Chronic low back pain (CLBP) is a prevalent and debilitating condition, with significant impacts on patients’ quality of life. Vertebrogenic pain, often linked to vertebral endplate degeneration and modic changes, represents a distinct subset of CLBP. Intraosseous basivertebral nerve (BVN) ablation has emerged as a minimally invasive treatment targeting this specific pain pathway. This review synthesizes evidence from multiple studies examining the safety, efficacy, and long-term outcomes of BVN ablation for CLBP. Studies consistently demonstrate significant improvements in pain and function, as measured by the Oswestry Disability Index (ODI) and Visual Analog Scale (VAS), with BVN ablation compared to standard care or sham procedures. Positive outcomes are observed as early as three months post-procedure and sustained for up to five years. Additionally, BVN ablation is associated with reduced opioid use, offering a potential solution to the growing opioid use in pain management. However, limitations include variability in patient selection, short follow-up durations in some studies, and reliance on narrow outcome measures. Future research should focus on long-term efficacy, broader patient populations, and additional measures such as mental health and quality of life. Identifying predictive factors for optimal outcomes will also enhance patient selection. BVN ablation is a promising intervention for vertebrogenic CLBP, providing significant pain relief and functional improvement. While early results are encouraging, further studies are necessary to refine its application, ensure durability, and expand its impact in clinical practice.

Chronic low back pain, Basivertebral nerve ablation, Vertebrogenic pain, Modic changes, Radiofrequency ablation, Pain management, Oswestry disability index, Visual analog scale.

Chronic low-back pain (CLBP) is one of the most common and debilitating health conditions globally, affecting millions of patients and profoundly reducing quality of life, functionality, and productivity. It is the most common cause of disability worldwide and is a significant economic burden through healthcare costs and lost productivity. [1-2] The causes of CLBP are multifactorial with common contributors such as muscle strain, intervertebral disc degeneration, and vertebral endplate abnormalities. Among them, vertebrogenic CLBP caused by injured or degenerated vertebral endplates has also emerged as an identifiable subgroup often associated with modic changes that is less sensitive to conventional interventions. [3-5]

Traditionally, management of CLBP focuses on conservative strategies, including physical therapy, non-steroidal anti-inflammatory drugs (NSAIDs), opioids, and spinal injections. Most of these have a short-term benefit but usually do not intervene in the basic mechanisms of vertebrogenic pain. [6-7] The largest drawback of long-term opioid therapy is the danger of dependency, tolerance, and a decreased quality of life. As a result, there is growing interest in minimally invasive interventions that target the root cause of pain while minimizing risks and improving outcomes. [8]

Intraosseous radiofrequency (RF) ablation of the basi-vertebral nerve (BVN) has been recognized as a promising alternative for the management of vertebrogenic low back pain. The BVN is a nerve located within the vertebral body and plays a crucial role in the transmission of pain signals from damaged vertebral endplates. RF ablation involves the targeted application of heat to this nerve, thereby denervating pain-sensitive structures and interrupting nociceptive signal transmission. [9-10] This is a minimally invasive technique, an alternative to the more invasive spinal fusion procedures with fewer complications and faster recovery times. Significant pain relief and functional improvement have been documented in several studies, particularly among patients with modic Type 1 or Type 2 changes, after RF ablation. [11-12]

Several studies have demonstrated the efficacy of BVN ablation in clinical trials, one of the most notable of which is the INTRACEPT study. [13] The patients enrolled in this trial were randomized between the treatment groups, RF ablation, and standard care. [13-14] This trial resulted in significant improvements in the VAS score of pain and ODI of disability scores, significantly after three months from treatment, with the sustained benefit lasting a year or more. Other research studies, including prospective, open-label trials, also reported very similar results that proved RF ablation can alleviate pain and improve quality of life in patients who do not respond to standard treatments. [15-16]

A further benefit of BVN ablation is a reduction in opioid prescriptions. Most patients experience adequate pain relief with RF ablation, leading to reduced opioid consumption and alleviation of apprehension regarding the long-term consequences of pharmacological management. [17-18]

The safety profile of BVN ablation is another important consideration. The procedure is generally well tolerated, with most patients experiencing mild to moderate discomfort that resolves within a few days. Serious complications, such as infection or nerve injury, are rare, and long-term outcomes appear favorable. [19-20]

There is a significant gap in the long-term benefits of BVN ablation. Most studies have had a short-to-medium-term follow-up period, ranging from 3 to 12 months. There is limited information available on longer-term outcomes. [21] Moreover, it is not clear if RF ablation is appropriate for all CLBP patients or certain subgroups. Further research is needed, then, to refine the selection criteria, define the optimal timing and frequency of the procedure, and assess the durability of its effects over time. [22-23]

A systematic review was conducted using PubMed as the primary database for literature retrieval. A structured search strategy was developed to ensure comprehensive identification of relevant studies while maintaining specificity.

Search Strategy and Keywords: The literature search focused on studies published within the last five years to ensure up-to-date evidence. A combination of Medical Subject Headings (MeSH) terms and free-text keywords was employed. Boolean operators (AND, OR) were used to refine the search results. The following keywords and search terms were applied:

The search strategy includes procedure-specific terms such as “Basivertebral Nerve Ablation” OR “BVN Ablation” AND “Nerve Ablation” OR “Radiofrequency Ablation.” It also incorporates condition-specific terms like “Chronic Low Back Pain” OR “Vertebrogenic Pain.” The study type and population criteria include “Clinical trial,” “Cohort study,” OR “Randomized controlled trial,” with a focus on “Humans” AND “Adults.” Additionally, a time restriction filter is applied to include studies from the last five years (2019-2024).

The search was conducted using a structured query, incorporating both MeSH terms and title/abstract keywords to maximize sensitivity while maintaining specificity. Studies were screened and selected based on predefined inclusion and exclusion criteria. The study selection process was documented using the PRISMA flowchart (Figure 1) to ensure transparency and reproducibility.

Inclusion criteria: Patients with CLBP for at least six months were studied. The participants were those who had modic Type 1 or 2 vertebral endplate changes between L3 and S1 as evident on MRI. All participants had to be more than 18 years old with a documented history of LBP that had not been appropriately treated by conventional treatments such as opioid therapy, injections, and physical therapy. Some of the studies had more specific inclusion criteria. In some studies, patients had previously failed spinal interventions, and a certain percentage of them had symptoms lasting more than five years. In certain studies, participants had also received other treatments like injections or physical therapy, but not to a satisfactory degree to reduce their symptoms.

Exclusion criteria: The exclusion criteria varied among the studies, but they typically involved other important spinal pathology conditions like fractures, tumors, infections, and deformities, including scoliosis. Others who were excluded had severe comorbid conditions such as uncontrolled diabetes, cardiovascular diseases, and those who were contraindicated to receive RF ablation, especially if they were prone to allergic reactions or carried implanted devices such as pacemakers. Pregnant women and patients who have psychiatric disorders that may prevent them from adhering to the study protocol were also excluded.

In the context of opioid use, some studies specifically excluded patients who were on long-term opioid regimens at baseline if the goal was to evaluate those with a higher chance of reducing opioid consumption post-treatment.

Data extraction: The data collection process was highly structured, focusing primarily on patient-reported outcomes and clinical assessments. For each study, baseline demographic data, clinical characteristics, and pre-existing medical conditions were recorded. The main data points included the ODI, VAS for pain, and secondary measures such as the SF-36 and EQ-5D-5L. These measures were collected at multiple time points: baseline, 3 months, 6 months, and 12 months, with some studies extending follow-ups to 2 years.

Most studies utilized a combination of objective clinical evaluations and self-reported questionnaires to assess changes in pain and disability over time. To ensure consistency, data were extracted using standardized electronic medical record systems across different sites. In cases where patients were lost to follow-up, an intent-to-treat analysis was employed. This approach included those patients in the final data analysis to minimize bias.

Evaluating the study quality: The quality of this narrative review was assessed using the Scale for the Assessment of Narrative Review Articles (SANRA). This validated tool evaluates six key domains: justification of the review, statement of aims, literature search description, referencing, scientific rigor, and data presentation. Each domain is scored from 0 (low) to 2 (high), with a total possible score of 12.

Statistical methods: The statistical methods used in these studies varied slightly but were robust and appropriate for randomized trials. The primary statistical analysis was based on comparing changes in ODI and VAS scores from baseline to follow-up periods, using analysis of covariance (ANCOVA) to adjust for baseline differences between groups. A two-sample t-test was used to compare mean differences at multiple follow-up points between the intervention and control arms, with significance set at a p-value of <0.05, in some studies.

Responder analysis was quite common, with the proportion of patients achieving a clinically significant improvement (for instance, ≥10-point improvement in ODI or ≥2-point improvement in VAS) being reported between treatment and control groups. Kaplan-Meier survival curves have also been applied in some studies for the analysis of the duration of pain relief or functional improvements. The sample size calculation was done to ensure sufficient effectiveness to detect significant differences in the primary endpoints.

Some studies included interim analyses, with data monitoring committees overseeing the results to ensure patient safety and to halt enrollment early if significant benefits were observed, as seen in studies evaluating RF ablation treatment. Additionally, all analyses adhered to intention-to-treat principles, ensuring that all randomized patients were included in the analysis regardless of whether they completed the study or received the intended treatment. These methods reflect a structured approach to evaluating intraosseous RF ablation for chronic low back pain, delivering robust and reliable outcomes while minimizing bias.

A total of 26789 articles were found; after applying the inclusion-exclusion criteria, 2056 references were downloaded from PubMed. Before the screening, 99 records were removed for other reasons. In the screening phase, the remaining 1,957 records are reviewed, out of which 1,900 are excluded. From the screened records, 57 reports were sought for retrieval, but 10 could not be retrieved. Moving to the eligibility assessment phase, 47 reports are assessed for inclusion. However, 42 reports are excluded based on a SANRA score of less than 10, which is a quality assessment criterion. Finally, in the inclusion phase, only 5 studies meet the necessary criteria and are included in the review. The detailed description is explained in Figure 1 through the PRISMA flow chart to ensure a systematic and transparent selection of studies for the review.

Figure 1: PRISMA flow diagram (downloaded from PRISMA Flow Diagram)

The study by Fischgrund et al.[24] investigated the safety and effectiveness of RF ablation of the BVN in managing CLBP. BVN, which innervates endplate nociceptors, is thought to play a role in CLBP. A total of 225 patients with CLBP, aged 25-69, were randomly assigned to either a sham group (78 patients) or a treatment group (147 patients). Pain improvement was assessed using the ODI, with evaluations conducted preoperatively and at 2 weeks, 6 weeks, and 3, 6, and 12 months postoperatively. At 3 months, the treatment group demonstrated a significant reduction in ODI scores by 20.5 points, compared to a 15.2-point reduction in the sham group (p = 0.019). Additionally, 75.6% of patients in the treatment group experienced clinically meaningful improvement (defined as an ODI decrease of ≥10 points), compared to 55.3% in the sham group. The study concluded that RF ablation of the BVN significantly reduces pain and functional disability, providing a minimally invasive therapeutic option for patients with CLBP associated with modic changes. These findings underscore the potential of BVN ablation as a promising treatment approach for CLBP.

Fischgrund et al.[25] reported the long-term outcomes of intraosseous BVN ablation for CLBP in a study that followed 117 patients over an average of 6.4 years. Clinical improvements were assessed using patient-reported outcomes, including the ODI and the VAS for pain. At the 5-year follow-up, the mean ODI score decreased significantly from 42.81 to 16.86, representing an improvement of 25.95 points (p < 0.001). Similarly, the mean VAS pain score showed a significant reduction of 4.38 points, decreasing from a baseline of 6.74 (p < 0.001). Additionally, 66% of patients reported a greater than 50% reduction in pain, 47% experienced a more than 75% reduction, and 34% reported complete pain resolution. The composite responder rate, defined as a ≥15-point improvement in ODI and ≥2-point reduction in VAS, was 75% at 5 years. These findings demonstrate that BVN ablation provides sustained improvements in both pain and function, with a high percentage of patients achieving clinically meaningful outcomes over an extended period. This supports BVN ablation as a durable, minimally invasive treatment for vertebrogenic CLBP.

Markman et al.[26] performed a post hoc analysis to examine the relationship between opioid use and patient-reported outcomes in a trial of BVN ablation for CLBP. The study tracked short-acting opioid use from baseline to one year and categorized patients into three groups based on changes in opioid consumption. Two-sample t-tests were used to compare ODI and VAS scores between patients who increased or decreased opioid use. Among patients who received active treatment, those who reduced opioid use demonstrated a mean ODI improvement of 24.9 points, compared to only 7.3 points in those who increased opioid use (P < 0.001). Similarly, VAS pain scores improved by a mean of 3.3 points in patients with decreased opioid use, whereas those with increased opioid use showed a minimal improvement of 0.6 points (P < 0.001). In the sham group, a similar trend was observed; however, the differences in ODI and VAS improvements were not statistically significant (P = 0.053 and P = 0.374, respectively). The study concludes that reduced opioid consumption in patients undergoing BVN ablation is associated with better functional outcomes, highlighting a potential link between the treatment’s efficacy and decreased reliance on opioids.

Truumees et al.[27] conducted a prospective, open-label, single-arm study to assess the effectiveness of intraosseous RF ablation of the BVN in treating vertebrogenic-related CLBP. The study included patients with CLBP lasting at least 6 months and modic Type 1 or 2 vertebral endplate changes between L3 and S1. The primary endpoint was the change in the ODI at 3 months post-procedure, while secondary outcomes included changes in the VAS, SF-36, EQ-5D-5L, and responder rates. Participants had a median age of 45 years, with a baseline ODI of 48.5 and a VAS score of 6.36. Among the participants, 75% had symptoms for at least 5 years, 25% were using opioids, and 61% had undergone prior injection treatments. The average change in ODI at 3 months after treatment was -30.07 ± 14.52 points (p < 0.0001), while the average change in VAS was -3.50 ± 2.33 (p < 0.0001). A total of 93% of patients experienced an improvement of at least 10 points in ODI, and 75% reported an improvement of 20 points or more. This study highlights that RF ablation of the BVN is a safe and effective treatment for improving both pain and function in patients with chronic vertebrogenic CLBP in real-world clinical settings.

Khalil et al.[28] conducted a prospective, randomized, multicenter trial to assess the effectiveness of intraosseous RF ablation of the BVN in patients with CLBP suspected to be related to vertebrogenic pathology. The study included 140 patients with CLBP and modic Type 1 or 2 vertebral endplate changes, randomized into two groups: RF ablation (n=51) and standard care (n=53). The primary endpoint was the change in the ODI from baseline to 3 months. Interim analysis demonstrated statistically significant superiority of RF ablation over standard care across all primary and secondary outcomes (p < 0.001). At 3 months, the mean ODI change was -25.3 points in the RF ablation group compared to -4.4 points in the standard care group, with an adjusted difference of 20.9 points (p < 0.001). Similarly, the mean change in VAS pain scores was -3.46 in the RF ablation group versus -1.02 in the standard care group, with an adjusted difference of 2.44 cm (p < 0.001). Additionally, 74.5% of patients in the RF ablation group achieved a ≥10-point improvement in ODI, compared to 32.7% in the standard care group (p < 0.001). The study concluded that RF ablation of the BVN significantly improved pain and function in patients with chronic vertebrogenic-related CLBP at 3 months, supporting its role as an effective treatment option.

Table 1: Results summary of authors contribution from each trial and studies.

The review achieved a SANRA score of 11/12, indicating high methodological quality. The strengths included a well-defined objective, comprehensive referencing, and a justified review rationale.

CLBP is a widespread and multifaceted condition that profoundly affects patients’ quality of life. One specific cause of CLBP that has garnered growing attention is vertebrogenic pain, which is commonly associated with damaged or degenerated vertebral endplates and modic changes. While traditional treatments for CLBP, such as physical therapy, medications, and injections, are widely used, they often fail to deliver lasting relief. In this context, intraosseous RF ablation of the BVN has emerged as a promising, minimally invasive alternative for addressing this challenging condition.

Recent studies have demonstrated that BVN ablation provides significant benefits in pain and disability for patients with vertebrogenic lower back pain. RF ablation interrupts pain signals by targeting the BVN, which innervates the vertebral endplates. In several trials, patients who received BVN ablation experienced significant reductions in pain (as measured by VAS) and improvements in function (as measured by ODI). These improvements were sustained over time, even beyond one year, showing the durability of the procedure’s effects.

The benefits of BVN ablation extend beyond mere pain relief. One significant challenge in managing CLBP is the reliance on opioids for pain control, which can result in dependence and a series of side effects. Many patients who undergo BVN ablation report a reduction in opioid use, potentially minimizing the risks associated with long-term opioid consumption.[29] This underscores a key advantage of BVN ablation: its ability to not only alleviate pain but also help mitigate opioid use, a crucial factor in considering the ongoing opioid crisis.

Safety is another crucial aspect of BVN ablation. Most studies indicate that the procedure has a low rate of complications, with most patients experiencing only mild to moderate post-procedure pain.[30] Severe complications, such as nerve injury or infection, are rare, making BVN ablation a relatively safe option for many patients.

Although the results are promising, there are still some gaps in the existing research. Many studies have primarily examined short-term outcomes, highlighting the need for more long-term data to evaluate the sustained effects of BVN ablation. Furthermore, while the procedure shows benefits for patients with vertebrogenic pain, its effectiveness may not extend to all individuals with CLBP. Further research is needed to identify the ideal patient population for this treatment and to determine the best approach for integrating it into the overall management of CLBP.

Limitations and Future Research: Intraosseous BVN ablation holds promise as a treatment for CLBP, but there are several important limitations to consider. A significant limitation is the relatively short follow-up periods in many studies. While positive outcomes have been reported within the first few months to years, long-term data remain scarce. To fully assess the durability and long-term effectiveness of BVN ablation, further research with extended follow-up periods is needed. [31]

Another limitation is the variability in patient selection criteria. While studies typically include patients with modic Type 1 or 2 vertebral endplate changes, it remains unclear whether the findings are applicable to all individuals with CLBP, particularly those without these specific imaging characteristics. Further research is needed to evaluate the effectiveness of BVN ablation in a broader range of patients, including those with different types of spinal degeneration or other causes of CLBP.

Furthermore, studies typically measure pain and disability primarily through the ODI and VAS, but few explore other patient-reported outcomes, such as quality of life, mental health, and patient satisfaction with the procedure. Future research should aim to incorporate a broader range of outcome measures to gain a more comprehensive understanding of how the procedure affects patients. Finally, the appropriate selection criteria for identifying the ideal patient for BVN ablation are not well defined. Identifying predictors of the best outcomes will be crucial for optimizing patient selection and ensuring the proper use of the procedure.[32]

Intraosseous BVN ablation appears to be a promising, minimally invasive treatment for CLBP associated with vertebrogenic pain.

A few studies have shown that it effectively reduces pain and improves function for months to years. BVN ablation offers an alternative to the traditional treatments that are currently being used, mainly by reducing dependence on opioids, which is one of the current concerns in pain management.

Although the results are encouraging, the existing research still has limitations, including short follow-up periods, narrow patient selection criteria, and limited outcome measures. Further studies with longer-term follow-ups, more diverse patient populations, and a broader assessment of patient-reported outcomes are necessary to fully evaluate the long-term effectiveness and safety of this procedure. In conclusion, while BVN ablation shows potential to improve outcomes in the management of CLBP, additional research is needed to optimize its use and refine patient selection.

The authors are grateful to Fondazone Paolo Procacci for the support received during the publication phases.

Not applicable

Corresponding Author: 
Suresh Srinivasan
Department of Anesthesiology
Trinity Health System, Steubenville, OH 43952, United States
Email: Suresh.Srinivasan@commonspirit.org

Co-Authors:
Mansi Srivastava
Independent Researcher, Department of Content
medtigo India Pvt Ltd, Pune, India
Email: srivastavamansi811@gmail.com

Samatha Ampeti
Department of Pharmacology
Kakatiya University, University College of Pharmaceutical Sciences, Warangal, TS, India
Email: ampetisamatha9@gmail.com

Sonam Shashikala B V
Independent Researcher, Department of Content
medtigo India Pvt Ltd, Pune, India
Email: venkateshsonams@gmail.com

Raziya Begum Sheikh
Independent Researcher, Department of Content
medtigo India Pvt Ltd, Pune, India
Email: raziya.pharma@gmail.com

Matteo L.G. Leoni
Department of Anesthesia and Pain Management
University “La Sapienza”, Roma, Italy

Alberto Pasqualucci
Department of Anesthesia and Pain Management
University of Perugia, Perugia, Italy

Giustino Varrassi
Department of Research and Development
Fondazione Paolo Procacci, 00193 Roma, Italy

All authors contributed to the conceptualization, investigation, and data curation by acquiring and critically reviewing the selected articles. They were collectively involved in the writing – original draft preparation, and writing – review & editing to refine the manuscript. Additionally, all authors participated in the supervision of the work, ensuring accuracy and completeness. The final manuscript was approved by all named authors for submission to the journal.

Not applicable

The authors declare no conflict of interest.

Not applicable

https://doi.org/10.63096/medtigo3067113

Mansi S, Samatha A, Sonam SBV et al. Basivertebral Nerve Ablation: A Promising Minimally Invasive Treatment for Chronic Low Back Pain Associated with Vertebrogenic Changes. medtigo J Anesth Pain Med. 2025;1(1):e3067113. doi:10.63096/medtigo3067113 Crossref