What is a Schmorl's node?

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I was just involved in a 3-panel arbitration for a patient of mine injured in a motor vehicle collision.  The patient did have lower thoracic disc damage.  There were also Schmorl’s nodes at 3 levels in the lumbar spine.  The defense tried to make the case about Schmorl’s nodes and not the disc damage.  It made me realize that Schmorl’s nodes may not be well understood in the personal injury world. 

I want to go over a 2013 study published in the European spine journal by Stig Sonne-Holm et al. titled The epidemiology of Schmorl’s nodes and their correlation to radiographic degeneration in 4,151 subjects.  They started this study by saying that little is known about Schmorl’s node etiology or cause.  They reported that Schmorl’s nodes are typically thought to have been caused by one of 2 separate categories. 

The first category is inert developmental or congenital herniations of disc tissue into weak areas of the vertebral end-plates.  The second is pathological or malignancy, trauma, infection, osteoporosis, Paget’s disease and so forth.  They reported that the purpose of this study was to investigate the prevalence of Schmorl’s nodes, and the relationship between Schmorl’s nodes and degeneration, gender, age, BMI and exposure to heavy lifting. 

They took 4,151 lateral lumbar x-rays to include in this study.  They defined Schmorl’s nodes as quote “a bell shaped, clearly delineated lesions in the central portion of the vertebral endplate in an otherwise normally looking vertebral body” End quote.  This would not include endplates that clearly have damage to the endplates and degenerative changes. 

In school I was taught that Schmorl’s nodes were congenital findings and when seen on x-rays were incidental findings.  I often seen these not even report by radiologists.  This was left off of the radiologist report on the patient I started talking about.  The training I got and the consensus I feel from providers is that these Schmorl’s nodes are congenital and have nothing to do with trauma or other problems. 

This study showed that 5% of men have Schmorl’s nodes and 3% of women have Schmorl’s nodes.  They showed an overall prevalence of Schmorl’s nodes at 3.8%.  They showed no statistically significant with age, weight, height, BMI, heavy lifting or manual labor.  They also showed that there is no relationship with Schmorl’s nodes and overall degenerative changes.  They reported that with the lack of association to increased BMI, heavy lifting, manual labor and degenerative changes that Schmorl’s nodes are quote “difficult to see them as dynamic lesions tightly associated with general or focal disease” end quote. 

In other words, this study supports the thought that Schmorl’s nodes are congenital incidental findings that are not associated with injuries, lifestyle or other factors.  This study correlates with what I was taught in school that Schmorl’s nodes are more incidental findings and not associated with trauma or symptoms. 

Real world

For my real-world example, I want to discuss the arbitration I brought up at the beginning of this podcast.  In this case my patient had 2 separate independent medical evaluations.  The first was in person and the second was a records review with no examination.  As typical the IME doctors did not take the time to actually look at the imaging.  They only read the radiologist report. 

This is an important part of this case in a lot of ways.  I am not an attorney, but from my understanding a medical professional is entitled to their opinion in court.  A medical professional is not allowed to share another medical provider’s opinion in court.  I believe this would be hearsay.  In this case the IME doctors would not be allowed to give their opinion of the imaging in the arbitration. 

As a side note I always give a report for all imaging that my patient has done.  With the proper training and credentials this allows me to have an opinion in court on a report on an arbitration.  In this case the only person able to give an opinion of the imaging would be the original radiologist and myself.  As I mentioned earlier in this podcast the radiologist did not report the Schmorl’s nodes seen on the MRI. 

The IME doctor used my report of the MRI to even know that the patient had Schmorl’s nodes.  This defense IME doctor went on to say quote “All patients who have Schmorl’s nodes have accelerated degenerative disc and joint changes at the affected levels” end quote.  He went on to say that the majority of patient with Schmorl’s nodes become symptomatic in their 50s.  The average age of patients in the study we went over today as 62 years. 

The defense attorney used the IME doctors opinions on Schmorl’s nodes to argue his case.  There was no mention of the actual disc damage above the Schmorl’s nodes.  Since the defense IME was not at the arbitration and would not have been able to testify about imaging since he didn’t even see the images the defense attorney went after me. 

Instead of asking me questions he would say the defense IME reported that all patients with Schmorl’s nodes have degenerative changes.  Then after I would sit there, he would say right?  He was using his questioning of me to state the other doctors’ opinions.  I would then say I am not sure what his opinion was, but that is not my opinion. 

I did not foresee the defense using Schmorl’s nodes as the most important part of their case.  To me Schmorl’s nodes are incidental and have nothing to do with her case.  The defense attorney asked if I was an expert of Schmorl’s nodes and I said I do know about them, but have not studied them in great detail and would not claim to be an expert on Schmorl’s nodes.  He then said, well if you are not an expert on Schmorl’s nodes then I have no other questions for you about them.  You just wouldn’t know. 

This bothered me and inspired me to cover this research article.  As seen in the study there is no association with degenerative changes in patients with Schmorl’s nodes.  This completely contradicts the IME doctor who said all patients with Schmorl’s nodes have degenerative changes.  Keep in mind the average age in this study was 62.  The Schmorl’s nodes had no association with age, gender, BMI, heavy lifting and manual labor.  This contradicts the IME doctor’s opinion that these people will eventual have degenerative symptomatic changes around the age of 50. 

In the end the arbitration went well and a good settlement was reached for the patient. 

Podcast 18 covered modic changes to endplates and basivertebral nerve ablations.  There are some similarities between damaged endplates and Schmorl’s nodes.  I have seen in the literature the term traumatic Schmorl’s nodes.  I have even used this term and believe this should not happen.  The study we covered in podcast 18 showed that the damage to the endplates was traumatic and micro fractures.  This is not a Schmorl’s node and just leads to confusion.  This is a traumatic endplate injury with microfractures.  This is distinct damage to the endplates from an event and not a congenital Schmorl’s node with damage. 

This endplate damage is very significant as seen in podcast 18 can lead to chronic pain and often treated with basivertebral ablations.  With the modic changes seen on MRI this endplate damage can in ways be time dated and correlated to injuries events.  To be clear both Schmorl’s nodes and traumatic endplate damage involves the same location of a vertebra.  The difference is Schmorl’s nodes are more likely than not congenital of from birth and are unrelated to age, gender, weight, heavy lifting or manual labor and do not cause degenerative changes.  Traumatic endplate damage is from trauma and permanently alters the bone and nerve leading chronic pain and degenerative changes.  I just think the term Traumatic Schmorl’s nodes can lead to confusion since it has nothing to do with a Schmorl’s nodes and may lead people to think that Schmorl’s nodes can be traumatic and have clinical significance.