Zoledronic Acid Injections as a Promising Treatment Option for Symptomatic Schmorl’s Nodes in a

Paediatric Patient: A Case Report.

Ali Khalid, Ameer Khamise, University of Buckingham

Investigations

Outcomes and Patient Perspectives

Schmorl’s Nodes (SNs) are malformations of the vertebral endplate, characterised by herniation of the intervertebral disc nucleus pulposus into the neighbouring vertebral body SNs strongly correlate with increasing age, particularly in individuals between 40 and 60, with higher prevalence in males (Kyere et al., 2012). Symptomatic SNs present with lower back pain and lumbar disc disease (William et al., 2007). This case report aims to demonstrate the potential of Zoledronate (a bisphosphonate) in managing symptomatic SNs in a 15year-old female patient. Treatment was assessed using the Visual Analogue Scale (VAS), a subjective and standardised tool for acute and chronic pain al., 2018).

Case Description

This case report reviews a 17-year-old female suffered from chronic lower back pain Despite no history of axial force exposure injuries, she was diagnosed with SNs aspects of L3-L4 and L4-L5 regions. The referred to a paediatric orthopaedic clinic investigations (Table 1). SNs were diagnosed scans at the age of 13 in 2018 (Figure concern revolved around the patient's pronounced pain, which significantly impacted her overall life. The back pain presented a challenge as effectively managed through conventional interventions such as NSAIDs and physiotherapy the patient's young age and absence of spinal nerve compression, surgical intervention deemed unsuitable.

Zoledronate Treatment

A multidisciplinary team comprised of a paediatric spine surgeon, a paediatric physician, and radiologists devised an experimental treatment regimen involving administering six intravenous Zoledronate injections over 29 months, which commenced in October 2020. VAS score was measured in the clinic follow-ups a month after each injection to evaluate the back pain (Figure 2,3)

Tests

Genetic testing: Marfan Syndrome Negative

CT spine

Bone scan

Rheumatological blood tests (Including HLA-B27)

Results

Excluded space-occupying lesions

Increased uptake in L3 and L4 vertebrae

Negative

Table 1:Back pain investigations and results.

Initial Evaluation

29-Month Treatment Period

" I experienced excruciating back pain which affected my ability to attend school”.

4th Injection " significant improvement in my ability to perform daily activities"

6th Injection (Final)

" I effortlessly go through my daily routine, hardly experiencing any pain."

Discussion and Conclusion

- There is insufficient literature on managing symptomatic SNs in paediatric patients; however, a course of six injections of Zoledronate demonstrated successful management of chronic back pain

- The case report demonstrates the potential of Zoledronate in managing symptomatic SNs, particularly in paediatric patients, where it reduced the VAS score from 9 to 2, significantly improving the child’s quality of life.

- The case report allows for further research to establish Zoledronate treatment’s long-term safety and efficacy.

After excluding other confounding factors, SNs were found to be the primary cause of back pain. Considering the hyperintense changes on MRI and increased uptake in L3 and L4 vertebrae on bone scan, Zoledronate was used to strengthen the anterior aspects of the intervertebral endplates and to decrease nucleus pulposus protrusion.

References

nodes: Common, highly heritable, and related to lumbar disc disease’, Arthritis & Rheumatism, 57(5), pp. 855–860. doi:10.1002/art.22789.

3. Delgado, D. et al. (2018) "Validation of Digital Visual Analog Scale Pain Scoring With a Traditional Paper-based Visual Analog Scale in Adults", JAAOS: Global Research and Reviews, 2(3), p. e088. doi: 10.5435/jaaosglobal-d-17-00088.