Can a Schmorl node cause back pain in an otherwise healthy adult with new‑onset focal low‑back or thoracic pain?

Can Schmorl Nodes Cause Pain?

Yes, Schmorl nodes can cause acute back pain, though they are usually asymptomatic incidental findings—when symptomatic, they present with sudden-onset severe localized pain and characteristic MRI findings of bone marrow edema. 1, 2

Understanding Schmorl Nodes and Pain

Typical Presentation

• Schmorl nodes are extremely common incidental findings, present in over 70% of the population at autopsy, and are usually asymptomatic. 1
• When symptomatic, acute Schmorl nodes cause sudden-onset severe localized back pain, often without preceding trauma. 2
• The pain mechanism involves herniation of nucleus pulposus through the vertebral endplate into the vertebral body, triggering an inflammatory response and bone marrow edema. 3

Diagnostic Approach

MRI is the imaging modality of choice because it detects bone marrow edema, neovascularization, and enhancement that characterize acute symptomatic Schmorl nodes. 1

Key MRI findings in symptomatic cases:

• Bone marrow edema surrounding the node indicates an acute symptomatic lesion. 1, 2
• Enhancement on contrast-enhanced sequences suggests active inflammation. 1
• Posterior extension through the vertebral body cortex into the epidural space can rarely cause radiculopathy by nerve root compression. 1

Critical Diagnostic Pitfall

On PET/CT imaging, recent Schmorl nodes with osteosclerotic rims can exhibit uptake and mimic malignant lesions—use MRI characteristics and low-dose CT to differentiate. 4

• Do not assume all vertebral uptake on PET/CT represents malignancy in elderly patients, as degenerative changes including Schmorl nodes cause false-positive findings. 4
• In patients with known malignancy, do not confuse new Schmorl nodes with bone metastases. 4

Management Algorithm

Conservative Management (First-Line)

Conservative therapy is the mainstay of treatment for both asymptomatic and symptomatic Schmorl nodes. 1

• Reassure patients that acute symptomatic Schmorl nodes are typically self-limited. 2
• Encourage continued activity and avoid prolonged bed rest, as maintaining activity promotes recovery. 5
• NSAIDs are the most effective pharmacologic option for pain control. 6

When to Consider Intervention

Surgical treatment should be considered only in patients with persistent disabling back pain despite conservative management or in rare cases of radiculopathy from nerve root compression. 1, 7

Surgical indications:

• Persistent radiculopathy from compression by a tunneling Schmorl node with posterior extension into the epidural space. 1
• Disabling back pain unresponsive to conservative therapy, confirmed by discography showing intravertebral disc herniation with concomitant pain reproduction. 7
• When surgery is indicated, eradication of the intervertebral disc including the Schmorl node and segmental fusion are preferable. 7

Special Consideration

In one reported case, percutaneous biopsy performed for diagnostic purposes resulted in almost immediate and complete symptom resolution, though this is not a standard treatment approach. 8

Clinical Context

Most chronic spine pain cannot be attributed to a specific cause, and approximately 85% of patients present with non-specific pain—incidental findings like Schmorl nodes are common and correlate poorly with symptoms. 9

• Disc protrusions are present in 29-43% of asymptomatic adults, varying with age—the same principle applies to Schmorl nodes. 5
• Schmorl nodes are most commonly found in the lumbar spine and are associated with mechanical loading and repetitive spinal stress from activities like horseback riding. 4