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Review
. 2022 Sep 14:15:2801-2819.
doi: 10.2147/JPR.S378544. eCollection 2022.

Best Practice Guidelines on the Diagnosis and Treatment of Vertebrogenic Pain with Basivertebral Nerve Ablation from the American Society of Pain and Neuroscience

Dawood Sayed  1 , Ramana K Naidu  2   3 , Kiran V Patel  4 , Natalie H Strand  5 , Pankaj Mehta  6 , Christopher M Lam  1 , Vinicius Tieppo Francio  7 , Samir Sheth  8 , Anthony Giuffrida  9 , Brian Durkin  10 , Nasir Khatri  11 , Shashank Vodapally  12 , Christopher O James  13 , Benjamin D Westerhaus  9 , Adam Rupp  7 , Newaj M Abdullah  14 , Kasra Amirdelfan  15 , Erika A Petersen  16 , Douglas P Beall  17 , Timothy R Deer  18
Affiliations
Review

Best Practice Guidelines on the Diagnosis and Treatment of Vertebrogenic Pain with Basivertebral Nerve Ablation from the American Society of Pain and Neuroscience

Dawood Sayed et al. J Pain Res. .

Abstract

Chronic low back pain is a worldwide leading cause of pain and disability. Degenerative disc disease has been the presumptive etiology in the majority of cases of chronic low back pain (CLBP). More recent study and treatments have discovered that the vertebral endplates play a large role in CLBP in a term defined as vertebrogenic back pain. As the vertebral endplates are highly innervated via the basivertebral nerve (BVN), this has resulted in a reliable target in treating patients suffering from vertebrogenic low back pain (VLBP). The application of BVN ablation for patients suffering from VLBP is still in its early stages of adoption and integration into spine care pathways. BVN ablation is grounded in a solid foundation of both pre-clinical and clinical evidence. With the emergence of this therapeutic option, the American Society of Pain and Neuroscience (ASPN) identified the need for formal evidence-based guidelines for the proper identification and selection of patients for BVN ablation in patients with VLBP. ASPN formed a multidisciplinary work group tasked to examine the available literature and form best practice guidelines on this subject. Based on the United States Preventative Task Force (USPSTF) criteria for grading evidence, gives BVN ablation Level A grade evidence with high certainty that the net benefit is substantial in appropriately selected individuals.

Keywords: back pain; basivertebral nerve; guidelines; lumbar degenerative disc; radiofrequency ablation; vertebrogenic pain.

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Conflict of interest statement

Dr Dawood Sayed reports grants from Relievant, during the conduct of the study; personal fees from Medtronic, personal fees from Nevro, personal fees from Saluda, personal fees, from Vertos, personal fees, from Mainstay, personal fees, from Painteq, personal fees from Surgentec, outside the submitted work. Dr Ramana K Naidu reports personal fees from Relievant, personal fees from Abbott, personal fees from Boston Scientific, personal fees from Medtronic, personal fees from Vivex, outside the submitted work; Dr Samir Sheth reports personal fees from Boston Scientific, personal fees from Nevro, personal fees from Medtronic, personal fees from Relievant, personal fees from SPR, outside the submitted work. Dr Anthony Giuffrida reports personal fees from Relievant, outside the submitted work. Dr Brian Durkin reports personal fees from Relievant Medsystemsduring the conduct of the study. Dr Erika A Petersen reports personal fees from Abbott Neuromodulation, personal fees from Medtronic Neuromodulation, grants from Nalu, grants, personal fees from Nevro, personal fees from Presidio Medical, grants from Saluda, personal fees from Vertos, grants from SPR, personal fees from Biotronik, grants from ReNeuron, grants from Neuros Medical, also has stock options from SynerFuse, outside the submitted work. Dr Douglas P Beall reports grants from Relievant, during the conduct of the study; also received fees for consulting from Medtronic, Spineology, Merit Medical, Johnson & Johnson, IZI, Techlamed, Peterson Enterprises, Medical Metrics, Radius Pharmaceuticals, Avanos, Boston Scientific, Sollis Pharmaceuticals, Simplify Medical, Stryker, Lenoss Medical, Spine BioPharma, Piramal, ReGelTec, Nanofuse, Spinal Simplicity, Pain Theory, Spark Biomedical, Micron Medical Corp, Bronx Medical, Smart Soft, Tissue Tech, Kahtnu Surgical, RayShield, Stayble, Thermaquil, Vivex, Stratus Medical, Genesys, Abbott, Eliquence, SetBone Medical, Amber Implants, Cerapedics, Neurovasis, outside the submitted work.Dr Timothy Deer reports personal fees from Abbott, personal fees from Painteq, personal fees from spinal simplicity, personal fees from saluda, personal fees from cornorloc, personal fees from Nalu, outside the submitted work. The authors report no other conflicts of interest in this work.

Figures

Figure 1
Figure 1
The BVN (white arrows) branches from the SVN as it enters the vertebral body through the central vascular foramen, accompanied by the basivertebral vessels, bifurcating to the endplates. Reprinted with permission from Fischgrund JS, Rhyne A, Franke J, et al. Intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: 2-year results from 415 a prospective randomized double-blind sham-controlled multicenter study. Int J Spine Surg. 2019;13(2):110–119, Copyright © International Society for the Advancement of Spine Surgery 2019. Creative Commons licensing agreement CC BY-NC-ND. Reprinted with permission from Traylor K, Murph D. Spinal Vascular Anatomy. The Neurosurgical Atlas. https://www.neurosurgicalatlas.com/volumes/neuroradiology/spinal-corddisorders/spinal-vascular-anatomy.
Figure 2
Figure 2
(A) Gross morphology of the lumbar intervertebral joint, (B) with the corresponding histological stain. (C) Histological depiction of endplate damage. Reproduced with permission from otz JC, Fields AJ, Liebenberg EC. The role of the vertebral end plate in low back pain. Global Spine J. 2013;3(3):153–164, Copyright 2013, SAGE Publication; and Dudli S, Fields AJ, Samartzis D, Karppinen J, Lotz JC. Pathobiology of Modic changes. Eur Spine J. 2016;25(11):3723–3734, copyright 2016, Spring Nature.
Figure 3
Figure 3
(Top) White arrows pointing to Modic changes appreciated on MRI T1/T2. (Bottom). (A) Midsagittal T1-weighted MRI; (B) T2-weighted MRI; and (C) ultra-short echo time (UTE) MRI, further elucidating endplate damage of L1-L2 motion segment. Reproduced with permission from Otz JC, Fields AJ, Liebenberg EC. The role of the vertebral end plate in low back pain. Global Spine J. 2013;3(3):153–164, Copyright 2013, SAGE Publication; and Dudli S, Fields AJ, Samartzis D, Karppinen J, Lotz JC. Pathobiology of Modic changes. Eur Spine J. 2016;25(11):3723–3734, copyright 2016, Spring Nature.
Figure 4
Figure 4
Diagnostic approach to vertebrogenic pain requires concordance of clinical presentation and radiographic finding on MRI.
Figure 5
Figure 5
Potential management options for vertebrogenic pain.
Figure 6
Figure 6
Oblique view of lumbar vertebrae with squared off endplates and facet centered at the midpoint of the vertebrae (arrow).
Figure 7
Figure 7
AP view showing progression of the trocar from the lateral to medial pedicle border while simultaneously traversing towards the posterior aspect of the lumbar vertebral body. As the trocar is advanced it is important that the stylet tip not pass the medial border of the lumbar pedicle in the AP view until it breaches the posterior vertebral body wall in the lateral view.
Figure 8
Figure 8
Lateral view showing progression of the trocar towards the posterior aspect of the lumbar vertebral body while simultaneously advancing the trocar from the lateral to medial pedicle border.
Figure 9
Figure 9
AP view (left) and lateral view (right) images showing final placement of J-stylet tip in lumbar vertebrae.
Figure 10
Figure 10
AP view (left) and lateral view (right) images showing final placement of bipolar radiofrequency (RF) probe in the lumbar vertebrae.
Figure 11
Figure 11
Trocar tip marks skin entry site when targeting the S1 pedicle. Once a Ferguson view is obtained, extend an imaginary line from the L5 transverse process (star) to the ipsilateral iliac crest and this marks the entry site of the introducer cannula assembly.
Figure 12
Figure 12
AP view showing progression of the trocar from the lateral to medial S1 pedicle border while simultaneously moving towards the posterior aspect of the S1 vertebral body. As the trocar is advanced it is important that the stylet tip not pass the medial border of the S1 pedicle in the AP view until it breaches the posterior vertebral body wall in the lateral view.
Figure 13
Figure 13
Lateral view fluoroscopic image showing progression of the trocar towards the posterior aspect of the S1 vertebral body while simultaneously advancing the trocar from the lateral to medial S1 pedicle border.
Figure 14
Figure 14
AP view (left) and lateral view (right) images showing final placement of bipolar radiofrequency (RF) probe in S1 vertebrae.
Figure 15
Figure 15
On the left, note the Modic changes at L3/4 on short tau inversion recovery (STIR) MRI. On the right, the first line starts in the vertebral body, passing the anteromedial pedicle, going through the posterolateral pedicle and terminating at the skin. The measurement from the spinous process to the terminus of the first line gives the best starting position for entry into the pedicle.
Figure 16
Figure 16
Schematic diagram outlining the algorithmic approach to BVN ablation.
See this image and copyright information in PMC

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