Basivertebral Nerve Ablation for Lower Back Pain

Basivertebral nerve ablation is a treatment option for chronic back pain caused by damaged vertebral endplates in the lumbar spine (lower back).

This procedure may be recommended for those with moderate to severe low back pain who have specific endplate changes identified on magnetic resonance imaging (MRI). These changes are usually seen at the L3-L4, L4-L5, and L5-S1 lumbar spine segments.

What Is a Basivertebral Nerve Ablation?

This procedure creates a heat lesion on the nerve, which supplies sensation to the injured endplate – the basivertebral nerve – to block pain signals and provide long-lasting pain relief.

The essentials of basivertebral nerve ablation are:

• The vertebral endplate is a thin structure made up of cartilage and bone connecting each vertebra – the cylindrical bony building blocks of the spine – and the adjacent spinal disc – the cushion-like structure providing shock absorption.
• The basivertebral nerve lies within the vertebra and branches into a cluster of nerve fibers within these vertebral endplates. 
• Ablation is a type of procedure in which a thin needle-like device is inserted into the targeted area, and heat is applied to destroy a small section of nerve tissue, preventing the nerve from communicating the pain sensation from the damaged endplate to the brain.

This ablation procedure involves inserting the device into the bone of the vertebra (intraosseous) and targeting the area of the nerve where it begins to branch.

Alternative names for basivertebral nerve ablation include:

• Basivertebral radiofrequency ablation because the heating mechanism is a radiofrequency probe. 
• BVN ablation (BVN is short for basivertebral nerve)
• Intracept^TM is the brand name of the device used in this procedure.

As noted above, the basivertebral nerve may also be referred to by its acronym “BVN.”

How Vertebral Endplates Cause Pain

Vertebral endplates are a common source of chronic lower back pain. Research shows up to 43% of patients with chronic lower back pain have vertebral endplate damage.

Pain that is caused by damaged endplates is called vertebrogenic pain.

Understanding vertebral endplates

The endplates have a complex anatomy and provide several functions:

• Each endplate comprises 2 layers – the bony layer attaches to the vertebral body, and the cartilaginous layer is affixed to the spinal disc.
• The rigid bony layer of the endplates provides support and protection for the vertebrae.
• The pliable layer of cartilage allows for transporting nutrients and fluid into the disc.

The competing structural needs of the endplate layers and the stress on these structures make them highly susceptible to damage from wear and tear over time, such as from everyday bending, twisting, and lifting, many sports, physically demanding jobs, and natural aging processes.

How endplates generate pain

When a vertebral endplate becomes damaged, basivertebral nerve fibers transmit pain signals to the brain. Injury also triggers inflammation, further damaging the endplate and worsening pain.

Common spinal conditions known to cause endplate damage include:

• Lumbar degenerative disc disease 
• Lumbar herniated disc

Basivertebral nerves are sensitized if these conditions cause direct injury to the endplate tissue or place excessive mechanical force on the endplate.^,

Modic changes in vertebral endplates

Changes in the structure of vertebral endplates caused by damage and inflammation create distinctive patterns visible on an MRI scan known as Modic changes.^,,

Modic changes are categorized into 3 main types based on their appearance on MRI scans and correlate to the nature of endplate injury.^,

Basivertebral nerve ablation is primarily performed in patients with:

1. Modic Type 1 (acute inflammation) or 
2. Modic Type 2 (chronic degeneration) changes.

BVN Ablation Treatment Goals

The primary goals of basivertebral nerve ablation are^,:

• Long-term pain relief
• Avoidance of surgery

The procedure is a form of pain management and does not cure the underlying cause of pain or repair endplate damage.

Improving low back pain allows patients to engage in rehabilitative activities such as exercise, physical therapy, and postural modifications, creating an optimal healing environment and helping prevent further endplate damage and/or disc degeneration. 

Effectiveness of Basivertebral Nerve Ablation 

Like most treatments for lower back pain, the success rates of an endplate injection are variable.  Current research shows:

• More than half of patients who undergo a basivertebral nerve ablation experience significant pain relief and functional improvement.
• Symptoms begin to improve for most patients within 2 to 6 weeks of the procedure, with maximum benefit felt at around 3 to 6 months.^,
• Approximately 35% of patients have complete resolution of pain.^,

Studies have focused primarily on the effects of this procedure on lower back pain and functional status in patients without additional spinal complications.

More research is needed to establish the benefit and safety of basivertebral nerve ablation when endplate damage is seen in patients with radicular pain in the lower extremities (sciatica).

Several variables influence the success rates of the procedure, such as: 

• Accurate clinical diagnosis of vertebrogenic pain
• Skill and experience of the physician performing the procedure
• The patient’s overall health status 
• The patient’s lifestyle factors, such as smoking/nicotine intake and fitness level

Adherence to physical therapy and rehabilitation recommendations following the procedure also contributes to the degree of pain relief and functional improvement following this procedure.

Effectiveness compared to standard treatments

One study has demonstrated that basivertebral nerve ablation provides pain relief for more patients compared to the nonsurgical standard of care – typically some combination of pain medications, epidural steroid injections, and facet joint procedures.^,

Additional studies have shown significant and sustained pain relief and functional improvement in patients with inadequate or “failed” responses to prior spinal injection treatments.

Long-term outcomes

While basivertebral nerve ablation is a newer procedure, results of studies to date show the potential for long-lasting pain relief.

• Improvements in pain and function last up to 2 years after the procedure for 50% to 70% of patients
• One study has demonstrated lasting efficacy at 5 years

Additional research is needed to fully understand the potential benefits, risks, and long-term pain reduction and safety issues.

Who May Be a Candidate 

Individuals with severe lower back pain who meet the following criteria are considered for basivertebral nerve ablation:

• Lower back pain lasting 6 months or longer
• Inadequate response to non-surgical therapies such as pain-relieving medications and physical therapy
• Functional impairment
• Confirmation of skeletal maturity on imaging, meaning the bones have stopped growing
• Modic Type 1 or Type 2 changes on MRI in the lumbar region 

If patients cannot undergo an MRI, alternative imaging methods, such as computed tomography (CT) and single photon emission computed tomography (SPECT), can detect vertebral endplate changes.

Contraindications and Precautions

Basivertebral nerve ablation is not recommended when the risk of complications is significantly increased, including:

• Systemic and/or spinal infection, such as osteomyelitis
• Pregnancy
• Children and adolescents (due to incomplete spinal maturity)
• Pacemakers and/or implanted defibrillators
• Severe cardiopulmonary disease (such as heart failure or chronic obstructive pulmonary disorder)

It is also recommended to avoid this procedure when hardware, such as pedicle screws or rods, from previous spinal surgery is present in the targeted ablation area, or an alternative is to consider hardware removal before this procedure.

Medical conditions requiring additional precautions

Greater caution is recommended in several conditions due to the potential for injury and/or difficulty performing the ablation:

• Osteoporosis
• Metastatic cancer or malignant spinal tumor
• Bleeding disorders
• Morbid obesity (BMI greater than 40)

The safety of vertebral endplate injection procedures in various medical conditions has yet to be adequately researched.

As with any invasive procedure, eligibility for basivertebral nerve ablation is impacted by general health status, severe heart or lung conditions, or any concerns that would affect the administration of anesthesia or sedating medications.

Doctors Who Perform Basivertebral Nerve Ablations

The following types of physicians who specialize and are board-certified in Pain Management may be consulted to perform the initial assessment and procedure:  

• Physical Medicine & Rehabilitation (Physiatrist)
• Interventional Radiologist 
• Anesthesiologist 
• Orthopedic spine surgeon
• Neurosurgeon
• Neurologist

In addition to Board Certification in Pain Management, specialized training in patient selection, procedural technique, and follow-up care for basivertebral nerve ablation is required.