Low back pain affects nearly 1 in 10 adults in the U.S. Degeneration of intervertebral disks is a common cause — but not always in the way physicians suspect.
Recent research shows that, in some cases, a damaged disk can cause inflammation in vertebral endplates that triggers a nerve inside the vertebrae. Many patients with this type of pain receive treatments that target the disk without addressing the endplate pathology. These patients often remain in pain and looking for answers.
Michal Glinianski, MD MBA
A new treatment offers hope. Basivertebral nerve ablation is a minimally invasive outpatient procedure that interrupts pain transmission from the damaged endplate. In fall 2024, WellSpan Health became one of the first health systems in Central Pennsylvania to offer the procedure. We help about 10 patients per month, including many who were diagnosed with degenerative disease of the spine long ago but remained in search of relief.
Here’s what physicians should know about this procedure and who is eligible so they can steer patients toward the treatment they need.
Disk Damage Can Have Cascading Effects on Adjacent Vertebrae
In many cases of low back pain, the disk itself acts as the pain generator. Patients who don’t respond to conservative care may advance to treatments like intradiscal thermal treatment, lumbar discectomy or another form of surgery.
But recent studies have shown that pain can also come from the nearby vertebrae. As a disk degrades, it releases proinflammatory factors that can seep into vertebral endplates, causing localized blood vessel and nerve proliferation. The end branches of the basivertebral nerve (BVN) inside the vertebrae sense this inflammation and transmit pain signals to the brain.
This condition is known as chronic vertebrogenic low back pain. Because it originates from the endplate, treatments targeting the disk may not bring relief. Instead, patients may need treatment that targets the BVN.
How to Spot and Treat Vertebrogenic Pain
Identifying features of vertebrogenic low back pain include:
- Patient presentation: Pain is localized in the middle of the low back and often increases with physical activity, prolonged sitting, bending forward or bending and lifting. Unlike sciatica pain, vertebrogenic back pain doesn’t extend into the lower extremities.
- MRI features: Endplate damage appears as darkening or lightening of the vertebrae just beyond the disk boundary. These features are known as Modic changes and are a biomarker for chronic vertebrogenic low back pain.
The bottom of three lumbar disks shown here is flattened and dark, indicating degeneration. The lightened areas just above and below the disk boundary are Modic changes.
BVN ablation is an FDA-cleared, minimally invasive procedure that takes under an hour to complete:
- Patients receive monitored anesthesia care or, in some cases, general anesthesia.
- I make a small incision (3-5 mm) in the lumbar region.
- Under fluoroscopic guidance, I advance an introducer through the pedicle, then I insert a curved instrument to create a channel for the radiofrequency probe.
- I slide the probe into the curved path and position the tip at the trunk of the BVN. The probe emits radiofrequency energy that ablates the BVN.
- Patients go home same day, with minimal post-procedural pain.
Illustration of basivertebral nerve ablation. The nerve is accessed via the pedicle.
Ablation Can Achieve Dramatic, Long-lasting Relief
Most patients start to feel pain relief within two weeks after the procedure, with maximum relief achieved at three months. In two large prospective randomized clinical trials, BVN ablation demonstrated statistically and clinically significant pain reduction and improvement in function lasting at least 5 years.
I’ve seen comparable results in my practice. Recently, I cared for a patient whose low back pain affected his ability to stand and often prevented him from finishing a round of golf. The patient didn’t respond to conservative treatment with medications and physical therapy. Diagnostic injections targeting lumbar facet joints were negative, and an MRI of the lumbar spine revealed Modic changes.
After BVN ablation, the patient’s back pain has diminished significantly. He plays golf more often and is able to finish the entire round. At our four-week follow-up, he told me, “I wish I could have done this sooner.”
Whom and How to Refer
Patients eligible for BVN ablation have the pain and MRI features listed above. Patients must also have failed at least six months of conservative therapy for low back pain.
Patients don’t require an MRI before referral, but it does accelerate our patient evaluation process and approval by insurance.
If you’re unsure if your patient is a candidate or have a question about basivertebral nerve ablation, please don’t hesitate to reach out.
To learn more about basivertebral nerve ablation or refer a patient, please contact WellSpan Health by phone at (717) 217-6072 or fax at (717) 839-6398.