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Low back pain remains a global concern in healthcare. Diagnosing the source of low back pain remains a clinical challenge for healthcare providers, and often treatment interventions have a wide level of efficacy given poor specificity in the diagnosis. Among the hypothesized sources of low back pain, vertebral pain resulting from damaged vertebral endplates has gained attention with specific and reliable diagnostic criteria and several clinical studies reporting robust effectiveness data using intraosseous basivertebral nerve ablation as a targeted intervention in this subset of patients with low back pain of vertebral etiology. This review describes the clinical evidence, indications, contraindications, equipment, preparation, technique, and complications of basivertebral nerve ablation. It highlights the important role of this procedure in the interprofessional team management of low back pain. Objectives: Identify the relevant pathoanatomical structures involved in back pain and addressed via basivertebral nerve ablation. Review the indications and contraindications for basivertebral nerve ablation in vertebral pain. Outline the clinical efficacy of basivertebral nerve ablation in vertebral pain. Summarize how interprofessional team strategies can improve results when using basivertebral nerve ablation to improve the care of patients with low back pain. Access free multiple choice questions on this topic.

Basivertebral nerve (BVN) ablation is a minimally invasive spinal procedure targeting the BVN, which is responsible for carrying nociceptive information from damaged vertebral endplates, an entity recently postulated as a source of chronic axial low back pain (LBP).[1][2][3][4] In the past, other structures were considered as sole contributors to the etiology of chronic axial LBP, such as intervertebral discs (IVD), zygapophyseal facet joints, ligaments, sacroiliac joints, muscles, etc.[5][6][7] However, the recent understanding that vertebral endplates are particularly susceptible to inflammatory changes, fissuring, post-traumatic degeneration, and intraosseous edema due to their highly vascularized and innervated terminals from the basivertebral nerve and venous plexus suggests that these structures are particularly likely to contribute to LBP symptomatology, in addition to other structures.[8][9][10][11] Finding the source of chronic axial LBP is clinically challenging, and often 80% of diagnoses are described as non-specific LBP, and in only 20% of cases, an anatomical source can be attributed.[12] Perhaps it is due to this variability and uncertainty that many interventions for the treatment of chronic axial LBP directly targeting anatomical structures, such as IVD, muscles, facet joints, and ligaments, have limited success rates and variable outcomes in the general population. Several studies have reported a high incidence of vertebral endplate damage in up to 43% of subjects suffering from chronic axial LBP symptoms. These tend to manifest differently than when the etiology is from other structures.[7][8] Often, vertebral endplate pain patients 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 a burning, deep and achy, located in the midline region of the lumbar spine without radicular symptoms, and without motor weakness, numbness or tingling.[4][7][10] In fact, vertebral pain from damaged endplates tends to present clinically different than non-specific etiologies with reported greater frequency and longer duration of painful episodes and worse outcomes with conservative treatment and surgery.[11][10][13][14]

Often, vertebral endplate pain patients 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 a burning, deep and achy, located in the midline region of the lumbar spine without radicular symptoms, and without motor weakness, numbness or tingling.[4][7][10] In fact, vertebral pain from damaged endplates tends to present clinically different than non-specific etiologies with reported greater frequency and longer duration of painful episodes and worse outcomes with conservative treatment and surgery.[11][10][13][14] Treatment options for chronic axial LBP from damaged vertebral endplates start with conservative care, similar to other treatment algorithms, such as oral analgesics, opioids, and therapeutic exercises. However, conservative methods tend to be ineffective, and the identification and diagnosis with history and physical exam of this subset of patients with pathoanatomical vertebral endplate damage on diagnostic imaging are crucial to optimize outcomes and offer an effective treatment option, such as the BVN ablation.[8][15]

The procedure is considered generally safe, with a very low rate of adverse events (AEs) reported among all clinical studies, totaling 473 procedures. Temporary exacerbation in LBP symptoms and incisional pain were the most commonly reported self-limiting AEs post-procedure. Additional minor AEs reported include transient radiculitis, which resolved after oral medication, and rare instances of non-permanent lumbar/sacral radiculopathy, nerve root injury, and motor/sensory deficits. Serious AEs reported in the 473 clinical procedures included one case of a vertebral compression fracture in a sham crossover-procedure patient taking hormonal therapy, and in commercially treated patients, there have been two serious adverse events that were device-procedure related, one case of retroperitoneal hemorrhage, and one case of vertebral compression fracture. There have been no reports of thermal injuries, spinal cord injury, avascular necrosis, and post-procedure infections were documented. Among the AEs reported in the clinical studies that were device-procedure related, the median time to resolution was 66.5 days postoperatively.[32][33][34][35]

Interprofessional team multidisciplinary collaboration is essential for optimal outcomes in low back pain treatment, and a risk/benefit analysis should always be completed before proceeding with this intervention, as any other spinal procedure, the standard of care should always be followed with conservative methods first, and a treatment plan embracing shared decision making between the patient and the health care team. Clinicians are responsible for proper diagnosis, perioperative assessment, surgical intervention, and postoperative follow-up. In addition, in this interprofessional model, clinicians act as guides to patients along the healthcare continuum of the low back pain treatment algorithm. Nursing facilitates coordination of activities among therapists and other consultants that help patients achieve their maximum clinical improvement after the intervention and alongside the device representative and the physician educating patients on the expected pre and post-intervention course. This interprofessional, multidisciplinary model will lead to the optimization of patient outcomes. [Level 5]