What are the considerations and procedures for a patient with chronic back pain undergoing basivertebral nerve ablation?

Basivertebral Nerve Ablation for Chronic Back Pain

Direct Answer

Basivertebral nerve (BVN) ablation is strongly recommended for middle-aged adults with chronic axial back pain (≥6 months duration) who have Modic type 1 or 2 endplate changes on MRI and have failed conservative management—this is the ONLY interventional spine procedure that received a strong FOR recommendation in the 2025 BMJ guideline. 1, 2

Why BVN Ablation Stands Alone

The 2025 BMJ clinical practice guideline issued strong recommendations AGAINST most common interventional procedures for chronic spine pain, including facet joint radiofrequency ablation, epidural steroid injections, and intramuscular trigger point injections. 2 BVN ablation uniquely received a strong FOR recommendation, distinguishing it from all other interventional spine procedures. 1

The American Society of Pain and Neuroscience (ASPN) provides Level A grade evidence supporting BVN ablation in appropriately selected patients, indicating high certainty that the net benefit is substantial. 2

Patient Selection Criteria

Required Clinical Features

• Chronic axial low back pain persisting ≥6 months (some sources specify ≥3 months minimum) 1, 2
• Pain worse with forward flexion and axial loading 3
• Failed conservative management including: 2
  • Physical therapy
  • NSAIDs and/or other analgesics
  • Activity modification
  • Other appropriate non-surgical interventions

Required Imaging Findings

• MRI demonstrating Modic type 1 or 2 endplate changes at L3-S1 levels 1, 4, 5
• The diagnosis is established through clinical presentation, MRI findings, and exclusion of other pain generators—diagnostic nerve blocks are NOT required 2

Absolute Contraindications

• Unwilling patients 1
• Active infection 1
• Coagulopathy 1
• Very short life expectancy 1
• Lack of technical expertise 1

Procedural Technique

Equipment and Approach

• Radiofrequency ablation system with transpedicular or extrapedicular approach 5
• Mandatory fluoroscopic or CT guidance 3
• Target the basivertebral nerve within the vertebral body endplates 3, 5

Technical Execution

• Preoperative planning determines targeted ablation zone and safety zones 5
• The procedure is minimally invasive and targets the intraosseous basivertebral nerve that innervates the vertebral endplates 3, 6
• The basivertebral nerve enters through the posterior vertebral body and branches to innervate the endplates, making it accessible via a transpedicular approach 3

Expected Outcomes

Efficacy Data

• Mean ODI improvement of 53.7% at 2 years compared to baseline 6
• Mean VAS pain reduction of 52.9% at 2 years 6
• 76.4% of patients achieved ≥10-point ODI improvement 6
• 70.2% of patients achieved ≥1.5 cm VAS improvement 6
• Benefits are maintained through 2-year follow-up with sustained clinical improvements 6

Early Response

• Statistically significant improvements observed at 3 months (mean ODI decreased from 52±13 to 23±21, p<0.001) 5
• Improvements persist throughout the 1-year study period 5

Safety Profile and Risks

Common Adverse Events

• 8.6% risk of prolonged (>48 hours) pain or stiffness 7
• 2.1% risk of temporary altered level of consciousness 7
• 1.4% risk of dural puncture 7
• 0.7% risk of deep infection 7

Catastrophic Harms (Very Rare)

• Infection resulting in meningitis 7
• Spinal cord injury 7
• Paraplegia 7

Practical Considerations

Treatment Frequency

• If effective, nerve ablation procedures are typically repeated approximately every 6 months 7
• This contrasts with injections (epidural, facet, intramuscular) which require repetition every 2 weeks to 3 months 7

Cost and Access

• Average cost for radiofrequency ablation in the US is approximately $6,000 7
• Patients must travel to a clinic or hospital that administers the procedure 7
• Expense may be a barrier unless government or private insurance covers the cost 7

Critical Evidence Limitations

Study Bias Concerns

• All studies performed to date have been industry-sponsored 4, 8
• Future non-industry-funded trials are needed to confirm results 4
• A very specific chronic pain population is utilized, leaving many with chronic low back pain ineligible 8
• High crossover rates in published studies limit true control group comparisons 8

Population Specificity

• The inclusion criteria are narrow and many patients with chronic low back pain remain ineligible 8
• Study demographics need diversification to truly represent the chronic low back pain population 8
• Additional research on the association between Modic changes and low back pain is still needed 8

Anatomic Rationale

The vertebral endplates are now recognized as a significant pain generator in anterior column low back pain. 3 Anatomic, histological, and clinical evidence supports the concept of the vertebral endplate as a source of chronic low back pain and the nociceptive role of the basivertebral nerve. 4 The strong innervation of vertebral endplates by the basivertebral nerve makes it a logical target for ablation in vertebrogenic chronic low back pain. 8