Source: Journal of Orthopedics, 2020,40 (08): 477-487
Author: orthopedic surgery branch of the Chinese Medical Association science set spine bone science branch of orthopedic rehabilitation study group
Chinese Medical Association (medical card has been added here, please Go to today's headline client to view)
Abstract
Lumbar disc herniation is a common disease in orthopedics with a high incidence of population. With social development and lifestyle changes, the incidence of lumbar disc herniation is gradually increasing. In view of the continuous progress in the diagnosis and treatment concepts and technical methods of lumbar disc herniation, it is necessary to summarize the diagnosis and treatment methods of lumbar disc herniation and standardize its diagnosis and treatment process. This guideline follows the principles of evidence-based medicine and refers to the "Expert Consensus and Clinical Pathway in the Guidelines for the Diagnosis and Treatment of Lumbar Intervertebral Disc Herniation" formulated in the 2013 China Health Industry Scientific Research Project and the "Lumbar Disc Herniation with Nerve Roots" developed by the North American Spine Surgery Association in 2013 "Guidelines for Disease Diagnosis and Treatment", after the guideline registration and guideline plan writing, the establishment of a guideline formulation expert working group and the determination of clinical problems; refer to the evaluation of the evidence recommendation classification, formulation and evaluation working group related methods to search for the evidence level and recommendation level of the literature, Form recommendations; after three rounds of discussion by the expert working group, the final draft is finalized. The guidelines elaborated on the diagnosis and treatment measures of lumbar disc herniation in terms of the definition, natural course, symptoms and signs, auxiliary examinations, diagnostic criteria, conservative treatment, surgical treatment, evaluation of surgical efficacy, and influencing factors of surgical effects. Provide a reliable clinical theoretical basis for the diagnosis and treatment of lumbar disc herniation.
In 2013, the North American Spine Society (NASS) formulated the "Guidelines for the Diagnosis and Treatment of Lumbar Intervertebral Disc Herniation with Nerve Root Disease", which put forward the diagnosis and treatment process and methods of nerve root compression for lumbar intervertebral disc herniation. In the same year, the "Expert Consensus and Clinical Pathway of the Guidelines for the Diagnosis and Treatment of Lumbar Intervertebral Disc Herniation" formulated by the special scientific research project of my country's health industry also made a series of summaries and generalizations on the diagnosis and treatment of lumbar disc herniation in my country. In order to further standardize the diagnosis and treatment technology of lumbar intervertebral disc herniation, and to improve the treatment effect and prognosis of lumbar intervertebral disc herniation, the research group based on the existing guidelines and consensus, carried out the Chinese and English literature related to the diagnosis and treatment of lumbar intervertebral disc herniation. System review, ask questions and start discussions, so as to formulate "Guidelines for the Diagnosis and Treatment of Lumbar Intervertebral Disc Herniation" for reference by clinicians.
refers to the literature retrieval principles of the 2013 NASS Guidelines, and aligns them in China National Knowledge Infrastructure (CNKI), Wanfang Data Knowledge Service Platform database, China Biology Medicine (CBM), and PubMed database English literature is searched. Use "lumbar disc herniation (LDH)" and "definition", "lumbar disc herniation (LDH)" and "natural history" [resorption or prognosis] ]","Lumbar intervertebral disc herniation (LDH)"and"diagnosis (symptom) or signs (sign) or imaging (imaging) or X-ray (X ray) or CT (Computer Tomography) or MRI ( Magnetic Resonance Imaging or myelography or discography or radiculography or electrodiagnostic testing]", "Lumbar disc herniation (LDH)" and "conservative treatment" therapy) [bed rest or drug therapy (drug/medical therapy or exercise therapy or epidural steroid injection or traction or manipulation]", "lumbar disc herniation (LDH)" and" surgical treatment ( Surgical treatment) [open surgery or minimally invasive surgery or fusion or total disc replacement]" is a search type, retrieve the literature before September 2019.
A total of 13 339 articles in English and 17 592 articles in Chinese were retrieved. The literature exclusion criteria were animal research, conference abstracts, social reviews, letters, conference papers and dissertations. The order of literature inclusion is prioritized for systematic reviews, meta-analysis, high-quality randomization Controlled studies, followed by prospective non-randomized controlled studies, retrospective cohort studies and case-control studies, and finally series of case reports, clinical experience, expert committee opinions, etc. The expert group screened by reading the title, abstract and original text of the literature. Finally, 119 articles were included, including 10 Chinese articles and 109 English articles. The grading of
articles adopts the revised guidelines of the North American Society of Spine Surgery in 2013, and refers to the evaluation, formulation and evaluation of evidence recommendation grading (Grading of Recommendations Assessment Development). and Evaluation, GRADE) working group related methods, assess the quality of research evidence, combine the research design and other evidence characteristics to comprehensively determine the evidence level of the research. A three-level classification standard is adopted, and the recommendation level corresponds to the literature level evaluation standard, and the recommendation strength is from level 1. Decrease to level 3.
1 level: ①High-quality randomized controlled studies with statistically significant differences, or high-quality randomized controlled studies with narrow confidence intervals although the differences are not statistically significant; ②Systematic reviews of high-quality randomized controlled studies (The premise is that the included studies are level 2: ①Randomized controlled studies of poor quality (such as follow-up rate <80%,>
3: ①Serial case report; ②Clinical experience, descriptive research or expert committee report Authoritative opinion.
1. The definition of lumbar disc herniation
lumbar disc herniation It is a clinical syndrome caused by the herniated intervertebral disc tissue stimulation and/or compression of the nerve root and cauda equina based on the pathological basis of the lumbar disc herniation. It manifests as low back pain, lower extremity radiating pain, lower extremity numbness, lower extremity weakness, bowel function Obstacles etc. [1,2,3,4].
2. The natural course of lumbar disc herniation
The research on the natural course of lumbar disc herniation is currently mostly limited to imaging and clinical follow-up. Most evidences show that herniated discs usually shrink to varying degrees over time, and the clinical function of patients is improved, but it is more common in non-inclusive disc herniation [5,6]; there is also relevant evidence that the symptoms of lumbar disc herniation are improved and herniated The volume of the intervertebral disc and the changes in the degeneration of the intervertebral disc are not related [7,8], and the specific mechanism is not clear (level 2 recommendation).
3. Diagnosis of lumbar disc herniation
(1) Symptoms
are based on the age and course of the patient, the position and size of the herniated intervertebral disc, the compression of the nerve and the degree of inflammation of the nerve. The common symptoms of lumbar disc herniation are:
1 . Radiation radiculopathy [9,10,11] (level 1 recommendation);
2. Muscle weakness innervated by the affected nerve root and/or paresthesia in the innervated area [9,10,11,12,13,14,15,16] (Grade 1Recommended);
3. May be accompanied by acute or chronic low back pain, restricted waist movement or compensatory scoliosis [10,16,17,18] (level 1 recommendation);
4. Children and adolescents with lumbar disc herniation often present with hamstring tension [19,20] (level 3 recommendation);
5. Cauda equina syndrome [21,22] (level 1 recommendation).
(two) signs
1. Movement and/or sensory disturbances innervated by the affected nerve roots, weakened tendon reflexes [9,10,11,12,13,14,15,16] (level 1 recommendation);
2. Nerve traction test is positive [9,10,12,13,14,16,23,24], mainly including femoral nerve traction test, straight leg elevation test, contralateral straight leg elevation test, Lasègue sign and contralateral Lasègue sign (level 1 recommendation);
3. Local lumbar tenderness, limited lumbar movement, tension or spasm of paraspinal muscles [16,17,24,25,26] (level 1 recommendation);
4. Cauda equina syndrome can cause perineal sensory disturbance, anal sphincter weakness and relaxation [21,22,27] (level 1 recommendation). Perineal sensory disturbance, anal sphincter weakness and relaxation [21, 22, 27] (1 level recommendation)
4. Auxiliary examination
(1) X-ray
X-rays are better than other imaging in judging the changes in spine bone structure and sequence The method has many advantages, suggesting that the indirect signs of intervertebral disc herniation include local instability, narrowing of the intervertebral space, compensatory scoliosis, distraction osteophytes, etc. [28], but it cannot directly show lumbar disc herniation, so there is no direct diagnosis Significance, cannot be used as a method to diagnose lumbar disc herniation [29] (level 3 recommendation).
(two) CT
CT and three-dimensional reconstruction methods can improve the detection rate of lumbar disc herniation [30,31,32]. CT can observe bony structures better than X-ray films, but the resolution of soft tissues such as nerves and intervertebral discs is poor, and it is more difficult to distinguish the relationship between intervertebral discs and nerve roots [33] (level 1 recommendation).
(three) MRI
MRI is the first choice for imaging examination for lumbar disc herniation. Compared with CT, it has the following advantages: no radiation damage, can assess the degeneration of the intervertebral disc, better observe the relationship between herniated intervertebral disc and nerve roots [34,35,36], but the ability to distinguish compression of bony structures is low [ 37,38] (level 1 recommendation).
(four) regional location of lumbar disc herniation
According to the pathology and degree of the disc herniation (CT or MRI), the herniated disc tissue has corresponding positions in the sagittal, horizontal and coronal planes [1,39].
1. Sagittal plane:
Ⅰ level, intervertebral disc level; Ⅱ level, upper intervertebral disc, that is, the subpedicle notch of the upper vertebral body. The vertebral body plane to the upper limit of the intervertebral disc. The plane of the vertebral body under the pedicle notch (Figure 1).
Figure 1 Sagittal plane stratification. Level I, the intervertebral disc level; Level II, the upper level of the intervertebral disc, that is the subpedicle notch of the upper vertebral body. The plane of the vertebral body to the upper disc boundary; Level III, the lower level of the intervertebral disc, that is the subpedicle notch of the next vertebral body. Cone plane
2. Horizontal plane:
is divided into zones 1 to 4 by the posterior edge of the vertebral body, the inner boundaries of the pedicles on both sides are zone 1, 2, the middle 1/3 is zone 1 (central zone), and the left and right 1/3 are zone 2 on the left and right sides. (Paraxial central area), there are 3 areas between the inner and outer sides of the pedicle (lateral area), and 4 areas outside the outside of the pedicle (extremely lateral area, Figure 2).
Figure 2 Horizontal divisions. Use the posterior edge of the vertebral body as the boundary zone, the inner boundaries of the pedicles on both sides are zone 1, 2, the middle 1/3 is zone 1, the left and right 1/3 are left and right sides 2 zones, and the inner and outer sides of the pedicle are zone 3 , Outside the pedicle of the pedicle is 4 zone
3. Coronal plane:
divides the sagittal diameter of the bony spinal canal into four equal parts, from front to back one to four parts are named a domain, b domain, c domain, and d domain (Figure 3).
Figure 3 Coronal sub-domain.The sagittal diameter of the bony spinal canal is divided into four equal parts, which are named a domain, b domain, c domain, and d domain
. Among them, the 3rd area of level III is occupied by the pedicle, which is the space area without actual area.
For the lumbar spine sagittal structure, MRI area positioning is more advantageous than CT area positioning. Ordinary CT scans are mostly limited to the intervertebral disc level, and images of intervertebral disc tissue in the spinal canal outside the intervertebral disc level (such as level II or level III) can be missed. At this time, lumbar spine MR or CT three-dimensional reconstruction inspection should be performed. Regional positioning can reflect the precise positioning and diagnosis of disc herniation of different pathological types and different degrees of severity [39,40,41], and provide a reference for the selection of treatment methods and the implementation of surgery (level 2 recommendation).
(5) Myelography and discography
For patients who have special metal implants (such as pacemakers) in their body that cannot undergo MR examination, myelography and CT myelography (computer tomography myelography, CTM) can be used to indirectly observe nerve compression . Myelography and CTM are more advantageous for patients with a history of lumbar spine surgery [37,42,43]. When diagnosing lumbar discogenic low back pain, cases where symptoms and signs and imaging do not match, and preparing preoperative planning for reoperation of lumbar disc herniation, discography and CTD (computer tomography discography, CTD) assisted diagnosis and surgical strategies are feasible Formulate [44,45,46,47] (level 2 recommendation).
(6) Selective radiculography, nerve root block
Selective radiculography, nerve root block can be used for diagnosis and treatment purposes. In terms of diagnosis, it is often used in the following situations: atypical sciatica , imaging inconsistency with symptoms and signs, multi-segment disc herniation to clarify the responsibility gap, and the formulation of treatment plans after failure of lumbar spine surgery, etc. [48,49] (Level 2 recommend).
(7) Electroneurophysiological examination
The diagnosis of lumbar intervertebral disc herniation during neuroelectrophysiological examination has practical value, which can further confirm the existence of nerve root damage on the basis of imaging evidence [50]. H reflex can assist in the diagnosis of lumbar disc herniation with compression of the S1 nerve root; the nerve conduction and F wave examination of electromyography are of limited value in the diagnosis of lumbar disc herniation [51,52,53,54]. Somatosensory evoked potentials can be used as an auxiliary means to diagnose nerve root compression, but it cannot independently diagnose lumbar disc herniation and nerve root compression [54,55]. The value of motor evoked potentials in the diagnosis of lumbar disc herniation is currently unclear [56] (level 2 recommendation).
Five, the diagnostic criteria of lumbar disc herniation
The difference between lumbar disc herniation and lumbar disc herniation must be clearly defined in the diagnosis. Lumbar disc herniation is defined by morphology or imaging, which refers to the abnormal shape of the intervertebral disc caused by the nucleus pulposus, annulus fibrosus or endplate tissue beyond the edge of the adjacent vertebral body [1,41]. It can be diagnosed only by MRI or CT, not as a clinical diagnosis. Lumbar intervertebral disc herniation is a clinical diagnosis term. It is a localized disc herniation that occurs on the basis of the pathological basis of lumbar intervertebral disc degeneration and injury. It stimulates and (or) compresses nerve roots and cauda equina to show low back pain, radicular pain, and numbness and weakness of the lower limbs. , Urine and stool dysfunction, etc.; the patient has the corresponding medical history, symptoms, signs and imaging manifestations of lumbar intervertebral disc herniation, and the imaging is consistent with neurological localization, and can be diagnosed as lumbar intervertebral disc herniation [2,57] (level 1 recommendation) .
6. Conservative treatment of lumbar disc herniation
Lumbar disc herniation has a benign natural course, and most patients with lumbar disc herniation can be improved by conservative treatment of symptoms [57,58,59]. Therefore, non-surgical treatment should be the first choice for patients with lumbar disc herniation without significant nerve damage. The herniated intervertebral disc usually shrinks to varying degrees over time, and the clinical function is improved. The success rate of non-surgical treatment is about 80~90%[60,61], but the recurrence rate of clinical symptoms reaches 25%[57] (level 1 recommendation).
(1) Time of conservative treatment
Literature reports that the symptoms of most patients with lumbar disc herniation are conservativeImproved after 6-12 weeks of treatment. Therefore, for cases without significant neurological damage, conservative treatment is generally recommended for 6-12 weeks [57,62] (level 1 recommendation).
(two) conservative treatment methods
1. Bed rest
Bed rest has always been considered as one of the most important ways of conservative treatment of lumbar disc herniation. However, more and more evidence-based medical evidence shows that compared with normal daily activities, bed rest cannot reduce the patient's pain and promote the patient's functional recovery [63]. For patients with severe pain and need to rest in bed, the bed rest period should be shortened as much as possible, and they should be encouraged to resume moderate normal activities as soon as possible after the symptoms are relieved. At the same time, they should pay attention to the daily activity posture to avoid twisting, flexion and excessive weight bearing [64] (level 1 recommendation ).
2. Drug treatment
nonsteroidal anti-inflammatory drugs (nonsteroidal anti-inflammatory drugs, NSAIDs): It is a first-line drug for the treatment of low back pain. NSAIDs can alleviate chronic low back pain and improve functional status, but the effect of improving sciatica is not clear, and there is no significant difference between the effects of different types of NSAIDs [65] (level 2 recommendation).
opioid analgesics: short-term benefits in reducing back pain [66]. In terms of symptom improvement and functional recovery in patients with sciatica, the effects of opioids are still unclear [67], and attention should be paid to the side effects of long-term drug use and drug dependence (level 2 recommendation).
glucocorticoids: systemic application can relieve pain in the short term, but long-term follow-up data is lacking; considering the side effects of systemic use of hormones, long-term use is not recommended [68] (level 2 recommendation).
muscle relaxants: can be used for the drug treatment of patients with acute and subacute low back pain [69]. However, in the treatment of sciatica, there is a lack of relevant research on whether to use muscle relaxants (level 2 recommendation).
Antidepressants: Antidepressants have a certain effect on chronic low back pain and sciatica [70], but there are currently few studies with high levels of evidence (level 2 recommendation).
Other drugs: There is not enough evidence to support the efficacy of narcotic sedatives and antiepileptic drugs on patients with lumbar disc herniation [71,72] (level 2 recommendation).
3. Exercise therapy
exercise therapy includes core muscle strength training, direction-specific training, low back pain school, etc. Targeted and individualized exercise therapy should be carried out under the guidance of rehabilitation medicine professionals [2,73]. Exercise therapy can relieve sciatica in the short-term, but the pain reduction is small, and patients with long-term follow-up have no obvious benefit in reducing pain or disability [74] (level 2 recommendation).
4. Epidural injection
epidural steroid injection (epidural steroid injection, ESI) can be used for the diagnosis and treatment of lumbar disc herniation. For patients with lumbar disc herniation with obvious root symptoms, ESI can improve symptoms in the short term, but the long-term effect is not significant [75] (level 2 recommendation).
5. Lumbar traction
Lumbar traction is a traditional method for the treatment of lumbar disc herniation, but the current value of traction for relieving low back pain and sciatica lacks high-quality evidence-based medical evidence to support [76]. Traction therapy should be performed under the guidance of a professional doctor in the rehabilitation department to avoid heavy and prolonged traction (level 2 recommendation).
6. Manual therapy
manual therapy can improve the back pain and functional status. Patients with mild to moderate lumbosacral neuralgia without surgical indications can improve the radicular symptoms caused by lumbar disc herniation [77], but it should be noted that manual treatment may increase the risk of lumbar disc herniation (level 2 recommendation).
7. Other
hot compresses, acupuncture, massage, Chinese medicine, etc. have certain effects on alleviating the symptoms of lumbar disc herniation [78], but the follow-up time of related literature is short, and the experimental design is limited (level 2 recommendation).
Seven. Surgical treatment
Compared with non-surgical treatment, surgical treatment is usually faster and to a greater extentImprove symptoms. Surgical treatment is safe and the incidence of complications is low, but surgery cannot improve the proportion of patients returning to work [79,80] (level 1 recommendation).
(1) Indications for operation
operation indications include: ①The history of lumbar intervertebral disc herniation exceeds 6 to 12 weeks, and the systemic conservative treatment is ineffective; or the symptoms aggravate or recur during conservative treatment; ②the pain of lumbar intervertebral disc herniation is severe, Or the patient is in a forced posture, which affects work or life; ③Single nerve palsy or cauda equina palsy in lumbar disc herniation is manifested as muscle paralysis or rectal and bladder symptoms [80,81,82] (level 1 recommendation).
(two) surgical methods
surgical procedures for lumbar disc herniation can be divided into four categories: open surgery, minimally invasive surgery, lumbar fusion, lumbar artificial disc replacement.
1. Open surgery
posterior lumbar herniated disc tissue extraction: posterior lumbar herniated disc tissue extraction should follow the principle of limited laminectomy to minimize damage to the stability of the spine. The excellent and good rate of short-term curative effect during operation is about 90%, and the excellent and good rate of long-term follow-up (>10 years) is 60%~80%[83,84,85] (level 1 recommendation).
Retroperitoneal discectomy: Retroperitoneal discectomy can preserve the integrity of the posterior structure of the spine, but the concept of indirect decompression makes it unfavorable for the treatment of non-inclusive disc herniation [86], and requires combined fusion technology . There are few studies on the treatment of lumbar disc herniation by retroperitoneal approach alone, but retroperitoneal discectomy is also an option for patients with recurrent disc herniation [87] (level 3 recommendation).
2. Minimally invasive surgery
percutaneous interventional surgery: percutaneous interventional surgery mainly includes percutaneous discectomy, percutaneous laser ablation of the disc, percutaneous ozone ablation of the disc, and radiofrequency ablation of nucleoplasty. Its working principle is to reduce the pressure in the intervertebral disc and indirectly reduce nerve root compression. It has a certain effect on the disc herniation with increased intradiscal pressure. It is not suitable for free or obviously displaced disc herniation. Strictly grasp the surgical indications [80,88] (level 2 recommendation).
Micro lumbar discectomy: Compared with open surgery, micro lumbar discectomy (including channel-assisted micro lumbar discectomy) is equally safe and effective, and can be used as an effective way for the surgical treatment of lumbar disc herniation [89 ,90] (level 1 recommendation).
micro-endoscopic discectomy (micro-endoscopic discectomy, MED): micro-endoscopic discectomy is the transition from open surgery to minimally invasive surgery. Although its surgical technique has a steep learning curve, its safety and effectiveness are comparable to open surgery, and it is superior to open surgery in terms of length of stay, blood loss, and early recovery. It can be used as an alternative to open surgery [91, 92] (Level 1 recommendation).
Percutaneous endoscopic lumbar discectomy: Percutaneous endoscopic lumbar discectomy is a safe and effective minimally invasive procedure for the treatment of lumbar disc herniation, which is compatible with open surgery, microscopic or microendoscopic lumbar discectomy The effect is the same, and percutaneous endoscopic lumbar discectomy is more minimally invasive, with less trauma and faster recovery [4,93] (level 1 recommendation).
3. Lumbar fusion
lumbar fusion is not the first choice for lumbar disc herniation, but lumbar fusion can be selected in the following cases[94,95,96]: lumbar disc herniation with obvious chronic axial low back pain; huge intervertebral disc Herniation, lumbar spine instability; recurrent lumbar disc herniation, especially with deformities, lumbar instability, or chronic low back pain (level 2 recommendation).
4. Lumbar artificial disc replacement
Lumbar artificial disc replacement is mainly used for lumbar discogenic low back pain, including patients with inclusive lumbar disc herniation. Whether it is suitable for non-inclusive disc herniation and patients with severe nerve compression symptoms is still inconclusive. A large number of long-term follow-up studies over 10 years have confirmed that this technique is no less effective and safe than lumbar fusion surgery [97]. At present, it is aimed at the treatment of lumbar disc herniation with artificial disc replacementThere are few studies on the high-level evidence of the disease. At the same time, it should be noted that the technical difficulty and technical requirements of artificial disc replacement of lumbar spine are relatively high, and it has a certain learning curve (3 level recommendation).
8. Evaluation of surgical curative effect
The evaluation index of surgical curative effect of lumbar intervertebral disc herniation is divided into two categories, namely, simpler evaluation standard and quantitative evaluation standard. The simpler evaluation criteria include the evaluation criteria for low back pain surgery in the Spine Group of the Orthopedic Branch of the Chinese Medical Association [84], Macnab criteria [98], visual analogue scale (VAS) [99,100] and so on. The quantitative evaluation standards are mostly evaluated in the form of questionnaires, including the Japanese Orthopaedic Association (JOA) low back pain surgery scoring standard [101,102], Oswestry disability index (ODI) [103,104], and health survey score sheet SF -12 (the short form-12 health survey)[105], SF-36 (the short form-36 health survey)[106,107], EuroQol health index EQ5D[108], Roland-Morris dysfunction Questionnaire survey [109] etc. Commonly used surgical efficacy evaluation indicators include VAS score, ODI index and SF-36 [110,111,112] (level 2 recommendation).
9. Factors affecting the efficacy of surgery
smoking, old age, obesity, diabetes, depression, preoperative muscle weakness or even complete neurological damage, preoperative course of disease greater than 3 to 6 months, combined with lower limb osteoarthropathy, etc. Factors affecting the poor prognosis of intervertebral disc herniation surgery [113,114,115,116,117,118,119,120] (level 2 recommendation).
Guide Formation Members
Tian Wei Chen Bohua Chen Zhongqiang Ding Wenyuan Feng Shiqing
Hao Dingjun He Baorong He Xijing Hu Yougu Hu Yongcheng
Hai Yong Jiang Jianyuan Li Bo Li Feng Liu Shaoyu
Li Weishi Luo Zhuo Jing Ma Xinlong Shen Huiyong Shu Jun
z0 Zhang Guodong Zhang Yinlong Shen Huiyong Shu Jun z0 Zhao Fengz Wang Huan Zhu Qing Sanxiang Hongfei Wang Yan
Writer
Chen Bohua Wang Yan Hu Yougu
