Vertebral Body Fracture and Vertical Herniated Disc
“Schmorl's nodes were first described by the pathologist Christian Schmorl in 1927, as a herniation of the nucleus pulposus through the cartilaginous and bony endplate into the vertebral body. [pg. 39]
There are two scientific methods used in determining the “age” of the Schmorl’s Node [SN], first is the comparison between plain film radiographs and the MRI. Acute SN will appear on the MRI but NOT the radiograph since there is no boney callus formation from the “healing” process. By way of comparison, a Chronic SN will appear on both the MRI and the radiograph.
The second scientific method is observing the changes in the vertebral body endplate using Modic’s methods which reached consensus in 1988. There are three different types of changes that can be observed and each identifies the progressive spectrum of injury and degeneration. Each of the 3 types of Modic changes have specific observational criteria on the MRI study, however the one that we are most interested in is Modic Type 1 which is the earliest observed change. The authors state, “Type I changes are hypointense [dark] T1WI [T1 weighted image] and hyperintense [bright] in T2WI [T2 weighted image] and represent, at the histological level, bone marrow edema and inflammation.”
The T1 and T2 images are MRI imaging protocols that help differential different types of injuries and compounds. When we see the presence of Modic 1 changes in the vertebral body on the MRI, correlation of pain at that level following a single traumatic event and the absence of boney callus on plain film there is no other diagnosis other than an Acute SN.
The interesting thing however is the authors continued statement, “In his original studies, Modic noted that the majority of patients with type 1 changes eventually had conversion to type 2 changes overtime, whereas patients with type 2 abnormalities usually displayed little change, occasionally progressing to type 3 after a long period. Therefore, it is common consent among the majority of experts that the progression of Modic type 1 to type 2 and type 3 represents the natural history of the endplate changes associated with degenerative disc disease, with type 1 representing the acute phase, type 2 the chronic phase, and type 3 the later sclerotic end stage.” [pg. 40] What this means is the patient’s spine after an Acute SN injury will degenerate, therefore FUTURE CARE is absolutely indicated and medically necessary.
The authors continue by stating “Such findings, which would indicate the presence of inflammation and edema in the bone marrow, seem to have a high sensitivity and specificity for identifying such subgroup of patients with so-called painful Schmorl's nodes.” [42] Working with a doctor that understands the evaluation and documentation of acute spinal injury including Schmorl’s nodes is a CRITICAL part of caring for and representing the traumatically injured patient. It is the proper ordering of tests, eliciting a proper history from the patient and correlating those findings clinically to the causative event that will identify the acute injury.
Reference:
1. Mattei, T. A., & Rehman, A. A. (2014). Schmorl's nodes: current pathophysiological, diagnostic, and therapeutic paradigms. Neurosurgical review, 37(1), 39-46.
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