Schmorl’s Node Refresher: 7 Surprising Facts Every DC Must Own
Are you interested in the latest buzz surrounding Schmorl's nodes? Want to gain new insights in less than five minutes? You're in the right place! Welcome to our ultimate Schmorl's Nodes refresher that keeps you in the know. Let’s pop right in. 😏
1. What is a schmorl’s node?
A Schmorl’s node (aka intraosseous disc herniation or intravertebral disc herniation) represents an area where the disc nucleus has herniated through the cartilaginous vertebral endplate. (1) The lesion appears on imaging as a well-defined, small, round or oval radiolucent vertebral indentation, often with a thin rim of sclerosis. (2)
Schmorl node facts:
Most common sites include the T7-L1 region, although any region is vulnerable, including the cervical spine. (3,4)
Average size is 7 × 9 mm, but this varies from minimally noticeable protrusions to large prominent indentations (5)
Approximately two-thirds affect the inferior endplate (3)
Typically impact the central or posterior portion of the endplate (1,3)
Schmorl’s nodes are best visualized on MRI or CT, but approximately 33% can also be seen on plain X-rays. (2,7)
Schmorls node spine MRI
Schmorl’s node lumbar spine x-ray
2. How common are schmorl’s nodes?
The reported frequency of schmorl’s nodes varies from 2–80%. (8-17) This uselessly extensive range is likely attributed to how the prevalence was measured in each study, i.e., calculating prevalence on plain films will yield lower estimates than measuring on advanced imaging or post-mortem assessments.
Experienced clinicians will confirm that schmorl’s nodes are relatively frequent benign findings.
3. What are the causes of schmorl’s nodes?
Spinal load + vertebral endplate vulnerability
Traumatic vertebral axial loading is a primary culprit. (1,18,19) One study concluded that 93% of acute, symptomatic endplate smorl’s node presentations included an identifiable traumatic onset, i.e., vehicular or sports injury, fall, etc. (20) The incidence of schmorl’s nodes is nearly twice as high in elite gymnasts as compared to non-athletes. (19) Not surprisingly, since axial load increases as we descend along the spine, the lower spine is most commonly affected.
Factors that weaken the vertebral architecture can increase the likelihood of developing a schmorl’s node. Although these factors are thought to be contributory to only a small percentage of cases, potential culprits include osteopenia, smoking (OR-3.2), congenital ossification gaps, Padget’s disease, autoimmune disease, ischemic necrosis, metabolic disease, malignancy, infection, inflammation (Modic changes), hyperparathyroidism, and Scheuermann’s disease. (6,8,13,21-25)
Any discussion of Schmorl’s node causes should also mention disc hydration status since a well-hydrated nucleus has more volume to punch an endplate defect when loaded. Thus, young patients with well-hydrated discs may be most vulnerable. This theory is further supported by several studies showing that the incidence of schmorl’s nodes does not increase appreciably with age. (16,26,27)
4. How can a disc nucleus cause an endplate fracture?
Schmorl’s node formation occurs via nuclear herniation through an endplate. To fully understand this process, you’ll first want to see what a disc nucleus looks like.
What is the consistency of the disc nucleus? Watch this one-minute video.
Your next logical question is, how can fluid fracture a bone? Two studies provide significant clues:
“The nucleus pulposus exhibited significant viscoelastic effects, characteristic of a fluid and a solid. Whether the nucleus pulposus behaves more as a fluid or a solid in vivo depends on the rate of loading.” (28)
“A log-linear relationship between intervertebral disc stiffness and strain rate was observed.” (29)
This means the disc nucleus becomes stiffer as the load rate increases. Watch this 60-second live demo of how a jelly-like nucleus instantly changes to a consistency that can dent bone.
5. What are the symptoms of schmorl’s nodes?
Do schmorls nodes cause pain?
Historically, schmorl’s nodes have been considered asymptomatic, incidental findings. (38) However, significant research has found a symptomatic relationship, including pain and limited function. (25,26,39)
“The presence of endplate defects was associated with 1.64 times increased risk of lifetime back pain.” (8)
Back pain patients are three times more likely to exhibit schmorls nodes than asymptomatic groups. (30)
“The presence of Schmorl's nodes was associated with neck pain." (31)
While chronic schmorls nodes that lack adjacent vertebral edema may be asymptomatic (18,32), acute presentations with accompanying inflammation would likely trigger a “symptom sandwich”:
Stage 1 - Avascular “foreign” nuclear material abruptly injected into a highly vascular vertebral body is not typically appreciated by the immune system. An acutely inflamed endplate fracture triggers non-radicular back pain and tenderness. (18,20) Acute defects sometimes start following an abrupt axial load (i.e., jumping off an elevated surface) followed by a painful “pop.” Acute schmorls node pain is provoked by trunk movement and may occasionally refer to the abdomen or thighs. (20) Acute schmorl's node symptoms in chronic LBP patients may present as an exacerbation that is “different.”
Stage 2 - Symptoms subside as fatty marrow changes and sclerosis replace acute inflammation. This process typically spans 3-18 months. (1,20)
Stage 3 - Annular degeneration follows schmorls node development. (33) Degenerative changes of the overloaded annulus and facets accelerate after support from the central nuclear material is absent. One study found that Schmorl’s node patients had “approximately 7-fold increased risk of severe intervertebral disc degeneration at the corresponding levels." (30)
This process mirrors Modic changes, which is unsurprising since endplate microfractures can trigger Modic changes. (34,35) To learn more, check out this past blog and infographic on Demystifying Modic Changes.
6. How to treat schmorl’s nodes
Schmorl’s node treatment is typically conservative. (2,9,26)
“In both asymptomatic and symptomatic patients, the mainstay of treatment for Schmorl’s nodes is conservative therapy.” (6)
Clinicians might manage acute schmorls nodes similar to a compression fracture. (36) Considerations include anti-inflammatory measures, bracing, soft-tissue therapy, nutritional support (particularly vitamin D and calcium in older patients), and progressive aerobic and therapeutic exercise as tolerated. (37) Patients sometimes need to be reminded that an acute schmorl’s node represents a fracture, and a period of relative rest may be necessary. (20)
Chronic schmorls nodes are often considered incidental findings. Management would address concurrent biomechanical issues and mitigate the impending degenerative changes.
7. How do I educate my patients about Schmorl’s nodes?
We made this one simple. Use the new ChiroUp lay infographic to answer your patient’s foremost questions quickly.
What is a schmorl’s node?
Is a schmorl’s node serious?
Do schmorls nodes cause pain?
What can be done for schmorl’s node?
As a subscriber you’ll be able to find this infographic in the forms library by searching “Schmorl’s”. Not a ChiroUp subscriber? Set up your FREE account today!
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