Is thermal destruction of the intraosseous basivertebral nerve medically necessary for a 40-year-old with low back issues and degenerative disc disease?

Basivertebral Nerve Ablation Should Be Denied for This Patient

This 40-year-old patient does not meet the established criteria for basivertebral nerve ablation and the procedure should be denied because: (1) her MRI shows no Modic changes at the proposed treatment levels L4-L5, which are required for this procedure; (2) her current acute pain is localized to L1-L2, not at the L4-L5 levels where treatment is planned; and (3) she has only been experiencing this acute exacerbation for 5 days without adequate conservative treatment trial for this specific episode. 1, 2, 3, 4

Critical Missing Criteria for Basivertebral Nerve Ablation

Absence of Required Modic Changes

• Basivertebral nerve ablation is specifically indicated only for patients with Modic Type I or Type II changes at L3-S1 on MRI 3, 4
• The provided MRI findings describe disc degeneration, disc extrusion at L1-L2, and facet arthropathy, but no Modic changes are documented at L4-L5 where the procedure is proposed 3
• Without Modic changes, the patient does not have vertebrogenic low back pain (ICD-10 code M54.51), which is the specific diagnosis for which this procedure is indicated 4

Anatomic Mismatch Between Pain Location and Proposed Treatment

• The patient's current acute pain is localized to L1-L2 on the left side, with focal tenderness at this level and a new moderate left neural foraminal stenosis at L1-L2 secondary to cranial disc extrusion 3
• The proposed basivertebral nerve ablation targets L4-L5, which does not correspond to her current symptomatic level 2, 3
• Her MRI findings at L1-L2 (disc extrusion with nerve root contact) provide a clear alternative explanation for her acute symptoms that would not be addressed by L4-L5 ablation 5

Insufficient Conservative Treatment for Current Episode

• Basivertebral nerve ablation requires failure of at least 6 months of conservative treatment for chronic vertebrogenic low back pain 2, 3, 4
• This patient's acute exacerbation began recently (requiring emergency room visit), and she has only been treated with dexamethasone, oxycodone, and Zofran for 5 days 2, 3
• While she has extensive prior treatment history, those treatments targeted different levels (L3-4, L4-5, L5-S1, sacroiliac joint) and her current L1-L2 pathology is described as "new" 3, 4

Additional Concerns Regarding This Case

Previous Failed Ablation at Same Levels

• The patient previously underwent radiofrequency ablation at L4-5 and L5-S1 medial branch nerves "which did not have durable relief" 6
• This prior failure of ablative therapy at the same spinal levels raises questions about the likelihood of success with a different ablation technique at these levels 6

No Diagnostic Block Performed

• The American Society of Anesthesiologists recommends that radiofrequency ablation should be performed when "previous diagnostic or therapeutic injections of the joint or medial branch nerve have provided temporary relief" 6
• No diagnostic block of the basivertebral nerve was performed to confirm this nerve as the pain generator 6
• The double-injection technique with 80% improvement threshold is recommended for establishing diagnosis of facet-mediated pain before ablation 6

Alternative Pathology Better Explains Current Symptoms

• The MRI demonstrates a new moderate left neural foraminal stenosis at L1-L2 with contact of the exiting left L1 nerve root from a cranial disc extrusion 5
• This structural pathology at L1-L2 directly correlates with her focal tenderness, pain location, and acute presentation 5
• Discogenic back pain from degenerative disc disease typically presents as transverse low back pain radiating to sacroiliac joints, not the focal unilateral upper lumbar pain this patient describes 5

Appropriate Next Steps for This Patient

Address the Acute L1-L2 Pathology

• The new disc extrusion at L1-L2 with nerve root contact requires targeted evaluation and treatment 5
• Consider epidural steroid injection at L1-L2 if conservative management fails, as this addresses the documented pathology at the symptomatic level 6

Complete Adequate Conservative Treatment Trial

• Continue conservative management including physical therapy and anti-inflammatory medications for at least 6 months before considering any ablative procedures 2, 3, 4
• The American Society of Anesthesiologists Task Force notes that "other treatment modalities should be attempted before consideration of the use of ablative techniques" 6

Obtain Proper Imaging Confirmation if Considering Future Ablation

• If chronic vertebrogenic pain persists after conservative treatment, repeat MRI should specifically evaluate for Modic changes at symptomatic levels 3, 4
• Basivertebral nerve ablation should only be considered at levels demonstrating both Modic changes and clinical correlation with pain location 3, 4

Common Pitfalls in This Case

• Proceeding with ablative procedures without meeting established diagnostic criteria (absence of Modic changes) represents a deviation from evidence-based indications 3, 4
• Treating levels that do not correspond to current symptoms (proposing L4-L5 treatment for L1-L2 pain) will not address the patient's presenting complaint 2, 3
• Insufficient conservative treatment duration for the acute exacerbation fails to meet the 6-month requirement 2, 3, 4
• Ignoring alternative explanations for pain (the new L1-L2 disc extrusion with nerve contact) may result in inappropriate treatment selection 5