Question
My daughter has had chronic back pain for over a year now.  She is 14 years old, very active, not overweight and complains of her back hurting everyday (she is a cheerleader).  She had a CAT scan and nothing showed up.  Then she had an MRI and the doctor told me over the phone that she has schmorl nodes.  we are going to discuss this at our appointment July 10.  can you give me some insight as to what this is and what kind of treatment would help her.

Answer
Hello Carol,

Sorry to hear of your daughter's problems.

"...Chronic back pain...over a year...very active...cheerleader...
CT scan (-)... mri (+)....Schmorl's Nodes..."

Way back, way back when I was in Chiropractic School, Schmorl's Nodes were thought to be asymptomatic and not a problem.  Now  we know that Schmorl's Nodes are an injury, do have inflammation, and can hurt, can 'run their course' and calm down.

The MRI is the better test to evaluate for this condition.  The MRI can also show the stage of inflammation- if the injury is newer- inflammation and pain; older= less inflammation, less pain.

Very active =  possible initiation of new injury, new schmorl's nodes, or aggravation of the older schmorl's nodes.  Jumping as a cheerleader is definitely related to the condition.

There is no surgery that I am aware of for schmorl's nodes.  Chiropractic is a good treatment approach.  Proper alignment, proper movement patterns, adjunctive physiotherapy, posture and movement instruction, perhaps a period of rest, and anti-inflammatory nutrition would be helpful.

+++++++++++++++++++++++++++++++++

Available through internet: http://www.ncbi.nlm.nih.gov/pubmed/7749909
Schmorl's nodes and low-back pain. Analysis of magnetic resonance imaging findings in symptomatic and asymptomatic individuals.Takahashi K, Miyazaki T, Ohnari H, Takino T, Tomita K.
Department of Orthopaedic Surgery, Kanazawa University, Japan.

Magnetic resonance imaging (MRI) findings in cases with symptomatic and asymptomatic Schmorl's nodes have been analysed. In all symptomatic cases, the vertebral body marrow surrounding the Schmorl's node was seen as low signal intensity on T1-weighted images and as high signal intensity on T2-weighted images. It was confirmed by histological examination that the MRI findings indicated the presence of inflammation and oedema in the vertebral bone marrow. These MRI findings were not seen in asymptomatic individuals. Inflammatory changes in the vertebral body marrow induced by intraosseous fracture and biological reactions to intraspongious disc materials might cause pain. We postulate that after fracture healing and subsidence of inflammation, the Schmorl's nodes become asymptomatic, in analogy with old vertebral compression fractures. MRI is not only useful in detecting the recently developed Schmorl's nodes but also in differentiating between symptomatic and asymptomatic Schmorl's nodes.

PMID: 7749909 [PubMed - indexed for MEDLINE]
++++++++++++++++++++++++++++++

As with any injury, when new, or acute, or aggravated- it is inflammed and hurts.  As time passes without re-injury, re-aggravation, the inflammation decreases, the pain decreases.

Decrease the inflammation = decrease the pain.

+++++++++++++++++++++++++++++++++++++++++

From my Staten Island Chiropractic office information handouts:
--- treating ( just about any ) injury :

P.R.I.C.E. =    P  protection.   R rest.   I  ice.   
C  compression.   E  elevation.
Hurt  yourself ??  injury/ trauma/  bruise/ not even sure - - a broken bone ??

You should certainly get to the Doctor or trained health professional to be looked at if you think it is bad enough.    BUT in the meantime, some simple steps may help. PRICE.
The  PRICE  protocol will usually help just about any musculoskeletal injury.

P = Protection;  protect the area from further injury- stop what you are doing, can you  pad  or bandage the area ? Tape the area? Do something to protect the area !

R = Rest;  rest the area as much as possible, if a part is damaged, give the body time to repair the area

I = Ice;  ice is a potent anti-inflammatory; it will slow swelling, help with pain control (ice is analgesic), place ice over cloth over the injured area for 5, 10 minutes, off the  njured area for 30 minutes; then back on again

C = Compression;  to help prevent swelling compression may be helpful- for example  if it is an ankle, wrap the ankle with an ace bandage and ice the area.  Many body  parts may not be applicable to compression.

E = Elevation; again to fight swelling and pain, raising the injured body part above the  heart may be helpful- ie raise an ankle or knee, you lay down, raise the injured part

PRICE  may  help :    Sprains,  Strains,  musculo-skeletal injury,  bruise,  contusion

Sometimes  a slip, trip, fall, heavy lift, athletic injury, or a motor vehicle accident can cause a bump or bruise, sprain or strain.  Sometimes also involved with the injury is a vertebral subluxation (or other joint subluxation) (subluxation is a mechanical problem- of any joint- and requires a mechanical correction).  In the spine, a sprain/strain  is a misalignment,  a 慿ink?in the joint, a stretch of the muscles, tendons and/ or ligaments:- more properly termed a Vertebral Subluxation.   Sometimes symptoms can come immediately, sometimes days, weeks or even months later!- Well after the actual trauma !!!

         Spinal = Vertebral   Subluxation   Complex    (a.k.a.  憇ubluxation?  ;   ( subluxation COULD be any joint )
The vertebral subluxation complex is the underlying cause of many healthcare problems.

A  subluxation  interferes with the proper functioning of the nervous system  (the master system  which controls and coordinates all function within the body)  and may cause various other conditions, symptoms and problems.

This is a serious condition identified by its five parts:

    Spinal Kinesiopathology:
         This is fancy way of saying the bones of the spine have lost their normal motion and position. It restricts your ability to turn and bend. It sets in motion the other four components.

    Neuropathophysiology:
         Improper spinal function can choke, stretch, or irritate delicate nerve tissue. The resulting nerve system dysfunction can cause symptoms elsewhere in the body.

    Myopathology:
          Muscles supporting the spine can weaken, atrophy, or become tight and go into spasm. The resulting scar tissue changes muscle tone, requiring repeated spinal adjustments.

    Histopathology:
         A rise in temperature from an increase in blood and lymph supplies result in swelling and inflammation. Discs can bulge, herniate, tear, or degenerate. Other soft tissues may suffer permanent damage.

    Pathophysiology:
         Bone spurs and other abnormal bony growths attempt to fuse malfunctioning spinal joints. This spinal decay, scar tissue, and long-term nerve dysfunction can cause other systems of the body to malfunction.

The Vertebral Subluxation Complex describes what happens when spinal bones lose their normal movement patterns and position.
         Automobile accidents, improper lifting, improper posture, alcohol, emotional stress, chemical imbalances, and long periods of sitting can cause the Vertebral Subluxation Complex.
          Vertebral  Subluxation  cannot be corrected through chemicals (medicine), stretching, yoga, vitamins or physical therapy alone.  Subluxation- a neuro/skeletal/muscular- mechanical- problem requires a mechanical correction-  -  -    a manipulation,     best performed with the chiropractic adjustment.  For good health- Treat the   Cause,  not just the Symptoms.  Sprain/ strain/ bump/ bruise?= may result in subluxation of the nearby joint.  CORRECT the subluxation !!!!
++++++++++++++++++++++++++++++++++++++++++++++++


Articles:  http://www.chiroweb.com/archives/09/19/16.html
Dynamic Chiropractic
September 13, 1991, Volume 09, Issue 19
Schmorl's nodes are defined as herniations of the intervertebral disc through the vertebral end-plate.

They were first described by a German pathologist, Christian G. Schmorl in 1927. These lesions are believed to be associated with trauma, especially in the thoracic and lumbar vertebrae.

It is generally agreed that trauma likely precipitates the actual formation of the Schmorl's node, but a possible congenital origin of a vertebral end-plate defect has also been suggested. In the maturing spine the epiphyseal plate may represent a weak spot of annular attachment, allowing for some discal material to extrude, causing an interbody nuclear herniation. It is now generally accepted that these nodes could predispose the disc to degenerative changes at an earlier onset, especially when observed in the earlier age groups.

Various configurations of nuclear herniations of the intervertebral disc have been described either occurring circumferentially through the annlus fibrosus or through the cartilage end-plates above and below. It has been noted that there is a high frequency of Schmorl's nodes in the adolescent males at the lower thoracic and upper lumbar levels; the nodes are believed to be caused by either a congenital weakness of the end-plate at the site of the notochordal canal or scarring of the degenerated blood vessels supplying the juvenile disc.

Many cases will present with back pain. The back pain is generally located at or near the thoracolumbar junction; most of the patients are adolescents between the ages of 14 and 18. Usually the patient cannot recall the specific motion that caused the onset of pain. Clinically, the pain is relieved with rest and spinal manipulation. Usually the pain is sufficient to prevent the patient from performing their particular sport at a competitive level.

Physical examination shows tenderness directly over the involved vertebrae. Paraspinous muscle spasm is usually not severe; however, the patient generally has flattening of the normal lumbar lordosis and stiffness of the lumbar spine. Forward flexion may be markedly limited. The neurological examination of the lower extremities is usually normal.

Radiographically, the most characteristic features are wedging of two adjacent vertebral bodies anteriorly; Schmorl's nodes; diminution of the intervertebral disc space; at times even fragmentation of the epiphyseal ring forming a limbus vertebra; and frequently sclerosis of the adjacent vertebral margins. Depending on the age of the patient and stage of development of the epiphyseal ring, these changes may remain throughout the patient's life.

A dorsolumbar kyphosis is a distinct clinical entity and may be associated with a Schmorl's node and should be considered as a possible etiology for low back pain in the active adolescent. The symptoms are relatively mild; however, in the initial stages, participation in competitive sports is significantly impaired. The diagnosis is confirmed by characteristic radiographic findings that can be correlated with the clinical findings.

The disease is self-limiting and usually does not require extensive treatment. A careful rehabilitation program consisting of an initial rest period followed by a gradual return to full activity is usually successful in returning the athlete to full competition.

Deborah Pate, D.C., D.A.C.B.R.
San Diego, California
http://www.chiroweb.com/archives/09/19/16.html

+++++++++++++++++++++++++++++++++++++

Articles:  http://www.chiroweb.com/archives/14/26/08.html
Dynamic Chiropractic
December 16, 1996, Volume 14, Issue 26

Schmorl's Nodes, Back Pain, and MRI -- Clinically Significant or Insignificant?
Schmorl's nodes are considered to be vertical disc herniations through the cartilaginous vertebral body endplates.

They can sometimes be seen radiographically, however they are more often seen on MRI, even when not visible on plain film x-ray. They may or may not be symptomatic, and their etiological significance for back pain is controversial.

In a recent study in Spine by Hamanishi, et al.,1 Schmorl's nodes were observed on MRI in 19% of 400 patients with back pain, and in only 9% of an asymptomatic control group. Plain film x-rays only revealed about 33% of the nodes identified on MRI. They also found a high incidence of nodes in the teenager group who had complaints of lower back pain and an increased level of participation in contact sports. The authors concluded that Schmorl's nodes are areas of "vertical disc herniation" through areas of weakness in the endplate.

In younger patients, it seems to be more common because the annulus is strong and intact, and thus nuclear material herniates through the weaker endplate. As the annulus degenerates with time and age, transverse or posterolateral herniations are more common.

In a more recent study published in the European Spine Journal by Takahashi, et al.,2 an analysis and correlation was made in symptomatic and asymptomatic patients with MRI evidence of Schmorl's nodes. There were five patients with pain and Schmorl's nodes, and 11 asymptomatic controls. Symptomatic Schmorl's nodes were classified by physical exam, radiographs, MRI, and lab tests. All other possible etiologies were reportedly ruled out. Patients with symptomatic Schmorl's nodes had pain on percussion, and manual compression of the vertebra was involved. Back pain was exacerbated by axial loading and extreme lumbar ROM. They found no differences in the two groups on plain film x-ray evaluation. However, on MRI, in symptomatic cases, the vertebral body bone marrow surrounding the node was seen as low-intensity on T1-weighted images, and high signal intensity on T2-weighted images. These changes were local to the area of the Schmorl's node. The signal changes on MRI are reflective of bone marrow edema and inflammation often seen in cases of fracture. The MRI findings in Takahashi's study were confirmed upon histological section in two cases where surgery was performed.

Conservative care was delivered for three patients with symptomatic Schmorl's nodes. All three patients were asymptomatic after 3-4 months of conservative care. Symptomatic Schmorl's nodes represent a fresh fracture of the vertebral endplate, which allows vertical disc herniation and nuclear migration. This may cause diffuse lower back pain without associated radicular findings often seen in transverse type herniations. It must be emphasized that for a Schmorl's node to be considered symptomatic or active subsequent to trauma, an MRI should demonstrate the T1 and T2 signal changes described above.

Figure I: The patient injured her cervical spine subsequent to trauma, with MRI evidence of C7 vertebral body deformity, and Schmorl's node at the superior vertebral endplate of the C7 body.

Figure I represents a patient who injured her cervical spine subsequent to trauma, with MRI evidence of C7 vertebral body deformity, with a Schmorl's node at the superior vertebral endplate of the C7 body. The MRI was obtained three months after trauma. The initial hospital x-rays were read as normal, and the patient was discharged despite having severe neck pain and limited ROM with myospasm.

Although Schmorl's nodes in the past have been considered clinically insignificant, clearly they may be an active symptomatic process and etiology of pain in some patients. Yochum3 states that Schmorl's nodes may be caused by numerous factors: trauma; hyperparathyroidism; osteoporosis; Schuermann's disease; osteomalacia; infections; and neoplasm. Yochum, et al., and Walters, et al.,4 state that trauma in adolescent athletes may be responsible for symptomatic Schmorl's nodes. Yochum, et al. also describe a unique large Schmorl's node that can cause a "squared off" vertebral body. They represent vertical disc herniation through a pain-sensitive endplate.

Recent studies have demonstrated that nucleus pulposis activates the release of inflammatory hormones and enzymes, such as leukotrenes, cytokines, PLA2, substance P, etc., and as such may be responsible for C-nociception or diffuse vertebrogenic pain seen in these types of cases.

David J BenIliyahu, DC, DACBSP, DAAPM
Selden, New York           http://www.chiroweb.com/archives/14/26/08.html

+++++++++++++++++++++++++++++++++++++++++++++++

I hope I have given you some information.

I would recommend your local family Doctor of Chiropractic.
I would recommend a period of rest.
I would recommend supplements of Vitamin C, D, glucosamine/ chondroitin/ MSM, calcium, proteolytic enzymes, fresh pineapple every day- especially when hurting.

Good luck, and good health naturally, your Staten Island Chiropractor,

Dr. Victor Dolan, DC
http://www.GoodHealthNaturally.info
http://drvictordolan.chiroweb.com   (email newsletter)
http://www.DocDolan.net