Management of Schmorl's Nodes
Schmorl's nodes should be managed conservatively with pain management and physical therapy as first-line treatment, with interventional procedures reserved for cases with persistent, disabling pain that fails to respond to conservative measures.
Understanding Schmorl's Nodes
Schmorl's nodes are herniations of nucleus pulposus through the cartilaginous and bony endplate into the adjacent vertebra. They are extremely common, with postmortem studies estimating that over 70% of the population has them 1. Most Schmorl's nodes are asymptomatic and discovered incidentally on imaging. However, they can occasionally become symptomatic, causing:
- Acute or chronic back pain
- Rarely, radiculopathy when there is posterior extension affecting nerve roots
Diagnostic Approach
When evaluating a patient with suspected symptomatic Schmorl's node:
MRI is the imaging modality of choice as it can detect:
- Edema surrounding the node (indicating acute/active lesion)
- Neovascularization
- Extruded disc material
- Extension into epidural space (in rare cases causing radiculopathy) 1
Discography may be used in select cases to confirm if a Schmorl's node is the source of pain by demonstrating:
- Leakage of contrast medium into the vertebra
- Reproduction of concordant pain 2
Treatment Algorithm
1. Conservative Management (First-line)
For most symptomatic Schmorl's nodes:
Pain management:
- NSAIDs for anti-inflammatory effects
- Short-term opioid analgesia for severe pain
- Muscle relaxants if muscle spasm is present 3
Physical therapy:
- Core strengthening exercises
- Range of motion exercises
- Proprioceptive training
- Neuromuscular training 4
Activity modification:
- Temporary reduction in mechanical loading activities
- Gradual return to activities as symptoms improve
2. Interventional Procedures (For persistent symptoms)
If pain persists despite 4-6 weeks of conservative management:
Epidural steroid injections:
- Transforaminal epidural blocks can be effective for radicular pain caused by Schmorl's nodes 5
- Should be considered before surgical intervention
Percutaneous vertebroplasty (PVP):
- Effective for symptomatic Schmorl's nodes refractory to conservative treatment
- Studies show immediate and long-term pain relief (mean VAS decrease from 7.9 to 2.1) 6
- Low complication rates with long-term follow-up
3. Surgical Management (Last resort)
Reserved for cases with:
- Persistent disabling pain despite conservative and interventional treatments
- Neurological deficits due to nerve compression
Surgical options include:
- Segmental fusion surgery to stabilize the affected segment 2
- Surgical removal of disc material in cases of persistent radiculopathy from a tunneling Schmorl's node 1
Prognosis and Follow-up
- Many symptomatic Schmorl's nodes resolve spontaneously within months 3
- Follow-up MRI may show resolution of edema and reduction in size of the intraosseous herniation
- Most patients can gradually return to full activities without recurrence of symptoms
Important Considerations
- Differential diagnosis: Rule out other causes of back pain including vertebral fractures, infections, and malignancy
- Red flags: Presence of fever, weight loss, night pain, or neurological deficits requires urgent evaluation
- Mechanical factors: Consider that Schmorl's nodes may be part of broader degenerative changes to the spine, particularly in the lumbar vertebrae 7
- Activity-related factors: Mechanical loading and impact stress on the lower spine can contribute to the development of Schmorl's nodes and associated degenerative changes 7
By following this structured approach to management, most patients with symptomatic Schmorl's nodes can achieve good pain control and functional outcomes without the need for invasive interventions.