Basivertebral Nerve Ablation for Chronic Back Pain
Direct Recommendation
Basivertebral nerve (BVN) ablation is strongly recommended for middle-aged adults with chronic back pain (≥3 months duration) who meet specific diagnostic criteria, based on the highest quality 2025 BMJ guideline evidence. 1
Key Diagnostic Requirements Before Proceeding
You must confirm vertebrogenic pain as the pain generator before offering BVN ablation:
- MRI evidence of Modic Type 1 or 2 changes at vertebral endplates between L3-S1 2, 3, 4
- Chronic axial low back pain (not radicular) persisting ≥6 months 2, 4
- Failed conservative management for at least 3-6 months including physical therapy, NSAIDs, and activity modification 2, 5
- Pain localized to the vertebral endplates with degenerative disc disease as the suspected etiology 2, 3
Evidence Hierarchy: Why BVN Ablation is Recommended
Guideline-Level Evidence (Highest Priority)
The 2025 BMJ guideline provides a strong recommendation IN FAVOR of basivertebral nerve ablation for chronic back pain, distinguishing it from other interventional procedures that received strong recommendations AGAINST. 1 This is the most recent and highest quality guideline available.
The guideline explicitly states:
- Strong recommendation FOR sacroiliac joint denervation/ablation for sacroiliac joint dysfunction pain 1
- Strong recommendation FOR basivertebral nerve ablation for chronic back pain 1
- Strong recommendation AGAINST facet joint radiofrequency ablation, epidural injections, and intramuscular injections for chronic axial spine pain 1
Supporting Research Evidence
The American Society of Pain and Neuroscience (ASPN) 2022 guidelines assign Level A grade evidence with high certainty that BVN ablation provides substantial net benefit in appropriately selected patients. 2
Clinical trial outcomes demonstrate:
- Mean ODI improvement of 25.3 points at 3 months (compared to 4.4 points with standard care, p<0.001) 4
- Mean VAS pain reduction of 3.46 cm (compared to 1.02 cm with standard care, p<0.001) 4
- 74.5% responder rate (≥10-point ODI improvement) versus 32.7% with standard care 4
- Sustained benefits at 5+ years: mean ODI reduction of 25.95 points maintained, with 66% achieving >50% pain reduction 6
Critical Distinction: BVN Ablation vs. Other Nerve Ablations
Do NOT confuse BVN ablation with facet joint radiofrequency ablation—these are entirely different procedures with opposite evidence profiles:
- BVN ablation targets the intraosseous basivertebral nerve within vertebral bodies for vertebrogenic pain (STRONG recommendation FOR) 1, 2
- Facet joint radiofrequency ablation targets medial branch nerves for facet-mediated pain (STRONG recommendation AGAINST for chronic axial pain) 1
The 2025 BMJ guideline explicitly recommends AGAINST facet joint radiofrequency ablation, epidural injections, and joint-targeted injections for chronic axial spine pain. 1
Technical Procedure Details
Approach and Guidance
- Percutaneous transpedicular or extrapedicular approach under fluoroscopic or CT guidance 3, 5
- Radiofrequency ablation using bipolar electrode system (e.g., STAR™ system) 3
- Target zone: basivertebral nerve within vertebral body at levels with Modic changes 2, 3
- Performed in local anesthesia with mean operative time of 32 minutes 3
Safety Profile
- No immediate or delayed complications reported in prospective trials 3
- 100% technical success rate for CT-guided targeting 3
- Contraindications include: unwilling patients, active infection, coagulopathy, very short life expectancy, or lack of technical expertise 1, 7
Patient Selection Algorithm
Proceed with BVN ablation if ALL criteria are met:
- ✓ Chronic axial low back pain ≥6 months duration 2, 4
- ✓ MRI shows Modic Type 1 or 2 changes at L3-S1 2, 3, 4
- ✓ Failed ≥3-6 months conservative care (PT, NSAIDs, activity modification) 2, 5
- ✓ Pain is axial (not radicular/sciatica) 2
- ✓ No contraindications (infection, coagulopathy, patient refusal) 1, 7
Do NOT proceed if:
- Pain is primarily radicular (consider other treatments per 2025 BMJ guideline) 1
- No Modic changes on MRI (vertebrogenic pain not confirmed) 2, 4
- Active infection or uncorrected coagulopathy present 1, 7
Common Pitfalls to Avoid
Pitfall #1: Confusing BVN ablation with facet joint procedures
- The 2025 BMJ guideline recommends FOR BVN ablation but AGAINST facet joint radiofrequency ablation 1
- These target completely different anatomical structures and pain generators 2
Pitfall #2: Offering BVN ablation without confirming Modic changes
- Modic Type 1 or 2 changes are the objective MRI biomarker for vertebrogenic pain 2, 6, 4
- Without these findings, patient selection is inappropriate 2
Pitfall #3: Using BVN ablation for radicular pain
- BVN ablation treats vertebrogenic axial back pain, not leg pain or sciatica 2, 4
- For radicular pain, the 2025 BMJ guideline recommends AGAINST most interventional procedures 1
Pitfall #4: Inadequate conservative care trial
- Minimum 3-6 months of failed conservative management is required before considering BVN ablation 2, 5
Expected Outcomes and Follow-Up
Short-term (3 months):
- Expect mean ODI reduction of ~25 points 4
- Expect VAS pain reduction of ~3.5 cm 4
- 75% of patients achieve clinically meaningful improvement 4
Long-term (5+ years):
- Sustained ODI improvement of ~26 points maintained 6
- 66% achieve >50% pain reduction, 47% achieve >75% reduction, 34% achieve complete resolution 6
- 75% composite responder rate using ≥15-point ODI and ≥2-point VAS thresholds 6
Follow-up imaging: