Is the Intracept Procedure (intra-osseous basivertebral nerve ablation) medically indicated for the treatment of low back pain?

Basivertebral Nerve Ablation (Intracept Procedure) is NOT Medically Indicated for Vertebrogenic Low Back Pain

The Intracept Procedure should be non-certified as it is classified as having "insufficient evidence or unproven" for the treatment of low back pain according to current neurosurgical guidelines, and no high-quality evidence demonstrates meaningful improvement in morbidity, mortality, or quality of life. 1

Guideline-Based Rationale for Non-Certification

Primary Evidence Against the Procedure

• Current neurosurgical guidelines explicitly state there is "insufficient evidence" for the effectiveness of the Intracept System (intraosseous basivertebral nerve ablation) for the treatment of low back pain. 1

• The 2014 Journal of Neurosurgery guidelines for fusion procedures in degenerative lumbar disease do not include basivertebral nerve ablation as a recommended treatment option, indicating this procedure lacks established evidence even compared to other interventional techniques. 1

• Even the 2022 American Society of Pain and Neuroscience guideline, which provides a "strong recommendation for basivertebral nerve ablation for chronic back pain," represents a consensus-based rather than evidence-based approach, and such guidelines are more likely to violate principles of evidence-based medicine. 2

Contradictory Guideline Landscape

• The 2025 BMJ clinical practice guideline highlights that there is "no consistency in recommendations for or against any interventional procedure" for chronic spine pain, with positive results in reviews being three times more likely when authored by interventionalists versus non-interventionalists. 2

• The 2021 American College of Occupational and Environmental Medicine guideline does not recommend basivertebral nerve ablation, and even established procedures like radiofrequency neurotomy are not recommended for chronic low back pain. 2

Risk-Benefit Analysis

Potential Harms

• Interventional procedures for chronic spine pain carry risks including prolonged pain/stiffness (8.6%), temporary altered consciousness (2.1%), dural puncture (1.4%), and deep infection (0.7%). 1

• There is a very small but catastrophic risk of infection resulting in meningitis, spinal cord injury, and paraplegia. 1

Cost Considerations

• The cost-benefit ratio is unfavorable given substantial costs of interventional procedures (up to $5000 per procedure in the US) with uncertain benefits. 1

• The previous certification expired more than one year ago, and the procedure was never performed, suggesting either patient hesitation or clinical reassessment that the procedure was not appropriate. 1

Comparison to Established Interventions

Evidence for Other Procedures

• Even well-established interventional procedures have limited evidence: epidural steroid injections have only weak evidence (Level III) for short-term relief in chronic low back pain from degenerative disease. 1

• Facet medial nerve ablation, which has been studied more extensively, only has moderate evidence (Level II) for short-term pain decrease lasting 3-6 months. 1

• The 2014 neurosurgical guidelines provide Grade B recommendation that trigger point injections "are not recommended in patients with chronic low-back pain without radiculopathy from degenerative disease of the lumbar spine because a long-lasting benefit has not been demonstrated." 2

Clinical Decision Algorithm

For this patient with vertebrogenic low back pain requesting basivertebral nerve ablation:

1. Confirm the diagnosis does not meet criteria - The procedure is classified as having insufficient evidence for effectiveness. 1

2. Consider evidence-based alternatives first:

   • NSAIDs have moderate-certainty evidence for small benefit in chronic low back pain (MD -6.97 on 0-100 scale for pain). 3
   • Physical therapy modalities such as the McKenzie method may decrease recurrence and healthcare expenditures. 4, 5
   • Yoga has strong evidence for short-term effectiveness and moderate-quality evidence for long-term effectiveness in chronic low back pain. 4

3. Avoid interventional procedures without established benefit - The requested procedure lacks the evidence base necessary to justify the risks and costs involved. 1

Common Pitfalls to Avoid

• Do not be swayed by previous certification - The fact that this was previously certified does not establish medical necessity, particularly when the procedure was never performed and the authorization expired. 1

• Do not equate "vertebrogenic pain" diagnosis with indication for basivertebral nerve ablation - This diagnostic label does not change the fundamental lack of evidence for the procedure's effectiveness. 1

• Recognize that consensus-based guidelines from specialty societies may not reflect evidence-based medicine principles - The ASPN strong recommendation conflicts with multiple other guidelines and lacks high-quality supporting evidence. 2