back pain. The incidence is highest in L4-5 and L5-S1 interspace. It belongs to the category of lumbago and paralysis in traditional Chinese medicine. Etiology] I. Traditional medicine: Chinese medicine believes that: qi and blood, meridians and internal organs dysfunction and the occurrence of low back pain has a close relationship, the causes of this disease are: l, trauma; 2, strain; 3, kidney qi deficiency, essence weakening, tendon and vein loss of nourishment; 4, wind, cold, dampness, heat of the evil flow of the meridians, so that meridians and channels blocked, stagnation of qi and blood stasis, do not pass is painful. The Spiritual Pivot? The beginning of all diseases”: “is why the evil of deficiency in the people also …… stay and do not go is transmitted to the loss, in the loss of time, six meridians can not be, the limbs are limb pain waist and spine is strong.” The origin of all diseases? Waist and foot pain wait”: “the kidney gas is insufficient, by the wind evil for also, labor injury is kidney deficiency, the virtual is subject to wind cold, wind cold and positive qi fight, so waist and foot pain.” Second, modern medicine: 1, internal causes: ①, congenital developmental abnormalities of the intervertebral disc. Degeneration of intervertebral disc, reduction of water content of nucleus pulposus, decrease of elasticity and resistance to load. 2. External causes: ①, a heavy trauma. Repeated mild trauma and cumulative injuries such as exertion. Cold stimulation. Pathological changes] l. Pre-prominent: nucleus pulposus scar-like connective tissue, degeneration of fibrous ring repeated injury, thinning, fissure, the patient may have lumbar discomfort or pain, no radiating lower limb pain. 2. Protruding period: acute traumatic inflammatory reaction occurs in the nerve root, congestion, edema, thickening and extreme sensitivity. 3, late protrusion: ①, protrusion fibrosis, calcification. (2) The whole disc is degenerated, the annulus fibrosus is crumpled, the vertebral body is sclerotic, the edge of the bone proliferation, and the formation of bony cumbersome. (iii) Adhesion, degeneration and atrophy of the nerve root, and loss of movement and sensation in its innervated area. (iv) Hypertrophy of ligamentum flavum as secondary lesion. (5) Degeneration and hyperplasia of intervertebral joints, due to the narrowing of the intervertebral space after intervertebral disk herniation and the increase of compensatory load on the intervertebral joints. 6.Secondary spinal stenosis. Classification] According to the direction and location of the herniation: 1. Lateral herniation The herniation is located at the posterior lateral side of the intervertebral disc, compressing the nerve root and causing radiating leg pain. 2. ①, root-shoulder type: the protrusion is located in the outer front of the nerve root (shoulder), the nerve root to the back of the medial extrusion, the spine is more to the healthy side of the curvature, to the affected side of the protrusion. (ii) Root-ventral type: the protrusion is located in front of the inner part of the nerve root (axilla), and the nerve root is extruded laterally, and the spine bends to the affected side and protrudes to the healthy side. ③, anterior root type: the protrusion is located in front of the nerve root, squeezing the nerve root to the posterior side, the physiological anterior protrusion of the spine disappears, and the anterior and posterior activities are restricted, mostly without lateral curvature deformity. Central type of herniation ①. Central type: located in the center, compressing the nerve roots and cauda equina on both sides. It is located in the center, compressing the nerve roots and cauda equina on both sides. ②, partial central type: favoring one side, mainly compression of one side of the nerve root and cauda equina or both sides of the pressure, but one side is lighter, one side is heavier. Clinical manifestations] I. Symptoms and signs 1. Lumbago and radiating leg pain Characteristics: ①, radicular radiating pain. The pain is related to abdominal pressure. The pain is related to abdominal pressure. ③ The pain is obviously related to activity and body position. Claudication The affected limb cannot take normal steps and bear weight, and often needs to walk with the help of crutches. 3. Lumbar muscle spasm, spinal deformity and activity limitation. 4, interspinous paraspinal tenderness and radiating pain. 5. Nerve function damage. Motor: atrophy of the muscles innervated by the involved nerves. Sensation: sensory hypersensitivity, hyperalgesia or loss of sensation in the distribution area of the involved nerve roots. Weakness or disappearance of reflexes. Commonly used examination methods and signs: 1) Straight leg raising test (lasegue sign) 2) Straight leg raising strengthening test 3) Flexion test 3) Auxiliary examination: 1) X-ray examination: lumbar vertebrae front and side view film 2) CT 3) MRI 【Diagnosis】 Refer to Diagnostic and Efficacy Criteria of Traditional Chinese Medicine (TCM) published by the State Administration of Traditional Chinese Medicine (SATCM) in 2004. 1) History of trauma to the lumbar region, chronic strain injury or exposure to cold and dampness, and most patients have a history of chronic injury prior to the onset of the disease. 2) Diagnosis of lumbar trauma, chronic strain injury or cold and dampness. Patients have a history of chronic strain injury or cold and dampness before the onset of the disease; most of them have a history of chronic strain injury or cold and dampness before the onset of the disease; 2. often occurring in young and middle-aged people; 3. lumbar pain radiating to the buttocks and lower limbs, and aggravated by increased abdominal pressure (e.g. coughing and sneezing); 4. scoliosis, loss of lumbar lordosis, pressure pain in the paravertebral region of the lesion site and radiating to the lower limbs, and the activities of the lumbar region are affected by 5. sensory hypersensitivity or retardation of the innervated areas of the lower limbs involved, and in cases with a long course of the disease, there may be muscular atrophy, and the positive test of straight-leg elevation or strengthening. Knee and Achilles tendon reflexes are weakened or disappeared, and bunion extension is weakened; 6. X-ray examination: scoliosis, lumbar physiological curvature straightening, the lesion intervertebral space can be narrowed, and there is osteophyte hyperplasia on the adjacent edge; CT or MRI examination can show the site of intervertebral disc herniation and the degree of protrusion (bulging). Modern medicine must consider and analyze the symptoms, signs and imaging data together to ensure the consistency of the three. 1, lateral consistency: the vast majority of lumbar vertebrae protruding on the side of the image and symptoms and signs are consistent; 2, level consistency: CT shows the level of herniated discs (interspace), the affected nerve and the complaint area and signs reflecting the lesion of the nerve is the same; 3, the degree of consistency: the greater the general image shows the greater the protrusion, the more severe the clinical manifestations and signs. The more the herniation is shown on the image, the heavier the clinical signs are, but it is not absolute, it is also affected by the positional relationship between the herniated disc and the compressed nerve root. Zhang Xiong, Department of Geriatrics, Guangyuan Hospital of Traditional Chinese Medicine 【Differential Diagnosis】 1, lumbar spine tuberculosis: the lower lumbar spine tuberculosis foci spread to the spinal canal or nerve root, appearing similar to lumbar intervertebral disc protrusion symptoms, the patient has symptoms of tuberculosis toxicity such as fatigue, low fever, accelerated sedimentation rate, the vertebral body destruction, narrowing of the intervertebral space, and cold abscess, etc.. 2. Ankylosing spondylitis: manifesting lumbar pain, lumbar back stiffness and limitation of lumbar activities, X-ray examination can see blurring of sacroiliac joint space, narrowing and ankylosis signs, calcification of spinal peripheral ligaments, vertebral body showing bamboo-like changes, HLA-B27 positive. 3. Tumor in lumbar spine canal: there may be signs of nerve root and cauda equina syndrome, and a few of them have unilateral lower limb symptoms, which can be easily confused with lumbar disc herniation, and the diagnosis can be confirmed by MRI examination. 4. Vertebral tumor: lumbar spine is the most common site of metastatic tumor, and middle-aged and old-aged patients need to pay attention to the severe lumbar back pain. Different from lumbar disc herniation, primary or secondary tumors can be found in the vertebral body and accessories with osteolytic destruction, and the intervertebral space is often unchanged, and ECT can show the abnormal concentration of nucleus pulposus, and MRI can show the low signal. 5. Osteoporosis: it can cause low back pain, and the pain is obvious in pathological fracture, and the pain range is wide, which can involve the whole low back and legs, and the severe cases are bedridden. The compression of spinal cord or nerve root can show corresponding signs, X-ray, CT and bone density examination can confirm the diagnosis. 6, Sacroiliac joint syndrome: no obvious radiating pain, no muscle strength, sensation and reflex changes, the pressure point is in the sacroiliac joint, not in the spinous process. 7. Piriformis syndrome: gluteal tenderness, gluteal muscle atrophy, pyriformis muscle tension, no spinous process tenderness. 8. Lumbar spinal stenosis: intermittent claudication, slow bending pain, many symptoms and few signs. Classification of TCM symptoms: Refer to “Diagnostic and therapeutic efficacy standards of TCM” published by the State Administration of Traditional Chinese Medicine in 1994: 1. Blood stasis: lumbar and leg pains are like pins and needles, the pains have a fixed place, light day and heavy night, the lumbar region is stiff, the rotation of the back is limited, and the pains are refusing to be pressed. The tongue is dark purple, or there are petechiae, and the pulse is tight or astringent. 2. Cold-dampness syndrome: Cold pain in the lower back and legs, with unfavorable rotation, unabated pain when lying down, aggravated by cold and rain, and cold limbs. The tongue is pale, the moss is white or greasy, and the pulse is dull and tight or moist. 3. Damp-heat syndrome: pain in the lower back, weakness of the legs, pain accompanied by a feeling of heat, pain increases in hot or rainy days, pain decreases after activity, malignant heat and thirst, short and red urine. Yellow and greasy moss, moist or stringy pulse. Deficiency of liver and kidney: lumbago, weakness of legs and knees, worse with exertion, relieved by lying down. In Yang deficiency, the color of the face is white, the hands and feet are not warm, the breath is lazy, the waist and legs are cold, or there is impotence, premature ejaculation, the women’s belt is clear and thin, the tongue is pale, the pulse is thin. Yin deficiency, dry throat and thirst, flushing, tiredness and fatigue, heartburn and insomnia, dreams or spermatorrhea, women’s yellowish odor, red tongue with little moss, fine pulse. Treatment: I. Conservative treatment 1, indications: ①, the first attack, or short duration of the disease. ②, longer duration of the disease, but the symptoms and signs of mild. (iii) Smaller protrusions by imaging. Those who cannot perform or do not agree with surgery. 2.Methods: ①, rest in hard bed ②, needle knife closed loosening treatment according to “Guangyuan Hospital of Traditional Chinese Medicine needle knife treatment technical operation procedures” on the supraspinatus, interspinous, transverse interosseous muscle, the nerve root outside the mouth and the exit of the compressed dermal nerves for the closed loosening of the needle knife, once a week, generally not more than three times. (iii) Nerve block treatment (iv) Anti-inflammatory, analgesic, nutritive and other symptomatic treatments based on the dialectical use of traditional Chinese medicines such as Tongluo lumbar and leg pain capsule and proprietary Chinese medicines. (5) Acupuncture, massage, local drug penetration and traction should be used to further loosen the adhesion. After the acute stage, bridge exercise and swallow function exercise should be given. Surgical treatment 1. Those who have not been treated with strict non-surgical treatment for at least three months. 2. 2. Those with incomplete paraplegia. 3. 3. Combined with severe spinal slippage. 4. Those who cannot be treated non-operatively for other reasons, but there must be a definite protruding object compressing the nerve root as confirmed by imaging. Nursing precautions: 1. Observe the basic vital signs, especially the sensation of the lower limbs; 2. Pay attention to the blood seepage around the incision, edema, and prevention of infection; 3. 3-5 days of bed rest, and wear a waist girdle when getting out of bed; 4. Strengthen the lumbar spine muscle exercise in the later stage to prevent recurrence. Cure: the original symptoms disappear, muscle strength and sensation are normal, and the patient can participate in normal labor and work. 2, good: the original symptoms reduced, limb function improved. 3. No cure: no improvement of symptoms.