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

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.

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

(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

(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

Diagnostic approach to vertebrogenic pain requires concordance of clinical presentation and radiographic finding on MRI.

Figure 5

Potential management options for vertebrogenic pain.

Figure 6

Oblique view of lumbar vertebrae with squared off endplates and facet centered at the midpoint of the vertebrae (arrow).

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

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

AP view (left) and lateral view (right) images showing final placement of J-stylet tip in lumbar vertebrae.

Figure 10

AP view (left) and lateral view (right) images showing final placement of bipolar radiofrequency (RF) probe in the lumbar vertebrae.

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

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

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

AP view (left) and lateral view (right) images showing final placement of bipolar radiofrequency (RF) probe in S1 vertebrae.

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

Schematic diagram outlining the algorithmic approach to BVN ablation.