The Basivertebral Nerve Ablation (BVNA) for Chronic Low Back Pain (CLBP).

In the investigation of the causes of lumbar back pain (LBP), vertebral endplate changes have come into focus. According to large MRI studies, endplate changes are associated with both disc degeneration and the presence and severity of LBP pain. Studies emphasize the importance of vertebral endplate changes as important imaging appearances associated with low back pain. Recent literature supports the use of nerve ablation of the basal vertebral nerve (BVNA) in a specific group of patients with chronic low back pain (CLBP) and vertebral endplate changes because of its ability to transmit pain signals as an intraosseous nerve.1,2
According to a study by Jensen3 vertebral endplate changes are a common MRI finding in 43% of individuals with low back pain whereas it is less common in non-clinical populations with a prevalence of 6%.

Patients who are eligible for radiofrequency ablation include those who:

  • have vertebrogenic pain.
  • have vertebral endplate changes.
  • have undergone conservative therapy.
  • have no signs of vertebral fractures.

Vertebral endplate changes according to Modic:4

Michael Modic, MD published a paper in 1988 to identify and classify degenerative vertebral endplate and marrow changes around a dehydrated disc. Modic Type I and Modic Type II can be used to identify vertebrogenic pain.

Modic Type I (Fig. 1 and 2)

T1-Weighted Imaging: hypointense low signal
T2-Weighted Imaging: hyperintense – high signal

  • Vascular development in the vertebral body
  • Findings of inflammation and edema
  • NO trabecular damage or marrow changes
Modic Typ II (Fig. 3 and 4)
T1-Weighted Imaging: hyperintense – high signal
T2-Weighted Imaging: isointense to slightly hyperintense – iso to high signal
  • Changes in the bone marrow
  • Fat replacement from formal red cellular bone marrow
  • Marrow is substituted with visceral fat

BVN-Ablation with the Vari-Tip Ablation Probe.

Cumulative data from multiple studies of BVN ablation show consistent, reproducible, clinically meaningful and statistically significant improvement in pain relief and functional improvement in patients with diagnostic findings of vertebrogenic pain. Indeed, studies indicate that BVN ablation has been shown to be more beneficial than the current standard of care for the treatment of back pain due to damaged vertebral endplates.5,6,7

The current literature with Level-Ia-IV studies shows consistently positive results. Based on the available data, guidelines from various societies recommend BVN ablation in certain patients with chronic axial lumbar spine pain. 8,9,10,11

  • Long-term improvements in pain and function that last more than 5 years.12
  • Continued decrease in patients requiring long-term injections and opioids.12
  • Almost 80% of patients stated that they would have the procedure performed again.12

Radiofrequency-Generator

200W Multifunctional RF-Generator

The RF-Generator has been optimized to provide therapeutic solutions with advanced technologies:

  • Compatible with various electrode types

  • Various treatment algorithms in memory

  • Switching Control System for larger ablation sizes

  • 3 channels of temperature sensing at the same time

Radiofrequency-Probe

With BVNA-Electrode

The BVNA-probe has been optimized to perform ablation of the basivertebral nerve (BVN) with a straight probe:

  • The exposure tip length is adjustable from 0.5cm to 4.0cm, which makes it possible to treat various lesions in different sizes with just one electrode.
  • There are length marks in centimeters on the body of the electrode, which makes it easier for the operator to identify how deep the electrode is inserted.
  • Real-time temperature monitoring is possible through the connected RF generator.

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1. Mok FP, Samartzis D, Karppinen J, Fong DY, Luk KD, Cheung KM. Modic changes of the lumbar spine: prevalence, risk factors, and association with disc degeneration and low back pain in a large-scale population-based cohort. Spine J. 2016 Jan 1;16(1):32-41. doi: 10.1016/j.spinee.2015.09.060. Epub 2015 Oct 8. PMID: 26456851.

2. Sherwood D, Miller S, Epps A, Gill B, Zhivotenko O, Khan S, Swenson T, Gardner J, Roehmer C, Martin D, Kennedy DDJ, Modic M, Schneider BJ. A First Estimate of the Annual Prevalence of Basivertebral Nerve Ablation Candidates in a Spine Clinic. Pain Med. 2022 Oct 29;23(11):1858-1862. doi: 10.1093/pm/pnac088. PMID: 35652735.

3. Jensen TS, Karppinen J, Sorensen JS et-al. Vertebral endplate signal changes (Modic change): a systematic literature review of prevalence and association with non-specific low back pain. Eur Spine J. 2008;17 (11): 1407-22.

4. Modic MT, Steinberg PM, Ross JS, Masaryk TJ, Carter JR. Degenerative disk disease: assessment of changes in vertebral body marrow with MR imaging. Radiology 1988;166:193-9.

5. Fischgrund JS, Rhyne A, Macadaeg K, Moore G, Kamrava E, Yeung C, Truumees E, Schaufele M, Yuan P, DePalma M, Anderson DG, Buxton D, Reynolds J, Sikorsky M. Long-term outcomes following intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: 5-year treatment arm results from a prospective randomized double-blind sham-controlled multi-center study. Eur Spine J. 2020 Aug;29(8):1925-1934.

6. De Vivo AE, D‘Agostino G, D‘Anna G, Al Qatami H, Gil I, Ventura F, Manfrè L. Intra-osseous basivertebral nerve radiofrequency ablation (BVA) for the treatment of vertebrogenic chronic low back pain. Neuroradiology. 2021 May;63(5):809-815.

7. Smuck M, Khalil J, Barrette K, Hirsch JA, Kreiner S, Koreckij T, Garfin S, Mekhail N., INTRACEPT Trial Investigators. Prospective, randomized, multicenter study of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: 12-month results. Reg Anesth Pain Med. 2021 Aug;46(8):683-693.

8. Nguyen KML, Nguyen DTD. Minimally Invasive Treatment for Degenerative Lumbar Spine. Tech Vasc Interv Radiol. 2020 Dec;23(4):100700.

9. Urits I, Noor N, Johal AS, Leider J, Brinkman J, Fackler N, Vij N, An D, Cornett EM, Kaye AD, Viswanath O. Basivertebral Nerve Ablation for the Treatment of Vertebrogenic Pain. Pain Ther. 2021 Jun;10(1):39-53.

10. Conger A, Schuster NM, Cheng DS, Sperry BP, Joshi AB, Haring RS, Duszynski B, McCormick ZL. The Effectiveness of Intraosseous Basivertebral Nerve Radiofrequency Neurotomy for the Treatment of Chronic Low Back Pain in Patients with Modic Changes: A Systematic Review. Pain Med. 2021 May 21;22(5):1039-1054.

11. Lorio M, Clerk-Lamalice O, Beall DP, Julien T. International Society for the Advancement of Spine Surgery Guideline-Intraosseous Ablation of the Basivertebral Nerve for the Relief of Chronic Low Back Pain. Int J Spine Surg. 2020 Feb;14(1):18-25.

12. Fischgrund, J.S., Rhyne, A., Macadaeg, K. et al. Long-term outcomes following intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: 5-year treatment arm results from a prospective randomized double-blind sham-controlled multi-center study. Eur Spine J 29, 1925–1934 (2020). https://doi.org/10.1007/s00586-020-06448-x