Basivertebral nerve ablation for vertebrogenic pain

Chronic axial low back pain with Modic type 1 or 2 endplate changes at L3–S1 suggests vertebrogenic pain carried by the basivertebral nerve; intraosseous radiofrequency ablation beat sham and standard care at 3 months in selected patients.

1. Vertebrogenic pain is a distinct subtype. It arises from sensitization of the basivertebral nerve within damaged endplates, and Modic type 1 and 2 changes on MRI are the primary selection biomarkers ¹.
2. Know the anatomy. The basivertebral nerve, usually paired, arises from the sinuvertebral nerves and enters the vertebral body posteriorly through the central vascular foramen, running with the basivertebral vessels ¹.
3. Read the Modic types. Type 1 is endplate marrow edema (low T1, high T2); type 2 is fatty conversion (high T1 and T2); type 3 is sclerosis (low on both) ¹.
4. Selection criteria are specific. Axial pain over 6 months, at least 6 months of failed conservative care, Modic 1 or 2 changes at L3–S1, Oswestry Disability Index at least 30 and pain at least 4/10 ¹.
5. It beat sham. In the sham-controlled trial of 225 patients, ODI fell 20.5 points with ablation versus 15.2 with sham at 3 months, with 75.6% versus 55.3% responders ².
6. It beat standard care. In a 140-patient open-label randomized trial at 20 US sites, interim analysis showed clear superiority over standard care for ODI change at 3 months ³.

Modic changes must match the clinical picture of chronic axial pain; degenerative imaging findings are common in pain-free adults, so imaging alone does not justify ablation; pair MRI with history and duration criteria ¹⁴.

• The basivertebral nerve innervates endplate nociceptors thought to generate chronic low back pain ².
• In the long-term cohort, 85% of treated patients were available at a mean 6.4 years ⁵.
• SMART patients had a mean age of 47 and mean baseline ODI of 42 ².
• The responder threshold in the sham trial was an ODI decrease of at least 10 points ².
• The standard-care trial's primary endpoint was the 3-month between-arm change in ODI ³.
• In the treatment arm followed long term, ODI improved from 42.8 to 16.9 at a mean 6.4 years, with a 75% composite responder rate ⁵.
• Emerging reports describe use beyond original criteria, such as multilevel Modic changes and osteoporosis ¹.
• Disc degeneration is present in 37% of pain-free 20-year-olds and 96% of pain-free 80-year-olds ⁴.

• Selecting patients with Modic type 3 changes ¹.
• Overlooking the sham response; the sham arm also improved ODI by 15.2 points at 3 months ².
• Ablating on imaging findings alone without matching symptoms ⁴.