Schmorl Nodes

Ovid: 5-Minute Orthopaedic Consult

Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.
Title: 5-Minute Orthopaedic Consult, 2nd Edition
> Table of Contents > Schmorl Nodes

Schmorl Nodes
Andrew P. Manista MD
  • Schmorl nodes are intraosseous vertebral
    lesions that are common incidental findings on plain radiographs and CT
    and MRI scans of the spine.
    • These nodes represent disc material that
      has herniated through weak areas in the adjacent vertebral endplates
      into the vertebral body.
    • In some cases, these weak areas may be
      the physiologic sequelae of the regression of vascular canals near the
      end of vertebral growth (particularly in young patients), whereas in
      other cases they represent a weakened endplate or subchondral bone.
    • Such herniations also may occur through
      pathologically weakened bone, and they usually are found in the
      thoracic or lumbar spine, although there have been reports of Schmorl
      nodes of the cervical spine.
  • These lesions were first described by Christian Georg Schmorl (1,2) as the cause of Scheuermann kyphosis, which results from decreased growth of the anterior portion of the endplates of at least 3 adjacent vertebral bodies.
    • Although the origin of Scheuermann
      kyphosis remains unclear, Schmorl nodes are unlikely to be the cause
      because they are not universally present.
  • Synonyms: Vertebral endplate irregularities; Intraosseous disc herniations
  • ~10% of the general population (3)
  • No gender predilection
  • Age ranging from childhood to old age, depending on the predisposing condition
Risk Factors
  • No specific genetic correlation has been made (4,5).
  • Metabolic bone diseases with genetic
    predispositions may predispose persons to an increased incidence of
    intraosseous disc herniation secondary to decreased bone density or
    defective bony matrix of the vertebral bodies.
  • Degenerative or acute rupture of the disc
    endplate and extrusion of the nucleus pulposus occur with sufficient
    force to penetrate the vertebral body superior or inferior to it.
  • Penetration may be secondary to acute trauma in the case of a normal vertebra and disc.
  • In the degenerative setting, penetration may occur slowly over time because of a weakened vertebral body.
  • Often, no obvious cause is found.
Associated Conditions (6)
  • Scheuermann (juvenile) kyphosis
  • Trauma
  • Osteoporosis and other metabolic disorders
  • Neoplastic disorders
  • Degenerative disc disease
Signs and Symptoms
  • Patients may be asymptomatic or may have pain secondary to Schmorl nodes.
  • Symptoms prompting radiographs may not necessarily be caused by this lesion.
  • Symptoms usually relate to the
    degenerative change or insufficiency of the particular disc and consist
    of axial backache or back pain.
  • Pain may radiate laterally around the trunk, but not distally down the extremities.
Physical Exam
  • Tenderness may or may not be elicited by deep palpation or percussion over the spine.
  • The degrees of kyphosis in the spine should be estimated.
  • A complete neurologic exam should be performed, but a neurologic deficit is unlikely.
    • If present, other causes should be sought.
  • Conventional radiographs show
    indentations or “pits” in the vertebral body, with radiolucencies
    within the body surrounded by varying degrees of sclerosis.
    • Variable degrees of disc thinning may be present as a result of the displaced nucleus.
    • Benign-appearing lesions
  • MRI may show low signal on T1-weighted
    and high signal on T2-weighted images in the setting of acute
    intraosseous herniation, which is more likely to be symptomatic (7).
    • Old, usually asymptomatic lesions show the opposite findings on T1- weighted and T2-weighted images.
    • MRI is more sensitive than plain radiographs in detecting the lesion.
  • Bone scanning may be useful in differentiating an acute lesion from an older lesion, although MRI is the standard.
Differential Diagnosis
  • Degenerative subchondral cyst
  • Bone neoplasm: Osteoid osteoma, metastatic cancer to bone, aneurysmal bone cyst, early EOG, lymphoma, multiple myeloma


General Measures
  • Treatment is symptomatic.
    • In the presence of an acute intraosseous
      herniation, NSAIDs and rest are the mainstay of care until the patient
      is able to resume normal activity.
    • Bracing may be initiated for comfort if needed.
Special Therapy
Physical Therapy
  • Physical therapy may help with persistent backaches.
  • Should consist of extensor strengthening and flexibility and endurance training
First Line
This condition is not a surgical entity.
Prognosis is generally good (8).
In the presence of loss of substantial disc space,
degenerative joint disease of the facet joints may result, with
additional symptoms.
Patient Monitoring
  • If the diagnosis is unclear, or if pain
    does not resolve within 6–8 weeks, serial radiographs should be taken
    to ensure that the lesion does not grow or change in character.
  • An MRI scan also may help rule out a malignant disease.
1. Schmorl GC. Die pathologische Anatomie der Wirbelsaule. Verh Dtsch Ges Orthop 1927;21: 3–41.
2. Vernon-Roberts B. Christian Georg Schmorl. Pioneer of spinal pathology and radiology. Spine 1994;19:2724–2727.
3. Hamanishi C, Kawabata T, Yosii T, et al. Schmorl’s nodes on magnetic resonance imaging. Their incidence and clinical relevance. Spine 1994;19: 450–453.
4. Hurxthal LM. Schmorl’s nodes in identical twins. Their probable genetic origin. Lahey Clin Found Bull 1966;15:89–92.
5. Karppinen
J, Paakko E, Raina S, et al. Magnetic resonance imaging findings in
relation to the COL9A2 tryptophan allele among patients with sciatica. Spine 2002;27:78–83.
6. Warner
WC, Jr. Kyphosis. In: Morrissy RT, Weinstein SL, eds. Lovell and
Winter’s Pediatric Orthopaedics, 6th ed. Philadelphia: Lippincott
Williams & Wilkins, 2006:797–837.
7. Seymour R, Williams LA, Rees JI, et al. Magnetic resonance imaging of acute intraosseous disc herniation. Clin Radiol 1998;53:363–368.
8. Murray PM, Weinstein SL, Spratt KF. The natural history and long-term follow-up of Scheuermann kyphosis. J Bone Joint Surg 1993;75A:236–248.
722.30 Schmorl node
Patient Teaching
Q: With what spine condition are Schmorl nodes most commonly associated?
A: Scheuermann kyphosis.
Q: What is the recommended treatment for most patients with Schmorl nodes?
A: Observation and nonoperative management.

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