Uploaded byProf. Dr. Mohamed Mohi Eldin
Schmorl’s nodes (spine 2010)
The document discusses Schmorl's nodes (sn), which are herniations of the nucleus pulposus into adjacent vertebral end plates, commonly observed in various conditions including Scheuermann's disease. It explores their prevalence, detection methods, clinical implications, and potential associations with low back pain, suggesting that while often asymptomatic, they may contribute to disc degeneration. Furthermore, the document highlights genetic factors and age-related patterns in the occurrence and effects of Schmorl's nodes, indicating that those present during skeletal maturation are less likely due to degenerative processes.
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Presentation by Professor Mohammed Moehmmed Eldin from Cairo University about spine studies.
Discussion on Schmorl's Nodes (SN) and intervertebral disc herniation, common in radiographs and autopsy.
Details on intervertebral herniation mechanisms and factors leading to end plate defects.
Schmorl's Nodes predominantly found in specific vertebral locations, particularly the posterior area.
Pathological features of Schmorl's Nodes and detection methods, including imaging techniques.
Variations in vertebral end plate shapes and their reaction under vertical loading pressure.
Frequency of Schmorl's Nodes in different age groups, noting discrepancies in detection.
Measurement of Schmorl Nodes size and volume, and their controversial clinical significance.
MRI characteristics and assessment of Schmorl Nodes, including case study visuals presented.
Heritability factors and genetic influences on Schmorl Nodes and associated disc issues.
Detailing the impact of age on the presence and effects of Schmorl's Nodes during disc degeneration.
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Schmorl’s nodes (spine 2010)
- 1. Spine Study Archives MMoohhaammeedd MMoohhii EEllddiinn , MB-BCH , M.Sc., MD Professor of Neurosurgery Faculty of Medicine Cairo University EGYPT Weekly Neurosurgical Conference – Kasr El Aini, 25 November 2010
- 2. Spine Study Archives Schmorl’s nodes (SN) (Intervertebral Disc Herniation)
- 3. Schmorl’s nodes (SN) • Commonly observed – on routine radiographs – at autopsy • Represent herniation of the nucleus pulposus into the adjacent end plate. • Forms a defect in the upper or lower surface of the involved vertebra. • Tend to occur near the central or posterior axis. • SN are also a common radiographic feature of – Scheuermann’s disease – Chondrodysplasias such as multiple epiphyseal dysplasia.
- 4. Intervertebral Herniation •The EP has less resistance to expansile pressure of nucleous pulposus than the normal annulus fibrosus • Disc herniation in the craniocaudal direction, through a defect or break in the VEP
- 5. EP Defects canbe • Developmental (intrinsic abnormality of EP) – Previous vascular channels – Ossification gaps – Small indentation defects left during the regression of chorda dorsalis (notochord) • Weakening of EP (numerous local and systemic) – Infection – Metabolic: osteomalacia, hyperparathyroidism – Paget disease – Degenerative – Neoplastic • Traumatic: axial loading • Scheuermann disease • Osteoporosis ?!!
- 6. SN Location •Intervertebral Location: – almost 2/3 in the posterior part of the VEP, – 1/3 in the middle part; – anterior nodes rare • However, traumatic Schmorl nodes occur – Predominantly in the posterior VEP – Mostly in sites that are particularly susceptible to injury • lower thoracic, • thoracolumbar junction and • upper lumbar spine
- 7. Pathologically Schmorl’s nodes • Represent the nucleous pulposus with degenerative or inflammatory changes & a sclerotic response in the adjacent vertebral spongiosa (trabeculat bone) • The herniated NP may become vasularised, and lately ossified or calcified
- 8. Schmorl’s nodes Detection • Conventional radiography depicts fewer SNs than cross-sectional imaging methods • Recently developed SNs may not be seen on conventional radiographs due to the absence of surrounding sclerosis • Slab contact radiographs obtained with the use of finegrain film allow detailed assessment of the presence of SNs • The size of SNs and the height of the intervertebral disk space can be measured without any magnification. Subtle bone changes accompanying those nodes also can be depicted.
- 9. Forms of theVEP VEP variations A: A Schmorl node defined as a focal indentation of the VEP B: The normal concave form of the VEP C: The cupid’s bow contour has a smooth concavity in the posterior portion of the VEP D: A straight VEP is present when a line drawn from the anterior edge to the posterior edge of the vertebral body is in contact with the central portion of the VEP E: A fractured VEP anterior posterior The lower part of the vertebral body, in a sagittal plane, is demonstrated
- 10. SN appear tobe VEP Reaction to Vertical Loading • Normal concave VEP (negative association), • A straight VEP seems to be more susceptible to the formation of SN • Explanations – expansive pressure of the nucleus pulposus per surface ratio, lower in a concave VEP (surface is larger than straight VEP) – there is more space for the nucleus pulposus, therefore, there is less pressure because the volume of an intervertebral space with concave VEPs is larger than that associated with a straight VEP.
- 11. Frequency of Schmorl’sNodes Literature Discrepancy • 58% in our elderly population • 57% in the 2nd decade of life and 5% in the 6th decade of life NO Discrepancy… WHY? Schmorl Nodes of Elderly Persons tend to be smaller and have more surrounding sclerosis (healing) less likely to have reactive concomitant bone marrow changes that facilitate their detection with MR imaging (18).
- 12. • A commonfinding in the spines of the elderly, with a frequency similar to that reported for a younger population
- 13. Size and Volumeof SN • Mean anteroposterior diameter – 6 mm (range, 2–15 mm) – 8.2 mm (range, 4–20 mm) by using MR imaging • Mean height of 3.3 mm (range, 1–9 mm). • No correlation between the size and volume of the Schmorl nodes and the degree of disc degeneration • Patients with LBP tended to have larger Schmorl nodes than those of asymptomatic patients.
- 14. Clinical Controversy ofSNs • Most consider them to be asymptomatic ( frequent finding in persons without back pain) • However, in patients with back pain MR-based studies showed – a significantly higher frequency in the symptomatic group (19%) in comparison with the control group (9%) – more frequent frequency of enhanced signal intensity after IV gadolinium – more frequent frequency of those accompanied by bone marrow changes • An autopsy study showed – 10% acute Schmorl nodes – Acute or chronic trauma due to excessive axial loading may cause Schmorl nodes that initially are symptomatic
- 15. SN and LBP • On MRI: detected in 19% without back pain • SN generally considered asymptomatic • However, acute SN may be painful • SN may give rise to disc degeneration • The relationship of SN with disc disease and their clinical significance as a source of low back pain remain unknown • Factors have been shown to have only modest effects, have yet to be formally evaluated and variability remains unexplained – Environmental factors • occupational physical loading, • trauma, and • smoking – Genetic factors.
- 16. MRI SN-Characteristics MRISN-Characteristics • Localized defect in a vertebral end plate • With a well-defined herniation pit in the vertebral body • With or without a surrounding sclerotic rim (low signal on all sequences) • Small erosive defects of the end plate in degenerate segments are not considered SN MR score • Absent (score 0) or • present (score 1) at cranial and caudal vertebral levels T9 to L5. • Multiple nodes at a particular vertebral level were recorded as present (score 1)
- 17. Although MRI isconsidered the most sensitive method for assessing the spine, there is no accepted or standard definition of SN, nor their size.
- 18. • a) Sagittalslab contact radiograph at the L3-4 level in a 74-year-old man shows a • Schmorl node (black arrow) in the distal VEP of L3 and shows a vacuum phenomenon in the • intervertebral disk (white arrow). (b) Gross specimen of the same slab shows the Schmorl node, • with displacement of the intervertebral disk (white arrow) in the VEP of L3. Cleft formation (black • arrow) in the intervertebral disk corresponds to the site of the vacuum phenomenon.
- 19. Sagittal slab contactradiograph of the L2-3 interspace in a 72-year-old man shows a Schmorl node (black arrow) in the lower endplate of L2 with traction osteophyte formation (white arrow). Sagittal slab contact radiograph of the L2-3 interspace in a 59-year-old man shows a Schmorl node (black arrow) in the lower endplate of L2 and claw osteophyte formation (white arrows).
- 20. Sagittal slab contactradiograph of the T11 to L1 levels of the spine in a 61-yearold man shows Schmorl nodes (straight arrows) at the T11-12 level, with a straight configuration of the VEP and moderate disk space loss. A cupid’s bow contour (curved arrows) is at the T12-L1 level.
- 21. Anteroposterior and (b) lateral specimen radiographs of the T11-L5 segment in a 60-year-old man show the transition of Schmorl nodes (white arrows) in the VEPs of T11 to L2 to a cupid’s bow contour (black arrows) of the VEP of L3 and L4.
- 22. Heritability of SN • A number of genes have been implicated in disc degeneration including – an aggrecan gene polymorphism – a vitamin D receptor and – matrix metalloproteinase 3 gene alleles • Several mechanisms may be proposed to account for genetic factors influencing SN. • Synthesis and breakdown of disc anatomic and biochemical structures could be genetically determined and lead to accelerated degenerative changes in some persons; for example, • SN are more common in premature disc degeneration – Scheuermann’s disease and – the chondrodysplasias • Disc disease may therefore be a constellation of several related phenotypes, and SN may be at the more severe end of the spectrum.
- 23. AGE and SN • SN present during skeletal maturation are unlikely to be the result of disc degeneration • In subjects under 50 years of age • disc degeneration in the T10–L1 region is more frequent in discs with SN than in those without SN; • In subjects over 50 years of age this difference becomes even more marked • So, in the T10–L1 region, SN originating in childhood or adolescence predispose to earlier-onset disc degeneration.