Developments in Minimally Invasive Surgical Options for Vertebral Pain: Basivertebral Nerve Ablation – A Narrative Review

Abstract

Historically, intervertebral disc degeneration has been the etiological target of chronic low back pain; however, disc degeneration is not necessarily directly associated with pain, and many other anatomical structures are potential etiologies. The vertebral endplates have been postulated to be a source of vertebral pain, where these endplates become particularly susceptible to increased expression of nociceptors and inflammatory proliferation carried by the basivertebral nerve (BVN), expressed on diagnostic imaging as Modic changes. This is useful diagnostic information that can help physicians to phenotype a subset of low back pain, which is known as vertebral pain, in order to directly target interventions, such as BVN ablation, to this significant pain generator. Therefore, this review describes the safety, efficacy, and the rationale behind the use of BVN ablation, a minimally invasive spinal intervention, for the treatment of vertebral pain. Our current literature review of available up-to-date publications utilizing BVN ablation in the treatment of vertebral pain suggests that there is limited, but moderate-quality evidence that this is an effective intervention for reduction of disability and improvement in function, at short- and long-term follow-up, in addition to limited moderate-quality evidence that BVN RFA is superior to conservative care for pain reduction, at least at 3-month follow-up. Our review concluded that there is a highly clinical and statistically significant treatment effect of BVN ablation for vertebral pain with clinically meaningful benefits in pain reduction, functional improvements, opioid dose reduction, and improved quality of life. There were no reported device-related patient deaths or serious AEs based on the available literature. BVN ablation is a safe, well-tolerated and clinically beneficial intervention for vertebral pain, when proper patient selection and surgical/procedural techniques are applied.

Best Practice Guidelines on the Diagnosis and Treatment of Vertebrogenic Pain with Basivertebral Nerve Ablation from the American Society of Pain and Neuroscience

“… 18 , 20 , 21 Post-procedure diagnostic imaging at longer follow-ups did not reveal any advanced disc degeneration, avascular necrosis or spinal cord injuries post BVNA and the rate of adverse events was very rare. 26 , 28 , 29 …”

“… 42 , 43 Vertebrogenic pain refractory to conservative treatment can be treated with BVNA, a safe procedure which leads to improved pain and functional outcomes. 18 , 21 , 29 …”

“…Initial patient evaluation involves identifying anterior column pain, which commonly manifests as pain with sitting, driving, lifting, tying shoelaces, and/or putting on socks. 29 Patients often cannot tolerate remaining in one position for too long and find themselves frequently shifting positions or standing rather than sitting. Such positional triggers can be picked up on the intake form or during the history portion of the exam.…”

“…The majority of the evidence at this time suggests that the two pathologies exists on a continuum that may start with discogenic pain and evolve into vertebrogenic pain. 29 …”

Non-Spinal Neuromodulation of the Lumbar Medial Branch Nerve for Chronic Axial Low Back Pain: A Narrative Review

“…With increasing pain, disability, pain duration, or failure of treatment, interventional approaches are subsequently attempted. Common interventional modalities include epidural steroid injections (ESI), medial branch blocks (MBB), intraarticular facet injections, lumbar radiofrequency ablation (RFA) of medial branches of dorsal rami or basivertebral nerve, mechanical surgical procedures (including posterior stabilization, interspinous spacers, or minimally invasive decompression) and neuromodulation, including spinal cord stimulation (SCS), or peripheral nerve stimulation (PNS) ( 10 , 14 , 15 ).…”