International Journal of Osteoarchaeology

Int. J. Osteoarchaeol. 18: 2844 (2008)

Published online 5 July 2007 in Wiley InterScience
(www.interscience.wiley.com) DOI: 10.1002/oa.924

Schmorls Nodes: Clinical

Significance and Implications for
the Bioarchaeological Record
K. J. FACCIA a* AND R. C. WILLIAMS b
a
University of Calgary, Department of Archaeology, 2500 University Dr. NW, Calgary, AB
T2N 1N4, Canada
b
Arizona State University, School of Human Evolution and Social Change, PO Box 872402,
Tempe, AZ 85287-2402, USA

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.

Key words: Schmorls node; back pain; vertebra; lesion; scoring

Introduction understood. Therefore it is important for studies to

Complementing bioarchaeological analyses with
current medical research allows more informed
interpretations of archaeological populations. The
Schmorls node is a vertebral lesion that is regular-
ly found in both present and past populations;
however, the impact of the Schmorls node on
quality of life (pain, mobility, etc.) is poorly
* Correspondence to: University of Calgary, Department of Archae-
ology, 2500 University Dr. NW, Calgary, AB T2N 1N4, Canada.
e-mail: kjfaccia@ucalgary.ca
address the impact of this lesion on an extant
populations quality of life because, if Schmorls
nodes do cause pain or disability, this lesion could
have had profound effects on archaeological indi-
viduals and populations with regard to activity,
productivity, social relationships and morbidity.
This study investigates the presence and impact
of Schmorls nodes in a clinical pain population,
addressing: (1) Schmorls nodes and sociodemo-
graphic factors; (2) the number, location and
quantitative aspects (e.g. length, depth, area) of
Schmorls nodes, and how these influence the

Copyright # 2007 John Wiley & Sons, Ltd. Received 25 June 2006
Revised 6 November 2006
Accepted 20 February 2007
Significance of Schmorls Nodes
reporting of pain; (3) the dynamic effects
of Schmorls nodes, in combination with other
variables, in reporting pain; and (4) the perception
and impact of pain attributed to Schmorls nodes by
patients on their quality of life. This study tests
whether Schmorls nodes are capable of causing
back pain, and it is hypothesised that the degree of
pain is related to the number, location and physical
characteristics (e.g. length, depth, area) of the
nodes. If a significant relationship between
Schmorls nodes and pain is found, then this study
will provide bioarchaeologists with an osteological
correlate to begin interpreting the presence and
impact of pain in archaeological populations.
Back pain
The ability to work and be a productive member
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 &
Wheeler, 1998). Approximately 27% of work-
place injuries are related to the back, costing that
nation an estimated 11 billion dollars in care
(1994 statistic: National Institutes of Health,
1997) and between 50 and 100 billion dollars
per year in lost work and disability payouts (1990
statistic: Centers for Disease Control and Pre-
vention, 1998). It is estimated that 80% of the US
population will at some point suffer from back
pain (Kelsey & White, 1980), the highest rates
occurring in middle-aged1 individuals (National
Institutes of Health, 1997). As Argoff & Wheeler
(1998) summarised, back pain is the leading cause
of disability in the under-45 age group, the fifth
leading cause of hospitalisation, and the third
leading cause of surgery.
Although back pain has such an adverse effect on
populations and productivity, its causes are still
under investigation, and corresponding osteologi-
cal indicators continue to perplex and/or evade the
medical community. As Argoff & Wheeler (1998)
argued in their review of various studies, most acute
pain is non-specific, and chronic pain is usually
considered to be caused by degenerative changes,
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
reason for activity limitation in individuals less than 45 years.
Copyright # 2007 John Wiley & Sons, Ltd.
29
although this is not often supported by radiological
findings. This is problematic for bioarchaeology, as
researchers in this field depend upon skeletal indi-
cators to interpret life in the past.
If back pain is so debilitating today, even with
the advantage of modern medicine, its effects on
populations in the past must have been profound
as well. Therefore, if skeletal correlates of back
pain are not understood, then a major issue of past
life is largely being overlooked. The present study
addresses this shortcoming in bioarchaeological
analysis by exploring the relationship between a
defined spinal osteological lesion and its effect on
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
bioarchaeologists to arrive at more holistic
interpretations of life in archaeological popu-
lations.
Schmorls nodes
Schmorls nodes were extensively studied by and
named after Georg Schmorl (Schmorl, 1926;
Schmorl & Junghanns, 1959). Technically, the
term Schmorls node applies to prolapsed inter-
vertebral disc material that enters into the
vertebral body, superior or inferior to the disc
(Schmorl & Junghanns, 1959: 133). However, this
term has been adopted to apply to the end result
of the prolapsed disc, or the lesion that eventually
forms on the surface of the affected vertebral
body. In this study, the term Schmorls node will
refer to the osteological lesion (Figure 1). Defined
as such, Schmorls nodes are quite commonly
found in archaeological, cadaveric and extant
populations (for examples, see Merbs, 1983;
Malmivaara et al., 1987; Wagner et al., 2000).
However, despite the prevalence of Schmorls
nodes throughout time, and despite the fact that
this type of lesion has been the focus of research
for nearly a century, the link between Schmorls
nodes and pain is still poorly understood.
The process of Schmorls node formation
(Schmorl & Junghanns, 1959) begins with an
nucleus pulposus material. Subsequently, the fluid
travels through a break or fissure in the cartila-
Int. J. Osteoarchaeol. 18: 2844 (2008)
DOI: 10.1002/oa
30
Figure 1. Arrow points to Schmorls node on thoracic
vertebral body. From Shamanka II, Lake Baikal, 2004,
V.I. Bazaliiskii (Director). Photograph by Mike Metcalf,
Baikal Archaeology Project (SSHRC-MCRI No.
412-200028). This figure is available in colour online at
www.interscience.wiley.com/journal/oa.
ginous endplate and erodes into the vertebral
body. Here, degeneration of local trabeculae
ensues, resulting in a small cavitation in the
surface of the vertebral body. In reaction to
changes in pressure within the vertebral body,
caused by intruding nucleus pulposus material, an
osseous barrier is formed that ultimately prevents
further progression of the extruded material
into the vertebral body. Once the reaction is
complete, the result is what is considered a
completed Schmorls node, a smooth-walled
lesion on the inferior or superior surface of the
vertebral body.
Currently, research indicates that Schmorls
nodes result from: (1) congenital defects of the
spine; (2) traumatic events; and (3) senescent
processes (Resnick & Niwayama, 1978). Congenital
defects include conditions such as Scheuermanns
kyphosis, which often results in a series of
Schmorls nodes throughout the spinal column
(Tribus, 1988). In Scheuermanns kyphosis, classic
vertebral symptoms include: contiguous vertebral
wedging of 58 or more, narrowed disc space, and
irregular endplates (Tribus, 1988). The combi-
nation of these factors, when coupled with the
normal loading regime of the spine, predisposes an
individual to disc rupture and, subsequently,
Schmorls nodes. Likewise, in instances of trauma,
Copyright # 2007 John Wiley & Sons, Ltd.
K. J. Faccia and R. C. Williams
high axial loading (Wagner et al., 2000) fractures
the cartilaginous endplate, causing deformation
and rupturing of the intervertebral disc, which may
ultimately result in the formation of Schmorls
nodes. With regard to senescent processes,
rupturing of the intervertebral disc, particularly
around the edges of the structure, is attributed to
disorganisation and weakening of the annulus
fibrosus (Hansson & Roos, 1983).
Schmorls nodes are relatively common in mod-
ern populations and, although they can appear at
any level in the spine, the lesions tend to con-
centrate in the lower back, specifically the lower
thoracic and lumbar regions (Resnick & Niwayama,
1978). The high frequency of Schmorls nodes in
the lower back is attributed to the anatomy and
biomechanics of the lower spine, as the amount of
loading on the spine normally increases from the
cervical to the lumbar regions (Argoff & Wheeler,
1998). However, back-related trauma is also
dependent on posture and various loading factors
(Smith, 1969; Chaffin & Park, 1973; Adams et al.,
1993). Therefore, the frequency of Schmorls nodes
in the spinal column can vary based on activity
patterns and postures. In addition, other factors
related to health and degenerative disease could
differentially affect the strength and integrity of
intervertebral discs and vertebral bodies through-
out the spinal column.
Bioarchaeological context
Schmorls nodes are frequently found in archae-
ological populations, regardless of the antiquity
of the population, the subsistence strategy or the
geographical location. For example, Schmorls
nodes have been noted in skeletal samples that
include (in basic chronological order, from ca.
7000 years BP to the 20th century), but are not
limited to: mid-Holocene hunter-gatherers
from Lake Baikal, Siberia (Faccia, n.d.); Neolithic
and medieval populations in western Switzerland
(Kramar et al., 1990); Middle Kingdom to Roman
period Egyptians buried at Abydos (Baker, 1997);
Iron Age Italians (Robb et al., 2001); Woodland
period Native Americans living in Illinois
(Buikstra & Cook, 1981); a Towton (English)
battlefield population (Coughlan & Holst, 2000;
Knusel, 2000; Knusel & Boylston, 2000); the
Int. J. Osteoarchaeol. 18: 2844 (2008)
DOI: 10.1002/oa
Significance of Schmorls Nodes
Sadlermiut of Hudson Bay, Canada (Merbs,
1983); and Colonial and slave era African-
American communities in the southern US
(Angel et al., 1987; Kelley & Angel, 1987; Owsley
et al., 1987; Rathbun, 1987; Parrington & Roberts,
1990). Together, these archaeological studies and
observations indicate that Schmorls nodes are
found cross-culturally, throughout various time
periods, and in groups differing in subsistence and
overall activity patterns.
A few of the bioarchaeological studies above
note the presence of Schmorls nodes, but do little
else to interpret them (Buikstra & Cook, 1981;
Merbs, 1983; Kramar et al., 1990). Others (Angel
et al., 1987; Owsley et al., 1987; Kelley & Angel,
1987; Baker, 1997; Coughlan & Hoist, 2000;
Knusel, 2000; Knusel & Boylston, 2000) use the
presence of Schmorls nodes as indicators of
demanding physical activity. Some authors go
further by using Schmorls nodes to assess
differences in activity patterns between the sexes
(Rathbun, 1987; Parrington & Roberts, 1990) or
between social classes (Robb et al., 2001).
However, none of the researchers question
how Schmorls nodes impacted the quality of
life experienced by historic and prehistoric
peoples. The lack of this sort of analysis is partly
due to ambiguity in the medical literature as to
whether Schmorls nodes cause pain. If the impact
of Schmorls nodes in clinical samples were better
understood, bioarchaeologists would be able to
assess these lesions with regard to their impact on
an individuals and groups quality of life, as well
as social dynamics issues. For example, in past
populations, back pain could have led to an
individuals dependence on others, and this could
have led to a diminished status within the social
group. Particularly if physical activity were
constant and demanding, pain could have greatly
affected the health and survival of an individual.
On a larger scale, chronic back-pain issues could
conceivably have compromised the overall
strength, health and viability of a social group.
Modern context
In the medical community, confusion exists as to
whether Schmorls nodes cause pain. Researchers
continue to study these lesions and, with the
Copyright # 2007 John Wiley & Sons, Ltd.
31
advent of MRI technology, Schmorls nodes are
more quickly and frequently detected in extant
populations (Walters et al., 1991; Hamanishi et al.,
1994). Therefore, the process of node formation,
and the prevalence of Schmorls nodes within
living individuals and populations, is becoming
clearer.
Currently, studies in extant populations pre-
sent reports of both symptomatic (Smith, 1976;
Walters et al., 1991; Hamanishi et al., 1994;
Takahashi & Takata, 1994; Takahashi et al., 1995;
Wagner et al., 2000) and asymptomatic nodes
(Hamanishi et al., 1994; Ogon et al., 2001). In
general, researchers argue that Schmorls nodes
may be an initial, post-traumatic source of pain,
but they hesitate to attribute long-lasting painful
effects to the lesions. Often, researchers report
the presence of a painful Schmorls node, but that
pain tends to subside within weeks (Smith, 1976;
Walters et al., 1991; Takahashi et al., 1995;
Wagner et al., 2000), often within the time-frame
necessary for the healing of joint and soft tissue
injuries (Argoff & Wheeler, 1998). However,
the conclusions of these studies do not echo the
experience of many patients, who insist that their
Schmorls nodes are chronically painful.
Although patients claim that their Schmorls
nodes cause pain, the medical community still
disputes whether these nodes are actually painful,
or whether the pain is due to other factors, either
physically or psychologically mediated (Argoff &
Wheeler, 1998). Essentially, a disconnection
exists between the pain that a patient attributes
to the Schmorls node(s) and the conclusions of
modern medical studies, which are unable to find
a link between the lesion and pain. Therefore,
particularly for bioarchaeological studies, it is
important to continue analysing the relationships
between qualitative and quantitative aspects of
the Schmorls node, a defined osteological lesion,
and perceived pain. Such analyses will then
facilitate more informed interpretations of
quality-of-life issues in the present and past.
The hesitation of the medical and research
communities to attribute pain to Schmorls nodes
may be due to a long-standing lack of under-
standing as to the innervation of the vertebral
body. Most research involving the innervation of
the spinal complex focuses on soft-tissue anatomy
rather than on the vertebrae themselves (Anto-
Int. J. Osteoarchaeol. 18: 2844 (2008)
DOI: 10.1002/oa
32
nacci et al., 1998). However, recent studies
indicate that nerves enter the vertebral body
through basivertebral foramina and small aper-
tures in the anterior cortex (Antonacci et al.,
1998). Also, Fras et al. (2003) found that
basivertebral nerves stain positive for substance
P, a peptide neurotransmitter that is released
in response to painful stimuli. Therefore, the
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-
ting painful signals (Fras et al., 2003). In addition
to the findings indicating that vertebral bodies are
heavily innervated, researchers have discovered
that nerve bundles are frequently found in
association with vertebral fractures, extruded
bone marrow, and, in some instances, near-new
endochondral bone formation (Antonacci et al.,
2002). Therefore, Antonacci et al. (2002) post-
ulate that these nerve bundles not only aid in the
healing process, but may be a factor in generating
back pain.
Based on this information, it seems logical that
spinal lesions, such as Schmorls nodes, would
cause pain. It further follows that the acuity and
longevity of pain caused by the Schmorls node
could be related to the location and size of the
lesion, or the degree to which it overlaps with or
aggravates an innervated region. In support of this
hypothesis, Ogon et al. (2001) did find that larger
and more anteriorly located (non-Schmorls
node) vertebral lesions were significantly corre-
lated with pain. Therefore, the premise of this
study is that Schmorls nodes are capable of
causing pain, and it is hypothesised that the
degree of pain is related to the number, location
and physical characteristics (e.g. length, depth,
area) of the nodes.
Materials and methods
Sample
All patients were adult (
18 years) volunteers
who were under the care of Spectrum Pain Clinics,
Inc., a chronic pain management group with
offices in Franklin, Clarksville and Cookeville,
Tennessee, US. Health Insurance Portability and
Copyright # 2007 John Wiley & Sons, Ltd.
K. J. Faccia and R. C. Williams
Accountability Act2 (HIPAA) and adult consent
forms were signed by all volunteers (291), and
those patients with documented evidence of
Schmorls nodes were chosen for inclusion in the
study (33; 11.3%). In compliance with HIPAA
regulations, all patient data were anonymised by
assigning each individual an identification number,
which was used for all subsequent data collection.
Data collection
Data were collected from the following sources:
the patient, the patients medical chart, diagnostic
imaging reports, and patient MRIs.
The questionnaire was based on a modified
clinic form that patients were required to
complete upon their initial visit to Spectrum
Pain Clinic. Demographic and socioeconomic
information was included, general questions
addressing back pain were modified to address
specifically the pain that patients attributed to
their Schmorls nodes, and questions were added
regarding the impact of Schmorls nodes on
quality of life issues. Twenty-six (79%) patients
completed and returned the questionnaire.
Two forms were used to collect data from the
patients chart. One form was used to collect
additional demographic, family medical, and pain
history information prior to clinic treatment. This
form was collected for all patients (n 33). The
second form was used to collect data based on
healthcare practitioner forms that were com-
pleted upon each individual medical appoint-
ment. In addition to the patients age, weight
and height, information was gathered on the
spinal region where pain was presented, aggra-
vating and relieving factors, the history of pain
and pain treatment, and a diagnostic review of
patient health. This form was collected for each
patient (n 33), for monthly visits extending as
far back as January 2002 (total n 328), but only
for the visits after which a Schmorls node(s) was
2
HIPAA is a United States federal act that was enacted in 1996 and
intended to (1) create standards and requirements for the electronic
submission of healthcare information, (2) protect the continuity of
patient healthcare coverage, and (3) protect the patient from the
abuse of their personal healthcare information (Public Law
104191).
Int. J. Osteoarchaeol. 18: 2844 (2008)
DOI: 10.1002/oa
Significance of Schmorls Nodes 33

diagnosed. Based on these criteria, a total of 328

patient visits were included in this study.
Two diagnostic imaging forms were used to
collect data based on MRIs. One form was used to
review those MRI reports that diagnosed the
presence of Schmorls nodes in the patient, and this
form was completed for all subjects (n 33). The
collected information included the number and
location of Schmorls nodes in the spinal column,
the region of the Schmorls node(s) (e.g. cervical,
thoracic, lumbar, sacral), and the hard and
soft tissue pathological conditions in the back
(e.g. discogenic, neurological, sclerotic, and joint-
related abnormalities). A second form was used to Figure 2. Schmorls node length calculated by polyline in
record qualitative and quantitative information ArcMap 8.2. This figure is available in colour online at
www.interscience.wiley.com/journal/oa.
gathered directly from the MRIs. Of the 33
patients, MRIs were obtained for 28 individuals, Data analysis
although one was excluded due to the extremely
poor quality of the film. Five MRIs were requested This study employs both descriptive and statisti-
but not provided by the diagnostic imaging cal analyses. Descriptive analyses were performed
centers. The general location3 (e.g. superior or on two levels: (1) the individual; and (2) the
inferior; anterior third, central third, and/or post- Schmorls node. Descriptive information on the
erior third) of the Schmorls node on the vertebral level of the individual includes: sociodemogra-
body was noted, as were the number of Schmorls phic information, patient answers regarding the
nodes per region, and the length, depth and area of impact of Schmorls nodes on quality of life, and
the Schmorls node relative to the vertebral body. the number and region of Schmorls nodes in the
Quantitative information was gathered using vertebral columns analysed. Descriptive infor-
two methods: (1) ArcMap 8.2, a GIS program mation on the level of the Schmorls node inclu-
that obtains length and area measurements for des: the position of Schmorls nodes on the
irregular shapes based on a system of polygons and vertebral body and the number of Schmorls
polylines (see Figures 27); and (2) computer nodes found in each segment of the vertebral
program rulers and a manual intercept-count column.
method (Russ, 1986), the latter of which uses Statistical analyses are also performed on two
the intersections of graph lines to determine levels: (1) the Schmorls node; and (2) the region
percentage area (Figure 8). The following measure-
ments were obtained and used in this study: area of
the Schmorls node relative to the vertebral body;
depth of the Schmorls node relative to the
vertebral body; and surface length of the Schmorls
node relative to the vertebral body.

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
Figure 4. Schmorls node depth calculated by polyline in
ArcMap 8.2. This figure is available in colour online at
www.interscience.wiley.com/journal/oa.
of the Schmorls node. Logistic regression models
were used to test whether there was any
relationship between the reporting of pain and
the characteristics of Schmorls nodes, as well as
whether or not a Schmorls node(s), in combi-
nation with other variables, is more likely to
predispose a person to report pain. For all
analyses, the explained (dependent) variable
was reported pain.
The Schmorls node is the level of analysis for
the physical characteristics of the lesions. In
exploring the relationship of Schmorls node
physical characteristics and pain, the explanatory
(independent) variables were: (1) the inferior or
Figure 5. Vertebral body height calculated by polyline in
ArcMap 8.2. This figure is available in colour online at
www.interscience.wiley.com/journal/oa.
Copyright # 2007 John Wiley & Sons, Ltd.
K. J. Faccia and R. C. Williams
Figure 6. Schmorls node area calculated by polygons in
ArcMap 8.2. This figure is available in colour online at
www.interscience.wiley.com/journal/oa.
superior location of the Schmorls node; (2) the
total number of Schmorls nodes in the region in
question; (35) the anterior, central or posterior
positioning of the Schmorls node on the
vertebral body; (6) the maximum length percen-
tage of the Schmorls node relative to the
vertebral body; (7) the maximum depth percen-
tage of the Schmorls node relative to the
vertebral body; and (8) the maximum area of
the vertebral body occupied by the Schmorls
node(s). Maximum percentage values, as
recorded in the MRI slices, were used because
one of the hypotheses tested in this study is that it
is the size of the Schmorls node that influences
Figure 7. Vertebral body area calculated by polygons in
ArcMap 8.2. This figure is available in colour online at
www.interscience.wiley.com/journal/oa.
Int. J. Osteoarchaeol. 18: 2844 (2008)
DOI: 10.1002/oa
Significance of Schmorls Nodes
Figure 8. Example of the intercept-count method. Graph
interceptions in the area of the Schmorls node (n 2) are
divided by the number of graph intersections in the
Schmorls node plus vertebral body (n 93) and multi-
plied by 100 to calculate the percentage area of the
Schmorls node relative to the vertebral body: (2/
93)  100 2.2%. This figure is available in colour online
at www.interscience.wiley.com/journal/oa.
the reporting of pain, and that a larger Schmorls
node is more likely to predispose a patient to
report pain than a smaller Schmorls node, based
on the assumption that a larger node would
overlap with more nerve bundles and hence cause
more pain. Seventy-nine Schmorls nodes were
noted. Nine Schmorls nodes were not included in
the analysis because their images were located at
the edges of the film, and certain measurements
were not attainable. However, for the other 70
Schmorls nodes, each was examined in relation
to the reporting of pain in the region of the
Schmorls node per office visit. Therefore, with
70 Schmorls nodes included in the analysis, and a
total of 327 office visits during which a patient
with at least one Schmorls node reported pain or
no pain in the region of the lesion, the sample size
for this analysis was n 583,4 with n 218
Schmorls nodes allocated to the pain group, and
4
The sample size of 583 Schmorls nodes is not perfectly divisible by
the number of Schmorls nodes (70) multiplied by the number of
office visits (327) because patients had varying numbers of Schmorls
nodes and were treated over different periods of time. For example,
one patient with two Schmorls nodes might present with pain for
both lesions over the course of ten office visits (n 20 to pain),
whereas another patient with three Schmorls nodes might present
without pain over the course of four office visits (n 12). Therefore,
the number of total office visits (14) multiplied by the total number
of Schmorls nodes (5) is not equal to the sample size of Schmorls
nodes included in the analysis (14 visits  5 lesions 70, but the
sample size of Schmorls nodes is 20 12, or n 32).
Copyright # 2007 John Wiley & Sons, Ltd.
35
365 Schmorls nodes allocated to the no-pain
group.
The region of the Schmorls node (e.g. cervical,
thoracic, lumbar, sacral) is the unit of analysis in
testing whether or not dynamic relationships
exist between Schmorls nodes and 12 variables in
the reporting of pain. The explanatory (inde-
pendent) variables used in this analysis included
the following: (1) age; (2) sex; (3) body mass
index; (4) the region of Schmorls node (e.g.
cervical, thoracic, lumbar or sacral); (5) a history
of trauma to the region; (6) the presence of
discogenic conditions (e.g. degenerative disc
disease; desiccated discs; and protruding, bulging
or ruptured discs); (7) failed back syndrome;5
(8) joint abnormalities; (9) compression fractures;
(10) stenosis; (11) osteophytes; and (12) spinal
cord abnormalities. Here, each region per patient
with a Schmorls node is accounted for in the
analysis, and each region is analysed with regard
to pain or no pain reported per office visit.
Therefore, the sample size for this analysis was
n 327, with 125 regions allocated to the pain
group and 202 regions allocated to the no pain
group.
Results
The results of this study are discussed in the
following order: (1) sociodemographic factors;
(2) Schmorls nodes as related to sex and age; (3) a
descriptive analysis of the number and location of
Schmorls nodes; (4) a statistical analysis of the
location and quantitative characteristics of
Schmorls nodes and their relationships with
pain; (5) a statistical analysis of whether a patient
is more predisposed to report pain in the region of
a Schmorls node(s) based on age, sex, body mass
index, or other pathological spinal conditions;
(6) perceived pain that patients attribute to their
Schmorls nodes; and (7) the effects of pain on
patient quality of life.
5
Failed back syndrome refers to chronic back pain after unspecific
treatment (Oaklander & North, 2001: 1540). At Spectrum Pain
Clinics, Inc., this term is normally used in place of failed back
surgery syndrome, which refers to chronic pain following at least
one surgery (Oaklander & North, 2001: 1540).
Int. J. Osteoarchaeol. 18: 2844 (2008)
DOI: 10.1002/oa
36
Sociodemographic factors
The following information is derived from patient
questionnaires and, when possible, charts. If
similar information was gathered from both
sources, the patient questionnaire was used
because (1) the information in the questionnaire
was more current; and (2) the answers were
directed toward the impact of Schmorls node(s)
on pain, and not back pain in general.
Sixteen of the 33 individuals in this study were
female (51.6%). The average age of the patient
was 42.7 years, and ages ranged from 23 to 62
years old. Twenty-six patients completed the
questionnaire. Of those, the average income (US
dollars) of the patients (22 responding, 4 failing
to respond) was $19,253, with incomes ranging
from $0 to $98,000 and a median income of
$13,000. At least 12 (55%) of these patients
are considered to be living below the poverty
level (Office of the Federal Register, 2002).
Occupations of the questionnaire sample were as
follows: 21% (7) unemployed; 54% (14) dis-
ability; 15% (4) employed; and 4% (1) failed to
respond to this question. Their relationship
statuses were as follows: 15% (5) single; 45%
(15) married; 24% (8) separated or divorced; and
15% (5) widowed. The average household size
for the questionnaire sample was 2.08 individuals,
with the mode being 1, and the range being 0 to 5
additional people in the household.
Schmorls nodes, age and sex
MRIs were reviewed (27), and 79 Schmorls nodes
were identified (see Table 1 for totals and
stratification by sex). The number of Schmorls
nodes per patient ranged from one to nine, with
Table 1. Schmorls nodes by spinal region and by sex
Spinal Females % Schmorls % Schmorls
region (n) nodes: nodes
female only (female/total)
Cervical 0 0% 0%
Thoracic 16 35.6% 20.3%
Lumbar 19 63.3% 24.1%
Sacral 0 0% 0%
Total 35 100% 44.4%
Copyright # 2007 John Wiley & Sons, Ltd.
K. J. Faccia and R. C. Williams
the average number of Schmorls nodes per
patient being 2.54. Overall, a greater percentage
of Schmorls nodes was detected in the thoracic
region (59.5%) than any other area of the spine,
with the lumbar region (38.0%) being the second
most numerous area; the sacrum and cervical
regions had one lesion (1.3%) each. When
stratified by sex, women had 35 Schmorls nodes,
or 44.4% of the total, and each woman had an
average of 2.19 lesions. Men had 44 Schmorls
nodes, or 55.7% of the total, with an average of
2.93 lesions. Schmorls nodes in women were
only found in the thoracic (16) and lumbar (19)
regions, with the greatest concentration in the
lumbar region. In contrast, men had Schmorls
nodes in the cervical (1), thoracic (31), lumbar
(11) and sacral (1) regions of the spine, with the
greatest concentration in the thoracic region.
Two contingency table analyses and Fishers
exact test were performed to assess the signifi-
cance in Schmorls node distribution by sex.
Results show that there is a significant difference
in the lesions distribution by sex when all
Schmorls nodes are considered (n 79; x2
7.991, df 3, P 0.0025, Fishers exact test),
as well as when the cervical and sacral lesions
are removed from consideration (n 77; x2
6.3366, df 1, P 0.0082, Fishers exact test).
Descriptive analysis of Schmorls
node location, size and number
Seventy Schmorls nodes were included in the
statistical analysis that tested the significance of
the relationship between physical characteristics
of Schmorls nodes and pain. Of these, 38
(53.3%) were inferior nodes and 32 (45.7%)
were superior nodes (Table 2 for inferior and
Males % Schmorls % Schmorls % Per Total
(n) nodes: nodes spinal
males only (males/total) region
1 2.3% 1.3% 1.3% 1
31 70.5% 39.2% 59.5% 47
11 25.0% 13.9% 38.0% 30
1 2.3% 1.3% 1.3% 1
44 100% 55.7% 100% 79
Int. J. Osteoarchaeol. 18: 2844 (2008)
DOI: 10.1002/oa
Significance of Schmorls Nodes 37

Table 2. Inferior and superior Schmorls nodes by spinal
region
Spinal region Inferior node Superior node
Cervical 1 0
Thoracic 24 17
Lumbar 13 14
Sacral 0 1
superior nodes by region). According to each
MRI slice per individual, the total percentage area
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
52.9% of the vertebral body depth at the location
of maximum node depth. Spinal regions had
between one and nine Schmorls nodes, with the
mode being one lesion per spinal region. Six
vertebrae had both superior and inferior nodes.
Schmorls nodes on the vertebral body were: 31
(44.3%) on the anterior third; 60 (85.7%) on the
central third; and 27 (38.6%) on the posterior
third of the vertebral body. These positional
categories were not mutually exclusive.
Statistical analysis of
Schmorls nodes and pain
A full logistic regression model (n 583) was
performed to assess whether the length, depth,
area, location or number of Schmorls nodes per
column was more likely to predispose a patient to
report pain (Table 3). The only variable that
proved significantly associated with a patient
reporting pain in the region of the Schmorls node
was a centrally-located lesion, and this was a
positively significant relationship (OR 2.781,
95% CI 1.471, 5.256, P 0.0016). Centrally-
located Schmorls nodes remained positively and
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,
where only age, sex and body mass index were
included as explanatory (independent) variables.
Impact of Schmorls nodes
and variables on pain
Two additional logistic regression analyses were
performed to assess whether synergistic effects
existed between Schmorls nodes and the other
independent variables, thereby predisposing an
individual to report pain. The full logistic
regression model included 16 explanatory (inde-
pendent) variables. Subsequently, a second,
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-
cantly associated with patient reporting of pain in
the full regression model. Both models tested
whether these independent variables predisposed
a person to report pain in the region of the
Schmorls node.
The first logistic regression included the
following explanatory (independent) variables:
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

Explanatory variable OR value, full model OR value, reduced model

(explanatory variables n 8) (explanatory variables n 1)

Inferior or superior 0.797 (95% CI 0.523, 1.214; P 0.2901)

Total number in region 0.920 (95% CI 0.823, 1.029; P 0.1437)
Maximum surface % of node 0.985 (95% CI 0.967, 1.003; P 0.1090)
Maximum depth % of node 0.995 (95% CI 0.967, 1.024; P 0.7202)
Maximum area % of node 0.944 (95% CI 0.878, 1.016; P 0.1227)
Anterior on vertebral body 1.238 (95% CI 0.775, 1.997; P 0.3725)
Central on vertebral body 2.781 (95% CI 1.471, 5.256; P 0.0016) 1.912 (95% CI 1.057,3.458; P 0.0321)
Posterior on vertebral body 0.712 (95% CI 0.422, 1.202; P 0.2030)

Statistically significant results.

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

Explanatory variable OR value, full model OR value, reduced model

(explanatory variables n 16) (explanatory variables n 4)

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),
whether a history of trauma was associated with
reported back pain, intervertebral disc abnorm-
alities (e.g. degenerative disc disease, desiccated
disc, and ruptured/bulging disc), failed back
syndrome, joint abnormalities, stenosis, compre-
ssion fractures, osteophytes, and spinal cord
abnormalities. For the pathological conditions
in the spine that were used as explanatory
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)
indicate that, when all of the aforementioned
variables were used in the model, only osteo-
phytes (OR 3.346, 95% CI 1.244, 9.002,
P 0.0168; positive relationship) and failed back
syndrome (OR 0.191, 95% CI 0.053, 0.689,
P 0.0115; negative relationship) were signifi-
cantly associated with Schmorls nodes and the
reporting of pain. Results indicate that the
presence of osteophytes, in association with
Schmorls nodes, is more likely to predispose a
person to report pain than a person without
osteophytes in the region of a Schmorls node(s).
However, the presence of failed back syndrome,
in the region of a Schmorls node(s), is less likely
to predispose a person to report back pain.
The second (reduced) logistic regression tested
the synergistic impact of Schmorls nodes and
osteophytes and failed back syndrome when only
age, sex and body mass index were controlled
in the model. In this analysis, neither osteophy-
tes (OR 0.943, 95% CI 0.448, 1.986, P
0.8770), nor failed back syndrome (OR 1.266,
95% CI 0.474, 3.381, P 0.6378), appeared to
predispose a person with Schmorls nodes to be
more or less likely to report pain at a level of
statistical significance (see Table 4).
Perceived pain attributed to Schmorls nodes
Twenty-six patients returned the patient ques-
tionnaire which addressed issues of pain that
patients perceived to be related to their Schmorls
nodes.6
6
It is important to know that this section deals with perceptions of
pain. According to the staff at Spectrum Pain Clinics, Inc., after
diagnostic imaging, patients are usually told about the presence of
Schmorls nodes, but that the lesions do not have a significant impact
on their condition. Before answering the questionnaire, patients
were again reminded of their lesion(s). Because this could have
affected the way in which they answered the questions (i.e. this
could have influenced patients to perceive pain to degrees or in
locations that might not have seemed significant before learning
about their lesions), the link between Schmorls nodes and the
reporting of pain was primarily drawn from past routine clinical
examinations, during which healthcare practitioners noted the
specific regions of the spine where pain was reported, and during
which time patients probably considered their Schmorls nodes
insignificant.

Copyright # 2007 John Wiley & Sons, Ltd. Int. J. Osteoarchaeol. 18: 2844 (2008)
DOI: 10.1002/oa
Significance of Schmorls Nodes
When asked if the pain that the patients
attribute to their Schmorls nodes began with
rupturing of a disc, 76.9% (20) of respondents
answered yes, 14.4% (4) answered no, 3.9% (1)
said that he or she didnt know, and 3.9% (1) did
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
to back pain, with the other most identifiable
activity being pulling (8; 31%).
Patients were also asked about the duration and
severity of their pain, with patients being allowed
to mark as many categories as applied. The
majority of patients, 69.2% (18), said that the
pain had been constant since the ruptured disc
was diagnosed, with the remaining patients,
30.8% (8), responding that the pain has been
frequent. Half (13) of the patients ranked the
severity of pain as moderate to severe, and over
50% (17) ranked their pain as severe and/or very
severe. No patients reported that they experi-
enced an absence of long-term pain related to
their Schmorls nodes.
In the questionnaire, patients addressed the
sensations and types of pain that they attributed
to their Schmorls nodes. These symptoms were
based directly on Spectrum Pain Clinics, Inc.
admittance forms. The sensations most frequently
attributed to Schmorls nodes were tingling (9;
73%), numbness (18; 69%) and pins and needles
(18; 69%). No patients reported an absence of
sensations attributed to Schmorls nodes.
The most common types of pain that the
patients attributed to the lesions were sharp
shooting (14; 54%), stabbing (13; 50%), burning
(12; 46%), throbbing (12; 46%) and aching (11;
42%). No patients reported an absence of pain
attributed to their Schmorls nodes.
Patients were asked what aggravates and
relieves their pain. The aggravating factors most
frequently cited included standing (20; 77%),
repetitive movements (18; 69%), stooping (15;
58%), sleeping (13; 50%), sneezing (13; 50%),
bowel movements (12; 46%), and emotional
upsets (11; 42%). No patients reported an
absence of aggravating factors.
Patients reported that the following methods
best helped to relieve their pain: prescription pain
pills (24; 92%); applying heat (20; 77%); other
Copyright # 2007 John Wiley & Sons, Ltd.
39
(12; 46%) [the most common answers included
hot baths (5) and lying on ones side (4)]; and
applying cold (11; 42%). One patient reported
that nothing relieves his or her pain (i.e. the pain
is constant).
Effects of pain
When patients were asked if the pain that they
attribute to their Schmorls nodes limits their
activities, 92% (24) responded yes, and 8% (4)
failed to answer this question. When asked if this
pain had caused the individual to miss work, of
the four patients still working, three (75%)
answered yes. Of the total sample, including
those now unemployed or on disability benefits,
answers to the same question (missed work) were:
69% (18) yes, 15% (4) no, and 15% (4) failed to
respond to this question.
Of the 33 patients included in the study, 15%
(5) of individuals have employed the use of
mobility aids when visiting the clinic. Also, 39%
(13) were diagnosed, in at least one visit, of
having an irregular gait. When healthcare practi-
tioners diagnosed patient range of motion, 58%
(19) of patients were assessed as having a reduced
range of motion in the region of the Schmorls
node in at least one office visit. However, in at
least one office visit, 70% (23) of patients were
diagnosed with normal range of motion in areas
affected by Schmorls nodes, and the same
percentage of patients were diagnosed with a
reduced range of motion in an area not diagnosed
as having a Schmorls node(s).
Notably, for those patients who had visited the
clinic three or more times, 19 (66%) reported
pain in the region of the Schmorls node at least
three times, or over the course of three months.
This is important, because chronic pain is
considered to be pain that lasts for three or
more months (Borenstein, 2002). Hence, it is
possible that Schmorls nodes are a source of
chronic back pain, although more detailed
analysis is necessary. Also noteworthy is the fact
that a third (11) of patients in this study were
diagnosed with depression during at least one
visit, with 27% (9) being diagnosed with
depression during multiple visits.
Int. J. Osteoarchaeol. 18: 2844 (2008)
DOI: 10.1002/oa
40
Discussion
The present study provides information regarding
the relationship between Schmorls nodes and
sociodemographic factors, as well as the impact
of pain in an extant patient population. Because
the influence of Schmorls nodes on patient
quality of life has remained somewhat ambiguous,
this study also attempts to clarify the relationship
that exists between a defined osteological lesion,
the Schmorls node, and pain.
Schmorls nodes in the clinical population are
concentrated primarily in the thoracic region, a
similar pattern to that noted in archaeological
samples (Merbs, 1983; Owsley et al., 1987;
Kramar et al., 1990; Coughlan & Holst, 2000).
Also, as in the archaeological samples (Rathbun,
1987; Parrington & Roberts, 1990), the number of
Schmorls nodes in males and females differs, with
males exhibiting a greater percentage of lesions.
Additionally, in the modern sample, the distri-
bution of Schmorls nodes by spinal region and by
sex is significantly different. The latter two trends
suggest that there still exists a sexual division of
labour that results in differentially distributed
back trauma. Unfortunately, a comparison of
social status and biological status, as per Baker
(1997) and Robb et al. (2001), could not be
performed, as the clinical sample lacked an
adequate range of income levels needed for
meaningful analysis.
Complete and reduced logistic regression
analyses were performed to assess whether the
location, number, and/or quantitative aspects of
Schmorls nodes predisposed an individual to
report pain in the region of the Schmorls node(s).
In each of the models, no significant relationship
was found between a patient reporting pain and:
(1) whether the Schmorls node was located on
the inferior or superior surface of the vertebral
body; (2) the total number of Schmorls nodes per
region; (3) the maximum percentage surface area
of the lesion; (4) the maximum percentage depth
of the lesion; (5) the maximum percentage area
occupied by the lesion(s); or (6) whether the
Schmorls node was anteriorly or posteriorly
located on the surface of the vertebral body. In
both models, only centrally located Schmorls
nodes were significantly associated with the
reporting of pain in the region of the Schmorls
Copyright # 2007 John Wiley & Sons, Ltd.
K. J. Faccia and R. C. Williams
node. Therefore, the hypothesis that variation in
the percentage node length, depth and area
occupied by the Schmorls node, in relation to the
vertebral body (e.g. the amount of trabecular and
cortical destruction caused by the Schmorls node
formation process), will affect the likelihood that
a patient will report pain is not supported.
However, these results do not nullify the aspect
of the hypothesis that predicts that Schmorls
nodes cause pain because they overlap with, or
aggravate, nerves within the vertebral body. To the
contrary, the fact that centrally located Schmorls
nodes are significantly related to patients report-
ing pain supports this hypothesis. According to
Antonnaci et al. (1998: 528), basivertebral nerves,
capable of transmitting painful signals (Fras et al.,
2003), enter the vertebral body posteriorly and run
towards more central areas. Additionally, accord-
ing to preliminary observations by Antonnaci et al.
(1998), it appears that the concentration of nerve
bundles in the vertebral body varies according to
location. Therefore, it follows that the important
factor in predisposing a person with a Schmorls
node to report pain is that the Schmorls node is
located in an area with a concentration of nerve
fibres. Hence, the pain or lack of pain attributed to
Schmorls nodes appears equally dependent on
neurological factors (i.e. distribution, level below
surface, etc.) as characteristics of the Schmorls
node itself.
Because it seems that centrally located
Schmorls nodes are significantly related to
patients reporting pain, the next step in the
analysis is to assess whether or not Schmorls
nodes, in combination with other spinal con-
ditions, would be likely to predispose a person to
report pain. The full and reduced logistic
regression analyses that examined the dynamic
effects of Schmorls nodes and other variables
produced interesting and seemingly contradic-
tory results. With multiple variables in the model,
the combination of Schmorls nodes and osteo-
phytes appears to increase the chances that a
person will report pain, while the combination of
Schmorls nodes and failed back syndrome
reduces the likelihood that someone will report
pain. However, in the second, reduced model,
when only age, sex and body mass index were
included, neither osteophytes nor failed back
syndrome seemed to significantly increase or
Int. J. Osteoarchaeol. 18: 2844 (2008)
DOI: 10.1002/oa
Significance of Schmorls Nodes
decrease the chances that a person with Schmorls
nodes would report pain.
There are several possible reasons for these
contradictory results. Firstly, it is possible that
there is no real relationship between osteophytes
or failed back syndrome and Schmorls nodes and
pain. Perhaps the seemingly significant results of
the first analysis were only artefacts of the data, or
they reflect other variables that were not
included, but are either (1) related to osteophytes
and/or failed back syndrome, or (2) their effects
only become observable when other factors are
included. Alternatively, perhaps these relation-
ships, between Schmorls nodes and osteophytes
and failed back syndrome, really do exist.
Osteophytes are known to cause pain in some
instances (Lanyon et al., 1998; Lamer, 1999), and,
in conjunction with Schmorls nodes, perhaps the
pain becomes significant enough for a patient to
report it to his or her healthcare practitioner.
With regard to failed back syndrome, the answer
for the counterintuitive relationship, that it
appears to reduce the likelihood of pain reported,
might be an indirect benefit of the failed back
surgery or another course of back treatment. As
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
vertebral body could result in a diffused pain that
is felt within the vertebral body. Thus it could
follow that, in conditions in which externally
located nerve fibres were impinged upon prior to
surgery or other form of treatment, the procedure
could have successfully relieved the aggravating
factor(s); this, in turn, would lead to relief in the
vertebral body with the Schmorls node. There-
fore, in instances where failed back syndrome
reduces the likelihood that a person with a
Schmorls node will report pain, the pain may
actually be a result of nerve aggravation at an
external location and not the node itself. In this
case, the Schmorls node(s) may only coinciden-
tally be located on the aggravated vertebral body
in question.
Implications for bioarchaeological research
The importance of this research for bioarchae-
ology is that it offers a beginning point for
Copyright # 2007 John Wiley & Sons, Ltd.
41
researchers to address the impact of back pain in
past populations by providing a link between a
defined osteological lesion, the Schmorls node,
and the presence of reported back pain.
Additionally, this study presents tentative evi-
dence that other pathological conditions, notably
osteophytes, in combination with Schmorls
nodes, increase the likelihood that a person
had experienced back pain. Therefore, it is
suggested that the bioarchaeologist score the
location of the Schmorls node (i.e. anterior 1/3,
central 1/3, posterior 1/3) and note the presence
of osteophytes in the affected vertebral region.
It should be noted that this study does not
demonstrate that the productivity of individuals
affected by Schmorls nodes was equally com-
promised in past and modern groups; but it does
provide evidence that Schmorls nodes could
have caused back pain, and that productivity
could have been affected. With this information,
the bioarchaeologist may begin to explore the
impact of pain in archaeological populations by
combining the results of this study with other
forms of evidence for pain, disability and social
dependence in the bioarchaeological record.
Conclusions
Analysing the impact of Schmorls nodes on pain
in a clinical sample, this study determined that
the only physical characteristic of Schmorls
nodes that is significantly correlated with pain is a
centrally located Schmorls node. In addition, the
presence of osteophytes, in combination with
Schmorls nodes, could significantly increase the
reporting of back pain. Ultimately, this study
provides evidence that a defined osteological
lesion, whose impact has perplexed the medical
community, is a likely contributor to chronic
back pain. These results allow for the bioarch-
aeologist to begin addressing a symptom that
probably had as profound implications for past
populations as it does for modern populations.
The evidence for back pain and its social
implications should be used in conjunction with
other bioarchaeological evidence for pain, dis-
ability and social dependence, in order to arrive at
more informed and insightful interpretations of
Int. J. Osteoarchaeol. 18: 2844 (2008)
DOI: 10.1002/oa
42
quality-of-life issues in archaeological popu-
lations.
Future directions
This study provides a beginning for more
informed analyses of Schmorls nodes in past
populations. However, the results should be
strengthened by future analyses that include: (1) a
non-Schmorls node population with back pain;
(2) a Schmorls node population that has never
presented for pain; and (3) a larger sample size, so
that the statistical and descriptive analyses will
encompass a much broader range of experiences,
leading to more comprehensive analyses.
Additionally, future studies should address the
long-term impact of Schmorls nodes. Now that it
has been shown that a significant relationship
exists between centrally located Schmorls nodes
and an increased predisposition to report pain, it
would be interesting to test the statistical
relationship between Schmorls nodes and
chronic pain, or pain lasting at least three
months. According to Valkenburg & Haanen
(1982), approximately 85% of people who report
lower back pain experience a recurrence in this
pain. The data collected for this study incorp-
orated long-term healthcare information; there-
fore, with a larger sample size based on the
suggestions listed above, a longitudinal study
investigating the long-term impact of Schmorls
nodes would greatly benefit the interpretation of
Schmorls nodes and pain in archaeological
populations.
Acknowledgements
Kathleen Faccia would like to thank Dr Charles F.
Merbs, Dr Brenda J. Baker and Dr Katherine A.
Spielmann for their assistance with this manu-
script. I am also indebted to the staff and patients
of Spectrum Pain Clinics, Inc. for agreeing to
participate in this project, as well as the various
diagnostic imaging centres for providing images
for this study. Thanks to Mr Vladimir I. Bazaliiskii
(Irkutsk State University), the Baikal Archaeology
Project (SSHRC MCRI No. 412-2000-28), and
Mike Metcalf for use of the thoracic vertebra
Copyright # 2007 John Wiley & Sons, Ltd.
K. J. Faccia and R. C. Williams
photograph. The authors would also like to thank
Dr M. Anne Katzenberg and the three anon-
ymous reviewers for their time, comments and
suggestions.
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