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|LETTER TO EDITOR
|Year : 2014 | Volume
| Issue : 5 | Page : 573-574
Acute severe backache: Do not forget to look beneath the disc
Mandeep Singh Ghuman, Sameer Vyas, Chirag K Ahuja, Niranjan Khandelwal
Department of Radio diagnosis, Post-Graduate Institute of Medical Education and Research, Chandigarh, India
|Date of Submission||01-Sep-2014|
|Date of Decision||03-Oct-2014|
|Date of Acceptance||05-Oct-2014|
|Date of Web Publication||12-Nov-2014|
Department of Radio diagnosis, Post-Graduate Institute of Medical Education and Research, Chandigarh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Ghuman MS, Vyas S, Ahuja CK, Khandelwal N. Acute severe backache: Do not forget to look beneath the disc. Neurol India 2014;62:573-4
Schmorl's nodes or intervertebral disc herniations are commonly seen incidental finding on imaging, often asymptomatic. However, acute Schmorl node, also known as acute cartilaginous node, is a rare and perhaps under-recognized entity, which can cause intense localized back pain. In this article, we describe one such case.
A 35-year-old otherwise healthy male presented with acute severe low backache of two days duration. There was no history to suggest radicular pain or claudication. Pain was localized to lower lumbar region. Neurologic examination was essentially normal. Magnetic resonance imaging (MRI) of lumbosacral spine [Figure 1] and[Figure 2] revealed intravertebral disk herniation through the superior endplate of L3 and S1 vertebrae with bone marrow edema surrounding the herniated nucleus pulposus.
|Figure 1: Sagittal T1-weighted (a), T2-weighted (b) and T2-weighted fat-suppressed (c) MR images demonstrate defect in superior end plate of L3 vertebra with herniation of disc material through it (thin arrow; a) with concentric rim like bone marrow hyperintensity (up arrow; b, c)|
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|Figure 2: Intraosseous disc prolapse is noted through superior end plate of S1 vertebra (down arrow, d), with subtle surrounding marrow edema on T2 weighted and fat suppressed images (down arrow; e, f respectively)|
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Schmorl's node classically known as intervertebral disc herniation was first described by Schmorl in 1927.  Generally, the Schmorl nodes are considered to be an asymptomatic incidental finding on imaging. Non-acute asymptomatic Schmorl nodes are common spinal abnormalities and are found in 38%-75% of the population.  A recent study reported that the majority of Schmorl nodes are located in the upper lumbar levels with the highest prevalence in L2/3 level, whereas earlier studies showed the location more common in the T7-L1 region. , MRI studies of lumbar spine in patients with low back pain have shown almost double the frequency of Schmorl nodes in the symptomatic group as compared to the control group (19% vs. 9%).  In addition, in symptomatic patients the vertebral body marrow surrounding the Schmorl node show marrow edema, hypointensity on T1-weighted sequences and hyperintensity on T2-weighted and short tau inversion recovery (STIR) sequence. 
Acute cartilaginous node, also known as acute Schmorl node, is an unusual cause of intense localized back pain.  In most of the cases, the presentation is spontaneous or can follow trauma, or vigorous exercise. Most common location is the upper lumbar spine. On MRI, diagnostic clue is the presence of focal bone marrow signal change, bone marrow edema. Close imaging differentials include infective spondylitis or neoplastic lesion, but acute Schmorl node can be diagnosed by demonstrating herniated disc content, marrow edema focally around the herniated disk, lack of diffuse disk signal change and osseous defect involving single end plate. , Management is usually conservative; bed rest, analgesics and bracing being the mainstay of treatment.  In cases where medical therapy is ineffective, various surgical interventions have been suggested, for example, excision of the disc with segmental fusion, vertebroplasty and denervation of the ramus communicans nerve. 
In cases of acute localized back pain, in addition to looking for the usual causes like spinal canal or foraminal herniation of the disc material, it is imperative to look beyond the disc margins in sagittal plane so as not to miss the acute intraosseous disc herniation, which is uncommon and at times, too subtle, to be detected if not sought specifically with careful scrutiny with high index of suspicion. Unusual features of this case include concurrent acute symptomatic Schmorl nodes at two different vertebral levels and sacral vertebral involvement, which have not been described previously.
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[Figure 1], [Figure 2]