In patients with axial low back pain and MRI-confirmed Modic type 1 or type 2 changes, the first diagnostic step is a fluoroscopically guided facet joint block to exclude facetogenic pain. If pain relief is less than 70%, Modic-related vertebrogenic pain is likely, and further discography is unnecessary, as treatment would focus on the basivertebral nerve. Accurate execution of the facet joint diagnostic procedure is essential to ensure correct diagnosis.
Low back pain (LBP) remains one of the leading causes of disability worldwide and presents a considerable diagnostic challenge for healthcare providers. In many cases, treatment efficacy is inconsistent due to insufficient specificity in identifying the exact source of pain.
Among the multiple possible origins of chronic axial low back pain, vertebrogenic pain due to damaged vertebral endplates has emerged as a distinct clinical entity. This is supported by increasing evidence and the development of specific, reliable diagnostic criteria.
1. Initial Clinical Assessment
In patients presenting with axial low back pain and MRI evidence of Modic type 1 or type 2 changes at one or more vertebral endplates (typically L3–S1), it is crucial to identify the pain generator.
Step 1 – Facet Joint Diagnostic Procedure
A fluoroscopically guided diagnostic facet joint block (medial branch block) is recommended as an initial interventional step to exclude facetogenic pain.
- Positive block: >70% pain relief → consider facet joint as the primary source, treat accordingly.
- Negative block: <70% pain relief → Modic-related vertebrogenic pain is more likely.
If facetogenic pain is excluded, further discography is not routinely indicated. Even if positive, treatment would still target vertebral endplate nociception via basivertebral nerve intervention.
2. Pathophysiological Rationale
Vertebral endplates are richly vascularized and innervated by branches of the basivertebral nerve. They are vulnerable to:
- inflammatory changes,
- fissuring,
- post-traumatic degeneration,
- intraosseous edema.
Modic type 1 changes indicate active inflammation and edema; type 2 changes indicate fatty degeneration of the bone marrow. Both correlate with vertebrogenic pain symptomatology and predict favorable outcomes with basivertebral nerve–targeted therapies [1,3,6].
3. Clinical Presentation of Vertebrogenic Pain
Patients typically report:
- midline low back pain without radicular symptoms,
- exacerbation during sitting, standing, or forward flexion (less so with extension),
- deep, aching, or burning character,
- absence of motor weakness, numbness, or tingling,
- significant functional impairment,
- frequent and prolonged pain episodes with poor response to conservative care [2,4,6].
4. Exclusion of Other Pain Generators
Prior to confirming vertebrogenic pain, exclude:
- lumbar radiculopathy,
- sacroiliac joint dysfunction,
- myofascial pain syndromes,
- inflammatory spondyloarthropathies,
- infection, tumor, fracture [1,4,5].
5. Imaging Criteria
MRI is the primary imaging modality. Diagnostic criteria include:
- Modic type 1 or type 2 changes at one or more vertebral levels from L3 to S1,
- correlation of imaging findings with clinical symptoms,
- absence of significant disc herniation or spinal instability that would better explain the symptoms [3,5,6].
6. Conservative Management Before Intervention
Guidelines (NASS, ISASS, ASPN) recommend at least 6 months of structured non-surgical management before proceeding to basivertebral nerve ablation. This includes:
- physical therapy,
- pharmacologic analgesia,
- activity modification [1,3,5].
7. Indications for Basivertebral Nerve–Targeted Intervention
Based on consensus statements [1,3,5,6], BVN ablation is indicated if:
- chronic axial LBP ≥6 months,
- failure of structured conservative care,
- MRI-confirmed Modic type 1 or 2 changes at L3–S1,
- exclusion of other primary pain generators,
- negative diagnostic facet block (<70% relief).
8. Educational Opportunity – Basivertebral Nerve Ablation Training
The basivertebral nerve ablation (BVNA) procedure, approved in Europe, is a minimally invasive, implant-free intervention that can be performed on an outpatient or inpatient basis. It uses targeted radiofrequency energy to block the nervus basivertebralis from transmitting pain signals to the brain, aiming to improve function and provide lasting relief.
An upcoming workshop in Warsaw on Thursday 6 November or Friday 7 November will focus on BVNA training, covering:
- clinical evidence,
- patient selection criteria and diagnostic procedures,
- contraindications,
- equipment and preparation,
- procedural technique,
- potential complications.
The educational goal is to train participants in accurate diagnostic methods that help determine which anatomical structures are responsible for low back pain and which cases may benefit from BVNA.
References
- Koreckij J, Fischgrund J, et al. Best Practice Guidelines on the Diagnosis and Treatment of Vertebrogenic Low Back Pain. J Pain Res. 2022;15:3183–3196.
- Al-Khayer A, et al. Vertebrogenic low back pain: pathophysiology, diagnosis, and treatment. Biomedicines. 2023;11(9):2046.
- ISASS Policy Statement 2022: Systematic review of intraosseous basivertebral nerve ablation. ISASS.org.
- Conger A, et al. Intraosseous Basivertebral Nerve Ablation for the Treatment of Chronic Low Back Pain. Pain Med. 2022;23(3):481–495.
- NASS Coverage Policy Recommendations for Basivertebral Nerve Ablation. 2023.