Back Pain – Car Accident & A Hidden Fracture Herniation; Could An Acute Traumatic Schmorl’s Node Be At Fault?

Never heard of a Schmorl’s node? Then this may be of interest to you. Think a Schmorl’s node is a normal variant seen on x-ray or MRI? Then this may be of interest to you too.

Yep, it’s happened again. Putting a doctor’s name on some condition and making it sound totally benign! It’s too bad, but more and more research is proving my theory true. About 8 years ago, I had a patient who kept on returning with complaints of lower back pain, yet nothing positive on the lumbar MRI. It puzzled me and then I re-read the MRI report and that’s when it hit me. Schmorl’s nodes!!! I checked several classic radiology texts, Yochum & Rowe, Paul & Juhl and there it was, on the bottom of each list, ‘trauma’ as the last possible cause for a Schmorl’s node.

Often times in life we get so use to calling things by the casual names we assign them, forgetting what they really are. For example, a soldier will talk about “Collateral Damage” when they actually mean they’ve killed an innocent civilian or they’ve blown up the wrong building. The term “co-lateral damage” sounds much less severe than what had actually taken place. Unfortunately, collateral damage happens. In the world of medicine, doctors and scientists often assign their own names to discoveries they make. This has been a common practice for over one-hundred years. Some nice doctors will honor their patient by naming a newly discovered disease or condition after the patient who presented with the disease. These names tend to make the diseases, conditions and tests more palatable for the general public. And for good reason., some of the actual medical/scientific names are so long that they are just too difficult for many to comprehend. So we give them simple benign names. Hence the term “Schmorl’s Nodes”.

Since I last wrote about them I had a conversation with a neuroradiologist about the phenomenon of acute-traumatic Schmorl’s nodes. I explained to him that if there is enough pressure and the outer fibers of the disc are in great-healthy shape, the force must go somewhere…up through and into the vertebral body. We discussed it a bit further and told me that if I could find it in the American Journal of Neuroradiology, then you’ve got something. So I researched it and found the reference I was looking for, and here it is:

AJNR Am J Neuroradiol 2000 Feb;21(2):276-81; Relationship ofSchmorl’snodes tovertebral body endplate fractures and acute endplate disk extrusions. Wagner AL, Murtagh FR, Arrington JA, Stallworth D. University of South Florida College ofMedicine, Department of Radiology, Tampa, USA

Classically, radiologists and clinical physiciansshrugged off Schmorl’s nodes as an incidental finding as part of another condition and having nothing to do with acute trauma. However, the more and more I read, the more I find out that these “incidental findings” were actually caused by prior traumatic events and were (again) shrugged off because doctors succumbed to convention and didn’t think outside the box.
Simply put, a Schmorl’s Node is a disc that has herniated up through the bony vertebral endplate and into the body of the vertebrae. It is a herniation that fractured through the bottom or top of the vertebrae. Even more simple, it’s a fracture-herniation!
So now it’s out in the open. There has been enough research to prove it and from more recent casual browsing of on-line research reports, there’s more support since the 2000 publication of the reference above.
The next time a physician says the MRI or X-ray report is negative, the patient is still in pain and there was an acute trauma as the cause for the patient’s pain…go back and read that radiology report again and see if there are any Schmorl’s nodes. Ruling out the other causes of a Schmorl’s node could leave the not-so-obvious fracture-herniation as the only diagnosis left standing.
Contact me if you have any questions.

Dr Todd Narson, Miami Beach, FL

References:
1) Yochum & Rowe; Essentials of Skeletal Radiology; p. 114
2) Paul & Juhl; The Essentials of Roentgen Interpretation
3) V. Fahey MBBS; et al.; The Pathogenisis of Schmorl’s Nodes in Relation to Acute Trauma. Spine 1998;23:2272-2275
4) Wagner AL, Murtagh FR, Arrington JA, Stallworth D, American Journal of Neuroradiology Feb;21(2):276-81; Relationship of Schmorl’s nodes to vertebral body endplate fractures and acute endplate disk extrusions.

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