Infliximab infusions for persistent back pain in two patients with Schmorl's nodes

G. T. Sakellariou, I. Chatzigiannis and I. Tsitouridis1

Department of Rheumatology, St Paul's Hospital and 1 Department of Radiology, Papageorgiou Hospital, Thessaloniki, Greece

Correspondence to: G. T. Sakellariou, Department of Rheumatology, St Paul's Hospital, 161 Ethnikis Andistaseos Street, 551 34, Thessaloniki, Greece. E-mail: sakelgr{at}otenet.gr or sakellariou.doc{at}mycosmos.gr

SIR, Schmorl's nodes (SNs) are herniations of the nucleus pulposus (NP) material through the vertebral endplates into the trabecular bone. SNs are the most common non-intervertebral disc abnormalities in magnetic resonance imaging (MRI) in persons without back pain [1]. However, SNs are seldom symptomatic, and treatment with analgesics, non-steroidal anti-inflammatory drugs (NSAIDs) or corticosteroids usually improves back pain. In contrast to SNs, herniated intervertebral discs (HIDs) are a common cause of back and radicular pain. TNF-{alpha} from the NP does appear to be pathogenic to nerve roots in animal models of sciatica [2]. Furthermore, TNF-{alpha} blockade is effective in preventing NP-induced functional and structural nerve root injury in animal models [3]. The efficacy of the TNF-{alpha} inhibitors infliximab and etanercept in leg and back pain has recently been shown in patients with HID-induced sciatica [4, 5]. These results of TNF-{alpha} blockade prompted us to test infliximab infusions for refractory symptoms to conventional conservative treatment in two patients with painful SN.

Two women aged 52 and 49 yr with SNs received infliximab because of severe, long-standing back pain (duration of pain 24 and 18 months, respectively) without radicular symptoms. There was a partial response of pain to treatment with NSAIDs and corticosteroids in both patients, but severe spinal pain recurred after discontinuation of the above agents. SNs of the L3 and L5 vertebrae in the first patient and of the T12, L1 and L2 vertebrae in the second patient were depicted by MRI. There were MRI findings of active SN (oedema of adjacent bone marrow and contrast enhancement of SN) in the L5 vertebra for the first patient and in the L2 vertebra for the second patient. After obtaining ethics committee approval and written consent from the patients, the patients scheduled to receive infliximab infusions at a dose of 3 mg/kg at weeks 0, 2, 6 and 14. Response was evaluated using a 0–100 mm visual analogue scale (VAS) for back pain. Furthermore, the first patient was evaluated for radiological progression of the lesions by sequential MRI examination.

Prior to infliximab treatment, the VAS score for back pain for the two patients was 90 and 85, respectively. The first patient responded promptly to infliximab with a decrease in VAS for back pain to 7, and back pain completely resolved after the second infusion. Due to a severe allergic reaction just after the second infusion, she discontinued the infliximab regimen. Six months later, MRI examination revealed disappearance of contrast enhancement of SN of the L5 vertebra and of bone marrow oedema (Fig. 1). She has remained asymptomatic for 30 months. The second patient completed four infliximab infusions. She also responded promptly to treatment. VAS for back pain ranged from 15 to 20 at weeks 2, 6 and 14. She was missed 5 months after the last infliximab infusion, and had VAS for back pain ~20 over the follow-up period.



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FIG. 1. Post-contrast T1-weighted image of lumbar spine in the first patient prior to (A) and 6 months after (B) infliximab infusions, showing disappearance of enhancement of Schmorl's node and of oedema of adjacent vertebral body marrow.

 
MRI is useful in differentiating between symptomatic and asymptomatic SNs. In an analysis of MRI findings of SNs [6], the vertebral body marrow surrounding the SN was seen as low signal intensity on T1-weighted images and as high signal intensity on T2-weighted images in all symptomatic cases. These MRI findings were not seen in asymptomatic individuals. Histological examination of two symptomatic cases demonstrated bone marrow oedema and inflammatory cell infiltration in the affected vertebral body. In a small number of cases of acute SNs [7], there had been improvement in back pain by the time the follow-up MRI (between 6 weeks and 7 months after the initial MRI) showed reduction in bone marrow oedema. Furthermore, there was resolution of oedema with fatty marrow change in two cases with longer follow-up at MRI (10 and 18 months after the initial MRI, respectively). In addition to surrounding bone marrow oedema, MRI can reveal vascularized tissue in SNs after the intravenous administration of contrast material [8]. Contrast-enhancing SNs are larger and more frequently associated with bone marrow oedema in patients with back pain than in asymptomatic patients.

Our patients had not only severe back pain, which was induced by active SNs (L5 vertebra in the first patient and L2 vertebra in the second patient), but also long-standing symptoms, which could be explained by previous active SNs that were in the healing stage at the time of MRI examination (L3 vertebra in the first patient and T12 and L1 vertebra in the second patient). A single infliximab infusion for HID-induced sciatica produced not only a sustained but also an immediate improvement (within hours) [4]. The first infliximab infusion led to prompt and significant improvement in back pain in our patients within the first 24 h. There was a complete response to the second infliximab infusion in the first patient, but the second patient did not have a complete improvement of back pain with the four-dose infliximab regimen. A pilot study is required to validate the results of our two case reports.

The authors have declared no conflicts of interest.

References

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Accepted 9 September 2005





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