Intra spongy hernia: What is it, and how to treat it? (tips)

Article reviewed and approved by Dr. Ibtissama Boukas, physician specializing in family medicine 

The intra spongy hernia is a little known condition, and very different from the herniated disc typical that we all know.

If you have been diagnosed with an intracancellous hernia (also called Schmorl's hernia or Schmorl's nodule), you're probably wondering what it is. What are the causes? Is that bad ? And above all, how to treat it?

This popular article explains everything you need to know about intra spongy hernia, from the diagnosis to the different treatments to get better.

Definition and anatomy

Before talking about intra spongy hernia, it is worth reviewing certain notions of anatomy that will allow you to better understand this condition.

The spine (or spine) is composed of vertebrae superimposed. The cervical region (the neck) includes 7 vertebrae numbered between C1 and C7. The thoracic region (or dorsal), for its part, comprises 12 vertebrae numbered between T1 and T12 (or even D1 to D12 according to nomenclatures). Then the lumbar region (the lower back) has 5 vertebrae numbered between L1 and L5. Finally, the sacral region (composed of the sacrum) has 5 fused vertebrae (although numbered between S1 and S5).

Between each vertebrate, there is a intervertebral disc. For example, we call disc C4-C5 the disc which is located between the cervical vertebrae C4 and C5. At neck level. Or, the T-T12 disc is between the T11 and T12 thoracic vertebrae. Last example: the intervertebral disc L5-S1 is between the last lumbar vertebra (L5) and the first sacral vertebra (S1).

In summary, the intervertebral discs are structures located between 2 consecutive vertebrae. When we study the composition of these discs, we see that they look like pads. More specifically, they are composed of a gelatinous nucleus (Nucleus pulposus) in the central region, surrounded by a fibrous ring (Annulus fibrosus).

But what are the intervertebral discs for? Their roles include:

Role of intervertebral discs:

• The separation of the vertebrae from the spine
• Shock absorption during movements involving impact (walking, running, jumping, etc.)
• The distribution of pressures thanks to the gelatinous core
• Mobility between the vertebrae

What you have to remember is that the gelatinous nucleus can move inside the disc. This displacement can sometimes be the cause of disc pathologies.

Intracancellous herniation (and difference with typical disc herniation)

Typically, a herniated disc occurs when the fibrous ring surrounding the intervertebral disc is fissured, and allows the gelatinous nucleus to pass through its fibers. Most of the time, this migration of the nuclei is done laterally, and sometimes causes irritation of an adjacent nerve root.

To know everything about conventional disc herniation and its management, see the following article. 

On the other hand, in the case of the intra spongy hernia, the sliding of the gelatinous core does NOT occur laterally. Rather, the nuclei migrate downward (or sometimes upward) toward the adjacent vertebra. She then enters the vertebral body of this vertebra.

Although an intracancellous hernia can develop anywhere in the spine, it mainly affects the thoracic and lumbar vertebrae (near the thoraco-lumbar junction). For example, a D12-L1 cancellous hernia means that it is between the last thoracic vertebra and the first lumbar vertebra.

This is a more common condition than one might imagine. Indeed, intra spongy hernias were found in 75% of the bodies studied during the autopsy, regardless of the age of the subject! 

Causes of intracancellous hernia

The exact cause of intracancellous hernias has not yet been identified.

However, certain factors can influence the appearance of the intra spongy hernia. One thinks of the vertical forces applied at the level of the spine (for example, walking or prolonged standing, jumping, etc.). Indeed, excessive and repeated forces could weaken the vertebral bodies and promote the appearance of intra spongy hernias. 

In adolescents, the vertebral endplates are not as strong as in adults. This can predispose to the appearance of intra spongy hernias. 

Besides the compressive forces on the spine and the fragility of the vertebral endplates, other factors can contribute to disc weakening:

• Any structural disorder of the spine
• Scheuermann's disease 
• Ankylosing spondylitis
• Any metabolic disorder of the bones (for example, osteopenia or osteoporosis)
• Disc degeneration et Osteoarthritis
• Trauma (such as vertebra fracture)
• Infections (not to be confused with spondylodiscitis)
• A tumor

Symptoms of the disease

Surprisingly, intracancellous hernia is often asymptomatic, that is, it does not cause any symptoms in the individual with this condition. Moreover, most people are unaware that they have an intra spongy hernia: it is often discovered by chance during a radiological examination carried out for another reason.

If you suffer from lumbar pain or back pain, you should know that the intra spongy hernia is not necessarily the responsible party. Indeed, low back pain is complex and depends on several factors.

On the other hand, it happens that the intra spongy hernia causes symptoms in some cases. Lower back pain can sometimes occur due to inflammation of the vertebral endplate of the affected vertebra. Also, the disc collapse can reduce the intervertebral space and irritate the articular cartilages of the vertebrae, causing pain.

Vertebral deformities may appear, and cause dorsal kyphosis. This is particularly true if the intracancellous hernia appears during the growth of an adolescent, and is accompanied by a disease such as Scheuermann's disease.

More rarely, the affected disc can become infected and indirectly cause irritation of the corresponding nerves. This can cause pain that radiates down the leg (like sciatica ou cruralgia), associated with numbness and/or weakness of the lower limbs.

Diagnostic 

The intra spongy hernia can be detected by several examinations ofmedical imaging. The imaging of choice is MRI (magnetic resonance imaging), but it can sometimes be seen on an X-ray or CT scan.

As mentioned previously, the intracancellous hernia could be asymptomatic, and therefore not responsible for the patient's symptoms. It is also often diagnosed incidentally.

To find out if it is indeed the intra spongy hernia that is the source of the pain, the doctor could carry out a clinical examination associated with tests such as a discogram. 

Treatment of intra spongy hernia

If the intra spongy hernia does not cause symptoms, no treatment will be carried out. In cases where symptoms are present and limit function, the following modalities can be attempted:

• Rest and reduction in impact sports (rugby, football, running, etc.)
• Medication anti-inflammatory
• Massages and mobilizations (such as lumbar pull-ups or the use of a spinal decompression table) in physiotherapy or osteopathy

If the intracancellous hernia is accompanied by a dorsal kyphosis, therapeutic exercises and mobilizations will aim to correct the deformity, correct the posture and straighten your back.

Apart from physical therapies, there are several products and accessories available in the market to relieve back pain caused by intra hernia. It should be remembered that these tools generally provide temporary relief, and should be used sparingly. Among the products recommended by our professionals, we have:

• acupressure mat

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• Heated lumbar belt

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• Postural T-Shirts

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• Ergonomic back cushion

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• massage gun

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• Spinal decompression table

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• Foam roller (sport massage roller)

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If conservative treatment is not effective, surgery can be performed as a last resort to remove the damaged disc (discectomy ou microdiscectomy), thereby relieving pain.

arthrodesis is also indicated in certain cases to fuse the vertebrae concerned. The operation is also indicated in case of symptomatic and disabling dorsal kyphosis, once the period of growth is over.

What about natural remedies?

Although they are not supported by solid scientific evidence, several natural products and home remedies are used to treat various body pains, especially for their anti-inflammatory power.

Here is a non-exhaustive list of plants and essential oils that are effective in controlling pain and inflammation:

• Turmeric : Thanks to its antioxidant and anti-inflammatory powers very powerful, turmeric is one of the most used plants in a culinary and therapeutic context. The composition of turmeric is essentially made of essential oils, vitamins (B1, B2, B6, C, E, K) and trace elements. But it is to its composition rich in curcumin and curcuminoids that we owe them and calm skin of this spice.

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• Ginger : In addition to the special flavor it brings to the kitchen and its aphrodisiac properties, ginger is a root well known for its anti-inflammatory powers. THE gingerol gives it its anti-inflammatory action. It is an active component acting on the inflammatory pain related to chronic joint inflammatory diseases, including rheumatoid arthritis, lupus, rheumatic diseases, etc. It has been proven that this active element is also effective in acting on the inflammation linked to arthritis and sciatica. Ginger also has other benefits thanks to its high potassium content and its richness in trace elements (calcium, magnesium, phosphorus, sodium) and vitamins (provitamin and vitamin B9).

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• Omega-3s : Omega-3 are polyunsaturated fatty acids that play a very important role in the functioning of our body. They are provided by food in three natural forms: docosahexaenoic acid (DHA), alpha linolenic acid (ALA) and eicosapentaenoic acid (EPA). Beyond their action on the brain and the cardiovascular system, omega-3s prove very effective against inflammation. Indeed, they have the ability to act on the inflammatory mechanisms in osteoarthritis by slowing down cartilage destruction, thus they reduce the intensity of osteoarthritis pain. Since sciatica is most often linked to inflammation secondary to a herniated disc, it can also respond to omega-3s if you consume them regularly. 

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• Lemon eucalyptus: Eucalyptus is a plant most often used in the form of herbal tea or essential oil. She would have anti-inflammatory effects which give it the ability to act on the bone and joint pain in general and the pain of sciatica in particular.

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• wintergreen : Wintergreen is a shrub from which a very interesting essential oil is extracted. It is one of the most used essential oils in aromatherapy. This oil extracted from the shrub bearing the same name, is used in massage to relieve sciatica and act like a analgesic. Indeed, it provides a heating effect thanks to its ability toactivate blood circulation locally.

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The intra spongy hernia, recognized as an occupational disease?

A disease is said to be occupational if it results from direct exposure to a physical, chemical or biological risk. It must also result from the conditions in which a worker exercises his professional activity, and must appear in one of the tables of the general or agricultural Social Security system.

The tables of occupational diseases 97 and 98 relate to back pain, and define a number of criteria which must all be met to allow recognition of the disease.

Here are the conditions that must be met for back pain to be recognized as an occupational disease:

• It must be a chronic condition (defined by a duration of at least 3 months)
• If the pain radiates into the leg: sciatica or radiculalgia femoral crural must be caused by a herniated disc with a topography consistent with the root involvement. For sciatica, the herniated disc must be level L4-L5 or L5-S1. For the radiculalgia crural, the herniated disc must be level L2-L3, or L3-L4, or L4-L5.
• The herniated disc must be explicitly qualified in the report of the radiological examination via a scanner ou IRM.
• The duration of exposure to the risk is 5 years, and the period of coverage must be a maximum of 6 months.

As mentioned previously, the intra spongy hernia is often asymptomatic. And even though it causes back pain, it does not meet the above criteria. This condition cannot therefore be recognized as an occupational disease.

If the pain is so intense that it prevents you from doing your job, the doctor may prescribe a sick leave. The duration will be determined based on the condition, symptoms, physical nature of the work, etc. The return to work will be gradual and will begin when the symptoms have improved.

In extreme cases, a professional redeployment could be considered.

References

• https://radiopaedia.org/articles/schmorl-nodes-2?lang=us
• https://pubmed.ncbi.nlm.nih.gov/5684361/
• https://www.youtube.com/watch?v=4i4S8dAkLvs