Outline:   
Prolapse of lumbar intervertebral disc refers to the disease characterized by symptoms of lumbago, accompanied by radiating pain in the lower limb due to stimulation or compression of nerve root by the protruding pulpiform nucleus resulting from the rupture of lumbovertebral fibrous rings. It mostly occurs in young adults.

Following the increase of age, lumbar load-bearing and activity, the lumbar intervertebral disc may degenerate and the elasticity of fibrous rings decrease gradually. On the basis of this change, an exogenous force in lumbar sprain can lead to rupture of fibrous rings of lumbar intervertebral disc and protrusion of pulpiform nucleus, which can further stimulate and compress sciatic nerve root to bring about lumbago and radiating pain in the lower limb. In a few cases of no definite external injury, it may be caused by cold attack on the waist, which leads to spasm of lumbar muscles and resultant increase of pressure to intervertebral disc, so further rupture of lumbovertebral ring may occur.

In most cases, the pulpiform nucleus protrudes to the posterolateral part of one side, leading to unilateral disease, which manifests lumbago and pain in the lower limb of one side. In a few cases, the pulpiform nucleus protrudes to the posterior center, leading to a disease of both sides by compression of cauda equina nerve, which manifests numbness of the saddle region and pain in the waist and both lower limbs. If the disease occurs between the third and fourth vertebrae, the femoral nerve will be compressed.

Generally its main symptom at the early stage is lumbago due to stimulation of posterior longitudinal ligament by the protruding pulpiform nucleus. If the protruding pulpiform nucleus breaks through the posterior longitudinal ligament, the pain in the lower limb will become the chief symptom. The attack of the disease, besides stagnation of qi and blood in the meridians due to trauma, is also closely related to dysfunction of the liver and kidney and invasion of pathogenic wind-cold-dampness in the case of healthy qi insufficiency.

Major points for diagnosis  
1. Most of the patients have a traumatic history of the waist in different extents.
 
2. The main symptoms are lumbago and radiating pain in the lower limb. Majorities of the patients have pain in a lower limb in one side, and only a few patients with central type of a bigger protrusion have pain in the lower limbs of two sides. The pain is aggravated by cough, sneezing and a forceful movement of bowel and alleviated by bed rest. The patients with a long course may have numbness of the lower limb. The patients with compression of cauda equina nerve due to central protrusion of pulpiform nucleus may sometimes have numbness and stabbing pain in the perineum, problem of urination and defecation, or incomplete paralysis of the limbs.
 
3. The main signs are disappearance of the physiological spinal curve or reverse-bowed change of the lumbar spine and scoliosis; limitation of forward flexion, rotation and sideward movement; tenderness on the side of spinous processes of lower segments of lumbar spine or interspinal portion, which can radiate to the lower limb. Raising test of the straightened leg, intensive raising test of the straightened leg and flexing test of neck are positive; and traction test of femoral nerve is positive in the case of protrusion of disc between the third and fourth lumbar vertebrae. The dermal sensation is hyperactive at the early stage, and then reduced or lost.
 
Sensory disturbance of skin occurs in the antemedial aspect of leg in the case of protrusion of disc between the third and fourth lumbar vertebrae; it occurs in the antelateral aspect of leg, the antemedial aspect of dorsum of foot and the sole in the case of protrusion of disc between the fourth and fifth lumbar vertebrae; it occurs in the posterolateral aspect of leg and lateral aspect of dorsum of foot in the case of protrusion of disc between the fifth lumbar vertebra and the first sacral vertebra; and it occurs in the saddle region in the case of protrusion of disc of central type. The power of muscle is decreased for dorsal extensor of foot and extensor muscles of great toe in the case of compression of the fifth lumbar nerve root, and for quadriceps muscle of thigh in a case of compression of the third or the fourth lumbar nerve root. The reflex of tendon is weakened or disappears in the knee in the case of compression of the fourth lumbar nerve root, and in the Achilles tendon in the case of compression of the first sacral nerve root. There is muscular atrophy in the case of a long course.
 
4. X-ray film may show disappearance of the physiological spinal curve or reverse-bowed change of the lumbar spine and scoliosis, or narrowing of intervertebral spaces, labial hyperosteogeny at the margin of vertebral body. CT and MRI examinations can confirm the site of prolapse and the condition of compression of intradural nerve root.
 
 
Treatment  
There are many therapeutic methods for the treatment of prolapse of lumbar intervertebral disc. Manipulations of smoothing tendons, medication, acupuncture maybe used for mild cases, and massage under anesthesia and pelvic traction may be used for serious cases.

Tendon-smoothing manipulation:       
The patient first takes a prone position. The operator successively applies kneading, rubbing, grasping, pinching, rolling and pressing manipulations on the painful regions of the waist and limbs. Then, the patient takes a lateral position with the lower limb on the top flexed and the other lower limb straightened. The operator presses the patient's posterolateral aspect of ilium with one hand and pushes the anterior part of shoulder with the other hand, pulling obliquely with his two hands in an opposite direction to make the waist twist, sometimes a "Kata" (click) sound can be heard or felt. Afterwards, the patient straightens his lower limbs, and the operator presses the lumbosacral portion with one hand and holds up the thigh with the elbow of the other arm, applying hyperextension of the waist and thigh for 3 to 5 times, then does the same on the other side. The manipulation should be done every day or every other day for a course of one month. This is suited for the mild case of prolapse of lumbar intervertebral disc.

Massage under anesthesia:     
This manipulation is of great advantages that relaxation of muscle is complete, the force of massage is easily to reach the diseased part and the effect can be achieved by only one operation. However, the central type of prolapse of lumbar intervertebral disc is contraindicated. The method is given as follows.
 
 
Epidural anesthesia is performed:
he patient takes a supine position. The operator and two or three assistants hold respectively the patient's two ankles and two axillae to do countertraction by pulling 3 to 5 minutes. Then, making the sick limb flex at hip and knee, rotate the hip joint clockwise and counterclockwise respectively for 3 or 4 rounds, raise and stretch the sick limb, and forcefully make the ankle joint dorsally extend when it gets to the highest level. Give the manipulation 3 times. And repeat the same manipulation on the normal side for 3 times, too.
 
The patient takes a lateral recumbent position with the sick side on the upper. The operator stands behind him, holds up with one arm the thigh of the sick side, pushes the waist on sick side with the palm of the other hand. Then, after rotating the hip joint for 3 rounds, he makes it do backward hyperextension for three times when it is in an abduction position of 300, or "pushing the waist and pulling the leg method". After that the operator applies obliquely pulling manipulation. Making the lower limb on the top flexed and the other on the bottom straightened, the operator presses the posterolateral border of ilium with his two hands, an assistant pushes the shoulder. They pull obliquely in an opposite direction for 3 times. And repeat the same manipulation on the normal side for 3 times, too.
 
The patient takes a prone position. The operator holds up the two lower limbs with one arm to do clockwise and counterclockwise rotation of the waist for 3 rounds respectively, then, do hyperextension of the waist for 3 times, or "holding up leg and rotation waist method". Finally, two or three assistants respectively hold up the patient's two ankles and axillae, to do counter traction by pulling for 3 to 5 minutes. At the same time, the operator presses with his palmar root the spinal process portion of the fourth and fifth lumbar vertebrae, which is done for 3 times, each for 1 minute.

After operation, the patient should take bed rest for 1 to 3 weeks with a thin pillow under the waist.


Herbal therapy  
Internal treatment based on syndrome differentiation
(1) Syndrome of qi and blood stagnation
   
Main symptoms and signs:
Serious lumbago referring to the lower limb, which is of stabbing or cutting nature; slight swelling in the waist with difficulty in movement, or ecchymoses on the tongue, stringy or choppy pulse.
 
Therapeutic methods:
Promoting blood flow to resolve the stasis, activating qi flow to stop pain.
   
Recipe and herbs:
Modified Taohong Siwu Decoction. Specifically, Cbaihu (Radix Bupleuri) 6 g, Honghua ( Flos Carthmi ) 6 g, Danggui ( Radix Angelicae Sinensis ) l0 g, Chishaoyao ( Radix Paeoniae Rubrae ) 10 g, Taoren ( Semen Persicae ) 10 g, Zhike ( Fructus Cirri Aurantii ) 10 g, Ruxiang ( Gummi Olibanum ) 10 g, Moyao (Myrrha) lOg, Zhechong (Eupolyphaga seu Steleophaga ) 10 g, Yanhusuo ( Rhizoma Corydalis )15 g, Xuejie (Resina Draconis) 3 g and Gancao (RadixGlycyrrhizae ) 3 g.
 
(2) Syndrome of collateral disharmony
Main symptoms and signs:
Aching and dull pain or numbness in the waist and lower limb, which is aggravated by walking or tiredness and alleviated by bed rest, impaired movement, pale tongue and choppy pulse.
 
Therapeutic methods:
Relaxing tendons and activating collaterals.

Recipe and herbs:
Modified Huoxue Shujin Decoction. The herbs see the treatment of the same syndrome in lumbar strain.
 
(3) Syndrome of blockage of pathogenic wind-cold dampness
Main symptoms and signs: Pain and weakness in the waist and lower limb, preference to warmth and aversion to cold, difficulty in turning about, having the history of catching cold, pale tongue with thin-greasy coating, floating and slippery pulse.
 
Therapeutic methods: Expelling wind and dampness, warming and dredging meridians.
 
Recipe and herbs:
Modified Wutou Decoction. Specifically, Zhichuanwu (Radix Aconiti Carmichaeli Praeparata) 9 g, Mahuang (Herba Ephedrae) 6 g, Qianghuo (Rhizoma seu Radix Notopterygii ) 10 g, Duhuo (Radix Angelicae Pubescentis ) 10 g, Fangfeng ( Radix Ledebouriellae Divaricatae ) 10 g, Baishaoyao ( Radix Paeoniae ) 10 g, Guizhi ( Ramulus Cinnamomi Cassiae ) 6 g, Huangqi (Radix Astragali seu Hedysari)10 g, Cangzhu ( Rhizoma Atractylodis ) 10g, Weilingxian (Radix Clematidis ) 10 g and Gancao (Radix Glycyrrhizae ) 5 g.
 
External therapy:      
In the early stage, Sanse Application is externally used. In the late stage, Shangke Xiaoyan Paste or Tianhe Gutong Plaster, or Zhenghonghua Oil or Zhenggu Liquor is externally applied.

Pelvic traction:      
It is suited for the acute patients with first attack or repeated attack or for the serious patients. Pelvic hammock can be used. After fixation, the traction is done with 10 to 15 kg for each leg, for 30 minutes, one or two times daily, with a course of 7 to 10 days. At present, all kinds of traction beds are used to replace pelvic traction.

Fixation:     
The patient at the acute stage should take rest in a hard plank bed for three weeks. Before and after massage, bed rest is also needed. For those with attack of severe pain, a waistband may be used for fixation.

Functional exercise:     
After pain is relieved at the late stage, the patient should practice functional exercise for lumbodorsal muscle. At the beginning, he conducts the Five-point, Three-point and Arch-bridge support exercise, then, the Flying-swallow-like exercise, once or twice a day. The functional exercise should be done in an order, step by step and persistently.

Acupuncture therapy:       
Theacupoints are Dachangshu (BL25), Zhibian (BL54), Ciliao (BL32), Huantiao (GB30), Chengfu (BL36), Weizhong (BL40), Yanglingquan (GB34 ), Chengshan ( BL57 ), Xuanzhong (GB39), Zusanli (ST36), Sanyinjiao (SP6), Kunlun (BL60) and Ashi points. Five to seven points on the sick side can be selected each time, reducing method is applied with the needle retained for 20 minutes, once a day, ten times making up a course.