Developments in Minimally Invasive Surgical Options for Vertebral Pain: Basivertebral Nerve Ablation - A Narrative Review

Abstract

Historically, intervertebral disc degeneration has been the etiological target of chronic low back pain; however, disc degeneration is not necessarily directly associated with pain, and many other anatomical structures are potential etiologies. The vertebral endplates have been postulated to be a source of vertebral pain, where these endplates become particularly susceptible to increased expression of nociceptors and inflammatory proliferation carried by the basivertebral nerve (BVN), expressed on diagnostic imaging as Modic changes. This is useful diagnostic information that can help physicians to phenotype a subset of low back pain, which is known as vertebral pain, in order to directly target interventions, such as BVN ablation, to this significant pain generator. Therefore, this review describes the safety, efficacy, and the rationale behind the use of BVN ablation, a minimally invasive spinal intervention, for the treatment of vertebral pain. Our current literature review of available up-to-date publications utilizing BVN ablation in the treatment of vertebral pain suggests that there is limited, but moderate-quality evidence that this is an effective intervention for reduction of disability and improvement in function, at short- and long-term follow-up, in addition to limited moderate-quality evidence that BVN RFA is superior to conservative care for pain reduction, at least at 3-month follow-up. Our review concluded that there is a highly clinical and statistically significant treatment effect of BVN ablation for vertebral pain with clinically meaningful benefits in pain reduction, functional improvements, opioid dose reduction, and improved quality of life. There were no reported device-related patient deaths or serious AEs based on the available literature. BVN ablation is a safe, well-tolerated and clinically beneficial intervention for vertebral pain, when proper patient selection and surgical/procedural techniques are applied.

Keywords: Modic changes; ablation; basivertebral nerve; neurotomy; vertebral pain; vertebrogenic.

Figure 1

Schematic diagram demonstrating signal intensity changes in Modic patterns.

Figure 2

T1 and T2 MRI images demonstrating Modic changes type 1 on the left and type 2 on the right. Note: White arrows on the left are pointing to Modic changes type 1, which represent vertebral endplates disruptions, fissuring and degeneration with active inflammation manifesting on MRI as hypodense or decrease signal intensity of fibrovascular intraooseous bone marrow edema. White arrows on the right are pointing to vertebral endplate Modic changes type 2, which manifest as hyperdense or increased signal intensity on MRI, representing fatty bone marrow infiltration/replacement. Image courtesy of Relievant Medsystems Inc.

Figure 3

PRISMA flow chart methodology with identification, screening, eligibility and inclusion and exclusion process. Note: Adapted from Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71.

Figure 4

Sagittal (A) and axial views (B) of the sinuvertebral nerve as it enters the vertebral body through the basivertebral foramen, becoming the basivertebral nerve. Note: Reproduced from 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.

Figure 5

Magnetic Resonance Image (MRI) with green arrow demonstrating the location of the basivertebral nerve 10mm posterior to anterior distance, site of the ablative procedure (red dot). Note: Image courtesy of Relievant Medsystems Inc.

Figure 6

AP (A–D) and Lateral (E–H) fluoroscopy views of curved stylet advancement towards the ideal location between the 25–40% midline, between the anterior and posterior vertebral walls. Note: Image courtesy of Relievant Medsystems Inc.

Figure 7

AP (A–C) and Lateral (D–F) views with safe needle advancement with a superior lateral transpedicular approach heading in an inferior medial direction.