The problem of lumbar disc herniation

I can tell you clearly that lumbar disc herniation is easy to cure! It can be cured!

How to treat it? Conservative treatment can be taken, including waist physiotherapy, traction, oral anti-inflammatory and analgesic drugs, massage, etc.; if symptoms are not relieved or relapse after conservative treatment for more than 3-6 months, surgical treatment, including nucleus pulposus removal and nucleus pulposus surgery, can be considered During surgery (depending on the situation), you should pay attention to bending as little as possible, pay attention to getting in and out of bed, and cooperate with low back muscle exercises. This is effective for some patients and can prevent the recurrence of symptoms. Data show that the vast majority of waist and leg pain is related to lumbar disc disease.

The traditional view is that pain symptoms may occur only when the intervertebral disc herniates and compresses the nerve root, but this view cannot explain all clinical phenomena. Some patients have mild lumbar disc herniation and a small range, but their symptoms and signs are very serious. Some patients have severe lumbar disc herniation, but their clinical symptoms are very mild.

In recent years, a large number of experimental research results in neurobiochemistry and immunology tell us that the non-bacterial inflammation caused by lumbar disc herniation is closely related to the patient’s symptoms. The basic lesion of the disease, eliminating this non-bacterial inflammation is an important task in the treatment of lumbar disc herniation.

How is an intervertebral disc formed? An intervertebral disc is located between two vertebral bodies and is the link between the vertebrae. It usually consists of three parts: cartilage plate, annulus fibrosus, and nucleus pulposus. Each intervertebral disc contains two plates of cartilage that cover two adjacent vertebrae. The annulus fibrosus is connected between two cartilage plates and surrounds the nucleus pulposus in the center. Under normal circumstances, the three form a closed "container" with good elasticity and toughness.

The root cause of the symptoms of "lumbar protrusion" is inflammation

The researchers took out the dog's own nucleus pulposus tissue, smashed it evenly, and then injected these fragments into the dog's nerve roots. Compared with the saline injection group, a severe inflammatory reaction could be observed under the microscope. This result shows that the own nucleus pulposus tissue can cause a chemical inflammatory reaction in the nerve root, and this inflammation can cause significant pain. Someone has also conducted similar experiments on pigs, and the results are the same.

If the annulus fibrosus surrounding the nucleus pulposus ruptures, the nucleus pulposus will leak out, and the inflammatory substances in it will stimulate the nerve roots and cause pain. When inflammation involves nearby nerve tissue to form radiculitis, symptoms such as nerve damage can occur. In addition, studies have shown that the immune status of patients with lumbar disc herniation is also abnormal, which may be related to the autoimmune reaction in the intervertebral disc tissue.

Autoimmune reactions can also cause edema or inflammation of nerve roots, causing corresponding symptoms.

Common treatment methods for "lumbar protrusion" are not effective

Common treatment options for "lumbar protrusion" include oral medications, acupuncture, massage and other physical therapies, as well as lumbar paravertebral and epidural treatments. Side space, epidural block and other methods. Most oral medications can only relieve symptoms, and physical therapy often cannot effectively eliminate inflammation. Nerve block involves injecting drugs into the local area of ​​the lesion so that the drug is fully in contact with the lesion, and the effect is relatively accurate. It is generally treated once every 7 days, and 3 to 5 times constitute a course of treatment. However, the duration of the efficacy of these conventional blocks is sometimes uncertain, and some people often experience symptoms such as pain returning shortly after treatment ends.

Not only are patients dissatisfied, doctors also become less confident with treatment. The main reason is that lumbar intervertebral disc lesions generally last for a long time, ranging from a few months to decades. Local inflammatory changes have accumulated over many years and have become deeply rooted, making simple blockade difficult. Completely eliminated.

The latest interventional treatment

To treat inflammatory lumbar disc herniation, minimally invasive neurointerventional treatment methods are now used. Under the guidance of imaging examination tools, a special catheter is inserted into the lesion, and a microinjection device is used to continuously administer anti-inflammatory, analgesic and other drugs over a long period of time to eliminate inflammation as much as possible. On this basis, combined with surgery or collagenase dissolution and other methods, generally satisfactory results can be achieved. It not only relieves patients' pain, but also gives doctors confidence.

He Mingwei, Ph.D., Department of Pain, Xuanwu Hospital Affiliated to Capital Medical University

Precautions for preventing "lumbar protrusion" in middle-aged and elderly people

1. Maintain good living habits to prevent lumbar protrusion. Keep your legs cold to prevent overexertion.

2. The standing or sitting posture must be correct. Spinal misalignment will cause uneven stress on the intervertebral disc, which is the hidden root cause of intervertebral disc herniation. The correct posture should be "standing like a pine tree, sitting like a bell", with the chest lifted and the waist straight. The same posture should not be maintained for too long. Proper in-situ activities or lower back activities can relieve the fatigue of the lower back muscles.

3. Don’t press your legs or bend your waist too much during exercise, otherwise not only will you fail to achieve the intended purpose, but it will also cause intervertebral disc herniation.

4. Don’t bend down when lifting heavy objects. You should squat down to get the heavy objects first, and then stand up slowly, trying not to bend down.

Patients with lumbar disc herniation can be relieved or recovered after treatment and rest. However, the recurrence rate of the disease is quite high. Although many patients are reluctant, they often become "visiting" doctors. "Repeat Customers".

The reasons for the high recurrence rate of the disease are as follows:

(1) Although the symptoms of lumbar disc herniation have basically disappeared after treatment, many patients have not completely returned the nucleus pulposus, but only compressed the nerves. The root degree has been relieved, or the adhesion to the nerve root has been relieved.

(2) Although the condition of patients with lumbar disc herniation has stabilized or recovered, in a short period of time, once the waist is strained or sprained, the nucleus pulposus may protrude again, leading to recurrence of the disease.

(3) If you do not pay attention to keeping warm during cold and humid seasons, wind, cold, and dampness will invade the diseased parts of the human body, and fatigue may easily induce the recurrence of the disease.

(4) Although the nucleus pulposus of the postoperative patient has been removed at this segment, the stability of the spine above and below the segment after surgery is not good, so there are two segments above and below the surgical segment. The intervertebral disc is prone to prolapse, leading to the recurrence of lumbar disc herniation.

For lumbar disc herniation, in addition to actively adopting various treatment methods, the most important measure is prevention.

So, how can we prevent the recurrence of lumbar disc herniation? In daily life, study and work, people need various postures and develop their own habits. Whether they are correct or not has an important impact on the human body. Therefore, we are required to pay attention to the rationality of our usual standing, sitting, working postures, and sleeping postures, correct bad postures and habits, strengthen exercise, and enhance physical fitness, especially strengthening the functional exercises of the lower back muscles. Because proper exercise can improve muscle blood circulation, promote metabolism, increase muscle reactivity and strength, loosen soft tissue adhesions, correct the imbalance between the internal and external balance of the spine, and improve the stability, flexibility and durability of the lumbar spine, So as to play a good therapeutic and preventive role.

After winter, due to the unpredictable weather and sudden high and low temperatures, orthopedic diseases such as cervical spine and lumbar spine are easy to relapse, and pain in the neck, shoulders, waist, and legs recurs. Most lumbar spine diseases have a long course, variable symptoms, and are easy to recur, and their treatment methods are also diverse. If there is a lack of correct understanding, it is easy to enter treatment misunderstandings. Not to mention spending more money, the condition will not be easily improved, and it may even delay the opportunity for treatment.

The treatment of "lumbar protrusion" cannot be stopped as soon as it is cured

Liu Hongqi told reporters that patients often come to the hospital for consultation. The intervertebral disc herniation is obviously almost cured, but why has it "recurred" recently? relapsed”. He said that the main reason for this type of patients is the following misunderstandings about the treatment of lumbar disc herniation, which causes the condition to recur and become difficult to cure. 1. The course of treatment is not enough. After a period of treatment, many patients' condition improves and they no longer continue treatment. They think that they have recovered and there is no need to continue treatment. 2. The principles of lumbar disc herniation rehabilitation require reducing strenuous exercise, increasing rest, and paying attention to protection after recovery. However, many patients think that not working or exercising means resting, and they sit all day watching TV, playing cards, etc. This is more tiring than working at work, increases the burden on the waist, and causes the condition to relapse or even worsen. Dean Liu emphasized that the treatment of lumbar protrusion should not be stopped until it is cured, and must be persisted to the end. Fishing for three days and drying nets for two days can only worsen the condition.

Which method is best for treating "lumbar protrusion"?

So which method is better for treating lumbar disc herniation?

According to Dean Liu Hongqi, there are currently three main methods for treating lumbar disc herniation: 1. Conservative therapy; 2. Surgical therapy; 3. Minimally invasive interventional therapy. The method used should be based on the patient's own situation and treatment based on symptom differentiation. It is not possible to generalize which method is better, as no method is perfect.

Conservative treatment: including bed rest, wearing a waistband, computer three-dimensional traction, massage, acupuncture, physical therapy, drug injection into the sacral canal or near the nerve root, and taking Chinese and Western medicines. However, conservative treatment is only suitable for patients with early-stage lumbar disc herniation, and the therapeutic effect is limited. With regular conservative treatment, 80% of patients with early lumbar disc herniation can receive excellent treatment results.

Surgical therapy: The key to treatment is to relieve the stimulation or compression of the nerve roots, eliminate inflammation and edema around the nerves and spinal cord, and promote nerve repair. It is characterized by complete removal, low recurrence rate, and quick results, but There is a certain amount of trauma, the operation is relatively complex, and there are strict clinical indications for lumbar disc herniation. Only surgery can achieve good results in several situations such as large disc herniation, calcified lumbar spondylolisthesis, and instability.

Minimally invasive interventional therapy: Under X-ray monitoring, fine needle puncture ozone injection or laser vaporization, incision and suction are used to decompress the intervertebral disc and retract herniation, thereby alleviating nerve compression symptoms. The current clinically advanced therapy is ozone injection therapy. By injecting ozone (O3) into the patient area. To achieve the therapeutic purpose of shrinking and retracting the protruding parts.

Advantages: Simple intervertebral disc nucleus pulposus, the effect is very good, the excellent and good rate can reach more than 90%; fine needle puncture, simple operation, safe to the human body, non-toxic, no adverse reactions; under monitor monitoring carried out with high success rate.

Lumbar disc herniation has entered the era of minimally invasive treatment

Minimally invasive treatment technology for lumbar disc herniation is an important achievement in the development of modern medicine.

Currently, the internationally accepted minimally invasive treatment techniques for lumbar disc herniation are ozone (O2-O3) injection, electric percutaneous cervical puncture, lumbar disc incision and suction technology, posterior endoscopic discectomy (M.E.D) discectomy technology and There are four collagenase nucleus pulposus chemical dissolution technologies, especially the ozone (O2-O3) injection method for the treatment of lumbar disc herniation. It is highly recognized by the academic community and the majority of patients because of its mature technology, significant curative effect, small trauma and quick recovery. Currently in Fuzhou, Fuxing Orthopedic Hospital is the only professional orthopedic hospital with these four minimally invasive treatment technologies.

Ozone (O2-O3) injection method

Intervertebral disc ozone (O2-O3) injection method is the most advanced minimally invasive technology for the treatment of intervertebral disc herniation in recent years. This therapy was first developed in Italy It was pioneered by doctors and has been widely used abroad. It has been confirmed to be the most effective method to treat cervical and lumbar disc herniation without surgery. O3 has a strong oxidizing ability, as well as anti-inflammatory and analgesic effects. It can instantly oxidize the proteoglycans in the nucleus pulposus tissue and destroy the nucleus pulposus cells, causing water loss and shrinkage, thereby relieving symptoms and achieving the purpose of treatment.

Advantages: 1. Quick onset and high efficacy. It can radically cure cervical and lumbar disc herniation. 2. It is less invasive, fine needle puncture under local anesthesia, painless, more effective than conservative treatment, and avoids the pain of surgery. It mainly acts on the nucleus pulposus and has no effect on other tissues. 3. Precise positioning, accurate positioning under the guidance of X-ray machine, high success rate. 4． Safe, O3 quickly degrades into O2 after entering the intervertebral disc, promoting the recovery of peripheral nerve tissue.

Electric percutaneous cervical and lumbar disc aspiration technology

Percutaneous disc aspiration is a treatment method currently recognized by the international medical community as having significant efficacy. Clinical application has proven that this surgery can quickly relieve nerve compression symptoms caused by nucleus pulposus herniation and is a safe, effective and economical treatment method. Under the guidance of a C-arm X-ray machine, the doctor uses a puncture guidance system to percutaneously puncture to the center of the intervertebral disc, and then delivers the nucleectomy device to cut, flush and aspirate the nucleus pulposus. The general treatment process takes 15-20 minutes. Domestic electric automatic disc cutting and aspiration device has treated more than 40,000 patients. The clinical effectiveness rate reached 94%, with no serious complications.

Three treatments for lumbar disc herniation:

The basic treatments for lumbar disc herniation include surgical therapy, conservative therapy and interventional therapy. Among interventional therapies, drug chemical dissolution is the most representative, and this therapy has been used in clinical practice for 30 years. The basic idea is to use chemical drugs to react with the intervertebral disc tissue to dissolve, absorb, and discharge the tissue that compresses the nerves in the intervertebral disc, thereby relieving nerve compression and eliminating symptoms. The initial dissolving drugs were papain, etc., but they were eliminated due to their serious side effects. In the 1960s, American scholars proposed using collagenase injection to treat lumbar disc herniation. my country also started basic pharmacological research on collagenase preparations in 1973. Later studies confirmed that collagenase can specifically hydrolyze the three-dimensional helical structure of natural collagen under physiological pH and temperature. Collagen is the main structural protein of the human body, accounting for approximately 50% of the dry weight of the annulus fibrosus and 20-30% of the dry weight of the nucleus pulposus in the lumbar intervertebral disc. When a lumbar disc herniates, the water content in the disc decreases and the collagen content increases. Collagenase has strong selectivity in dissolving the nucleus pulposus. It only dissolves the part of the nucleus pulposus that is mainly composed of collagen. The final product is neutralized and absorbed by the plasma, thereby gradually reducing the volume of the intervertebral disc and reducing or eliminating the stimulation and stimulation of nerve tissue. oppression. But it will not dissolve the nerve roots and normal structures near them, so it is safer. It can be observed in animal experiments and human specimens that the intervertebral disc turns into paste or slag under the action of collagenase. This therapy has the following advantages:

1. It is performed under local anesthesia, the operation is simple and only takes 10-15 minutes. It is safe, non-toxic and has no adverse reactions to the human body;

2. Curative effect Very good, with an excellent and good rate of 77%;

3. It will not cause epidural fibrosis and scarring, and epidural scarring is the main complication of surgical treatment.

However, the efficacy of collagenase dissolution is not 100%. Its excellent and good rate is 77%, and the recurrence rate after 10 years is 23%. Therefore, the indications should be strictly controlled. Its basic indications are: 1. Lumbar disc herniation diagnosed as lateral or lateral type clinically and radiologically, which is ineffective after three months of regular conservative treatment; 2. Failure or recurrence of surgery; 3. Incomplete percutaneous aspiration. who. The following are contraindications for collagenase dissolution: 1. Patients with lumbar spinal stenosis; 2. Patients with lumbar disc herniation and calcification, free type, prolapse type, and sequestrum type; 3. Cauda equina syndrome, manifested by bowel obstruction and People with functional disabilities; 4. People with diabetes, tumors, mental illness, neurosis, serious organic diseases and drug allergies; 5. Pregnant women and children under 14 years old.

The intervertebral disc usually consists of three parts: ① ointment plate; ③ annulus fibrosus: ③ nucleus pulposus.

The special functions of the lumbar intervertebral disc: (1) Maintain the height of the spine, maintain height, and follow the development of the vertebral body; (2) Connect the upper and lower vertebral bodies of the intervertebral disc and allow a certain degree of mobility between the vertebral bodies. (3) Allow the vertebral bodies to move The surface bears the same force. (4) Buffering effect. (5) Maintaining a certain distance and height of the lateral articular processes. (6) Maintaining the size of the intervertebral foramen. (7) Maintaining the curvature of the spine. Causes of lumbar disc herniation The following 5 common causes are: 1. Degenerative changes of the intervertebral disc 2. Trauma 3. Overload 4. Lumbar puncture 5. Long-term vibration.

Causes of lumbar disc herniation: 1. Causes of lumbar disc herniation

< p>After the degeneration of the lumbar intervertebral disc, due to some reason (injury, overuse, etc.), the annulus fibrosus may be partially or completely ruptured, and the nucleus pulposus may bulge outward, compressing the nerve roots or spinal cord (cauda equina), causing low back pain Those with a series of neurological symptoms become lumbar disc herniation.

Lumbar disc herniation is one of the common causes of low back and leg pain, and its main symptoms are low back pain and lower limb pain.

Traditional Chinese medicine has long described "lumbar disc herniation". For example, it is said in "Su Wen: Pricking on Back Pain Chapter": "The pulse of Hengluo causes back pain, so it should not be tilted down. If you raise it up, you will be afraid of falling, and if you lift it, it will hurt your waist." It also says: The pulse in the flesh causes pain in the lower back and one should not cough. Coughing causes contraction of the muscles. ""Medical Enlightenment" also said: Low back pain, tightness, and pulling on the legs and feet." All the above indicate that this disease can be caused by trauma. The symptoms are low back pain combined with lower limb pain, which is aggravated by coughing. This is basically similar to the symptoms of lumbar disc herniation described by Western medicine. Traditional Chinese medicine calls it "lumbar and leg pain" or "lumbar pain with knees".

The incidence of lumbar disc herniation is about 15% of outpatients with low back and leg pain. This disease is more common in prime-age male manual workers, with workers being the most common. It is most likely to occur between the ages of 20 and 40, with an average The age is about 30 years old, and the male to female ratio is about 10 to 30:1. The most common areas of disease are between waist 4 and 5, followed by waist 5 and sacral 1, and waist 3 and 4 are less common.

2. Cause and pathogenesis

The cause of lumbar disc herniation is mainly the degeneration of the disc itself, plus some external factors, such as trauma, chronic strain, cold and dampness, etc. As a result, the annulus fibrosus of the lumbar intervertebral disc ruptures, causing the nucleus pulposus to herniate.

Under normal circumstances, the intervertebral disc often bears the pressure of body weight, and the waist often undergoes flexion and extension activities. It is subject to great compression stress and wear, especially the lower waist. Therefore, by the age of 30, the intervertebral disc That is when degeneration begins. If the annulus fibrosus and the nucleus pulposus degenerate at the same rate, intervertebral disc narrowing and intervertebral disc herniation are common. If degeneration follows this balance and the cartilage plate also ossifies, the vertebral body will tend to be stable, and no low back pain will occur except for limited waist movement. If the degeneration of the two is obviously unbalanced, the annulus fibrosus will change earlier and more obviously. Its toughness decreases and the pressure of the nucleus pulposus remains unchanged. Even if there is no obvious trauma, the annulus fibrosus can still be ruptured. If it is subjected to a larger rotation or twisting force, the annulus fibrosus can be broken in a circular or radial shape on the posterolateral side. Annular ruptures are mostly located around the interstitial disc, which can cause low back pain clinically; radial ruptures often extend outward from the nucleus pulposus to the edge of the interstitial disc, but the outer annulus fibrosus can remain intact. At this time, the nucleus pulposus is It is squeezed into the fissure under greater pressure. After that, the waist continues to move and exert force, which forces the nucleus pulposus to gradually protrude outward, compressing the nerve root, causing sciatica.

In adulthood and the prime of life, the water content of the nucleus pulposus is high and its expansibility is large. Once the annulus fibrosus ruptures, the nucleus pulposus will protrude due to high pressure; after old age, the nucleus pulposus becomes dehydrated and its expansion force decreases. Although the fiber The ring is broken and the nucleus pulposus is mostly not prominent.

Repeated minor waist injuries in daily work and life, such as lifting heavy objects and frequent bending activities, can produce a pump-like squeezing effect on the intervertebral disc_. These minor injuries continuously act on the intervertebral disc, which can change from quantitative to qualitative changes, and can also cause degenerative changes in the annulus fibrosus. On this basis, coupled with waist trauma, it is more likely to cause the rupture of the annulus fibrosus and cause disease.

Many patients with lumbar disc herniation have no history of trauma or strain, and only develop the disease due to exposure to cold and dampness. Cold and dampness can cause small blood vessels to contract and muscles to spasm, both of which can affect local blood circulation and thus affect the nutrition of the intervertebral disc; muscle tension or spasm can increase the pressure on the intervertebral disc, which can cause degeneration of the intervertebral disc. causing further damage. As a result, disc herniation can occur.

Clinically, this disease can also occur in patients who are only due to excessive mental stress. This is due to the lack of proper muscle relaxation, which increases the pressure on the intervertebral disc, causing the degenerated intervertebral disc to herniate.

The annulus fibrosus is relatively weak on the posterior side. When the posterior longitudinal ligament reaches the lumbar 5-sacral plane, its width becomes significantly smaller, especially on both sides. At the same time, the lower waist is the most susceptible to sprains, strains, and compressions. This makes it easier for the nucleus pulposus to protrude backward from both sides.

Type: According to the direction of protrusion of the nucleus pulposus, it can be divided into:

1. Posterior protrusion: The posterior protrusion of the nucleus pulposus can compress the nerve root and cause low back pain. This type of protrusion is the most common clinically.

2． Anterior protrusion does not cause symptoms and has no practical clinical significance.

3. Intravertebral herniation is when the nucleus pulposus protrudes into the cartilage plate and vertebral body through an occluded blood vessel, forming a cup-shaped gap. This type mostly occurs in adolescence.

According to the different parts that protrude backward, it can be divided into:

1. The unilateral type is the most common clinically, with protrusion of the nucleus pulposus and nerve root compression limited to one side.

2． Bilateral type: the nucleus pulposus protrudes from both sides of the posterior longitudinal ligament, and the nerve roots on both sides are compressed.

3. The central intervertebral disc herniates from the middle part of the back and generally does not compress the nerve roots, but only compresses the descending cauda equina nerve, causing symptoms such as sellar area paralysis and urinary and defecation disorders. If the protrusion is large, it can also compress the nerve root.

It can be divided into the following three categories according to the degree of prominence:

1. Hidden type (young and weak type) is incomplete rupture of the annulus fibrosus, and its outer layer remains intact. The nucleus pulposus protrudes toward the weak part of the rupture under pressure. At this time, if the pressure on the interstitial disc is large, the annulus fibrosus will rupture more often. Then the nucleus pulposus will continue to protrude outward; if you can rest properly, the nucleus pulposus can be completely restored, and the ruptured annulus fibrosus can also be healed. This type sometimes produces sciatica, but it gets better after rest.

2． Protruding type (transitional type): The annulus fibrosus fissure is large, but incomplete, the outer layer remains intact, and the nucleus pulposus protrudes large and is spherical. This type can be converted into a ruptured type, and can also be cured by manual reduction.

3. Rupture type (mature type): the annulus fibrosus is completely ruptured, and the nucleus pulposus can protrude into the spinal canal. The clinical symptoms are more severe and mostly persistent, and surgical treatment is generally performed.

3. Clinical manifestations

1. Symptoms

The main symptoms of lumbar disc herniation are waist pain and radiating pain in the lower limbs. Radiating pain in the lower limbs appears at different times: some appear at the same time after the waist injury; some only feel waist pain at the time, and then feel radiating pain in the lower limbs a day or two later; or sciatica may not appear until weeks or months later. Lower limb pain is often accompanied by abnormal sensation in the thighs, calves, and feet. Low back pain and lower limb pain can coexist. It can also occur alone. Low back pain is mostly in the lower waist, lumbosacral region or limited to one side. And the waist extension and flexion activities are affected due to pain and muscle spasm. According to statistics, most people suffer from low back pain first and then leg pain, accounting for 53.3%; 20.8% suffer from leg pain first and then low back pain; 8.3% suffer from simultaneous pain; 15% suffer from leg pain only; and 2.5% suffer from low back pain only.

Low back pain originates from injured tissues in the waist, and string pain in the lower limbs is caused by nerve root compression. In severe cases, it affects life and work, but it can often be relieved with adequate bed rest. Later, it relapsed due to factors such as fatigue, twisting the waist, catching cold, etc. Such attacks occur repeatedly, sometimes mildly and sometimes severely, and can last for many years without recovery. However, some cases do not relapse for many years after rest and treatment.

Manifestations of sciatica: Pain radiates downward along the sciatic nerve or the distribution area of ​​a certain nerve root in the lower limbs, usually starting from the buttocks and radiating to the lower limbs to the back of the thigh, the outside of the calf, and even the instep and toes. The pain area is relatively fixed, and most patients can point out the specific location.

Radiated pain is often aggravated by standing, exerting force, coughing, sneezing or exercising, and can be relieved after rest; but in some cases, the pain is relieved when standing or walking, and sometimes the symptoms are aggravated when resting at night, but after adequate rest The pain can usually be alleviated; those with a long course of disease or severe nerve root compression often experience numbness in the lower limbs. The numb area is consistent with the distribution area of ​​the affected nerve roots and is limited to the outside of the calf or the foot. Central protrusion may cause sella. Areas of numbness; some patients feel coolness in their lower limbs, never feeling warm, and objective examination shows that the temperature of the affected limb is lower than that of the unaffected side; some dorsalis pedis artery pulses are also weak, which is caused by stimulation of the sympathetic nerve.

2. Signs

The signs of this disease can be divided into two categories: waist and spine signs; nerve root compression signs.

(1) Waist and spinal signs

1. Abnormal posture: In order to avoid nerve root compression, patients tend to naturally fix their waist in a certain appropriate posture. Depending on the severity of the disease and the body's ability to adjust itself, the waist may become excessively lordotic, flattened, or curved.

(1) Increased lumbar lordosis: mostly caused by small protrusions on the posterolateral side. Due to excessive lordosis of the lumbar spine, the cauda equina can be moved to the back of the spinal canal, thereby avoiding the stimulation and compression of protrusions. Increased lordosis can make the lumbar intervertebral space narrow in front and wide in the back, effectively preventing small protrusions from continuing. Moving it posteriorly relaxes the ruptured annulus fibrosus, which facilitates repair and also protects the posterior longitudinal ligament. When the patient stands, the trunk tends to lean forward slightly, and the waist can straighten and bend sideways, but forward bending is limited.

(2) Flattening or inversion of the lumbar curve: This posture is caused by a large posterolateral or posterior protrusion that is enough to prevent the waist from extending backward. It is often accompanied by severe sciatica and Lumbar scoliosis, any movement to straighten the waist can aggravate the radiating pain in the lower limbs.

(3) Scoliosis has a high incidence, accounting for more than 80% of patients with intervertebral disc herniation. The scoliosis may be convex toward the healthy side or toward the affected side. Scoliosis is a protective reaction that relaxes the nerve root and relieves pain; the direction of the scoliosis can indicate the location of the protrusion and its relationship to the nerve root. Generally speaking: the protrusion is located on the anteromedial side of the nerve root (axillary), and the spine bulges toward the healthy side in order to avoid the nerve root; if the protrusion is located on the anterolateral side of the nerve root (i.e., on the shoulder of the nerve root), The spine must be convex toward the affected side. But this is not always the case clinically. If the protrusion is in the front and outside of the nerve root, the spine will convex toward the affected side in the early stage, keeping the nerve root away from the protrusion and reducing compression; at the same time, the gap on the convex side will widen, making it easier for the protrusion to be sucked back into the disc. Inside.

In the late stage, the protrusion has been fixed and adhesions are no longer possible, and the spine is convex to the healthy side, which relaxes the nerve roots and reduces the compression of the nerve roots. Some people believe that the presence or absence of scoliosis, its direction and degree are related to the degree of hypertrophy of the ligamentum flavum and the size of the protrusion. The larger the protrusion, the thicker the ligamentum flavum, the greater the pressure and tension on the nerve roots, and the more severe the pain. When the protrusion is located directly in front of the nerve root, the nerve root sometimes slides to the outside or front and medial side in front of the protrusion; because the relative positions of the two often change, the direction of the side bend is not constant, sometimes convexing to the healthy side, sometimes convexing to the affected side. side, and sometimes no scoliosis. If the protrusion is completely in the center of the horse's tail, no side bending will occur.

2． Spinal movement is limited. Spinal flexion, extension, lateral bending and rotation are all restricted to varying degrees, especially back extension. The reason is: when the spine is flexed, the front of the interstitial disc is squeezed more, and the posterior gap is widened. The nucleus pulposus shifts backward, increasing the tension on the mature protrusion; at the same time, the spinal cord moves upward, pulling the nerve roots, increasing pain and limiting movement; when stretched. The protrusion enlarges, and the ligamentum flavum protrudes forward, directly squeezing the protrusion and nerve roots, aggravating the pain and limiting stretching movements. When the patient stands and tilts his spine later, he feels the pain in his waist and lower limbs getting worse.

3. Tender points and radiating pain: Tender points are mostly between the spinous processes of the lower lumbar vertebrae and 1 to 2 centimeters beside the vertebrae, which is equivalent to the plane of the protrusion. Pressure on the ligamentum flavum, nerve roots and protrusions can cause radiating lameness of the lower limbs. The location of pain corresponds to the area where the affected nerve roots are distributed. This is a reliable basis for the diagnosis of this disease. This kind of radiating pain is different from the referred pain caused by general sprains or strains, and is used to identify sprains and strains.

If the tender point is difficult to find, the patient can get out of bed and stand, with the spine slightly extended backward, so that the patient's back rests on the front of the examiner's left shoulder to relax the sacrospinal muscles, and the examiner's left hand Press the patient's anterior superior iliac spine and use the thumb of the right hand to find tender points. This method is easier to detect tender points than in the supine position.

(2) Signs of nerve root compression or involvement

1. The straight leg raise test was positive, the foot excessive dorsiflexion test was positive, the sit-up and knee extension test was positive, the neck flexion test was positive, and the jugular vein compression test was positive.

2． Neuromuscular system examination: The herniated intervertebral disc presses on the nerve root, which can cause sensory impairment in the area controlled by it, weakened muscle strength, weakened or disappeared tendon reflexes, and muscle atrophy, which provides an important basis for further confirming the diagnosis.

(1) Tendon reflex: 70-80% of patients have abnormal knee and Achilles tendon reflexes. During the examination, both sides should be compared. The reflexes may be reduced, increased, or disappeared. When the nerve root is only stimulated, the reflex may be hyperactive; if there is but not severe compression, the reflex will be reduced; if the compression is severe, the reflex will disappear. The change of reflex is related to the height of the protruding part. Protrusion of waist 4 to 5 will mostly change the knee reflex; protrusion of lumbar 5 and sacral disc will mostly change the Achilles tendon reflex.

(2) Muscle strength test: In clinical practice, muscle strength tests of the quadriceps femoris, hamstrings, gastrocnemius, tibialis anterior, and extensor pollicis longus muscles of the lower limbs are often performed. Compared with the unaffected side, the quadriceps femoris is innervated by the 3rd lumbar nerve; the tibialis anterior and extensor pollicis longus are innervated by the 5th lumbar nerve; the hamstrings and gastrocnemius are innervated by the 1st sacral nerve. When the strength of these muscles weakens When, it indicates that the corresponding nerve that controls the muscle is involved. If the strength of the dorsiflexion of the foot and the extensor hallucis is weakened, it is a sign of disc herniation at waist 4 to 5; if the strength of the toe flexion or one-leg raise in an upright position is weak, it is a sign of disc herniation at waist 5 or 5.

(3) Sensory examination: Sensory examination should include examination of pain, temperature and touch. When the nerve root is squeezed by the protruding disc, there will be sensory changes in its innervated area. The sensory changes vary with the degree of nerve root involvement. Mild stimulation can cause hyperesthesia; heavier stimulation or compression can cause decreased sensation. For example, hidden protrusions generally do not cause sensory impairment; smaller protrusions can stimulate nerve roots and cause hyperesthesia; larger protrusions may compress nerve roots or cause adhesions. Most patients have obvious sensory loss. The sensory impairment area is consistent with the nerve distribution area and is also consistent with the subjective numbness area. For example, sensory disturbances from lumbar 4 and 5 disc herniation often occur on the outside of the calf and the instep; while lumbar 5 and sacral disc herniation may cause sensory disturbances on the little toe, the outside of the foot, and the back of the calf. After the examination, a diagram should be drawn to show the sensory impairment area.

(4) Muscle atrophy: Muscle atrophy of lower limbs is caused by neurotrophic disorders or disuse due to pain. It is manifested in muscle atrophy of thighs and calves. Comparing both sides, the degree of muscle atrophy is related to the nerve root damage. The pressure is directly proportional to the duration of the disease.

3. Laboratory tests

General blood and urine tests are normal. If the diagnosis is difficult to confirm and needs to be differentiated from other diseases, other laboratory tests should be done, such as routine blood tests, Erythrocyte sedimentation rate, rheumatoid factor, etc. If necessary, perform lumbar puncture, measure the pressure of cerebral effusion, perform Quigen's test, and conduct routine examination of cerebral effusion. To exclude tuberculosis, rheumatoid and spinal cord tumors.

IV. X-ray examination

Patients should routinely take anteroposterior and lateral X-rays of the lumbar spine. The lateral X-ray can show that the affected intervertebral space is narrowed, sometimes narrowing in front and wide in the back, bone hyperplasia on the upper and lower edges of the vertebral body, or the lumbar lordosis disappears; scoliosis can be seen in the anteroposterior X-ray. X-ray examination is only for reference in the diagnosis of lumbar disc herniation, and its importance lies in excluding other lesions of the lumbar spine. Such as tuberculosis, tumors, rheumatoid spondylitis and lumbosacral congenital malformations.

5. Special examinations

After the above examinations, most intervertebral disc herniations can be diagnosed. Special examinations are only performed in cases where individual diagnosis is difficult and are generally not recommended for routine use.

(1) Myelography The diagnostic reliability rate is 29 to 40%. The currently commonly used contrast agent is iodophenyl ester, which is relatively thin, has little reaction, is easy to extract, and can also be absorbed by itself in a short period of time. The advantage of myelography is that it can see the entire spinal canal and identify tumors and spinal stenosis. In the case of intervertebral disc herniation, it is usually on one side of the spinal canal, and a small and regular filling defect or indentation is formed on the outer front of the dura mater. The location of the indentation is facing the intervertebral space. Spinal cord cauda equina tumors can follow tumors.

5. Differential diagnosis

Typical cases of lumbar disc herniation are easier to diagnose. However, it should be distinguished from the following diseases clinically:

1. Acute lumbar myofascial and ligament sprains and small joint synovial incarceration

These diseases all have severe low back pain and difficulty in moving. Restriction and lumbar muscle spasm, etc., may also cause referred pain in the buttocks and lower limbs.

Is this kind of referred pain related to the lumbar spine?/div>