Overview of Basivertebral Nerve Ablation
Basivertebral nerve (BVN) ablation is a straightforward spinal procedure aimed at the BVN. This nerve is involved in carrying information about pain from damaged areas of the spine, specifically the ends of the vertebrae. This damage is believed to cause persistent or chronic lower back pain.
Previously, it was thought that other structures in the back, such as the discs between vertebrae, joints, ligaments, muscles, and so on, were solely responsible for chronic lower back pain. However, recent research suggests that the ends of the vertebrae may be particularly prone to inflammation, cracks, wear and tear following injury, and fluid build-up, due to their rich blood supply and nerve endings from the BVN. This implies that these structures may also contribute significantly to lower back pain, along with other structures.
Identifying the exact source of chronic lower back pain is a complex task for healthcare professionals. Eighty percent of the time, no specific cause can be found for the pain, making the diagnoses as non-specific lower back pain. In only 20% of cases, a precise anatomical cause can be identified. Given this uncertainty, treatments aimed directly at anatomical structures, like discs, muscles, facet joints, and ligaments, have variable success and outcomes amongst patients.
There is a significant number of people with chronic lower back pain related to damage to the ends of the vertebrae, accounting for up to 43% of cases. This damage often results in symptoms that are different from other causes of pain. People with this type of pain experience a great deal of discomfort and loss of function when sitting, standing, or bending the spine forward. They describe the pain as a burning, deep, dull ache in the middle of the lower spine. This pain doesn’t radiate outwards, and they don’t experience any weakness, numbness, or tingling. Chronic lower back pain due to damaged ends of vertebrae often lasts longer, occurs more frequently, and results in worse outcomes with regular treatment and surgery.
For treating this type of chronic lower back pain, treatment starts with conservative options like oral painkillers, opioids, and physical therapy exercises – much like it does for most backs pain. However, these conservative methods often don’t work well. Identifying the patients with damage to the ends of their vertebrae through history, physical exam, and imagery is key to guaranteeing better results. This identification allows for a more targeted and effective treatment option, such as the BVN ablation procedure.
Anatomy and Physiology of Basivertebral Nerve Ablation
Chronic lower back pain (or chronic axial LBP) is a major global health issue. It affects about 30 million individuals in America alone and costs the healthcare system around 90 billion dollars each year. So, there’s a crucial need for doctors and researchers to better understand and treat the pain, especially when it’s related to damage in an area called the vertebral endplate.
One key element involved in back pain is the sinuvertebral nerve. This nerve starts from a part of the spinal nerves and heads into the spinal canal. It then moves towards the back of a vertebra (one of the bones in your spine), going inside through an opening called the basivertebral foramen. This nerve travels into the vertebra and forms a trunk of fibers that extend upwards and downwards to the vertebral endplates. These fibers provide sensory information about pain from damaged vertebral endplates. Interestingly, this part of the nerve is the area targeted when a pain relief technique called an ablative procedure is performed.
Vertebral endplates are the top and bottom borders of the vertebra. These parts can easily get injured and develop issues like cracks, swelling within the bone, and inflammation, all of which can cause pain. These symptoms are visible markers of back pain, and they can be seen on magnetic resonance images (MRI), where they are classified as Modic changes.
There are three types of Modic changes, distinguished based on MRI findings. Type 1 Modic changes indicate signs of active inflammation and disruption in the vertebral endplates. Type 2 changes suggest a condition where fat cells infiltrate or replace the affected area of the bone marrow. Type 3 changes show a decreased intensity in the MRI scans. While these changes are seen in the MRI scans, their relationship with lower back pain symptoms has been suggested based on medical history and physical examination.
Damage to the vertebral endplates stimulates the release of certain substances and inflammatory cytokines (proteins that boost your body’s immune response) that are linked to pain. Type 1 Modic changes and associated back pain seem to be more severe and longer-lasting compared to other types. This finding emphasizes the importance of designing treatments that directly target these pain generators, such as nerve ablation, a technique that uses heat to decrease pain signals from these nerves.
Why do People Need Basivertebral Nerve Ablation
Certain studies have been conducted on a specific procedure known as BVN ablation, which is a treatment for persistent lower back pain (LBP) that hasn’t improved despite trying non-surgical methods for least six months. This type of back pain is often linked with certain abnormal tissues, Type 1 or Type 2 Modic changes (MCs), which can be seen on a MRI scan in parts of the spine, specifically between the L3 and S1 region. Some research focused only on those who had not undergone spinal surgery, didn’t have spinal narrowing (spinal stenosis), or used opioid painkillers. However, other studies looked at a broader group of patients, which better reflects the various types of individuals a doctor might see in their clinic.
To be considered for BVN ablation therapy, the patient should have severe pain that makes it hard for them to do their daily activities, and this pain shouldn’t go away even after trying other non-surgical methods to manage it. They should be fully grown, as shown on a diagnostic image. Additionally, the doctor should have ruled out other possible sources of the pain through a physical exam and medical history, suggesting that the pain is coming from the spine. The Food and Drug Administration (FDA) approved the use of this procedure in 2016 for those who meet these criteria.
When a Person Should Avoid Basivertebral Nerve Ablation
There are a few circumstances where using BVN ablation (a type of treatment for spine pain) might not be suitable, just like with other spine treatments. These include:
– If you have a general infection in your body or an infection in your spine
– If you are pregnant
– If your skeleton hasn’t fully grown yet
– If you have a device placed in your body like a pacemaker or defibrillator
– If you have serious issues with your heart or lungs
– If the area that needs to be treated is too close (less than 10 mm away) to a sensitive body part which isn’t meant to be treated. This includes the spinal canal, which is the hollow part of the bone that houses the spinal cord.
– If the doctor thinks that the treatment could harm a specific part of your body unintentionally. For example, if you’ve previously had spine surgery and there’s equipment left in that area then BVN ablation might not be best for you.
There are also a few other things to consider, based on research in the field:
– If you’re very overweight (morbid obesity) it might not be possible to use the tools needed for the procedure because there’s too much fat in the lower back.
– If you have a narrowing of the spinal canal (spinal stenosis) or nerve-related pain as your main issue, then this treatment might not work.
– If the doctor believes that the procedure might harm you because you have osteoporosis (weaker bones) this treatment may not be advisable. This is particularly important if you’ve previously had a compressed (squashed) bone in the spine or are taking hormone therapy.
– If you have a cancer that has spread or a local cancer then this treatment might not be recommended.
– If you’re at risk of bleeding, for instance, if you’ve been diagnosed with low platelets (thrombocytopenia) or a blood clotting disorder (coagulopathy), BVN ablation might be too risky.
Equipment used for Basivertebral Nerve Ablation
Getting the target location right in the operation to treat the basivertebral nerve (BVN) – which is a part of your spine – is very important to making the treatment work. This operation can be done by a doctor who specializes in treating pain, a spine surgeon, or a radiologist who is skilled in doing spinal procedures with the help of images. They use special types of X-rays like C-arm or computerized tomography (CT) scans, to see what’s going on inside your spine. They use these images to find the right spot on your spine and guide their tools. Sometimes they just use a single C-arm for taking images, but other times they might use two C-arm machines to take pictures from different angles.
Alongside a CT or fluoroscopy machine (which takes special X-ray images), other equipment needed for a BVN treatment includes: a special needle called an introducer diamond or bevel tipped trocar to get inside the bone of your spine; a curved tube with a straight rod inside to make a pathway in the bone to the end of the BVN (the target area), and a tool that uses radio waves to burn the nerve at its end point. Other items include standard clean and safe surgery supplies: sterile gowns, gloves, hats, shoe covers, masks, drapes, sponges, and other items to keep the area clean and prevent infection.
Who is needed to perform Basivertebral Nerve Ablation?
This procedure should be performed by a seasoned medical professional. In addition to the doctor who will do the procedure, there will also be several other team members present. These include a fluoroscopy technologist – a type of radiology technician who uses imaging to see structures in your body, a scrub technician who helps with medical equipment, and a circulating nurse who assists in the operating room.
Additionally, an anesthesiologist or nurse anesthetist will be there to provide the right amount of sedation, ensuring that the patient is comfortable, safe, and properly monitored throughout the procedure.
Preparing for Basivertebral Nerve Ablation
If a patient is experiencing chronic lower back pain (LBP), the doctor will first gather a complete medical history and perform a physical exam to confirm that the pain is indeed coming from the spine. Imaging technology like MRI will be used to see specific changes in the spine (referred to as Modic type 1 or type 2 changes) that could be causing chronic pain. It is also necessary to show that pain and functional issues have persisted for over six months, even after at least six months of non-surgical (conservative) treatments.
A procedure called BVN ablation might be used to help reduce this chronic pain. It is similar to other surgical methods called vertebral augmentation. There are no universally agreed-upon rules for how to care for a patient before this procedure, but it’s generally good to follow the same practices as for other similar spinal procedures.
To prepare for BVN ablation, the doctor will need to run some tests. These could include a complete metabolic profile (CMP), which gives a broad look at the body’s chemical balance and metabolism; a complete blood count (CBC), which measures different components of the blood; and a coagulative profile that checks for potential complications like infections, issues with blood platelets, anemia, or metabolic disorders.
Furthermore, guidelines are usually followed concerning the use of blood transfusion, discontinuation of blood-thinning medication (anticoagulation), and giving antibiotics before surgery (prophylactic measure). The antibiotic, often cefazolin (or clindamycin if the patient is allergic to penicillin), is given to prevent any possible infections that could occur from the procedure. Given the overall health of the patient and the doctor’s assessment, the procedure might be performed using general anesthesia or a relaxation technique known as monitored anesthesia care (MAC) sedation.
How is Basivertebral Nerve Ablation performed
The BVN ablation procedure is conducted in a doctor’s clinic and is taken care of by experienced doctors and surgeons. This method shares some common techniques with two other procedures: vertebra augmentation, because it uses a similar approach through the thick part of the spinal bone; and lumbar radiofrequency ablation, because it uses high-intensity rays to treat a targeted area in the BVN to stop the feeling of pain from damaged spinal bone ends.
To start, the patient is laid face down and is either put to sleep or given medicine to make them comfortable and relaxed. Their heart rate, oxygen levels, and blood pressure are constantly monitored. In a sterile manner, the patient is cleaned, and a special X-ray machine or a CT scan is used to mark the exact location where the treatment will be done. It’s required to get a flawless imaging guide, so the X-ray is positioned to get a front-to-back view of the thick part of the spinal bone where it will be entered.
The area of skin where the procedure will be done is marked with a sterile marker, numbed with 1% lidocaine anesthetic, and a small cut is made with a scalpel. A thin, long, needle-like instrument may be then used at the target spot to numb the path towards the bone surface. A larger, hollow needle is then placed along the same part and pushed through the part of the spine that sticks out and into the body until it passes the back wall of the spinal bone. It’s essential to keep the needle’s path above the lower hard part of the spine and to the side of the middle hard part to prevent the needle from entering the space within the spine or near nerves. As the needle is slowly pushed in using a small hammer, multiple X-ray images are taken to make sure it is going the right way.
Once the needle enters the spinal bone, the needle is removed from the hollow needle, and a curved needle assembly is used to create a curved channel toward the target site in the BVN. Once this target site is confirmed, a bipolar radiofrequency probe is inserted, which sends out radio waves to create a treatment area, about the size of a 1 cm ball, at the end of the BVN. The radiofrequency probe and the hollow needle are then removed, the under-skin tissue and the skin are closed in a safe way using a pressure dressing and skin glue or steri-strips. Mostly, stitches or staples aren’t required.
Patients are then taken to a post-treatment care unit for observation. Their vitals and neurological function are reassessed after the procedure. Patients are usually discharged the same day with instructions to look out for signs of infection, restrictions on activities (no lifting more than 15 lbs, twisting, bending of the back), and to not immerse themselves in water for at least 48 hours after the procedure. Follow-ups and full return to everyday activities vary depending on each doctor’s discretion.
Possible Complications of Basivertebral Nerve Ablation
The procedure that is being discussed is generally considered safe, with very few negative side effects or unexpected problems cropping up in the various clinical studies that have been done, which involved a total of 473 procedures. The most common issues that people faced after the procedure were a temporary increase in lower back pain and pain at the spot where the incision was made. These issues don’t last long and fix themselves with time. There were also a few minor issues reported, like brief nerve pain that went away with oral medication, and in rare instances, some temporary nerve issues around the lower back that didn’t cause any lasting harm.
In the 473 clinical procedures that were analyzed, a few serious issues did come up. One patient, who was actually part of a ‘fake’ procedure and was on hormone therapy, ended up having a vertebral compression fracture, which is a type of bone break in the back. There were also two serious problems that were caused by the device used in the procedure. One case involved internal bleeding in the area behind the abdominal cavity, and the other case had another instance of vertebral compression fracture. However, there were no reports of thermal injuries (burns), spinal cord injuries, bone death due to lack of blood flow, or infections after the procedure was done. Among the problems that were specifically related to the device used in the procedure, on average, it took about 66.5 days after the operation for the issues to get resolved.
What Else Should I Know About Basivertebral Nerve Ablation?
Numerous studies have shown that an operation known as BVN ablation can effectively reduce pain and improve function in patients suffering from chronic back pain, caused by damage to part of the spine (vertebral endplate). These studies unanimously agree that this procedure can offer both short-term and potentially long-term relief for patients who fit the criteria for this type of chronic pain.
Patients who underwent BVN ablation reported significant improvements in their pain levels (measured by a visual analog scale), their capability to function (measured by the Oswestry disability index), reduction in opioid use (strong painkillers), and above all, an improved overall quality of life (measured by the short-form 36 and EQ-5D-5L). According to the studies, BVN ablation even proves to be more beneficial than the standard care for treating lower back pain caused by damaged spinal components.
Research from various levels of studies consistently shows positive results, with crucial, noticeable differences in pain relief and function improvement. Therefore, based on the current data, society guidelines strongly recommend BVN ablation to certain patients suffering from chronic lower back pain, particularly those who have been in pain for more than six months, found no relief with conservative treatment over the same period, and have been diagnosed with spinal damage (MCs), indicating that the origin of their pain is in their spine.