From the Guidelines
The treatment of painful vertebral Schmorl's nodes should initially focus on conservative management, including rest, activity modification, and medical management with or without methods of immobility, as the majority of patients experience spontaneous resolution of pain within 6-12 weeks 1.
Initial Management
- Rest and activity modification are crucial in the initial management of painful vertebral Schmorl's nodes.
- Over-the-counter pain medications such as acetaminophen (500-1000mg every 6 hours, not exceeding 4000mg daily) or NSAIDs like ibuprofen (400-800mg three times daily with food) can be used for 1-2 weeks to manage pain.
- Physical therapy focusing on core strengthening exercises and proper body mechanics is beneficial for long-term management.
Medical Management
- Medical management includes the use of nonsteroidal anti-inflammatory drugs and narcotics, with caution due to the associated effects of sedation, nausea, further decrease in physical conditioning, and fall risks 1.
- For more severe pain, prescription medications may be considered, including muscle relaxants like cyclobenzaprine (5-10mg three times daily) for short-term use (1-2 weeks), or in some cases, a short course of oral steroids like prednisone (starting at 40mg daily and tapering over 5-7 days).
Interventional Procedures
- Local interventions such as epidural steroid injections may provide relief for patients with persistent pain.
- Percutaneous Vertebral Augmentation (VA) may be considered for patients with osteoporotic vertebral compression fractures who have not responded to conservative management, as it has been shown to provide better pain relief and improved functional outcomes compared to conservative therapy 1.
Surgery
- Surgery is rarely indicated and reserved only for cases with severe, persistent pain unresponsive to comprehensive conservative management or with neurological complications.
- The majority of patients with painful vertebral Schmorl's nodes can be effectively managed with conservative treatment, and surgery should only be considered in exceptional cases 1.
From the Research
Treatment Options for Painful Vertebral Schmorl's Nodes
- Conservative therapy is the mainstay of treatment for Schmorl's nodes, including asymptomatic and symptomatic cases 2
- Percutaneous vertebroplasty (PVP) has been shown to be an effective and safe procedure for the treatment of symptomatic Schmorl's nodes that are refractory to medical or physical therapy 3, 4
- Surgical removal of disc material has been successful in cases of persistent radiculopathy from compression by a tunneling Schmorl's node 2
- Vertebrectomy and fusion may be necessary in cases where the integrity of the vertebral body is severely compromised 5
- Medical management, including non-steroidal anti-inflammatory drugs (NSAIDs) and steroids, can also be used to reduce pain levels 3
Imaging and Diagnosis
- Magnetic resonance imaging (MRI) is the imaging modality of choice for the diagnosis of a Schmorl's node, as it can detect edema, neovascularization, and extruded disc material 2
- Computed tomography (CT) can also be used to diagnose Schmorl's nodes, particularly in cases where MRI is not available or contraindicated 4
Pathogenesis and Clinical Presentation
- The pathogenesis of Schmorl's nodes is not fully understood, but an axial load model appears to have the greatest supporting evidence 6
- Symptomatic Schmorl's nodes are thought to be due to the inflammatory response solicited by the herniation of nucleus pulposus into the well-vascularized vertebral body 6
- Schmorl's nodes can present with a range of symptoms, including back pain, radiculopathy, and pathologic fracture of the vertebral body 2, 5