Appendix
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Pain Management

Basivertebral Nerve Ablation

Chronic axial low back pain associated with vertebral endplate damage is an important and often underrecognized cause of persistent pain, disability, opioid exposure, and healthcare utilization. Basivertebral nerve ablation is a minimally invasive intervention for carefully selected patients with vertebrogenic pain, particularly those with Modic type 1 or type 2 changes on magnetic resonance imaging and symptoms refractory to conservative care. A persistent practice gap exists in clinicians' fai

v1 · Reviewed Nov 7, 2026 by Automated Clinical Reviewer (Strict Verbatim v1)
  • Chronic axial low back pain associated with vertebral endplate damage is an important and often underrecognized cause of persistent pain, disability, opioid exposure, and healthcare utilization.
  • 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.
  • 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.
  • 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.
  • 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.
  • Radiologists help confirm Modic type 1 or type 2 changes and identify exclusionary pathology.
  • 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.
  • 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.
  • 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.
  • 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.
  • Basivertebral nerve ablation is a minimally invasive intervention for carefully selected patients with vertebrogenic pain, particularly those with Modic type 1 or type 2 changes on magnetic resonance imaging and symptoms refractory to conservative care.
  • 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.
  • 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.
  • 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.
  • 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.
  • 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.
  • review
    Basivertebral Nerve Ablation. StatPearls [Internet] — Vinicius Tieppo Francio, Mitsukuni Yoshida, Konstantinos Margetis — StatPearls Publishing, 2026

Decision support only. Verify against local protocols and current labeling. Source: www.ncbi.nlm.nih.gov