From the Guidelines
Diagnosing Schmorl's nodes as the cause of back pain typically involves a combination of imaging studies, with MRI being the gold standard, rather than relying on intradiscal injections with anesthetic. When considering the diagnosis of Schmorl's nodes, it's crucial to prioritize imaging studies that can clearly visualize the herniation of disc material into the vertebral endplate. The most effective approach to diagnosing Schmorl's nodes involves:
- Using MRI as the primary diagnostic tool due to its ability to clearly show the herniation of disc material into the vertebral endplate 1.
- Considering CT scans as an alternative or complementary imaging method to visualize these lesions.
- Recognizing that while diagnostic intradiscal injections with anesthetic (discography) can identify painful discs, they are not the first-line approach for diagnosing Schmorl's nodes and come with risks such as infection and accelerated disc degeneration.
- Understanding that most Schmorl's nodes are asymptomatic and found incidentally on imaging, making the correlation between clinical symptoms and imaging findings essential for diagnosing symptomatic Schmorl's nodes.
- Noting that pain from symptomatic Schmorl's nodes typically worsens with activity and improves with rest, and that conservative treatments like NSAIDs, physical therapy, and activity modification should be considered before more invasive diagnostic procedures.
- Following the guideline that clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with MRI (preferred) or CT only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) 1.
From the Research
Diagnosis of Schmorl Herniation
To diagnose if back pain is caused by Schmorl herniation, several methods can be employed:
- Discography: This method involves injecting a contrast medium into the disc to visualize the herniation of the nucleus pulposus into the vertebral body 2, 3.
- Magnetic Resonance Imaging (MRI): MRI can be used to evaluate the presence of Schmorl's nodes and their characteristics, such as low T1 and high T2 signals on MRI 3.
- Provocation discography: This method involves injecting a contrast medium into the disc to provoke pain and confirm the diagnosis of painful Schmorl's nodes 3.
Intradiscal Injection with Anesthetic
Intradiscal injection with anesthetic, also known as discoblock, can be used to treat painful Schmorl's nodes:
- Discoblock has been shown to be effective in reducing low back pain and improving functional outcomes in patients with painful Schmorl's nodes 3.
- The procedure involves injecting an anesthetic into the disc to block the pain signals and reduce inflammation.
- Studies have reported significant improvements in visual analogue scores (VAS) and Oswestry Disability Index (ODI) scores after discoblock treatment 3.
Key Findings
Some key findings related to the diagnosis and treatment of Schmorl herniation include:
- Schmorl's nodes are common findings on imaging, but most are asymptomatic 4, 5.
- Symptomatic Schmorl's nodes can cause back pain due to the inflammatory response solicited by the herniation of nucleus pulposus into the vertebral body 4, 6.
- Discography and discoblock can be effective in diagnosing and treating painful Schmorl's nodes 2, 3.