Is thermal destruction of the intraosseous basivertebral nerve (TRML DSTRJ IOS BVN) medically necessary for a patient with vertebrogenic low back pain?

Basivertebral Nerve Ablation for Vertebrogenic Low Back Pain

Thermal destruction of the intraosseous basivertebral nerve (BVN ablation) is medically necessary for this 63-year-old female with vertebrogenic low back pain, given her chronic symptoms unresponsive to conservative care and the strong evidence supporting this intervention for her specific diagnosis. 1

Evidence Supporting Medical Necessity

High-Quality Clinical Trial Data

The American Society of Pain and Neuroscience assigns Level A grade evidence with high certainty that the net benefit is substantial for BVN ablation in appropriately selected patients with vertebrogenic low back pain. 1 This represents the highest quality recommendation available for this specific condition.

A multicenter randomized controlled trial (140 patients) demonstrated overwhelming superiority of BVN ablation over standard care at 3 months: 2

• Mean ODI reduction of 25.3 points in the ablation group versus 4.4 points in standard care (adjusted difference 20.9 points, p<0.001)
• Mean VAS pain reduction of 3.46 cm versus 1.02 cm (adjusted difference 2.44 cm, p<0.001)
• 74.5% of ablation patients achieved ≥10-point ODI improvement versus only 32.7% in standard care (p<0.001)

These improvements are sustained long-term: At 12 months post-ablation, patients maintained a 25.7-point ODI reduction and 3.8 cm VAS reduction from baseline, with 64% achieving ≥50% pain reduction and 29% becoming pain-free. 3

Patient Selection Criteria Met

This patient meets the established criteria for BVN ablation: 1

• Chronic low back pain duration of several years (requirement: ≥6 months)
• Failed conservative management including physical therapy
• Diagnosis of vertebrogenic pain (vertebral endplate pain)
• Severe functional impairment (10/10 pain, radiating symptoms, lower extremity weakness)

Comparison to Alternative Interventions

Current guidelines provide limited support for alternative interventions in this population. The 2023 PM&R synthesis of interventional guidelines shows that for chronic non-radicular low back pain: 4

• Epidural steroid injections have one strongly-against recommendation from high-quality guidelines
• Radiofrequency procedures for general chronic low back pain have mixed evidence (two weakly-against, three weakly-for from high-quality guidelines)
• Most radiofrequency recommendations require positive diagnostic blocks first, which are not mentioned in this case

In contrast, BVN ablation specifically targets vertebrogenic pain with demonstrated 96.5% clinical success rates for both pain and disability reduction in prospective trials. 5

Safety and Procedural Considerations

The procedure demonstrates excellent safety: 5, 2

• No immediate or delayed complications in 56 consecutive patients
• Mean operative time of 32 minutes
• Performed under local anesthesia with CT guidance
• 100% successful targeting of ablation zones

Long-term healthcare utilization data supports durability: 6

• 40.3% reduction in opioid use at 1 year, 61.7% at 5 years
• 81.2% reduction in lumbar spinal injections at 1 year
• Lumbar fusion rate of only 6.5% at 5 years (less than half the published rate for similar populations)

Critical Distinction from General Low Back Pain Treatments

The older guidelines cited (2007-2018) do not address vertebrogenic pain specifically. 4 These guidelines discuss:

• General chronic low back pain interventions (massage, acupuncture, exercise)
• Facet-mediated pain treatments
• Discogenic pain treatments
• Vertebral compression fractures from metastatic disease 4

None of these address the specific pathophysiology of vertebrogenic pain (vertebral endplate degeneration with basivertebral nerve involvement), which is a distinct clinical entity requiring targeted treatment. 1

Common Pitfalls to Avoid

Do not confuse vertebrogenic pain with facet-mediated or discogenic pain. While radiofrequency ablation of medial branch nerves has moderate support for facet pain 4, vertebrogenic pain requires intraosseous BVN ablation targeting the vertebral endplates, not the facet joints.

Do not delay treatment awaiting further conservative care. This patient has already failed physical therapy over several years with worsening symptoms and severe functional impairment (10/10 pain, lower extremity weakness). The evidence shows BVN ablation is dramatically superior to continued standard care. 2

Ensure proper imaging confirmation. While not explicitly stated in the case, appropriate patient selection requires MRI documentation of Modic Type 1 or 2 vertebral endplate changes between L3-S1, which should be verified before proceeding. 2, 1