Author: Sound of Xinglin Expert Profile
: Lvbi Tao, MD, Master Instructor, is now the Shanghai Changzheng Hospital spine three subjects deputy chief physician, associate professor, head of the ward.
Lumbar disc herniation is one of the more common diseases. The intervertebral disc is equivalent to the "soft cushion" between two adjacent vertebral segments, which can relieve the shock when the human body moves. The intervertebral disc is composed of the outer fibrous ring and the central nucleus. The annulus fibrosus firmly connects the vertebral bodies, has greater elasticity and toughness, and plays a role in withstanding pressure and preventing the nucleus pulposus from overflowing. The nucleus pulposus is a white gelatinous substance with elasticity. Once the annulus fibrosus ruptures, the nucleus pulposus will depart from its original position and form a protrusion. When the protrusion compresses the nerve and produces clinical symptoms, it is called lumbar disc herniation. Only a herniated disc, no nerve compression, and no clinical symptoms can not be diagnosed as lumbar disc herniation. This condition does not require surgical treatment. Close follow-up and active rehabilitation exercises can be taken to prevent the herniated disc from further aggravating the nerve compression.
The main reasons for lumbar disc herniation are: Degeneration of the intervertebral disc and decreased water content of the nucleus pulposus under the influence of factors such as increasing age, long-term fatigue, poor living habits, trauma, etc., causing a decrease in intervertebral height and loosening of intervertebral joints , The annulus fibrosis is degenerated and its firmness is reduced. Under the further promotion of minor trauma, the annulus fibrosus ruptures and the nucleus pulposus protrudes along the fibrous annulus. Therefore, the disease mostly occurs in the elderly, but the pace of modern life is fast and young people The incidence of the disease is increasing year by year. Intervertebral disc herniation, the corresponding intervertebral height will drop, irritating the sinus vertebral nerve, will cause the symptoms of low back pain; Back of the foot or sole); if the protrusion is further aggravated or the nerve is compressed for too long, it will cause foot drop (toes or ankles cannot be extended back, and a lame gait when walking) and cauda equina syndrome (dysfunction of urine and bowel, Sellar paresthesia, sexual dysfunction), surgery is needed as soon as possible.
So how to treat lumbar disc herniation?
treatment can be divided into conservative treatment and surgical treatment:
conservative treatment: acute attack can choose bed rest, traction, symptomatic oral or intravenous medication, etc. Most patients can get temporary relief of symptoms. During the remission period, oral medication can be continued, exercises for strengthening back muscle function, and bad lifestyle changes can be treated. Conservative treatment is mainly applicable to: ① those who are young, have a first attack or have a short course of disease; ② those who have mild symptoms and can relieve themselves after rest; ③ there is no obvious spinal stenosis on imaging examination.
Surgical treatment: patients who have one of the following conditions require surgical treatment: ①Severe low back and leg pain symptoms, recurring, no conservative treatment after 3 months, and the condition gradually worsens, affecting work and life; ② Cauda equina syndrome or foot drop should be treated with surgery as soon as possible.
So how to choose the surgical method for lumbar disc herniation? Surgical methods can be divided into open surgery and minimally invasive surgery. Let us first understand the advantages and disadvantages of various surgical methods.
open surgical methods are divided into simple nucleus pulposus removal, posterior lumbar decompression, bone grafting, fusion and internal fixation. Thirty years ago, pure nucleus pulposus was the main surgical procedure for the treatment of lumbar disc herniation. The method was to open a "small window" at the back of the lumbar spine, or to remove the bone structure behind the spinal canal in a larger area to open the vertebrae. After the tube stretches the nerve, you can see the herniated part of the intervertebral disc. The protruding nucleus pulposus tissue can be removed directly under direct vision. The advantage is that the operation cost is low. The disadvantage is that you need to rest in bed for at least 8 weeks after the operation. There will be recurrence in the future. The lumbar spine is unstable and cannot relieve the possibility of low back pain. In view of the shortcomings of simple nucleus extraction, posterior lumbar decompression and bone grafting and internal fixation were later introduced. This operation is currently the mainstream operation for the treatment of lumbar disc herniation. This operation requires titanium implantation through the pedicle Screws, connected with titanium rods, are conducive to fully removing the herniated intervertebral disc tissue, completely removing the compression on the nerve tissue, and restoring the intervertebral height. Its advantages are sufficient nerve decompression, reliable curative effect, no recurrence, and can relieve low back pain at the same time And leg pain, you can get out of bed 1 week after surgery. The disadvantage is that the operation is more traumatic and expensive.
minimally invasive surgery: minimally invasive surgery has many methods, mainly including percutaneous puncture disc ablation (using ozone, laser, chemical dissolution, etc. to retract the herniated disc) and endoscopic technology. formerDue to the unreliable curative effect, it has gradually withdrawn from the stage of history. This article mainly introduces endoscopic technology. According to different approaches, endoscopic techniques can be divided into transforaminal approach and translaminar approach endoscopic minimally invasive techniques. The basic method is to make a small incision on the surface of the patient’s skin and insert the perforator into In the intervertebral foramen or between the lamina, the protruding and protruding nucleus pulposus tissue is removed with a matching surgical instrument to achieve the purpose of releasing nerve compression. Minimally invasive technology has less trauma, quick recovery after operation, and low cost. However, not all patients with lumbar disc herniation are suitable for minimally invasive technology. Minimally invasive technology has its limitations. It cannot effectively relieve low back pain after surgery and may not be completely during surgery. After removal of the herniated nucleus pulposus, there is a certain possibility of recurrence of herniated disc after surgery. Endoscopic minimally invasive surgery for lumbar disc herniation generally needs to meet the following conditions: (1) Single-segment lumbar disc herniation, lower limb radiating pain is the main symptom, and low back pain is not obvious; (2) no spondylolisthesis or spondylolisthesis or Instability, etc.; (3) Simple lateral recesses and nerve root compression caused by stenosis of the intervertebral foramina. For elderly patients, the general herniated disc is combined with the posterior ligamentum flavum hypertrophy and the spinal canal stenosis is obvious, and it is generally not suitable for endoscopic minimally invasive techniques.
Figure 1 Transforaminal approach minimally invasive technique
Figure 2 Posterior lumbar decompression, bone graft, fusion and internal fixation
In short, for most patients with lumbar disc herniation, formal conservative treatment and symptomatic oral medication can be carried out in the early stage. Avoid sitting for a long time and bend over to bear weight, and strengthen the back muscle function exercises during the remission period; surgery is only recommended for patients with surgical indications. If cauda equina nerve damage or foot drop occurs, surgery is recommended as soon as possible . Under normal circumstances, for young patients with single-segment lumbar disc herniation, radiating pain in the lower limbs is the main symptom without obvious low back pain. Minimally invasive treatment is recommended. However, if there is spinal stenosis, multi-segment herniation, combined with spondylolisthesis, etc. In patients with such conditions, traditional surgical treatment is recommended. The specific surgical plan needs to make a personalized treatment plan after specific assessment of the condition in order to achieve the best treatment effect.
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