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Basivertebral Nerve Ablation
Introduction
Basivertebral nerve (BVN) ablation is a minimally invasive spinal procedure targeting the BVN, which carries nociceptive information from damaged vertebral endplates, structures that have recently been postulated as sources of chronic axial low back pain (LBP).[1][2][3] Since the initial randomized clinical trials, intraosseous basivertebral nerve ablation (BVNA) has evolved into an evidence-supported intervention, with multiple systematic reviews, pooled analyses, and long-term (up to 5 years) outcome data demonstrating durable improvements in pain, function, and healthcare utilization.[4][5][6] Historically, other structures were considered the primary contributors to the etiology of chronic axial LBP, including intervertebral disks, zygapophyseal facet joints, ligaments, sacroiliac joints, and muscles. However, the recent understanding that vertebral endplates are particularly susceptible to inflammatory changes, fissuring, posttraumatic degeneration, and intraosseous edema due to their highly vascularized and innervated terminals from the basivertebral nerve and venous plexus suggests that vertebral endplates are likely contributors to LBP symptomatology, in addition to other structures.[7][8][9][10][11][12]
Finding the source of chronic axial LBP is clinically challenging because 80% of diagnoses are nonspecific LBP, and an anatomical source can be identified in only 20% of cases.[13] This variability and uncertainty may contribute to the limited success rates and variable outcomes of many interventions for chronic axial LBP that directly target anatomical structures, including the intervertebral disk, muscles, facet joints, and ligaments. Results from several studies reported a high incidence of vertebral endplate damage in up to 43% of patients with chronic axial LBP symptoms, and vertebral endplate damage tends to manifest differently than pain arising from other structures.[1][2][3][14][15] Often, patients with vertebral endplate pain tend to present with significant functional impairment and debilitating pain while seated, standing, or during spinal flexion (in contrast to extension), with the pain reported as burning, deep, and achy, located in the midline region of the lumbar spine without radicular symptoms, and without motor weakness, numbness, or tingling. Vertebral endplate pain tends to present clinically differently from nonspecific etiologies, with reported greater frequency and longer duration of painful episodes, as well as worse outcomes with conservative treatment and surgical procedures.[16][17][18][19][20]
Treatment options for chronic axial LBP from damaged vertebral endplates begin with conservative care, similar to other treatment algorithms, including oral analgesics, opioids, and therapeutic exercises; however, conservative methods tend to be ineffective. Identification and diagnosis in patients with pathoanatomical vertebral endplate damage, using history, physical examination, and diagnostic imaging, are crucial for optimizing outcomes and offering effective treatment options, such as BVN ablation.[21][22][23] Since early randomized clinical trials established the efficacy of BVNA, subsequent systematic reviews and pooled analyses have demonstrated durable clinical benefits extending beyond 5 years, including sustained pain reduction, functional improvement, and reduced opioid use. Results from these studies support BVNA as a validated intervention for a specific subset of patients with chronic vertebrogenic low back pain.[24][25][26]
Anatomy and Physiology
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Anatomy and Physiology
Chronic axial low back pain remains a global healthcare problem, affecting 30 million people in the United States and costing the healthcare system $90 billion annually.[18][27] Given the high financial burden, clinicians and researchers need to understand the pathoanatomical considerations and phenotypic profile of chronic axial LBP associated with vertebral endplate damage to target this source and optimize treatment options and success rates. Additionally, the sinuvertebral nerve arises from the ventral rami of the spinal nerves bilaterally, takes a recurrent course, and enters the spinal canal, traveling toward the posterior aspect of the vertebra, where it enters the vertebral body through the basivertebral foramen.
This foramen lies in the midline of the posterior vertebral body and is the entry point for the neurovascular bundle comprising the basivertebral nerve and the basivertebral vascular plexus. Although anatomical variability occurs along its course, the nerve travels anteriorly into the vertebral body by about 30% to 50%, where it forms a trunk cluster of fibers that migrate cranially and caudally toward the vertebral endplates, with nociceptive fibers implicated in endplate-mediated pain. This branching point is the anatomical site targeted for the ablative procedure (see Image. Anatomical Distribution of the Basivertebral Nerve Within the Vertebral Body).[2][7][28]
Vertebral endplates are the superior and inferior edges of the vertebral body. Vertebral endplates are highly susceptible to microfracture, inflammatory degeneration, fissuring, fibrovascular ingrowths, and intraosseous edema, which are visible on MRI and commonly correlate with vertebral pain; these changes are classified as vertebral endplate Modic changes.[29][30][31] Three types of Modic changes can occur: type 1, type 2, and type 3, and these differ based on MRI findings (see Image. Sagittal MRI of the Lumbar Spine Demonstrating Modic Type 1 and Type 2 Vertebral Endplate Changes).
- Type 1 Modic changes represent vertebral endplate disruption, fissuring, degeneration, and active inflammatory vertebral endplate changes and manifest as hypointense or decreased signal intensity findings from fibrovascular intraosseous bone marrow edema on T1-weighted MRI sequences and as hyperintense or increased signal intensity findings on T2-weighted MRI sequences.
- Type 2 Modic changes represent subacute or chronic fatty bone marrow infiltration or replacement and show increased signal intensity on both T1- and T2-weighted MRI sequences.
- Type 3 Modic changes are characterized by decreased signal intensity findings on both T1- and T2-weighted MRI sequences.[3][8][31][32]
Although Modic changes are radiological findings on MRI, they have been reported to be associated with a history and physical examination compatible with axial LBP in numerous clinical and basic science studies, suggesting a positive association with a specific vertebral etiology (vertebrogenic pain). Nociceptive input from these damaged vertebral endplates carried by the BVN is directly related to inflammatory cytokines, substance P, and calcitonin gene-related peptide, as confirmed by histology with protein gene product 9.5–positive staining, supporting the BVN as a key pain mediator. In particular, type 1 Modic changes have been reported to have a stronger direct association with more debilitating, severe LBP of longer duration, greater frequency, and worse functional impairments than patients with chronic axial LBP but without Modic changes, supporting the need to focus on a treatment intervention directly targeting this pain generator, such as ablation of the BVN.[3][7][30][31][33][34]
Indications
Results from clinical studies evaluating BVN ablation consistently include patients with chronic axial LBP lasting longer than 6 months that is refractory to at least 6 months of conservative treatment. MRI findings must demonstrate Modic type 1 or type 2 changes at 1 or more vertebral endplates between L3 and S1. Patients should have significant functional impairment attributable to vertebrogenic pain, and alternative primary pain generators, such as radiculopathy, instability, or infection, should be excluded.
Results from several studies excluded patients with a history of spinal surgical procedures, spinal stenosis, and opioid use, whereas other studies' results included these patients, allowing for a more generalizable patient population more similar to daily clinical practice. Additional requirements when selecting patients for BVN ablation include documented evidence of significant functional impairment, debilitating pain unresponsive to conservative care, confirmed skeletal maturity on diagnostic imaging, and a history and physical examination excluding other potential primary sources of pain. Randomized trial criteria are consistent and reinforced by society guidelines from the International Society for the Advancement of Spine Surgery, American Society of Pain and Neuroscience, and North American Spine Society coverage recommendations. The Food and Drug Administration cleared the procedure in 2016 for patients who meet the preceding criteria.[7][22][24][26][35][36][37][38][39][40][41][42][43]
Contraindications
Contraindications to BVN ablation mirror those of other interventional spine procedures, such as systemic infections, spinal infections, pregnancy, incomplete skeletal maturity, implantable pulse generators (pacemakers, defibrillators), severe cardiopulmonary compromise, coagulopathy, patients in whom the targeted ablation zone is less than 10 mm away from a sensitive structure not intended to be ablated, including the vertebral foramen (spinal canal), and clinical situations in which unintended tissue damage may result based on the clinician’s assessment, such as spine surgical procedures at the treatment level when existing hardware is within the zone of the BVN ablation. Results from published studies reported additional exclusion criteria, including patients with severe obesity due to potential instrument length limitations when accessing the target with elevated levels of adipose tissue in the lumbar region; patients in whom symptomatic spinal stenosis or radicular pain is the primary pain source; and clinical situations in which injury may result from the procedure based on clinician assessment, such as osteoporosis (particularly in patients with prior vertebral compression fracture or who are actively taking hormonal therapy), metastatic disease or local malignant neoplasm, and bleeding risk, such as diagnosed thrombocytopenia or coagulopathy disorders.[36][37][38][44][45]
Equipment
Safe and accurate targeting of the BVN is critical to the success of the ablation procedure. The procedure is performed by a pain clinician, spine surgeon, or interventional radiologist with experience in image-guided spinal procedures, preferably with C-arm fluoroscopy or CT guidance. A combination of anteroposterior, lateral, and oblique C-arm fluoroscopic views is used to localize the pedicle and guide instrument placement.
A single C-arm is most often used; however, 2 C-arms may be used, with 1 for lateral images and 1 for anteroposterior and oblique images. In addition to CT or fluoroscopic imaging, equipment for BVN ablation includes an introducer diamond- or bevel-tipped trocar to access the vertebral body through a transpedicular approach; a curved cannula assembly with an accompanying straight stylet to create a channel in the vertebral body to the BVN terminus (target site); and a bipolar radiofrequency ablation probe and radiofrequency generator to create the ablative lesion in the nerve terminus (see Technique or Treatment section below for details). The next-generation access instruments with the EDGE J stylet (Boston Scientific) were released in 2025 and are purpose-built curved access tools intended to provide a more predictable and precise pathway to the BVN terminus. The OptaBlate system (Stryker Instruments), which recently received Food and Drug Administration clearance, offers 4 channels, allowing simultaneous ablation of up to 4 vertebral levels, a 7-minute ablation time, and a microinfuser, which is suggested to provide more consistent ablations. Additional supplies include standardized sterile surgical items, such as sterile gowns, gloves, sterile hats, shoe covers, masks, appropriate drapes, sponges, laparotomy pads, and other supplies to minimize the risk of infection.
Personnel
The procedure must be performed by a clinician experienced in image-guided spinal procedures, such as an interventional pain clinician, spine surgeon, or interventional radiologist. In addition to the clinician performing the procedure, the intraoperative personnel include a fluoroscopy technologist (radiology technologist), scrub technician, circulating nurse, and an anesthesiologist or nurse anesthetist to provide appropriate sedation and monitor the patient. Radiology support is important for confirming Modic type 1 or type 2 changes and excluding competing pathology. Device representatives may assist with equipment workflow.
Preparation
In addition to a detailed medical history and physical examination to support vertebral pain as the source of the patient's chronic axial LBP, the clinician must document radiological evidence of type 1 or type 2 Modic changes on MRI and a complete treatment history to support the rationale for the procedure, including longstanding debilitating LBP with functional impairment lasting longer than 6 months and unresponsive to at least 6 months of conservative care. The BVN ablation procedure uses a transpedicular approach similar to that used for vertebral augmentation procedures. Although no consensus exists on perioperative treatment before BVN ablation, clinicians may reasonably follow a standard of care similar to that used for other percutaneous spinal interventions. In preparation for the procedure, the following should be obtained: a complete metabolic profile, a complete blood count, and coagulation studies to assess bleeding risk and rule out underlying infection, severe thrombocytopenia, anemia, or metabolic disorders. Clinicians should also follow guidelines for blood transfusion, discontinuation of anticoagulation, and perioperative intravenous antibiotics, which vary based on the anticoagulant in question, including 2 g of cefazolin (or 600 mg of clindamycin if a patient has a penicillin allergy) 60 min before the procedure, as a prophylactic measure and standard of care for interventional spinal procedures. Based on the patient's comorbidities and the clinician's judgment, the procedure may be performed under general anesthesia or monitored anesthesia care sedation.
Technique or Treatment
BVN ablation is performed in an outpatient setting by properly trained clinicians and surgeons. The procedure has technical similarities to vertebral augmentation because both use a transpedicular approach. However, an extrapedicular approach has been described for lumbar radiofrequency ablation, which uses an ablative lesion of the BVN to interrupt nociceptive signaling from damaged vertebral endplates. The first step in this procedure is to position the patient prone under general anesthesia or monitored anesthesia care, with continuous cardiac monitoring, pulse oximetry, and blood pressure monitoring. Next, using standardized sterile technique, the patient is prepared, and the target level and entry location are marked and confirmed with C-arm fluoroscopy or computed tomography guidance. Obtaining optimal image guidance is essential for this procedure, so the C-arm should first be rotated to obtain a true anteroposterior view of the pedicles at the level of entry, thereby optimizing a transpedicular approach.
The skin entry point and angle are marked with a sterile marker, the skin is anesthetized with 1% lidocaine, and a small incision is made with a scalpel. Next, a 22-gauge spinal needle may be used at the target entry position to anesthetize the pathway toward the periosteum. An introducer trocar is placed along the same trajectory and advanced through the pedicle starting at the superolateral aspect until it passes the posterior vertebral body wall.
Maintaining a trajectory superior to the inferior cortex and lateral to the medial cortex of the pedicle is important to prevent trocar entry into the spinal canal or near neural elements. As the trocar is slowly advanced using a mallet, multiple anterior-posterior and lateral C-arm views are obtained to ensure a safe trajectory. Once the vertebral body is breached, the trocar is removed from the introducer cannula.
A curved cannula assembly (curved cannula and curved stylet) is used to facilitate the creation of a curved channel toward the target site at the BVN terminus found in the midline, approximately 30% to 50% across the vertebral body width from posterior to anterior (see Image. Transpedicular Needle Positioning). Once the target site is confirmed with anterior-posterior and lateral C-arm views, the curved stylet is removed, and a bipolar radiofrequency probe is inserted. The probe is connected to a radiofrequency generator, and radiofrequency energy is used to create an approximately 1 cm spherical lesion at the BVN terminus (75 °C to 85 °C for 7 to 15 min).
While variations in ablation duration and generator design have emerged, most long-term outcome data supporting BVNA durability come from protocols that use longer ablation times (15 min at 85 °C). Shorter ablation protocols remain under investigation. Upon completion, the radiofrequency probe and the introducer cannula are removed, and the subcutaneous tissue and skin are closed in a standard sterile fashion with a pressure dressing and skin glue or Steri-Strips (3M Health Care). Sutures or staples are usually not necessary.
Patients are transferred to a postanesthesia care unit for monitoring. Vital signs and neurological function are reassessed after the procedure. Patients should be discharged the same day. After discharge, patients should be instructed to monitor the procedure site and to be educated on signs of infection, activity restrictions (no lifting more than 15 lb, twisting, or bending of the spine), and avoidance of water submersion for at least 48 hours after the procedure. The timing of follow-up postprocedure visits and the full return to activity is at each clinician's discretion.[4][46][47][48][49][50][51]
Complications
The procedure is generally considered safe, with a very low rate of adverse events reported across all clinical studies totaling 473 procedures. Temporary exacerbation of LBP symptoms and incisional pain were the most commonly reported self-limited adverse events after the procedure. Rare adverse events reported include transient radiculitis, which resolved after oral medication, and rare instances of nonpermanent lumbar or sacral radiculopathy, nerve root injury, and motor or sensory deficits.
Serious adverse events reported in the 473 clinical procedures included 1 case of vertebral compression fracture in a patient undergoing a sham crossover procedure who was taking hormonal therapy. In commercially treated patients, 2 serious adverse events were related to the device or procedure: 1 case of retroperitoneal hemorrhage and 1 case of vertebral compression fracture. No reports have described thermal injuries, spinal cord injury, avascular necrosis, or postprocedure infections. Among adverse events related to the device or procedure reported in the clinical studies, the median time to resolution was 66.5 days postoperatively.[4][35][44] Across pooled analyses and long-term follow-up, no serious device-related adverse events have been reported, and complication rates remain low.[46]
Clinical Significance
Results from randomized controlled trials, pooled long-term analyses, systematic reviews, and real-world utilization studies demonstrated that intraosseous basivertebral nerve ablation provides consistent, clinically meaningful, and durable benefit in carefully selected patients with vertebrogenic chronic low back pain, most commonly defined by Modic type 1 or type 2 vertebral endplate changes at L3 through S1.[48][52][53] Across studies, BVNA reliably meets established thresholds for clinical significance, including at least a 10-point improvement in the Oswestry Disability Index, at least a 2-point reduction in pain scores, at least 50% pain relief, and reductions in opioid use, often within 3 months of treatment.[16][54][55][56] Durability of benefit is supported by pooled intermediate- and long-term outcomes.
At 3 years, treated patients demonstrated mean reductions of approximately 30 points in the Oswestry Disability Index and approximately 4 points in pain scores, with responder rates of approximately 70% to 75% and approximately one-quarter reporting pain-free status.[46] At 5 years, results from pooled data showed sustained reductions in pain (4.3 points) and disability (28 points), approximately one-third of patients reporting complete pain resolution, and nearly two-thirds of baseline opioid users discontinuing opioids, alongside declining use of spinal injections and no serious device- or procedure-related adverse events.[4] Results from real-world data further supported the clinical and healthcare system impact of BVNA, demonstrating reductions in opioid use and subsequent spinal interventions within the first postprocedure year, with relatively low rates of subsequent spine surgical procedures.[47]
Results from narrative and economic reviews integrating randomized, observational, and use data emphasized that vertebrogenic pain represents a distinct anterior column pain phenotype best identified through concordant clinical features and MRI–confirmed Modic changes, and suggested that BVNA may be cost-effective compared with prolonged conservative treatment in appropriately selected patients.[48][57] Although broader radiofrequency denervation strategies targeting sinuvertebral pathways show overall improvements in discogenic and vertebrogenic pain populations, current evidence underscores the importance of distinguishing BVNA as a targeted intervention for endplate-mediated vertebrogenic pain.[58] Overall, literature spanning levels 1 to 4 evidence consistently supports BVNA as a safe, durable, and effective treatment option, and contemporary society guidelines recommend its use in a defined subset of patients with chronic axial low back pain refractory to conservative therapy and with imaging evidence of vertebral endplate pathology.
Enhancing Healthcare Team Outcomes
Optimal outcomes require coordinated evaluation, shared decision-making, and follow-up across the interprofessional team. The treating clinician confirms the diagnosis, reviews MRI findings, excludes competing pain generators, discusses alternatives, obtains informed consent, performs the procedure, and treats complications. Advanced practice clinicians may support longitudinal assessment, documentation of conservative care failure, preprocedure optimization, and follow-up.
Radiologists help confirm Modic type 1 or type 2 changes and identify exclusionary pathology. Nurses coordinate preprocedure screening, medication reconciliation, education, recovery monitoring, and escalation of concerning symptoms. Pharmacists can assist with anticoagulant planning, analgesic optimization, and opioid tapering when clinically appropriate. Physical therapists help the patient transition from procedural recovery to graded activity- and function-based rehabilitation.
Nursing, Allied Health, and Interprofessional Team Interventions
Nursing and allied health professionals should verify that the patient has appropriate MRI documentation, a history of chronic axial low back pain refractory to conservative care, completed consent, medication reconciliation, allergy review, pregnancy screening when relevant, anticoagulant or antiplatelet planning, and transportation or postanesthesia instructions. The team should reinforce that BVNA is intended for vertebrogenic pain with concordant Modic type 1 or type 2 changes, not for nonspecific low back pain, radiculopathy, or untreated competing pain generators. Pharmacists may assist with perioperative medication safety, especially antithrombotic treatment and opioid stewardship. Physical therapists should tailor postoperative rehabilitation to gradual activity restoration rather than to immediate, aggressive strengthening.
Nursing, Allied Health, and Interprofessional Team Monitoring
Postprocedure monitoring should include vital signs, wound assessment, pain assessment, and a focused neurological evaluation before discharge. Patients should receive instructions to report fever, drainage, worsening back pain beyond the expected recovery course, new radicular pain, weakness, numbness, bowel or bladder dysfunction, syncope, signs of bleeding, or symptoms concerning for vertebral compression fracture. Follow-up should assess pain intensity, functional status, activity tolerance, analgesic and opioid use, adverse events, and need for additional evaluation of competing pain generators if response is incomplete. Patients with osteopenia, osteoporosis, prior compression fracture, or other fracture risk factors may require closer follow-up and coordination with primary care, endocrinology, or bone health specialists.
Media
(Click Image to Enlarge)
Anatomical Distribution of the Basivertebral Nerve Within the Vertebral Body. Sagittal (A) and axial views (B) of the basivertebral nerve as it enters the vertebral body through the basivertebral foramen, and the midline nerve tree, the anatomical target site for the ablative procedure.
Kim HS, Adsul N, Yudoyono F, et al. Transforaminal epiduroscopic basivertebral nerve laser ablation for chronic low back pain associated with modic changes: a preliminary open-label Study. Pain Res Manag. 2018;2018:6857983. doi: 10.1155/2018/6857983.
(Click Image to Enlarge)
Sagittal MRI of the Lumbar Spine Demonstrating Modic Type 1 and Type 2 Vertebral Endplate Changes. The white arrows indicate the signaling changes across different MRI sequences. Modic changes type 1 (A, B) with hypodense or decreased signal intensity of fibrovascular intraosseous bone marrow edema on T1-weighted MRI sequence and as hyperintense or increased signal intensity on T2-weighted MRI sequence, while Modic type 2 (C,D) shows increased signal intensity in both T1 and T2 MRI sequence images.
Relievant Medsystems Inc.
(Click Image to Enlarge)
Transpedicular Needle Positioning. Transpedicular approach with safe needle advancement and placement visualized in an anterior-posterior (A-D) and lateral (E-H) fluoroscopy views towards the anatomical target.
Relievant Medsystems Inc.
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