ABSTRACT Back pain is one of the major contributors to disability and loss of productivity in modern
populations. However, osteological correlates of back pain are often absent or, as yet,
unidentified. As bioarchaeologists depend on osteological evidence to interpret quality of
life in the past, back pain, with its profound effects on modern populations, is largely
overlooked in archaeological samples. This study addresses this shortcoming in bioarch-
aeological analysis by exploring the relationship between a defined vertebral osteological
lesion, the Schmorls node, and its effect on quality of life in a clinical population. Using patient
insight, healthcare practitioner diagnoses and MR imaging analyses, this study investigates:
(1) Schmorls nodes and sociodemographic factors; (2) the number, location and quantitative
aspects (e.g. length, depth, area) of Schmorls nodes, and how these influence the reporting
of pain; (3) the dynamic effects of Schmorls nodes, in combination with other variables, in the
reporting of pain; and (4) the perception and impact of pain that patients attribute to Schmorls
nodes with regard to quality-of-life issues. The results of this study indicate that Schmorls
nodes located in the central portion of the vertebral body are significantly associated with
patient reporting of pain, and that the presence of osteophytes, in the affected vertebral
region, may increase the likelihood that an individual will report pain. This finding provides
bioarchaeologists with an osteological correlate to begin interpreting the presence and
impact of pain in archaeological populations, with implications for scoring Schmorls nodes.
Copyright 2007 John Wiley & Sons, Ltd.
Copyright # 2007 John Wiley & Sons, Ltd. Received 25 June 2006
Revised 6 November 2006
Accepted 20 February 2007
Significance of Schmorls Nodes 29
reporting of pain; (3) the dynamic effects although this is not often supported by radiological
of Schmorls nodes, in combination with other findings. This is problematic for bioarchaeology, as
variables, in reporting pain; and (4) the perception researchers in this field depend upon skeletal indi-
and impact of pain attributed to Schmorls nodes by cators to interpret life in the past.
patients on their quality of life. This study tests If back pain is so debilitating today, even with
whether Schmorls nodes are capable of causing the advantage of modern medicine, its effects on
back pain, and it is hypothesised that the degree of populations in the past must have been profound
pain is related to the number, location and physical as well. Therefore, if skeletal correlates of back
characteristics (e.g. length, depth, area) of the pain are not understood, then a major issue of past
nodes. If a significant relationship between life is largely being overlooked. The present study
Schmorls nodes and pain is found, then this study addresses this shortcoming in bioarchaeological
will provide bioarchaeologists with an osteological analysis by exploring the relationship between a
correlate to begin interpreting the presence and defined spinal osteological lesion and its effect on
impact of pain in archaeological populations. quality of life in a clinical population, using
patient insight, healthcare practitioner diagnoses,
and magnetic resonance imaging (MRI) analyses.
The results of this study may then be used by
Back pain bioarchaeologists to arrive at more holistic
interpretations of life in archaeological popu-
The ability to work and be a productive member lations.
of society is important. In the US, health statistics
indicate that back pain is one of the primary
factors leading to a loss of productivity (Argoff & Schmorls nodes
Wheeler, 1998). Approximately 27% of work-
place injuries are related to the back, costing that Schmorls nodes were extensively studied by and
nation an estimated 11 billion dollars in care named after Georg Schmorl (Schmorl, 1926;
(1994 statistic: National Institutes of Health, Schmorl & Junghanns, 1959). Technically, the
1997) and between 50 and 100 billion dollars term Schmorls node applies to prolapsed inter-
per year in lost work and disability payouts (1990 vertebral disc material that enters into the
statistic: Centers for Disease Control and Pre- vertebral body, superior or inferior to the disc
vention, 1998). It is estimated that 80% of the US (Schmorl & Junghanns, 1959: 133). However, this
population will at some point suffer from back term has been adopted to apply to the end result
pain (Kelsey & White, 1980), the highest rates of the prolapsed disc, or the lesion that eventually
occurring in middle-aged1 individuals (National forms on the surface of the affected vertebral
Institutes of Health, 1997). As Argoff & Wheeler body. In this study, the term Schmorls node will
(1998) summarised, back pain is the leading cause refer to the osteological lesion (Figure 1). Defined
of disability in the under-45 age group, the fifth as such, Schmorls nodes are quite commonly
leading cause of hospitalisation, and the third found in archaeological, cadaveric and extant
leading cause of surgery. populations (for examples, see Merbs, 1983;
Although back pain has such an adverse effect on Malmivaara et al., 1987; Wagner et al., 2000).
populations and productivity, its causes are still However, despite the prevalence of Schmorls
under investigation, and corresponding osteologi- nodes throughout time, and despite the fact that
cal indicators continue to perplex and/or evade the this type of lesion has been the focus of research
medical community. As Argoff & Wheeler (1998) for nearly a century, the link between Schmorls
argued in their review of various studies, most acute nodes and pain is still poorly understood.
pain is non-specific, and chronic pain is usually The process of Schmorls node formation
considered to be caused by degenerative changes, (Schmorl & Junghanns, 1959) begins with an
1 inferiorly or superiorly directed extrusion of
Although middle-aged is not defined in this publication (NIH,
1997), the author does note that back pain is the most frequent nucleus pulposus material. Subsequently, the fluid
reason for activity limitation in individuals less than 45 years. travels through a break or fissure in the cartila-
Copyright # 2007 John Wiley & Sons, Ltd. Int. J. Osteoarchaeol. 18: 2844 (2008)
DOI: 10.1002/oa
30 K. J. Faccia and R. C. Williams
Copyright # 2007 John Wiley & Sons, Ltd. Int. J. Osteoarchaeol. 18: 2844 (2008)
DOI: 10.1002/oa
Significance of Schmorls Nodes 31
Sadlermiut of Hudson Bay, Canada (Merbs, advent of MRI technology, Schmorls nodes are
1983); and Colonial and slave era African- more quickly and frequently detected in extant
American communities in the southern US populations (Walters et al., 1991; Hamanishi et al.,
(Angel et al., 1987; Kelley & Angel, 1987; Owsley 1994). Therefore, the process of node formation,
et al., 1987; Rathbun, 1987; Parrington & Roberts, and the prevalence of Schmorls nodes within
1990). Together, these archaeological studies and living individuals and populations, is becoming
observations indicate that Schmorls nodes are clearer.
found cross-culturally, throughout various time Currently, studies in extant populations pre-
periods, and in groups differing in subsistence and sent reports of both symptomatic (Smith, 1976;
overall activity patterns. Walters et al., 1991; Hamanishi et al., 1994;
A few of the bioarchaeological studies above Takahashi & Takata, 1994; Takahashi et al., 1995;
note the presence of Schmorls nodes, but do little Wagner et al., 2000) and asymptomatic nodes
else to interpret them (Buikstra & Cook, 1981; (Hamanishi et al., 1994; Ogon et al., 2001). In
Merbs, 1983; Kramar et al., 1990). Others (Angel general, researchers argue that Schmorls nodes
et al., 1987; Owsley et al., 1987; Kelley & Angel, may be an initial, post-traumatic source of pain,
1987; Baker, 1997; Coughlan & Hoist, 2000; but they hesitate to attribute long-lasting painful
Knusel, 2000; Knusel & Boylston, 2000) use the effects to the lesions. Often, researchers report
presence of Schmorls nodes as indicators of the presence of a painful Schmorls node, but that
demanding physical activity. Some authors go pain tends to subside within weeks (Smith, 1976;
further by using Schmorls nodes to assess Walters et al., 1991; Takahashi et al., 1995;
differences in activity patterns between the sexes Wagner et al., 2000), often within the time-frame
(Rathbun, 1987; Parrington & Roberts, 1990) or necessary for the healing of joint and soft tissue
between social classes (Robb et al., 2001). injuries (Argoff & Wheeler, 1998). However,
However, none of the researchers question the conclusions of these studies do not echo the
how Schmorls nodes impacted the quality of experience of many patients, who insist that their
life experienced by historic and prehistoric Schmorls nodes are chronically painful.
peoples. The lack of this sort of analysis is partly Although patients claim that their Schmorls
due to ambiguity in the medical literature as to nodes cause pain, the medical community still
whether Schmorls nodes cause pain. If the impact disputes whether these nodes are actually painful,
of Schmorls nodes in clinical samples were better or whether the pain is due to other factors, either
understood, bioarchaeologists would be able to physically or psychologically mediated (Argoff &
assess these lesions with regard to their impact on Wheeler, 1998). Essentially, a disconnection
an individuals and groups quality of life, as well exists between the pain that a patient attributes
as social dynamics issues. For example, in past to the Schmorls node(s) and the conclusions of
populations, back pain could have led to an modern medical studies, which are unable to find
individuals dependence on others, and this could a link between the lesion and pain. Therefore,
have led to a diminished status within the social particularly for bioarchaeological studies, it is
group. Particularly if physical activity were important to continue analysing the relationships
constant and demanding, pain could have greatly between qualitative and quantitative aspects of
affected the health and survival of an individual. the Schmorls node, a defined osteological lesion,
On a larger scale, chronic back-pain issues could and perceived pain. Such analyses will then
conceivably have compromised the overall facilitate more informed interpretations of
strength, health and viability of a social group. quality-of-life issues in the present and past.
The hesitation of the medical and research
communities to attribute pain to Schmorls nodes
Modern context may be due to a long-standing lack of under-
standing as to the innervation of the vertebral
In the medical community, confusion exists as to body. Most research involving the innervation of
whether Schmorls nodes cause pain. Researchers the spinal complex focuses on soft-tissue anatomy
continue to study these lesions and, with the rather than on the vertebrae themselves (Anto-
Copyright # 2007 John Wiley & Sons, Ltd. Int. J. Osteoarchaeol. 18: 2844 (2008)
DOI: 10.1002/oa
32 K. J. Faccia and R. C. Williams
nacci et al., 1998). However, recent studies Accountability Act2 (HIPAA) and adult consent
indicate that nerves enter the vertebral body forms were signed by all volunteers (291), and
through basivertebral foramina and small aper- those patients with documented evidence of
tures in the anterior cortex (Antonacci et al., Schmorls nodes were chosen for inclusion in the
1998). Also, Fras et al. (2003) found that study (33; 11.3%). In compliance with HIPAA
basivertebral nerves stain positive for substance regulations, all patient data were anonymised by
P, a peptide neurotransmitter that is released assigning each individual an identification number,
in response to painful stimuli. Therefore, the which was used for all subsequent data collection.
authors postulate that basivertebral nerves are
probably a part of the sympathetic nervous
system, which strongly suggests that nerves
within vertebral bodies are capable of transmit- Data collection
ting painful signals (Fras et al., 2003). In addition
to the findings indicating that vertebral bodies are Data were collected from the following sources:
heavily innervated, researchers have discovered the patient, the patients medical chart, diagnostic
that nerve bundles are frequently found in imaging reports, and patient MRIs.
association with vertebral fractures, extruded The questionnaire was based on a modified
bone marrow, and, in some instances, near-new clinic form that patients were required to
endochondral bone formation (Antonacci et al., complete upon their initial visit to Spectrum
2002). Therefore, Antonacci et al. (2002) post- Pain Clinic. Demographic and socioeconomic
ulate that these nerve bundles not only aid in the information was included, general questions
healing process, but may be a factor in generating addressing back pain were modified to address
back pain. specifically the pain that patients attributed to
Based on this information, it seems logical that their Schmorls nodes, and questions were added
spinal lesions, such as Schmorls nodes, would regarding the impact of Schmorls nodes on
cause pain. It further follows that the acuity and quality of life issues. Twenty-six (79%) patients
longevity of pain caused by the Schmorls node completed and returned the questionnaire.
could be related to the location and size of the Two forms were used to collect data from the
lesion, or the degree to which it overlaps with or patients chart. One form was used to collect
aggravates an innervated region. In support of this additional demographic, family medical, and pain
hypothesis, Ogon et al. (2001) did find that larger history information prior to clinic treatment. This
and more anteriorly located (non-Schmorls form was collected for all patients (n 33). The
node) vertebral lesions were significantly corre- second form was used to collect data based on
lated with pain. Therefore, the premise of this healthcare practitioner forms that were com-
study is that Schmorls nodes are capable of pleted upon each individual medical appoint-
causing pain, and it is hypothesised that the ment. In addition to the patients age, weight
degree of pain is related to the number, location and height, information was gathered on the
and physical characteristics (e.g. length, depth, spinal region where pain was presented, aggra-
area) of the nodes. vating and relieving factors, the history of pain
and pain treatment, and a diagnostic review of
patient health. This form was collected for each
Materials and methods patient (n 33), for monthly visits extending as
far back as January 2002 (total n 328), but only
Sample for the visits after which a Schmorls node(s) was
Copyright # 2007 John Wiley & Sons, Ltd. Int. J. Osteoarchaeol. 18: 2844 (2008)
DOI: 10.1002/oa
Significance of Schmorls Nodes 33
3
The location of a Schmorls node is dependent on several factors,
including the structural integrity of the intervertebral disc and
cartilaginous endplate, the shape of the vertebral body, and the
direction of loading on the spine. All but one of the Schmorls nodes
in this study are considered central (versus peripheral) Schmorls
nodes, as defined by Hansson & Roos (1983), meaning that the
lesion is found directly under the intervertebral disc. However, in
this study, the terms anterior, central and posterior are used to
describe the location of the Schmorls node on the vertebral body in Figure 3. Vertebral body length calculated by polylines in
order to analyse how location on the sagittal plane influences the ArcMap 8.2. This figure is available in colour online at
reporting of pain. www.interscience.wiley.com/journal/oa.
Copyright # 2007 John Wiley & Sons, Ltd. Int. J. Osteoarchaeol. 18: 2844 (2008)
DOI: 10.1002/oa
34 K. J. Faccia and R. C. Williams
of the Schmorls node. Logistic regression models superior location of the Schmorls node; (2) the
were used to test whether there was any total number of Schmorls nodes in the region in
relationship between the reporting of pain and question; (35) the anterior, central or posterior
the characteristics of Schmorls nodes, as well as positioning of the Schmorls node on the
whether or not a Schmorls node(s), in combi- vertebral body; (6) the maximum length percen-
nation with other variables, is more likely to tage of the Schmorls node relative to the
predispose a person to report pain. For all vertebral body; (7) the maximum depth percen-
analyses, the explained (dependent) variable tage of the Schmorls node relative to the
was reported pain. vertebral body; and (8) the maximum area of
The Schmorls node is the level of analysis for the vertebral body occupied by the Schmorls
the physical characteristics of the lesions. In node(s). Maximum percentage values, as
exploring the relationship of Schmorls node recorded in the MRI slices, were used because
physical characteristics and pain, the explanatory one of the hypotheses tested in this study is that it
(independent) variables were: (1) the inferior or is the size of the Schmorls node that influences
Figure 5. Vertebral body height calculated by polyline in Figure 7. Vertebral body area calculated by polygons in
ArcMap 8.2. This figure is available in colour online at ArcMap 8.2. This figure is available in colour online at
www.interscience.wiley.com/journal/oa. www.interscience.wiley.com/journal/oa.
Copyright # 2007 John Wiley & Sons, Ltd. Int. J. Osteoarchaeol. 18: 2844 (2008)
DOI: 10.1002/oa
Significance of Schmorls Nodes 35
Copyright # 2007 John Wiley & Sons, Ltd. Int. J. Osteoarchaeol. 18: 2844 (2008)
DOI: 10.1002/oa
36 K. J. Faccia and R. C. Williams
Copyright # 2007 John Wiley & Sons, Ltd. Int. J. Osteoarchaeol. 18: 2844 (2008)
DOI: 10.1002/oa
Significance of Schmorls Nodes 37
Table 2. Inferior and superior Schmorls nodes by spinal proved significantly associated with a patient
region reporting pain in the region of the Schmorls node
Spinal region Inferior node Superior node
was a centrally-located lesion, and this was a
positively significant relationship (OR 2.781,
Cervical 1 0 95% CI 1.471, 5.256, P 0.0016). Centrally-
Thoracic 24 17 located Schmorls nodes remained positively and
Lumbar 13 14
Sacral 0 1 significantly (OR 1.912, 95% CI 1.057,
3.458, P 0.0321) associated with the report-
ing of pain in a reduced logistic regression model,
superior nodes by region). According to each where only age, sex and body mass index were
MRI slice per individual, the total percentage area included as explanatory (independent) variables.
that Schmorls nodes occupied within a vertebral
body ranged from 0.10% to 21.1%. Schmorls
nodes ranged in length from 7.5% to 57.3% of the
vertebral body length, and in depth from 2.8% to Impact of Schmorls nodes
52.9% of the vertebral body depth at the location and variables on pain
of maximum node depth. Spinal regions had
between one and nine Schmorls nodes, with the Two additional logistic regression analyses were
mode being one lesion per spinal region. Six performed to assess whether synergistic effects
vertebrae had both superior and inferior nodes. existed between Schmorls nodes and the other
Schmorls nodes on the vertebral body were: 31 independent variables, thereby predisposing an
(44.3%) on the anterior third; 60 (85.7%) on the individual to report pain. The full logistic
central third; and 27 (38.6%) on the posterior regression model included 16 explanatory (inde-
third of the vertebral body. These positional pendent) variables. Subsequently, a second,
categories were not mutually exclusive. reduced logistic regression model included five
explanatory variables: age, sex, BMI, and the two
variables (i.e. failed back syndrome and osteo-
phyte presence) that were found to be signifi-
Statistical analysis of cantly associated with patient reporting of pain in
Schmorls nodes and pain the full regression model. Both models tested
whether these independent variables predisposed
A full logistic regression model (n 583) was a person to report pain in the region of the
performed to assess whether the length, depth, Schmorls node.
area, location or number of Schmorls nodes per The first logistic regression included the
column was more likely to predispose a patient to following explanatory (independent) variables:
report pain (Table 3). The only variable that age, sex, body mass index, spinal region of the
Table 3. Odds ratio (OR) values for explanatory variables used in the full and reduced regression models to test
whether Schmorls nodes and other variables are more likely to predispose an individual to report pain
Copyright # 2007 John Wiley & Sons, Ltd. Int. J. Osteoarchaeol. 18: 2844 (2008)
DOI: 10.1002/oa
38 K. J. Faccia and R. C. Williams
Table 4. Odds ratio (OR) values for explanatory variables used in full and reduced regression models to test whether
Schmorls nodes and other variables are more likely to predispose an individual to report pain
Age 0.987 (95% CI 0.960, 1.016; P 0.3756) 0.987 (95% CI 0.968, 1.007; P 0.1997)
Sex 0.889 (95% CI 0.412, 1.921; P 0.7652) 1.111 (95% CI 0.677, 1.822; P 0.6767)
Body mass index 0.999 (95% CI 0.937, 1.066; P 0.9858) 0.993 (95% CI 0.956, 1.031; P 0.7042)
Lumbar column 3.065 (95% CI 0.287, 32.697; P 0.3538)
Thoracic column 0.631 (95% CI 0.058, 6.835; P 0.7050)
History of trauma 1.088 (95% CI 0.489, 2.420; P 0.8361)
Degenerative disc disease 1.423 (95% CI 0.702, 2.886; P 0.3277)
Disk bulge/extrusion 1.790 (95% CI 0.693, 4.625; P 0.2293)
Desiccated disc 1.085 (95% CI 0.512, 2.297; P 0.8319)
Failed back syndrome 0.191 (95% CI 0.053, 0.689; P 0.0115) 1.266(95% CI 0.474,3.381; P 0.6378)
Joint abnormalities 1.237 (95% CI 0.492, 3.298; P 0.6186)
Stenosis 2.930 (95% CI 0.911, 9.428; P 0.0714)
Compression fracture 0.961 (95% CI 0.329, 2.811; P 0.9421)
Osteophytes 3.346 (95% CI 1.244, 9.002; P 0.0168) 0.943 (95% CI 0.448,1.986; P 0.8770)
Spinal cord abnormalities 1.084 (95% CI 0.310, 3.794; P 0.8993)
Cervical column Discarded by analysis
Statistically significant results.
Schmorls node (e.g. lumbar, thoracic, cervical), osteophytes and failed back syndrome when only
whether a history of trauma was associated with age, sex and body mass index were controlled
reported back pain, intervertebral disc abnorm- in the model. In this analysis, neither osteophy-
alities (e.g. degenerative disc disease, desiccated tes (OR 0.943, 95% CI 0.448, 1.986, P
disc, and ruptured/bulging disc), failed back 0.8770), nor failed back syndrome (OR 1.266,
syndrome, joint abnormalities, stenosis, compre- 95% CI 0.474, 3.381, P 0.6378), appeared to
ssion fractures, osteophytes, and spinal cord predispose a person with Schmorls nodes to be
abnormalities. For the pathological conditions more or less likely to report pain at a level of
in the spine that were used as explanatory statistical significance (see Table 4).
variables, each variable was recorded as present
only if the pathological condition was reported in
the same spinal region (e.g. lumbar, thoracic,
cervical) as the Schmorls node. Results (Table 4) Perceived pain attributed to Schmorls nodes
indicate that, when all of the aforementioned
variables were used in the model, only osteo- Twenty-six patients returned the patient ques-
phytes (OR 3.346, 95% CI 1.244, 9.002, tionnaire which addressed issues of pain that
P 0.0168; positive relationship) and failed back patients perceived to be related to their Schmorls
syndrome (OR 0.191, 95% CI 0.053, 0.689, nodes.6
P 0.0115; negative relationship) were signifi- 6
It is important to know that this section deals with perceptions of
cantly associated with Schmorls nodes and the pain. According to the staff at Spectrum Pain Clinics, Inc., after
reporting of pain. Results indicate that the diagnostic imaging, patients are usually told about the presence of
presence of osteophytes, in association with Schmorls nodes, but that the lesions do not have a significant impact
on their condition. Before answering the questionnaire, patients
Schmorls nodes, is more likely to predispose a were again reminded of their lesion(s). Because this could have
person to report pain than a person without affected the way in which they answered the questions (i.e. this
osteophytes in the region of a Schmorls node(s). could have influenced patients to perceive pain to degrees or in
locations that might not have seemed significant before learning
However, the presence of failed back syndrome, about their lesions), the link between Schmorls nodes and the
in the region of a Schmorls node(s), is less likely reporting of pain was primarily drawn from past routine clinical
to predispose a person to report back pain. examinations, during which healthcare practitioners noted the
specific regions of the spine where pain was reported, and during
The second (reduced) logistic regression tested which time patients probably considered their Schmorls nodes
the synergistic impact of Schmorls nodes and insignificant.
Copyright # 2007 John Wiley & Sons, Ltd. Int. J. Osteoarchaeol. 18: 2844 (2008)
DOI: 10.1002/oa
Significance of Schmorls Nodes 39
When asked if the pain that the patients (12; 46%) [the most common answers included
attribute to their Schmorls nodes began with hot baths (5) and lying on ones side (4)]; and
rupturing of a disc, 76.9% (20) of respondents applying cold (11; 42%). One patient reported
answered yes, 14.4% (4) answered no, 3.9% (1) that nothing relieves his or her pain (i.e. the pain
said that he or she didnt know, and 3.9% (1) did is constant).
not answer the question. Patients were also asked
to state what movements were involved in
injuring their backs. Lifting (13; 50%) was
identified as the most common activity leading Effects of pain
to back pain, with the other most identifiable
activity being pulling (8; 31%). When patients were asked if the pain that they
Patients were also asked about the duration and attribute to their Schmorls nodes limits their
severity of their pain, with patients being allowed activities, 92% (24) responded yes, and 8% (4)
to mark as many categories as applied. The failed to answer this question. When asked if this
majority of patients, 69.2% (18), said that the pain had caused the individual to miss work, of
pain had been constant since the ruptured disc the four patients still working, three (75%)
was diagnosed, with the remaining patients, answered yes. Of the total sample, including
30.8% (8), responding that the pain has been those now unemployed or on disability benefits,
frequent. Half (13) of the patients ranked the answers to the same question (missed work) were:
severity of pain as moderate to severe, and over 69% (18) yes, 15% (4) no, and 15% (4) failed to
50% (17) ranked their pain as severe and/or very respond to this question.
severe. No patients reported that they experi- Of the 33 patients included in the study, 15%
enced an absence of long-term pain related to (5) of individuals have employed the use of
their Schmorls nodes. mobility aids when visiting the clinic. Also, 39%
In the questionnaire, patients addressed the (13) were diagnosed, in at least one visit, of
sensations and types of pain that they attributed having an irregular gait. When healthcare practi-
to their Schmorls nodes. These symptoms were tioners diagnosed patient range of motion, 58%
based directly on Spectrum Pain Clinics, Inc. (19) of patients were assessed as having a reduced
admittance forms. The sensations most frequently range of motion in the region of the Schmorls
attributed to Schmorls nodes were tingling (9; node in at least one office visit. However, in at
73%), numbness (18; 69%) and pins and needles least one office visit, 70% (23) of patients were
(18; 69%). No patients reported an absence of diagnosed with normal range of motion in areas
sensations attributed to Schmorls nodes. affected by Schmorls nodes, and the same
The most common types of pain that the percentage of patients were diagnosed with a
patients attributed to the lesions were sharp reduced range of motion in an area not diagnosed
shooting (14; 54%), stabbing (13; 50%), burning as having a Schmorls node(s).
(12; 46%), throbbing (12; 46%) and aching (11; Notably, for those patients who had visited the
42%). No patients reported an absence of pain clinic three or more times, 19 (66%) reported
attributed to their Schmorls nodes. pain in the region of the Schmorls node at least
Patients were asked what aggravates and three times, or over the course of three months.
relieves their pain. The aggravating factors most This is important, because chronic pain is
frequently cited included standing (20; 77%), considered to be pain that lasts for three or
repetitive movements (18; 69%), stooping (15; more months (Borenstein, 2002). Hence, it is
58%), sleeping (13; 50%), sneezing (13; 50%), possible that Schmorls nodes are a source of
bowel movements (12; 46%), and emotional chronic back pain, although more detailed
upsets (11; 42%). No patients reported an analysis is necessary. Also noteworthy is the fact
absence of aggravating factors. that a third (11) of patients in this study were
Patients reported that the following methods diagnosed with depression during at least one
best helped to relieve their pain: prescription pain visit, with 27% (9) being diagnosed with
pills (24; 92%); applying heat (20; 77%); other depression during multiple visits.
Copyright # 2007 John Wiley & Sons, Ltd. Int. J. Osteoarchaeol. 18: 2844 (2008)
DOI: 10.1002/oa
40 K. J. Faccia and R. C. Williams
Copyright # 2007 John Wiley & Sons, Ltd. Int. J. Osteoarchaeol. 18: 2844 (2008)
DOI: 10.1002/oa
Significance of Schmorls Nodes 41
decrease the chances that a person with Schmorls researchers to address the impact of back pain in
nodes would report pain. past populations by providing a link between a
There are several possible reasons for these defined osteological lesion, the Schmorls node,
contradictory results. Firstly, it is possible that and the presence of reported back pain.
there is no real relationship between osteophytes Additionally, this study presents tentative evi-
or failed back syndrome and Schmorls nodes and dence that other pathological conditions, notably
pain. Perhaps the seemingly significant results of osteophytes, in combination with Schmorls
the first analysis were only artefacts of the data, or nodes, increase the likelihood that a person
they reflect other variables that were not had experienced back pain. Therefore, it is
included, but are either (1) related to osteophytes suggested that the bioarchaeologist score the
and/or failed back syndrome, or (2) their effects location of the Schmorls node (i.e. anterior 1/3,
only become observable when other factors are central 1/3, posterior 1/3) and note the presence
included. Alternatively, perhaps these relation- of osteophytes in the affected vertebral region.
ships, between Schmorls nodes and osteophytes It should be noted that this study does not
and failed back syndrome, really do exist. demonstrate that the productivity of individuals
Osteophytes are known to cause pain in some affected by Schmorls nodes was equally com-
instances (Lanyon et al., 1998; Lamer, 1999), and, promised in past and modern groups; but it does
in conjunction with Schmorls nodes, perhaps the provide evidence that Schmorls nodes could
pain becomes significant enough for a patient to have caused back pain, and that productivity
report it to his or her healthcare practitioner. could have been affected. With this information,
With regard to failed back syndrome, the answer the bioarchaeologist may begin to explore the
for the counterintuitive relationship, that it impact of pain in archaeological populations by
appears to reduce the likelihood of pain reported, combining the results of this study with other
might be an indirect benefit of the failed back forms of evidence for pain, disability and social
surgery or another course of back treatment. As dependence in the bioarchaeological record.
Antonacci et al. (1998) discussed, nerves enter the
vertebral body though various foramina. Because
of the partially exterior nature of the nerves,
impingement of the nerve fibres outside of the Conclusions
vertebral body could result in a diffused pain that
is felt within the vertebral body. Thus it could Analysing the impact of Schmorls nodes on pain
follow that, in conditions in which externally in a clinical sample, this study determined that
located nerve fibres were impinged upon prior to the only physical characteristic of Schmorls
surgery or other form of treatment, the procedure nodes that is significantly correlated with pain is a
could have successfully relieved the aggravating centrally located Schmorls node. In addition, the
factor(s); this, in turn, would lead to relief in the presence of osteophytes, in combination with
vertebral body with the Schmorls node. There- Schmorls nodes, could significantly increase the
fore, in instances where failed back syndrome reporting of back pain. Ultimately, this study
reduces the likelihood that a person with a provides evidence that a defined osteological
Schmorls node will report pain, the pain may lesion, whose impact has perplexed the medical
actually be a result of nerve aggravation at an community, is a likely contributor to chronic
external location and not the node itself. In this back pain. These results allow for the bioarch-
case, the Schmorls node(s) may only coinciden- aeologist to begin addressing a symptom that
tally be located on the aggravated vertebral body probably had as profound implications for past
in question. populations as it does for modern populations.
The evidence for back pain and its social
Implications for bioarchaeological research implications should be used in conjunction with
other bioarchaeological evidence for pain, dis-
The importance of this research for bioarchae- ability and social dependence, in order to arrive at
ology is that it offers a beginning point for more informed and insightful interpretations of
Copyright # 2007 John Wiley & Sons, Ltd. Int. J. Osteoarchaeol. 18: 2844 (2008)
DOI: 10.1002/oa
42 K. J. Faccia and R. C. Williams
quality-of-life issues in archaeological popu- photograph. The authors would also like to thank
lations. Dr M. Anne Katzenberg and the three anon-
ymous reviewers for their time, comments and
suggestions.
Future directions
This study provides a beginning for more
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Copyright # 2007 John Wiley & Sons, Ltd. Int. J. Osteoarchaeol. 18: 2844 (2008)
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