Best Practice Guidelines on the Diagnosis and Treatment of Vertebrogenic Pain with Basivertebral Nerve Ablation from the American Society of Pain and Neuroscience

Abstract

Chronic low back pain is a worldwide leading cause of pain and disability. Degenerative disc disease has been the presumptive etiology in the majority of cases of chronic low back pain (CLBP). More recent study and treatments have discovered that the vertebral endplates play a large role in CLBP in a term defined as vertebrogenic back pain. As the vertebral endplates are highly innervated via the basivertebral nerve (BVN), this has resulted in a reliable target in treating patients suffering from vertebrogenic low back pain (VLBP). The application of BVN ablation for patients suffering from VLBP is still in its early stages of adoption and integration into spine care pathways. BVN ablation is grounded in a solid foundation of both pre-clinical and clinical evidence. With the emergence of this therapeutic option, the American Society of Pain and Neuroscience (ASPN) identified the need for formal evidence-based guidelines for the proper identification and selection of patients for BVN ablation in patients with VLBP. ASPN formed a multidisciplinary work group tasked to examine the available literature and form best practice guidelines on this subject. Based on the United States Preventative Task Force (USPSTF) criteria for grading evidence, gives BVN ablation Level A grade evidence with high certainty that the net benefit is substantial in appropriately selected individuals.

Keywords:

• back pain
• vertebrogenic pain
• lumbar degenerative disc
• radiofrequency ablation
• basivertebral nerve
• guidelines

Abbreviations

AP, anterior-posterior; ASA, acetylsalicylic acid; BleedMAP, one point for each risk factor: history of prior bleeding [Bleed], mechanical mitral heart valve [M], active cancer [A], and low platelets [P]); BVN, basivertebral nerve; BVNA, basivertebral nerve ablation; CCA, curved cannula assembly; COX-2, cyclooxygenase 2; CPT, current procedural terminology; CT, computed tomography; DDD, degenerative disc disease; FAD, functional anesthetic discogram; FDA, Food and Drug Administration; HAS-BLED, hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile INR, elderly, drugs/alcohol concomitantly; IDET, intra-discal electrothermal therapy; INR, international normalized ratio; IV, intravenous; LBP, low back pain; LMWH, low molecular weight heparin; MCID, meaningful clinically important difference; MRI, magnetic resonance imaging; NOACs, new oral anticoagulants; NSAIDs, non-steroidal anti-inflammatory drugs; ODI, Oswestry Disability Index; PEEK, polyether ether ketone (thermoplastic polymer); P2Y12, platelet receptor; RF, radiofrequency; SPECT, single-photon emission computed tomography; STIR, short tau inversion recovery (MRI); SVN, sinuvertebral nerves; USPSTF, United States Preventive Services Task Force; UTE, ultrashort time to echo (MRI); VAS, visual analog scale; VCF, vertebral compression fracture; VTE, venous thromboembolism.

Acknowledgments

Allison Foster, PhD provided editing support.

Disclosure

Dr Dawood Sayed reports grants from Relievant, during the conduct of the study; personal fees from Medtronic, personal fees from Nevro, personal fees from Saluda, personal fees, from Vertos, personal fees, from Mainstay, personal fees, from Painteq, personal fees from Surgentec, outside the submitted work. Dr Ramana K Naidu reports personal fees from Relievant, personal fees from Abbott, personal fees from Boston Scientific, personal fees from Medtronic, personal fees from Vivex, outside the submitted work; Dr Samir Sheth reports personal fees from Boston Scientific, personal fees from Nevro, personal fees from Medtronic, personal fees from Relievant, personal fees from SPR, outside the submitted work.

Dr Anthony Giuffrida reports personal fees from Relievant, outside the submitted work.

Dr Brian Durkin reports personal fees from Relievant Medsystemsduring the conduct of the study. Dr Erika A Petersen reports personal fees from Abbott Neuromodulation, personal fees from Medtronic Neuromodulation, grants from Nalu, grants, personal fees from Nevro, personal fees from Presidio Medical, grants from Saluda, personal fees from Vertos, grants from SPR, personal fees from Biotronik, grants from ReNeuron, grants from Neuros Medical, also has stock options from SynerFuse, outside the submitted work.

Dr Douglas P Beall reports grants from Relievant, during the conduct of the study; also received fees for consulting from Medtronic, Spineology, Merit Medical, Johnson & Johnson, IZI, Techlamed, Peterson Enterprises, Medical Metrics, Radius Pharmaceuticals, Avanos, Boston Scientific, Sollis Pharmaceuticals, Simplify Medical, Stryker, Lenoss Medical, Spine BioPharma, Piramal, ReGelTec, Nanofuse, Spinal Simplicity, Pain Theory, Spark Biomedical, Micron Medical Corp, Bronx Medical, Smart Soft, Tissue Tech, Kahtnu Surgical, RayShield, Stayble, Thermaquil, Vivex, Stratus Medical, Genesys, Abbott, Eliquence, SetBone Medical, Amber Implants, Cerapedics, Neurovasis, outside the submitted work.Dr Timothy Deer reports personal fees from Abbott, personal fees from Painteq, personal fees from spinal simplicity, personal fees from saluda, personal fees from cornorloc, personal fees from Nalu, outside the submitted work. The authors report no other conflicts of interest in this work.