A 19 y.o. male is driving down the highway when he is cut off by a semi and swerves into the median. His car becomes airborne and rolls five times. He comes to the ED complaining of neck pain.
What abnormality is present on the C-spine xray?
The patient had Schmorl’s nodes at C6 . These are protrusions of disc material into the cartilaginous vertebral body endplates which can cause inflammation. The protrusions cause necrosis of vertebral bone. These bony erosions have been reported after trauma but are much more commonly associated with aging and degenerative disease. There is a theory that they are exacerbated by Vit D deficiency.
These nodes are also found in animals with a report of symptom resolution after surgery. See the reference to an Airedale terrier below.
Teaching points
The classical teaching of how to read a cervical spine xray involves checking the anterior vertebral line, the posterior vertebral line and thespinolaminar line. After reviewing the diagram try to draw the lines on the image below. This is a patient who presented after a Saturday party ( where he became quite intoxicated) with severe neck pain.
this patient had a complex C2 fracture and required surgical fixation.
CONCLUSION
The 19 y.o. pt who rolled his car received a CT of the neck showing the schmorl’s node. He then received an MRI showing marrow edema at C6. It was felt this was not an acute injurysince there was no surrounding prevertebral edema and he was discharged. His Vit D level was sent from the ED and found to be low. The patient was notified that he should follow up with his primary care physician for Vit D replacement and if his Vit D remains low; for a workup for malabsorption.
Peng B, Wu W, Hou S, Shang W, Wang X, Yang Y. 2003. The pathogenesis of Schmorl’s nodes. J Bone Joint Surg Br. 85(6): 879-82.
Abu-Ghanem S. Ohana N. Abu-Ghanem Y et al. Acute schmorl node in dosal spine: an unusual cause of sudden severe bacvk pain in a young female Asian Spine J. 2013;7(2):131-5.
Diehn FE, Maus TP, Morris JM et al. Uncommon Manifestations of Intervertebral Disk Pathologic Conditions. Radiographics. 2016;36(3): 801-23.
Plomp, K, Vioarsdottir U, Weston D, Dobney K, Collard M. (2015) The ancestral shape hypothesis: an evolutionary explanation for the occurrence of intervertebral disc herniation in humana. BMC Evolutionary Biology 15.
Balzer W, Hillebrand L, Smith J, Stieger-Vanegas M. Surgical management of a Schmorl’s node in an Airedale Terrier and review of the literature. Vet Comp Orthop Traumatol 2012;25:167-171.