Case report: Basivertebral nerve block during vertebral augmentation: an alternative approach to intraprocedural pain management

Abstract

Osteoporotic compression fractures can be treated with vertebral augmentation. Since intraprocedural pain is common during vertebral body endplate manipulation, these procedures are often performed with conscious sedation or general anesthesia. Research has shown that vertebral endplates are innervated by the basivertebral nerve (BVN), which has been successfully targeted via radiofrequency ablation to treat chronic vertebrogenic lower back pain. With this physiology in mind, we evaluated if temporary BVN block would provide sufficient analgesia so that patients could forego sedation during percutaneous vertebral augmentation. Ten patients with single-level vertebral compression fractures were selected. Prior to balloon augmentation, temporary intraosseous BVN block was achieved using 2% lidocaine injection. All ten patients successfully completed their procedure without intraprocedural sedative or narcotic medications, and without significant deviation from baseline vital signs. Temporary BVN block can be used as intraprocedural anesthesia in select patients who may be poor candidates for general anesthesia or conscious sedation.

Keywords: anesthesia; kyphoplasty; nerve block; pain; vertebral augmentation; vertebroplasty.

Figure 1

Example axial (A) and sagittal (B) CT images demonstrating normal vertebral bodies and the expected location of the basivertebral nerve (yellow star). Example cone-beam CT images acquired using a Medtronic Kyphon® training model showing transpedicular curved canula placement on axial (C), lateral (D), and oblique lateral (E) views. Canula tip placement (red circles) is ideally centrally located within the vertebral body on AP imaging and between 30% and 50% of the anterior-to-posterior length of the vertebral body from the posterior wall on lateral view. Example showing curved canula placement in a patient undergoing kyphoplasty with BVN block (F).

Figure 2

Example intraprocedural fluoroscopic images from two patients (A,B) enrolled in the study are shown. Anteroposterior (A1,B1) and lateral (A2,B2) views demonstrate curved canula positioning in the expected anatomic location of the basivertebral nerve plexus.