Vertebral morphology influences the development of Schmorl's nodes in the lower thoracic vertebrae

Schmorl's nodes in a historic adult skeletal sample (19th to 20th centuries): An analysis of age, sex and occupation

OBJECTIVE

This study explores the interplay between age-at-death, sex and occupation and the presence, location and severity of Schmorl's nodes.

MATERIALS

Vertebral columns of 327 individuals, 180 (55.1%) males and 147 (44.9%) females, with age-at-death between 20 and 65 years old, with known occupation.

METHODS

Schmorl's nodes were recorded as present/absent and by location and severity.

RESULTS

In this sample, 58.7% (192/327) of individuals were affected by Schmorl's nodes, 75.6% (136/180) were males and 38.1% (56/147) were females, with statistically significant differences (p=0.000). Schmorl's nodes were most commonly found on the T7-L2 (77.1% of all Schmorl's nodes) vertebrae and at the center (73.4%) of the vertebral body surface. Age and occupational categories did not correlate with prevalence, quantity or severity.

CONCLUSIONS

Males appear more prone to develop Schmorl's nodes than females. In this study, the prevalence of Schmorl's nodes does not increase with age, nor with the type of occupation held by males.

SIGNIFICANCE

This study rejects the purported associations between prevalence of Schmorl's nodes and age and physical stress.

LIMITATIONS

It is unknown whether individuals had the same occupation throughout their lives or for how long they performed it. Additionally, it is impossible to access when the individual developed the Schmorl's node.

SUGGESTIONS FOR FURTHER RESEARCH

Evaluate the onset of Schmorl's nodes in individuals under 20 and explore possible links between vertebral morphology and the occurrence of Schmorl's nodes.

Bioarchaeological investigations of the princely grave at Helmsdorf attesting to the violent death of an Early Bronze Age leader

The Helmsdorf "princely" tomb, excavated at the beginning of the twentieth century, is one of the most important archaeological discoveries dating from the Early Bronze Age in central Germany. In addition to the burial inventory, which points to an elevated social position of the deceased, a number of highly fragmented skeletal remains were preserved. Forensic anthropological investigation identified three distinctive bone defects, the surfaces of which were macromorphologically and microscopically examined in greater detail. Micro-CT analyses were also carried out. The results of all examinations suggested that the defects represented three perimortem injuries. The wound morphology was indicative of the use of a bladed weapon. The combination of injuries and their locations supported the assumption of a targeted use of force to kill. A comparison of Early Bronze Age weapons and tools with the bone lesions led to the identification of a type of weapon possibly used in the attack.

A Influência dos nódulos de Schmorl no equilíbrio sagital de adultos jovens

Objectives  The present study aims to characterize the spinal balance (SB) in young adults with Schmorl nodes (SN).

Methods  A cross-sectional study was conducted on a sample of 47 young adults. Lumbar magnetic resonance imaging (MRI) was used to divide the patients into an SN group and a control group. Standing full spine radiographs were used to compare the spinopelvic SB parameters between groups: sagittal vertical axis, thoracic kyphosis, lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), and sacral slope (SS).

Results  The LL and SS values were significantly lower in patients with SN when compared with the control group (54.5° versus 64.3°; 36.2° versus 41.4°, respectively). No significant differences were observed for the other parameters. Significant correlations were found in both groups between LL and SS; PI and PT; and PI and SS.

Conclusions  Young adults with SN have associated SB modifications, particularly lower LL and SS values, when compared with a control group. This flatter profile resembles that observed in patients with lower back pain and early disc pathology. We believe that SNs are relevant clinical findings that should prompt the study of the SB of a patient, as it may uncover variations associated with early disc degeneration.

Level of Evidence III

Schmorl's nodes: demystification road of endplate defects-a critical review

BACKGROUND

Schmorl's nodes (SN) were the first vertebral endplate defects described. Debate continues about their epidemiology, physiopathology, and clinical significance. The purpose of this work was to summarize and discuss available literature about SN.

METHODS

We have searched for relevant papers about SN until April 2020, with 104 articles have been reviewed.

RESULTS

More than half of the available literature described the epidemiological aspects of SN or reported rare clinical presentations and treatment options. The lack of a consensual definition of SN, among other endplate defects, contributed to difficulties in literature results' interpretation. Summing up, SN is a frequent vertebral defect at the thoracolumbar juncture, with ethnic and gender influence. Lumbar Schmorl's nodes were frequently associated with disc degenerative disease and back pain. Their physiopathology remains unknown. However, strain energy changes in the spine along with morphological aspects of the vertebra, the genetic background, and the osteoimmunology may constitute possible clues. New SN could be confused in malignancy context with bone metastasis. The literature describes some imaging techniques to differentiate them, avoiding invasive approaches. Treatment options for rare painful presentations remain few with low evidence. Further studies are needed to establish a consensual definition for SN, understand clinical aspects, and provide adequate therapeutic strategies.

3D reappraisal of trepanations at St. Cosme priory between the 12th and the 15th centuries, France

OBJECTIVE

This study aims to place trepanation in a medieval therapeutic context by addressing its medical use in neurological disorders and by testing the existence of particular dietary care for the sick.

MATERIALS

Six cases of trepanation found at the St. Cosme priory (La Riche, France) dated from the 12th-15th centuries.

METHODS

Neurological health was explored by geometric morphometrics by comparing the six cases to 68 skulls and 67 endocraniums belonging to individuals from the same period and geographical area. Trepanned diet was investigated by carbon and nitrogen isotopes and compared to 49 individuals from the same site.

RESULTS

The study of shapes suggests a possible pathological state for four subjects. The diet of the trepanned is not different from the rest of the population.

CONCLUSIONS

The treatment of neurological disorders emerges as the main therapeutic motivation in the corpus, contrary to the reports from the ancient surgical treatises. A specific diet for the sick is not highlighted.

SIGNIFICANCE

Geometric morphometrics is rarely used in paleopathology and the results suggest a potential of this type of analysis in the identification of pathological cases. The results on therapeutic motivations and diet do not fit the descriptions from ancient medical sources.

LIMITATIONS

The study of forms did not lead to definitive diagnosis. The isotopic study does not allow us to appreciate all the aspects of the diet.

SUGGESTIONS FOR FURTHER RESEARCH

A geometric morphometric study of the skulls and endocraniums of individuals with a known neurological condition would allow a better appreciation of the link between shapes and pathologies.

Percutaneous vertebroplasty (PVP) to treat specialized type of endplate fractures around the Schmorl's node: a prospective study of 65 patients

BACKGROUND

The Schmorl's nodes (SNs) are defined as the herniation of the intervertebral disc into the vertebral body. Endplate fractures around the Schmorl's node could result in severe back pain that is similar to vertebral compression fractures. The objective of this study was to prospectively analyze the surgical effectiveness and safety of percutaneous vertebroplasty (PVP) for endplate fractures around the SNs.

METHODS

Seventy-one consecutive patients with the fresh endplate fracture around SNs from October 2017 to February 2018 were enrolled in this study. The visual analog scale (VAS) and Oswestry disability index (ODI) scores of low back pain were evaluated in all patients preoperatively, postoperatively, and at 1 month, 6 months, and 1 year after primary single level PVP. Surgery-related data including duration of the operation, injected cement volumes, and surgical complications were recorded.

RESULTS

Sixty-five patients with fresh endplate fractures around the SNs were treated successfully via percutaneous vertebroplasty. Our study showed that the VAS scores and ODI scores of patients were obviously improved after operation. Cement leakage into the disc space occurred in 5 patients (7.7%), and adjacent segment refractures occurred in 2 patients (3.1%). No other surgical complications, including infections or nerve root injuries were encountered.

CONCLUSIONS

Based on the results of this prospective study, PVP was an effective and safe procedure for endplate fractures around the SNs.

TRIAL REGISTRATION

ChiCTR, ChiCTR1800016453 . Registered 2 June 2018-retrospectively registered, http://www.chictr.org.cn/com/25/historyversionpuben.aspx?regno=ChiCTR1800017602.

Temporal Trends in Vertebral Dimensions - a case study from Finland

Vertebral fractures and other back problems represent a major, increasing worldwide health problem. This has increased the need to better understand the reasons behind this phenomenon. In addition to a reduction in bone mineral density and overall size of the vertebral body, research has indicated a possible association between the shape of the endplate and spinal disorders. As one previous study has shown changes in vertebral body dimensions between contemporary people and their medieval counterparts, we wanted to examine the potential temporal trends in vertebral size and dimensions in Finnish samples of archaeological and contemporary individuals. To conduct this study, we utilized three archaeological populations from the 16^th–19^th century and clinical materials from two population-based Finnish birth cohorts. As the average height of people has increased greatly since the first time period, we also height-adjusted the dimensions to provide a clearer picture of the dimensional changes that have occurred in the later temporal group. Our results were in agreement with those of the earlier study. The archaeological samples had a larger vertebral size than the contemporary population when height was adjusted for. Vertebral mediolateral width in particular had decreased, and the shape of the vertebral body had changed.

3D shape analyses of extant primate and fossil hominin vertebrae support the ancestral shape hypothesis for intervertebral disc herniation

BACKGROUND

Recently we proposed an evolutionary explanation for a spinal pathology that afflicts many people, intervertebral disc herniation (Plomp et al. [2015] BMC Evolutionary Biology 15, 68). Using 2D data, we found that the bodies and pedicles of lower vertebrae of pathological humans were more similar in shape to those of chimpanzees than were those of healthy humans. Based on this, we hypothesized that some individuals are more prone to intervertebral disc herniation because their vertebrae exhibit ancestral traits and therefore are less well adapted for the stresses associated with bipedalism. Here, we report a study in which we tested this "Ancestral Shape Hypothesis" with 3D data from the last two thoracic and first lumbar vertebrae of pathological Homo sapiens, healthy H. sapiens, Pan troglodytes, and several extinct hominins.

RESULTS

We found that the pathological and healthy H. sapiens vertebrae differed significantly in shape, and that the pathological H. sapiens vertebrae were closer in shape to the P. troglodytes vertebrae than were the healthy H. sapiens vertebrae. Additionally, we found that the pathological human vertebrae were generally more similar in shape to the vertebrae of the extinct hominins than were the healthy H. sapiens vertebrae. These results are consistent with the predictions of the Ancestral Shape Hypothesis. Several vertebral traits were associated with disc herniation, including a vertebral body that is both more circular and more ventrally wedged, relatively short pedicles and laminae, relatively long, more cranio-laterally projecting transverse processes, and relatively long, cranially-oriented spinous processes. We found that there are biomechanical and comparative anatomical reasons for suspecting that all of these traits are capable of predisposing individuals to intervertebral disc herniation.

CONCLUSIONS

The results of the present study add weight to the hypothesis that intervertebral disc herniation in H. sapiens is connected with vertebral shape. Specifically, they suggest that individuals whose vertebrae are towards the ancestral end of the range of shape variation within H. sapiens have a greater propensity to develop the condition than other individuals. More generally, the study shows that evolutionary thinking has the potential to shed new light on human skeletal pathologies.

Potential adaptations for bipedalism in the thoracic and lumbar vertebrae of Homo sapiens: A 3D comparative analysis

A number of putative adaptations for bipedalism have been identified in the hominin spine. However, it is possible that some have been overlooked because only a few studies have used 3D and these studies have focused on cervical vertebrae. With this in mind, we used geometric morphometric techniques to compare the 3D shapes of three thoracic and two lumbar vertebrae of Homo sapiens, Pan troglodytes, Gorilla gorilla, and Pongo pygmaeus. The study had two goals. One was to confirm the existence of traits previously reported to distinguish the thoracic and lumbar vertebrae of H. sapiens from those of the great apes. The other was to, if possible, identify hitherto undescribed traits that differentiate H. sapiens thoracic and lumbar vertebrae from those of the great apes. Both goals were accomplished. Our analyses not only substantiated a number of traits that have previously been discussed in the literature but also identified four traits that have not been described before: (1) dorsoventrally shorter pedicles in the upper thoracic vertebrae; (2) dorsoventrally longer laminae in all five of the vertebrae examined; (3) longer transverse processes in the upper thoracic vertebrae; and (4) craniocaudally 'pinched' spinous process tips in all of the vertebrae examined. A review of the biomechanical literature suggests that most of the traits highlighted in our analyses can be plausibly linked to bipedalism, including three of the four new ones. As such, the present study not only sheds further light on the differences between the spines of H. sapiens and great apes but also enhances our understanding of how the shift to bipedalism affected the hominin vertebral column.

Beyond Individual Lives: Using Comparative Osteobiography to Trace Social Patterns in Classical Italy

Osteobiographical studies have usually focused upon investigating an individual's life experience. However, we can also understand variation in the shape of the life course itself as an object of study: Are there common patterns for how lives unfold within a society? Are there events or experiences that channel life courses? This approach to the life course can be adopted for ancient as well as for modern lives. A key element here is developing new methodologies for characterizing and comparing how lives develop through time, for instance, by ordering biological data in sequence, looking for time-structured patterns in them both by eye and through multivariate statistics. This article presents an initial exploration of this problem, using skeletal and archaeological data on 47 adults from the fifth to third centuries B.C. at Pontecagnano, an urban site in Campania, Italy. The results show both the importance of gender in the life course and the effects of different kinds of physical stress, probably due to specialization in labor. The result is not discrete categories of people but fuzzy envelopes of life possibilities.

Lumbar Schmorl's Nodes and Their Correlation with Spine Configuration and Degeneration

The aim of this study was to reveal whether demographic aspect, vertebral morphometry, and spine degeneration are associated with lumbar Schmorl's nodes (SNs). A retrospective cross-sectional study was performed using data from the Department of Radiology (Carmel, Medical Center, Israel) for 180 individuals: age range between 40 and 99 years; 90 males and 90 females. All participants had undergone high-resolution CT scans for abdominal diagnostic purposes in the same supine position prior to our study, which enabled the processing of the scans in all planes and allowed a 3D reconstruction of the lower lumbar region. Eighty individuals (44.4%) had at least one SN along the lumbar spine, particularly at L3-4 level (30%). Vertebral body length (L1 to L3) and width (L1 and L4) were significantly greater in the SNs group compared to non-SNs group. On contrast, disc height (L3-4 and L4-5) was significantly lesser in SNs group than non-SNs group. SNs was significantly associated with smoking (X²= 4.436, P=0.02) and degenerative lumbar spinal stenosis (X²= 5.197, P=0.038). Moreover, the prevalence of SN was significantly greater in individuals with vacuum phenomenon and osteophytes formation (L1-2 to L4-5 levels). This study indicates that vacuum phenomenon on L3-4 (OR: 4.7, P=0.034), smoking habit (OR: 3.2, P=0.003), disc height loss of L4-5 (OR: 0.798, P=0.008), vertebral body length of L1 (OR: 1.37, P<0.001), and age (OR: 1.05, P=0.002) increase the probability of developing lumbar SNs.

High stature and body mass might affect the occurrence of Schmorl’s nodes

Schmorl’s nodes are vertical herniation of intervertebral discs into the body of neighbouring vertebral endplate. Notwithstanding extensive studies, no consensus has been reached in the subject of their possible etiology. It is hypothesized that physical stress, trauma and high axial loading are the key factors in the occurrence of this pathology. The main objective of the current work is to reevaluate the relationship between stature and body mass and Schmorl’s nodes. For this purpose, skeletal samples from Lithuania (44 males and 19 females) and Poland (97 males and 60 females) were used. The study confirmed that Schmorl’s nodes are age-independent, and more frequent in males (12.63% on the superior and 19.32% on the inferior surface of vertebrae) than in females (6.23% and 12.29% respectively). Obtained results also suggest that high stature (e.g. Spearmann correlation for superior: R=0.20 p=0.017, and inferior: R=0.31 p=0.000 surface of vertebrae) and body mass (R=0.25, p=0.002 and R=0.32, p<0.001, respectively) are factors that increase the risk of Schmorl’s nodes. Authors hypothesize that the afore-mentioned body size traits alter loadings acting on intervertebral discs, and rigidity of the spine.

A Retrospective Study of Percutaneous Balloon Kyphoplasty for the Treatment of Symptomatic Schmorl's Nodes: 5-Year Results

BACKGROUND Despite literature supporting the efficiency of percutaneous balloon kyphoplasty (PKP) in treating osteoporotic and malignant vertebral compression fractures, few reports exist that document its use for treatment of symptomatic Schmorl's nodes (SNs) refractory to conservative treatment. Patients with symptomatic SNs could have pain in the vertebrae similar to an acute vertebral compression fracture. MRI is very helpful in diagnosing symptomatic SNs when x-ray and CT scan are unremarkable. In painful cases, the vertebrae bone marrow around the SNs is hyperintense on T2-weighted subsequence. We evaluated the long-term safety and effectiveness of PKP for the treatment of symptomatic SNs not responding to conservative therapy. MATERIAL AND METHODS From January 2008 to December 2012, 32 patients suffering from symptomatic SNs underwent 43 PKP procedures. Outcome data, including mean height ratio of anterior and middle vertebral body, Visual Analog Scale (VAS score) for pain measurement, Oswestry Disability Indexes (ODI score) and SF-36 questionnaires for function measurement were recorded preoperatively, postoperatively, and at one month, six months, two years, and five years after treatment. RESULTS Thirty-two patients were treated successfully with PKP. Clinically asymptomatic cement leakage was observed in three (6.98%) of the treated vertebral bodies. The mean height ratio of anterior and middle vertebral bodies changed from 98.2±1.6% preoperatively to 98.5±1.4% postoperatively (p>0.05) and 98.3±1.5% preoperatively to 98.8±1.9% postoperatively (p>0.05). The mean VAS scores, ODI score, and SF-36 scores for physical function (PF), bodily pain (BF), social functioning (SF), and vitality (VT) all showed significant improvements (p<0.05). During the 5-year follow-up, the stabilization of the height of the vertebral body and functional improvements were all maintained. CONCLUSIONS PKP is a safe and effective procedure for the treatment of symptomatic SNs refractory to conservative therapy.

The face of war: Trauma analysis of a mass grave from the Battle of Lützen (1632)

Contemporary accounts of battles are often incomplete or even erroneous because they reflect the—often biased—viewpoints of the authors. Battlefield archaeology faces the task of compiling an historical analysis of a battle and of gathering all the available facts. Besides cultural historical evidence and artefacts, the human remains of those who have fallen in battle also provide invaluable information. In studying mass graves from a military context, the injury types and patterns are significant. They allow us to reconstruct the circumstances surrounding the soldiers’ deaths and provide information on the hostilities that occurred on the battlefield. One such mass grave was discovered in 2011 at Lützen, Saxony-Anhalt (Germany). Based on its geographical location and on the results obtained from archaeological examinations carried out in the area, the grave could be dated to the Thirty Years War (1618–1648). Further archaeological research confirmed that the dead had been soldiers from the Battle of Lützen (1632). The mass grave was block-lifted and then comprehensively examined at the State Museum of Prehistory in Halle (Saale). As well as osteological examinations to determine age, sex, height, state of health, i.e. diseases or injuries, imaging methods were also employed and histological and isotopic analyses carried out. The focus of this study was on the injuries sustained by the soldiers both prior to and during the battle. The results revealed that the 47 deceased had been between the ages of 15 and 50 when they died. Numerous healed injuries showed that the men had often been involved in violent encounters. Approximately three in every four soldiers had injuries that could have been fatal. Wounds inflicted by handguns, particularly to the skull, were predominant. The integrative analysis of the archaeological and anthropological data allowed us to conclude that the majority had been killed during a cavalry attack.

In the quest for degenerative lumbar spinal stenosis etiology: the Schmorl's nodes model

BACKGROUND

Degenerative lumbar spinal stenosis (DLSS) is a common health problem in the elderly and usually associated with three-joint complex degeneration. Schmorl's nodes (SNs) are described as vertical herniation of the disc into the vertebral body through a weakened part of the end plate that can lead to disc degeneration. Since SNs can harm the spine unit stability, the association between DLSS and SNs is expected. The aim of this study is to shed light on the relationship between degenerative lumbar spinal stenosis and SNs.

METHODS

Two groups of individuals were studied: the first included 165 individuals with DLSS (age range: 40-88, sex ratio: 80 M/85 F) and the second 180 individuals without spinal stenosis related symptoms (age range: 40-99, sex ratio: 90 M/90 F). The presence or absence of SNs on the cranial and caudal end plate surfaces at the lumbosacral region (from L1 to S1 vertebra) was recorded, using CT images (Brilliance 64 Philips Medical System, Cleveland Ohio, thickness of the sections was 1-3 mm and MAS, 80-250). Chi-Square test was taken to compare the prevalence of SNs between the study groups (control and stenosis) by lumbar disc level, for each gender separately. Multivariable logistic regression analysis was also used to determine the association between DLSS and SNs.

RESULTS

The prevalence rate of SNs was significantly greater in the stenosis males (L1-2 to L5-S1) and females (L4-5 and L4-S1) compared to their counterparts in the control (P < 0.001). In addition, the presence of SNs in both males and females was found to increase the likelihood for DLSS.

CONCLUSIONS

Our results indicate that SNs prevalence is significantly greater in the DLSS group compared to the control. Furthermore, SNs are strongly associated with DLSS.

The ancestral shape hypothesis: an evolutionary explanation for the occurrence of intervertebral disc herniation in humans

Background

Recent studies suggest there is a relationship between intervertebral disc herniation and vertebral shape. The nature of this relationship is unclear, however. Humans are more commonly afflicted with spinal disease than are non-human primates and one suggested explanation for this is the stress placed on the spine by bipedalism. With this in mind, we carried out a study of human, chimpanzee, and orangutan vertebrae to examine the links between vertebral shape, locomotion, and Schmorl’s nodes, which are bony indicators of vertical intervertebral disc herniation. We tested the hypothesis that vertical disc herniation preferentially affects individuals with vertebrae that are towards the ancestral end of the range of shape variation within Homo sapiens and therefore are less well adapted for bipedalism.

Results

The study employed geometric morphometric techniques. Two-dimensional landmarks were used to capture the shapes of the superior aspect of the body and posterior elements of the last thoracic and first lumbar vertebrae of chimpanzees, orangutans, and humans with and without Schmorl’s nodes. These data were subjected to multivariate statistical analyses.

Canonical Variates Analysis indicated that the last thoracic and first lumbar vertebrae of healthy humans, chimpanzees, and orangutans can be distinguished from each other (p<0.028), but vertebrae of pathological humans and chimpanzees cannot (p>0.4590). The Procrustes distance between pathological humans and chimpanzees was found to be smaller than the one between pathological and healthy humans. This was the case for both vertebrae. Pair-wise MANOVAs of Principal Component scores for both the thoracic and lumbar vertebrae found significant differences between all pairs of taxa (p<0.029), except pathological humans vs chimpanzees (p>0.367). Together, these results suggest that human vertebrae with Schmorl’s nodes are closer in shape to chimpanzee vertebrae than are healthy human vertebrae.

Conclusions

The results support the hypothesis that intervertebral disc herniation preferentially affects individuals with vertebrae that are towards the ancestral end of the range of shape variation within H. sapiens and therefore are less well adapted for bipedalism. This finding not only has clinical implications but also illustrates the benefits of bringing the tools of evolutionary biology to bear on problems in medicine and public health.

Electronic supplementary material

The online version of this article (doi:10.1186/s12862-015-0336-y) contains supplementary material, which is available to authorized users.

Does the correlation between Schmorl's nodes and vertebral morphology extend into the lumbar spine?

Schmorl's nodes are depressions on vertebrae due to herniation of the nucleus pulposus of the intervertebral disc into the vertebral body. This study provides an extension of our previous study which analyzed the shape of the lower thoracic spine and found that vertebral morphology was associated with the presence of Schmorl's nodes. Ninety adult individuals from the late Medieval site of Fishergate House, York, and the Post-Medieval site of Coach Lane, North Shields, Tyne and Wear, England, were analysed using 2D geometric morphometrics to identify possible relationships between vertebral morphology and Schmorl's nodes at the thoraco-lumbar junction and in the lumbar spine. A significant correlation was found between vertebral shape and the presence of Schmorl's nodes in the twelfth thoracic vertebrae and the first to third lumbar vertebrae. The findings corroborate previous studies and suggest that vertebral shape may be an important factor in spinal health. It is hypothesized that the pedicle shape of affected vertebrae may not provide adequate structural support for the vertebral bodies, resulting in vertical disc herniation.