Schmorl's nodes: current pathophysiological, diagnostic, and therapeutic paradigms

Management of low back pain accompanying sagittal plane pathologies in children: Spondylolysis/spondylolisthesis and Scheuermann's disease

Background

Low back pain in childhood was underappreciated for a long time, but recent studies report higher prevalences, up to 70%. Two of the common causes are spondylolyis/spondylolisthesis and Scheuermann's disease. These disorders are relevant in a way they both cause significant back pain, and may disrupt the sagittal spinal balance.

Purpose

To present the current evidence on the diagnosis, natural history and treatment of these disorders with a special focus on sagittal spinal alignment.

Methods

This study is conducted as a literature review.

Results and Conclusions

Spondylolysis and low-grade spondylolisthesis have a benign course and are typically treated conservatively. When pars repair is indicated, pedicle screw-based techniques achieve more than 90% fusion with acceptable complication rates. High-grade spondylolisthesis, however, is frequently progressive. Surgical treatment involves fusion, which can be done in situ or after reduction. Reduction is useful for "unbalanced" patients to acquire sagittal spinopelvic balance, and it is important to distinguish these patients. Despite lowering the risk for pseudoarthrosis, reduction brings a risk for neurologic complications. With re-operation rates as high as 40%, these patients definitely require careful preoperative planning. Scheuermann's disease generally causes back pain in addition to cosmetic discomfort during adolescence. If the kyphosis is lower than 60°, symptoms typically resolve into adulthood with conservative measures only. However, it must be kept in mind that these patients may experience problems with physical performance and have a lower quality of life even when the problem seems to have "resolved". Severe kyphosis and intractable back pain are the most frequently referred surgical indications, and surgery typically involves fusion. Proper utilization of osteotomies and proper selection of the upper and lower fusion levels are of utmost importance to prevent complications in these patients.

Increased 18F-FAPI uptake in bones and joints of lung cancer patients: characteristics and distributions

OBJECTIVE

This study investigated the distribution and characteristics of various bone and joint lesions on 18F-FAPI PET/CT in lung cancer patients.

METHODS

Seventy-four lung cancer patients who underwent 18F-FAPI PET/CT were reviewed. Bone and joint lesions with elevated 18F-FAPI uptake were recorded and analyzed. The distribution and maximum uptake value (SUVmax) of different benign lesions or bone metastases were presented. In addition, the SUVmax of bone metastases on 18F-FDG and 18F-FAPI-04 PET/CT were also compared.

RESULTS

In 53 patients, a total of 262 lesions presented 18F-FAPI accumulation. Bone metastases were mainly in vertebrae, pelvis, and ribs, while benign lesions were in vertebral margins, alveolar bone, and shoulder joints. The SUVmax of bone metastases was significantly higher than that of benign lesions ([Formula: see text] vs. [Formula: see text], [Formula: see text]), with NSCLC cases having higher SUVmax values than SCLC cases ([Formula: see text] vs. [Formula: see text], [Formula: see text]). Among benign lesions, arthritis and periodontitis demonstrated higher SUVmax than degenerative lesions (arthritis: [Formula: see text]; periodontitis: [Formula: see text]; degenerative diseases: [Formula: see text]; [Formula: see text] and [Formula: see text], respectively). The SUVmax of bone metastases was comparable between 18F-FDG and 18F-FAPI PET/CT. However, 18F-FAPI PET/CT was found to be superior in identifying cranial metastases compared to 18F-FDG PET/CT (TBRmet/brain: [Formula: see text] vs. [Formula: see text], [Formula: see text]).

CONCLUSION

This study demonstrated that 18F-FAPI PET/CT is a valuable imaging modality for detecting bone and joint lesions in lung cancer patients. The SUVmax of malignant lesions was higher than that of benign lesions, but cannot accurately distinguish benign and malignant lesions. The uptake of FAPI differs among lesions with different pathological types.

Percutaneous Vertebroplasty in a Patient with Chronic Back Pain Caused by Multiple Schmorl's Nodes: A Case Report

Background and Objectives: Schmorl's nodes (SNs), formed by the herniation of intervertebral discs into adjacent vertebral bodies, are generally asymptomatic and do not require treatment. However, certain types of SNs can cause intractable back pain. Case Presentation: A 63-year-old man presented to our hospital with back pain after a fall 1 month prior. Physical examination revealed back pain that worsened with movement and paraspinal tenderness. Magnetic resonance imaging (MRI) performed immediately after presentation revealed subacute to chronic compression fractures with SNs at the upper endplates of the 11th and 12th thoracic and 1st lumbar vertebrae. Pain (numeric rating scale (NRS), 7-8/10) persisted despite 6 months of conservative treatment and MRI revealed increased signal intensity in T2-weighted images in the regions around the SNs. Based on these findings, an epidural nerve block was performed, and then repeated; however, no significant improvement was observed. Percutaneous vertebroplasty (PVP) was performed at the 11th and 12th thoracic and 1st lumbar vertebrae. Pain levels decreased substantially 1 week after PVP (NRS, 3-4/10). Subsequent treatment with non-steroidal anti-inflammatory drugs (NSAIDs) and steroids for two weeks further reduced pain levels (NRS, 1-2/10), following which steroid use was discontinued and NSAID use became intermittent. At the six-month follow-up, pain levels remained low and the patient reported an improvement in activity levels of 90% or more. Conclusions: This case report demonstrates that PVP safely and effectively improved symptoms in a patient with multiple SNs and intractable back pain. Nevertheless, further research, particularly large-scale randomized prospective studies, is necessary to validate the long-term efficacy and safety of this intervention.

Living with lower limb traumas and below-knee amputation in a Jordanian Late Ottoman nomadic community

OBJECTIVE

Paleopathological analysis is combined with ethnohistorical, ethnographic and ethnomedical reports to assess the sociocultural implications for a historical nomadic Bedouin female following her survival of a below-knee amputation and multiple injuries to the stump.

MATERIALS

A middle-aged female recovered from a nomadic-style burial dated to the Late Ottoman Period (1789-1918) in Jordan's Wadi ath-Thamad region.

METHODS

Macroscopic and radiographic assessment.

RESULTS

A supracondylar femur (Hoffa) fracture, knee complex injury and lower leg amputation were observed on the right lower limb. Other pathological lesions that may have affected movement included bilateral os acromiale, intervertebral disc disease, osteoarthritis and right hook of hamate fracture.

CONCLUSIONS

The individual survived a below-knee amputation, two injuries to the stump, and likely experienced lower back pain. Mobility may have been painful, but she likely functioned within the community performing gender-specific daily tasks within the family tent and designated community female workspaces. Ethnohistoric and ethnographic reports suggest that marital demotion by other wives or a return to her father's tent may have occurred.

SIGNIFICANCE

Healed multiple injuries and amputation affecting one limb are rare in paleopathological literature.

LIMITATIONS

It is uncertain whether the amputation or either of the stump injuries occurred during the same event. If they resulted from separate events, slight hip joint osteoarthritis suggests that the amputation preceded the other injuries.

SUGGESTIONS FOR FURTHER RESEARCH

Full pathological assessment of individuals with amputations may provide additional insight into impairment resolution, health problems and injury arising from impairment following amputation.

Articular Findings on Chest Computed Tomography: An Algorithmic Approach for Radiologists

ABSTRACT

Chest computed tomography (CT) is one of the most frequently performed imaging studies. Incidental osseous and articular findings are commonly encountered in chest CTs in daily practice. The spectrum of findings is broad, varying from benign to malignant, and interpretation of these incidental musculoskeletal findings could be challenging for radiologists. In this review, we provide a systematic algorithmic approach for the diagnosis of common articular findings seen on chest CT with recommendations for appropriate follow-up evaluation.

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

The prevalence of Schmorl's nodes in osteoporotic vs normal patients: a Middle Eastern population study

The study was conducted to establish the association of Schmorl's nodes and osteoporosis in a Middle Eastern cohort. The prevalence of SN in this sample was 41.1%. It was most frequent in the lumbar spine typically solitary central lesions. Over 88% Schmorl's node cases were osteoporotic/osteopenic and only 11.6% normal.

INTRODUCTION

This study aims to identify the prevalence of Schmorl's nodes (SNs) in a cohort of Omani nationals, and also to determine any relation between osteoporosis and Schmorl's nodes.

METHODS

This retrospective observational study was conducted on Omani nationals. One thousand three hundred and forty-eight DEXA scan patients were included. Of these, 545 patients had complete X-rays and MRI scans that would help determine the SN status. The X-rays and sagittal, coronal, and axial T2-weighted MR images were used to identify the presence and exact location of the Schmorl nodes by one orthopedic trainee and confirmed by the senior author. The correlation of each parameter with the presence of SN was analyzed by the independent-samples T test and one-way ANOVA.

RESULTS

The overall prevalence of SN in this population sample appeared to be 41.1%. Over 88% of the SN-positive cases were either osteopenic or frankly osteoporotic by the WHO definition. Vast majority of SNs (87.1%) occurred in the lumbar spine and were central in location and mostly solitary. Statistical analysis of the data revealed significant correlation between osteopenia or osteoporosis and the presence of SNs.

CONCLUSIONS

The prevalence of SN in the sample of Omanis studied was 41.1% and was most frequently seen in older men in the lumbar spine. It is strongly associated with osteoporosis/osteopenia (88.4%) and frequently presents as solitary central lesions.

Regenerating and repairing degenerative intervertebral discs by regulating the micro/nano environment of degenerative bony endplates based on low-tension mechanics

Background

Conservative treatment is the recommended first-line treatment for degenerative disc diseases. Traction therapy has historically been one of the most common clinical methods to address this, but the clinical effect remains controversial.

Methods

Forty-two six-month-old male Sprague-Dawley rats were randomly divided into six groups: the model group (Group A, four coccyx vertebrae (Co7-Co10) were fixed with customized external fixators, and the vertebral disc degeneration model was constructed by axial compression of the target segment Co8 - Co9 for 4 weeks), the experimental control group (Group B, after successful modeling, the external fixation device was removed and self-rehabilitation was performed) and four intervention groups (Groups C to F): Groups C and E: Co8 - Co9 vertebrae compressed for 4 weeks followed by two or 4 weeks of high tension traction (HTT), respectively, and Groups D and F: vertebrae compressed for 4 weeks followed by two or 4 weeks of low-tension traction (LTT), respectively. Imaging tests (X-ray and MRI) were performed to assess disc height and T2 signal intensity at each time point. After the experiment, the animals were euthanized, and the caudal vertebrae were collected for analysis of intervertebral disc histopathology, proteoglycan content, and micronanostructure of the annulus fibrosus, nucleus pulposus and bony endplate.

Results

Signs of tissue regeneration were apparent in all four intervention groups. After two to 4 weeks of intervention (HTT and LTT), the morphology of pores in the bony endplate, their number, and diameter had recovered significantly compared with those in Group A. The LTT group was superior to the HTT group, and the 4w in situ group was significantly superior to the 2w group. Meanwhile, the histological scores of discs, the mean fibril diameter and modulus of annulus fibrosus were significantly improved compared with the control groups, and the LTT group was superior to HTT group.

Conclusions

Low-tension traction better promotes active reconstruction of bony endplates and improves the elastic modulus and micro/nanostructure of the disc. Thus, it further promotes the regeneration and repair of intervertebral discs.

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.

Schmorl's nodes could be associated with intervertebral disc degeneration at upper lumbar levels and end-plate disease at lower lumbar level in patients with low back pain

Schmorl's nodes (SNs) have increasingly been recognized on vertebral end-plates using advanced imaging techniques. Even though vertebral end-plates are the closest structures to discs, their pathologies are underestimated in the etiology of low back pain (LBP). We aimed to detect the prevalence of SNs and other end-plate defects in subjects with/without LBP and to understand whether SNs were associated with LBP and spinal degeneration. Subjects were evaluated in terms of end-plate defects, intervertebral disc degeneration (IVDD), and vertebral end-plate changes (Modic changes) at all lumbar levels on lumbar spine magnetic resonance imagings (MRI). Control subjects were compared to patients with LBP. Higher Pfirrmann scores (OR: 2.696) and higher SN scores (OR: 8.076) were significantly associated with Modic changes at L4-L5 disc level. Patients with higher SN scores at L1-L2 or L2-L3 levels had approximately 7-fold increased risk of severe IVDD at the corresponding levels. The most significant factor associated with presence of SNs was body weight of the patients (OR: 1.417). The most significant factor associated with intensity of LBP was severe IVDD at L5-S1 level (OR: 3.670). Having higher total SN score had an OR of 1.230 (95% CI: 1.003-1.509; p = 0.047) for predicting LBP. Schmorl's nodes were seen in 33.1% of patients and 11.5% of asymptomatic subjects. Body weight was the most significant factor associated with SNs. The most significant factor associated with LBP was severe IVDD at L5-S1 level.

Cortical step sign in spinal clearance on trauma computed tomography – Indicator of acute thoracolumbar compression fracture

Introduction

Differentiating an acute from chronic compression fracture of the thoracolumbar (TL) spine can pose a dilemma for radiologists interpreting spinal imaging following trauma. Mild wedging of the vertebrae can be due to spondylosis or osteoporosis, whilst acute simple compression fractures may not always be associated with loss of body height. In this observational study, we hypothesize that the presence of a vertebral body cortical step is a reliable sign of an acute compression fracture on Computed Tomography (CT) scans.

Methods

In a retrospective review of thoracolumbar CT scans following trauma, two observers analysed for the presence of a cortical step at the anterior or posterior vertebral body cortex, fracture morphology and associated injuries. A ‘cortical step’ is defined as a break of hyperdense cortex on CT scans, intervening non-sclerosed trabecular bone, and sharp overlap of the underlying cortex. MRI of the spine was used as gold standard.

Results

187 consecutive CT scans over 2 years were assessed. Sensitivity, specificity and accuracy of cortical step sign were 100%, 90.2% and 97% in diagnosing an acute thoracolumbar compression fracture, respectively. The interobserver reliability was high (kappa = 0.97). False positive cortical step was seen in Kummel’s disease and large Schmorl’s nodule.

Conclusion

Our results demonstrate high sensitivity and specificity of ‘cortical step sign’ in diagnosing acute vertebral body compression fractures of TL spine on CT scans in patients with trauma. This sign can be useful to radiologists for safe clearance of the thoracolumbar spine following trauma, helping distinguish acute trauma from chronic causes of vertebral body height loss.

The greatest health problem of the Middle Ages? Estimating the burden of disease in medieval England

OBJECTIVE

To identify the major health problems of the Middle Ages. Bubonic plague is often considered the greatest health disaster in medieval history, but this has never been systematically investigated.

MATERIALS

We triangulate upon the problem using (i) modern WHO data on disease in the modern developing world, (ii) historical evidence for England such as post-medieval Bills of Mortality, and (iii) prevalences derived from original and published palaeopathological studies.

METHODS

Systematic analysis of the consequences of these health conditions using Disability Adjusted Life Years (DALYs) according to the Global Burden of Disease methodology.

RESULTS

Infant and child death due to varied causes had the greatest impact upon population and health, followed by a range of chronic/infectious diseases, with tuberculosis probably being the next most significant one.

CONCLUSIONS

Among medieval health problems, we estimate that plague was probably 7th-10th in overall importance. Although lethal and disruptive, it struck only periodically and had less cumulative long-term human consequences than chronically endemic conditions (e.g. bacterial and viral infections causing infant and child death, tuberculosis, and other pathogens).

SIGNIFICANCE

In contrast to modern health regimes, medieval health was above all an ecological struggle against a diverse host of infectious pathogens; social inequality was probably also an important contributing factor.

LIMITATIONS

Methodological assumptions and use of proxy data mean that only approximate modelling of prevalences is possible.

SUGGESTIONS FOR FURTHER RESEARCH

Progress in understanding medieval health really depends upon understanding ancient infectious disease through further development of biomolecular methods.

The biological index of frailty: A new index for the assessment of frailty in human skeletal remains

OBJECTIVE

Frailty is the physiological stress that individuals suffer during their life. In past populations, frailty is conventionally assessed through the occurrence of different biomarkers of biological stress. Some efforts have been made to propose indexes that combine all biomarkers. However, these indices have some critical limitations: they cannot be used on incomplete skeletons, do not consider the severity and/or healing of lesions, and assign equal importance to different biomarkers. To address these limitations, we propose a new index to assess frailty in skeletal individuals.

MATERIAL AND METHODS

By statistically analyzing a large amount of osteological data available from the Museum of London, and using a Logit model, we were able to define a different weight for each reported biomarker of frailty, based on their importance in increasing the risk of premature death for the individuals.

RESULTS

The biological index of frailty (BIF) is the weighted mean of all biomarkers scored on the individuals, according to a different degree of importance assigned to each one. It also considers the severity and healing of the biomarkers when this is relevant to diagnose frailty. We applied BIF on a sample of Monastics and Non-Monastics from medieval England and compared it with the skeletal index of frailty (SFI).

DISCUSSION

BIF is the first frailty index that gives a different weight to each skeletal biomarker of stress, considers both severity and healing of the lesions, and can be applied on partial skeletal remains. The comparison with SFI showed that BIF is applicable to a larger number of skeletal individuals, revealing new differences between the Monastic and the Non-Monastic groups.

Schmorl node induced multiple radiculopathy: A rare case report

RATIONALE

We report a case of Schmorl node induced multiple radiculopathy.

PATIENT CONCERNS

A 70-year-old female patient complained of lower back pain in the left leg accompanied by numbness and weakness.

DIAGNOSIS

Radiographs showed obvious osteoporosis in the lumbar vertebrae. Computed tomography demonstrated a hole in the upper posterior half of the L2 vertebral body. Magnetic resonance imaging of the lumbar spine revealed a herniated disc involving a protrusion at the posterior wall of the L2 vertebral body, which was present in the left lateral and dorsal epidural spaces. There was significant lumbar stenosis at the L2 vertebral body secondary to dural sac compression due to the mass.

INTERVENTION

Left-sided hemilaminectomy was performed at L2 with screw fixation at L1-3. Intraoperatively, the severely ruptured disc compression in the dural sac and nerve root was removed.

OUTCOMES

The patient's leg pain was immediately resolved, and her back pain was reduced. The patient recovered normal motor function at 20 days after surgery.

LESSONS

A Schmorl node can progress and break through the lumbar vertebral body, resulting in nerve compression. A large proximal herniated mass can cause distal multiple radiculopathy. Therefore, this special case of Schmorl node with multiple radiculopathy should be treated by removing the proximal herniated nucleus pulposus from the vertebral body.

Characterization of chondroitinase-induced lumbar intervertebral disc degeneration in a sheep model intended for assessing biomaterials

Intervertebral disc (IVD) degeneration (IVDD) leads to structural and functional changes. Biomaterials for restoring IVD function and promoting regeneration are currently being investigated; however, such approaches require validation using animal models that recapitulate clinical, biochemical, and biomechanical hallmarks of the human pathology. Herein, we comprehensively characterized a sheep model of chondroitinase-ABC (ChABC) induced IVDD. Briefly, ChABC (1 U) was injected into the L_1/2 , L_2/3 , and L_3/4 IVDs. Degeneration was assessed via longitudinal magnetic resonance (MR) and radiographic imaging. Additionally, kinematic, biochemical, and histological analyses were performed on explanted functional spinal units (FSUs). At 17-weeks, ChABC treated IVDs demonstrated significant reductions in MR index (p = 0.030) and disc height (p = 0.009) compared with pre-operative values. Additionally, ChABC treated IVDs exhibited significantly increased creep displacement (p = 0.004) and axial range of motion (p = 0.007) concomitant with significant decreases in tensile (p = 0.034) and torsional (p = 0.021) stiffnesses and long-term viscoelastic properties (p = 0.016). ChABC treated IVDs also exhibited a significant decrease in NP glycosaminoglycan: hydroxyproline ratio (p = 0.002) and changes in microarchitecture, particularly in the NP and endplates, compared with uninjured IVDs. Taken together, this study demonstrated that intradiscal injection of ChABC induces significant degeneration in sheep lumbar IVDs and the potential for using this model in evaluating biomaterials for IVD repair, regeneration, or fusion.

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.

Schmorl Node-A Cause of Acute Thoracic Pain: A Case Report and Pathophysiological Mechanism

Purpose

We report a case of a patient with an acute symptomatic Schmorl node (SN) that spontaneously resolved with characteristic imaging findings. The extensive hematological investigations also allow some insight as to the likely pathophysiology of the painful lesion.

Methods

Case report of an acute symptomatic SN.

Results

A fit and athletic 44-year-old female participant in a competitive paddling event developed atypical thoracic pain and was admitted for further investigation. Normal blood results included complete blood cell count, clotting, and D-dimer. Creatine phosphokinase was 63 U/L (reference < 167 U/L) and troponin I levels were not raised. Her only hematological abnormality was an elevated C-reactive protein (CRP) at 60.2 mg/L (reference < 5 mg/L). Magnetic resonance imaging (MRI) scan showed signal hyperintensity involving T7 vertebral body, surrounding an enlarged SN. Patient was given oral nonsteroidal anti-inflammatory drugs, opioid analgesia, and gradually mobilized. After 3 days, the pain had sufficiently subsided and CRP was 17.8 mg/L. Follow-up MRI scan showed some reduction in the T2 hyperintensity and size of the intraosseous herniation. Patient gradually returned to full activities and had no recurrence of symptoms. MRI scan 8 months after the initial scan showed almost complete resolution of the T2 hyperintensity and pan-vertebral marrow edema.

Conclusion

Symptomatic SN should be part of the differential diagnosis of unexplained thoracolumbar pain. Modality of choice for diagnosis would be MRI. Once diagnosed, several treatment options are available with the most likely being spontaneous resolution of symptoms and bone healing within a few months. The conservative approach is recommended when the symptoms can be medically well controlled.

Vertebral intraosseous plasma rich in growth factor (PRGF-Endoret) infiltrations as a novel strategy for the treatment of degenerative lesions of endplate in lumbar pathology: description of technique and case presentation

BACKGROUND

Motivation and necessity to adopt minimally invasive therapies in the field of spinal regenerative medicine is increasing. Autologous platelet-rich plasma (PRP) therapy has recently been used as an effective technological and biological approach to tissue repair and has shown to improve multiple conditions including back pain and degenerative disc pathology. In addition, it is well established that the anatomic elements of the spinal system affected by degenerative pathology include the intervertebral disc (IVD) and vertebral subchondral bone (VSB), which play a crucial role in maintaining a healthy spinal column. Both elements are the target of a novel biological approach to the treatment of low back pain.

METHODS

A novel minimally invasive regenerative therapeutic approach is presented herein with a protocol based on combining vertebral intraosseous (VIO) and intradiscal (ID) infiltrations of plasma rich in growth factors (PRGF-Endoret), a type of leukocyte-free PRP, for the treatment of disc degeneration pathology.

RESULTS

We describe a novel technique applied in a patient treated for IVD degeneration and VSB damage, showing significant improvement on magnetic resonance imaging, including partial regression of protruded disc and significant resorption of intravertebral herniations (Schmörl's nodes), after PRGF therapy.

CONCLUSIONS

To the best of our knowledge, we present the first reported case description of the utilization of VIO and ID PRP infiltrations to treat protruded discs and intravertebral herniations with a successful clinical outcome.

Lumbar spine Schmorl's nodes; prevalence in adults with back pain, and their relation to vertebral endplate degeneration

Background

In 1927, Schmorl described a focal herniation of disc material into the adjacent vertebral body through a defect in the endplate, named as Schmorl’s node (SN). The aim of the study is to reveal the prevalence and distribution of Schmorl’s nodes (SNs) in the lumbar spine and their relation to disc degeneration disease in Kirkuk city population.

Results

A cross-sectional analytic study was done for 324 adults (206 females and 118 males) with lower back pain evaluated as physician requests by lumbosacral MRI at the Azadi Teaching Hospital, Kirkuk city, Iraq. The demographic criteria of the study sample were 20–71 years old, 56–120 kg weight, and 150–181 cm height. SNs were seen in 72 patients (22%). Males were affected significantly more than the females (28.8% vs. 18.8%, P = 0.03). SNs were most significantly affecting older age groups. L1–L2 was the most affected disc level (23.6%) and the least was L5–S1 (8.3%). There was neither a significant relationship between SN and different disc degeneration scores (P = 0.76) nor with disc herniation (P = 0.62, OR = 1.4), but there was a significant relation (P = 0.00001, OR = 7.9) with MC.

Conclusion

SN is a frequent finding in adults’ lumbar spine MRI, especially in males; it is related to vertebral endplate bony pathology rather than discal pathology.

A longitudinal investigation of the endplate cystic lesion effect on oblique lumbar interbody fusion

OBJECTIVE

To determine longitudinal effects of changes in endplate cystic lesions on oblique lumbar interbody fusion (OLIF), the relationship between bone healing and endplate cystic lesion changes, and clinical significance of cyst formation.

PATIENTS AND METHODS

A total of 107 segments in 67 patients who underwent OLIF between January 2013 and July 2016 were examined in this retrospective study. Using computed tomography, radiographic examinations of endplate cystic lesion, positive or negative cyst formation, cage subsidence, and fusion status were performed. Clinical outcomes were measured using visual analogue scale (VAS) pain scores, Oswestry disability index (ODI), and modified Macnab criteria. Outcomes were compared with preoperatively and postoperatively. A logistic regression analysis was performed to evaluate the relationship between measurements for endplate cysts.

RESULTS

The fusion rate after OLIF was 94.4% at 2-year follow-up, with 86% of cases reporting satisfactory outcome (based on modified Macnab criteria). A significantly higher (P <  0.01) VAS score for back pain was observed in the cystic lesion group than non-cystic lesion group at 6-month follow-up. Cage subsidence significantly increased the risk of non-union (odds ratio [OR]: 17.24; 95% confidence interval [CI]: 1.67-178.09). Positive cyst sign was a significant risk factor for cage subsidence (OR: 8.52; 95% CI: 2.73-26.62) while cage subsidence was also a significant risk factor for positive cyst formation (OR: 8.37; 95% CI: 2.71-25.89).

CONCLUSIONS

Cystic lesion may increase back pain in the early postoperative period. However, the preoperative cystic lesion does not aggravate a positive cyst formation or affect the final clinical result. Positive cyst formation was a significant risk factor for cage subsidence. In addition, cage subsidence was a significant predictor of non-union. Thus, the authors can speculate that positive cyst sign was potentially an indirect predictor of non-union.

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.

Treatment of Naturally Degenerated Canine Lumbosacral Intervertebral Discs with Autologous Mesenchymal Stromal Cells and Collagen Microcarriers: A Prospective Clinical Study

Intervertebral disc (IVD) degeneration is a frequent disease in modern societies and at its later stages is likely to cause chronic low back pain. Although many studies have been published, the available treatments for IVD degeneration fail to promote regeneration or even marginal repair of the IVD structure. In this study, we aimed to establish veterinary canine patients as a translational large animal model that recapitulates IVD degeneration that occurs in humans, and to investigate the suitability of intradiscal application of mesenchymal stromal cells (MSC). Twenty client-owned dogs diagnosed with spontaneous degenerative lumbosacral IVD and low back pain were included in the study. Autologous MSC were isolated from bone marrow and cultured for 2 weeks. Prior to injection, MSC were attached on collagen microcarriers for delivery, with or without TGF-β1 crosslinking. After decompressive spinal surgery, dogs received an intradiscal injection of MSC-microcarriers (n = 11), MSC-TGF-β1-microcarriers (n = 6) or microcarriers only (control, n = 3). MSC-microcarriers were initially evaluated in vitro and ex vivo, to test cell chondrogenic potential and biomechanical properties of the microcarriers, respectively. Clinical performance and Pfirrmann grading were evaluated at 10 months after the injection by magnetic resonance imaging. MSC differentiated successfully in vitro towards chondrogenic phenotype and biomechanical tests showed no significant differences of IVD stiffness after microcarrier injection. In vivo injection was successful in all dogs, without any visible leakage, and clinical functioning was restored back to normality. However, postoperative Pfirrmann grade remained identical in all dogs, and formation of Schmorl’s nodes was detected in 45% of dogs. This side effect was reduced by halving the injection volume, which was then observed only in 11% of dogs. In conclusion, we observed marked clinical improvement in all groups, despite the formation of Schmorl’s nodes, but microcarriers and MSC failed to regenerate the structure of degenerated IVD.

Evolution of a Schmorl's Node and a Degenerative Osteophyte on Sequential 68Ga-DOTATATE PET/CT Scans: Potential Pitfalls in Neuroendocrine Tumor Imaging

Schmorl's node (SN) arises from the herniation of the nucleus pulposus of the disc through the cartilaginous endplate into the body of the vertebra. Our report describes a patient with carcinoid tumor who underwent a series of Ga-DOTATATE PET/CT scans for follow-up, demonstrating gradually increasing focal vertebral uptake in absence of CT abnormality, suspicious for a metastasis. Both CT and MRI eventually revealed classical findings of a SN. Also observed in the same vertebra is a degenerative osteophyte showing intense Ga-DOTATATE uptake. This interesting case shows 2 benign spinal lesions, which potentially can simulate bone metastasis in patients with neuroendocrine tumors.

Back Pain in a Pediatric Emergency Department: Etiology and Evaluation

OBJECTIVES

Back pain is an uncommon chief complaint in the pediatric emergency department (ED). However, there are serious underlying conditions requiring prompt diagnosis and treatment. While the etiology is usually benign, variation exists in the evaluation. The study purpose was to describe pediatric patients who presented to the ED with back pain and evaluate for associations with laboratory and radiologic abnormalities indicative of underlying musculoskeletal pathology.

METHODS

A retrospective review was conducted of patients aged birth to 18 years who presented to a pediatric ED with a chief complaint of back pain during a 1-year period. Primary outcome was discharge diagnosis, categorized as nonpathologic back pain, pathologic back pain, and other etiologies. Descriptive statistics were used.

RESULTS

Two-hundred thirty-two patient encounters were reviewed, with 177 included in data analysis. A nonpathologic diagnosis of back pain was found in 76.8% of visits. Back pain and back or muscle strain were the most common diagnoses. Pathologic back pain diagnoses represented 2.3% of visits. Radiologic imaging was performed in 37.9%. Positive findings were noted in 16.9% of radiographs; no abnormalities were noted on computed tomography scan or magnetic resonance imaging. Laboratory studies were conducted in 35%. Abnormal plain radiographs were associated with a pathologic diagnosis of back pain (P < 0.001).

CONCLUSIONS

Most pediatric patients presenting to the ED with back pain were found to have a nonpathologic etiology and were discharged. Among those with a pathologic back pain diagnosis, abnormal radiograph findings were the only statistically significant factor, whereas laboratory studies, computed tomography scans, and magnetic resonance imaging scans were less indicative.

A Case of Persistent Low Back Pain in a Young Female Caused by a Trauma-Induced Schmorl's Node in the Lumbar Spine Five Vertebra

Physicians are often faced with managing difficult conditions such as chronic lower back pain. Intervertebral disk herniation typically occurs horizontally, leading to impingement of the spinal cord which can potentially cause radicular symptoms or other spinal cord pathologies; however, disk herniations can also occur vertically and extend through the endplate of an adjacent cranial or caudal vertebra: a phenomenon known as a Schmorl’s node. Although Schmorl’s nodes can be seen in many asymptomatic individuals, they can be a cause of degenerative disk disease and low back pain. An 18-year-old female with a history of trauma presented to urgent care with increasing lower back pain for the past six weeks. Four months prior, she was struck by a motor vehicle while riding her bicycle, and she had residual back pain since then. Plain radiography at the time of the accident showed no acute abnormalities. She had no other associated symptoms. On presentation, her vital signs were within normal limits, and her physical examination was largely unremarkable except for point tenderness along the lumbar (L4-L5) region of the spine. A complete blood count showed no leukocytosis and plain radiography of the lumbosacral spine showed a Schmorl’s node in the inferior endplate of L5. The patient was diagnosed with a trauma-induced Schmorl’s node and was treated with physical therapy, ice packs, and non-steroidal anti-inflammatory drugs. Her symptoms improved over the next several months. For patients with a history of axial load trauma and persistent back pain, clinicians should consider the possibility of a trauma-induced Schmorl’s node. Plain radiography or magnetic resonance imaging can help with the diagnosis and guide further management.

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.

Magnetic resonance imaging assessment of degenerative cervical myelopathy: a review of structural changes and measurement techniques

Degenerative cervical myelopathy encompasses a spectrum of age-related structural changes of the cervical spine that result in static and dynamic injury to the spinal cord and collectively represent the most common cause of myelopathy in adults. Although cervical myelopathy is determined clinically, the diagnosis requires confirmation via imaging, and MRI is the preferred modality. Because of the heterogeneity of the condition and evolution of MRI technology, multiple techniques have been developed over the years in an attempt to quantify the degree of baseline severity and potential for neurological recovery. In this review, these techniques are categorized anatomically into those that focus on bone, ligaments, discs, and the spinal cord. In addition, measurements for the cervical spine canal size and sagittal alignment are also described briefly. These tools have resulted collectively in the identification of numerous useful parameters. However, the development of multiple techniques for assessing the same feature, such as cord compression, has also resulted in a number of challenges, including introducing ambiguity in terms of which methods to use and hindering effective comparisons of analysis in the literature. In addition, newer techniques that use advanced MRI are emerging and providing exciting new tools for assessing the spinal cord in patients with degenerative cervical myelopathy.

Schmorl Nodes Can Cause Increased 68Ga DOTATATE Activity on PET/CT, Mimicking Metastasis in Patients With Neuroendocrine Malignancy

Schmorl node (SN) is the herniation of the nucleus pulposus through the cartilaginous and bony endplate into the adjacent vertebral body. It is documented that SNs produce areas of moderately increased F-FDG uptake. We present a case of a patient with history of neuroendocrine tumor, who underwent Ga DOTATATE PET/CT for follow-up, showing increased focal vertebral uptake suggestive of bone metastasis. CT revealed typical findings of an SN. The presented case indicates that SNs should be considered when encountering focally increased skeletal uptake in Ga DOTATATE PET/CT studies, which can mimic metastasis in patients with history of neuroendocrine tumors.

Computed Tomography Findings Associated with Clinical Outcome After Dynamic Posterior Stabilization of the Lumbar Spine

OBJECTIVE

To evaluate whether preoperative multirow detector computed tomography (MDCT) findings were associated with clinical outcome 24 months after dynamic stabilization for painful degenerative lumbar spine disease.

METHODS

Preoperative MDCT examinations of 63 patients (66 ± 11.7 years; 60% women) treated with a dynamic screw rod system for painful degenerative segmental instability with/without spinal stenosis were assessed for quantitative and qualitative parameters defining degenerative changes of the thoracolumbar spine, including grades of disc herniation, degenerative spondylolisthesis, vertebral body sclerosis, cross-sectional area of the spinal canal at disc level, intervertebral disc height, ancillary bone mineral density, and anteroposterior diameter of intervertebral foramina. Clinical performance was assessed at baseline and 24 months with quantitative scales, including the Oswestry Disability Index and Short-Form 36 physical component summary. For statistical analysis classification and regression trees, linear regression and nonparametric tests were used.

RESULTS

Clinical scores improved substantially over 24 months compared with preoperative values (delta Oswestry Disability Index -32.1 ± 17.2, delta Short-Form 36 physical component summary 4.9 ± 2.3). Physical component summary improvement was significantly better in patients with lower grades of disc herniation (P < 0.001) and/or spondylolisthesis (P = 0.011), lower cross-sectional area of the spinal canal (P = 0.043), high intervertebral disc height (P = 0.006), and high grades of vertebral body sclerosis (P = 0.002). Patients with high bone mineral density and initially low diameter of intervertebral foramina showed a significantly better improvement of Oswestry Disability Index (P < 0.05).

CONCLUSIONS

Clinical improvement after dynamic stabilization was significantly associated with 7 independent baseline imaging findings. Preoperative evaluation of these MDCT parameters may improve therapy selection for patients with degenerative lumbar spine disease.

CONTROVERSIES ON VERTEBROPLASTY AND KYPHOPLASTY FOR VERTEBRAL COMPRESSION FRACTURES

Vertebroplasty and kyphoplasty are widely used for osteoporotic and cancer-related vertebral compression fractures refractory to medical treatment. Many aspects of these procedures have been extensively discussed in the literature during the last few years. In this article, we perform a critical appraisal of current evidence on effectiveness and ongoing controversies regarding surgical technique, indications and contraindications, clinical outcomes and potential complications of these procedures.

Giant Schmorl's Node may Cause High Uptake and Mimic a Bone Metastasis on (18)F-Choline Positron Emission Tomography/Computed Tomography

Bone metastasis in prostate cancer are detected by choline positron emission tomography/computed tomography (PET/CT) with high sensitivity and specificity. We report the case of a patient with previous prostatectomy for prostate cancer who underwent F-choline PET/CT for a recent increased of prostate-specific antigen value and showed focal vertebral uptake suggestive for skeletal metastasis; magnetic resonance imaging revealed unexpectedly a Schmorl's node (SN). False positives on choline PET-CT caused by SN has not be reported in the literature and the present case highlights that this possibility should be considered in case of choline vertebral increased uptake in the patient with prostate cancer.