Procedures · Axial back pain

Low back pain

Pain in the back itself — not down the leg — is a different problem from a pinched nerve, and most of it is not a surgical problem at all. Two of its commonest sources can be treated through a needle without fusing anything: the small facet joints at the back of the spine, and the nerve inside the vertebral body.

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Two pain generators

Two sources, two procedures

The disc, the endplates above and below it and the joints at the back all wear together, and all three can hurt. The animation shows that process. Two parts of it can be treated through a needle without fusing anything — and which of the two applies to you is decided by what your MRI shows and by how your back responds to a diagnostic block. Some people turn out to have both.

Degenerative disc diseaseWhat happens to the disc, and to the bone above and below it. 2:05.

Radiofrequency ablation

For pain coming from the facet joints

What it treats
Pain from the small paired joints at the back of each spinal level, worn the way any joint wears. Typically worse standing, arching backwards or turning, and easier sitting or leaning forwards. It can be done in the neck as well as the low back.
How it works
The joints are supplied by tiny medial branch nerves that carry nothing but sensation from the joint itself. A radiofrequency probe heats a short segment of those nerves so they stop conducting. The joint is left exactly as it was; what is interrupted is the signal from it.
How it is confirmed
By a diagnostic medial branch block, and this sequencing is the whole logic. No scan can tell you a facet joint is the source of pain — worn facets are visible on almost every adult MRI, including in people with no pain at all. Numbing the nerves temporarily and seeing what happens is the test, and the ablation is only offered once it has passed.
The procedure
Outpatient, under live X-ray, local anaesthetic with light sedation, usually under an hour. Home the same day with a driver.
How long it lasts
Nerves regenerate, so relief is durable rather than permanent — the literature generally describes several months to around a year or more in appropriately selected patients. It can be repeated when the pain returns, and the second one usually behaves like the first.
Who it is not for
Anyone whose diagnostic block did not help, and anyone whose dominant problem is leg pain from a compressed nerve — that is a different diagnosis with a different answer.

Basivertebral nerve ablation

For pain coming from the vertebral body

What it treats
Vertebrogenic low back pain — pain arising from the vertebral body and its endplates rather than from the disc, the joints or a nerve root. Typically deep, midline, made worse by sitting and by bending forwards, and often long-standing.
How it works
The basivertebral nerve runs into the middle of each vertebral body and carries pain signals from the damaged endplates. A probe is passed through the pedicle into the body and that nerve is ablated at a point where it cannot regrow the way a medial branch does. Nothing is fused, no bone is removed and no implant is left behind.
How it is confirmed
On MRI, by Modic type 1 or type 2 endplate changes at the affected levels — this is the one of the two that is chosen on imaging rather than on a block. The clinical picture has to match, and the pain has to have persisted despite at least six months of conservative care.
The procedure
Outpatient, under live X-ray, usually under general or deep sedation, around an hour. Home the same day. A small skin incision, but no fusion and no hardware.
How long it lasts
Because of where the nerve is interrupted, the intent is durable relief rather than a treatment that is repeated on a cycle. Randomised trials — against a sham procedure and against continued standard care — reported improvement in pain and function that was sustained at follow-up measured in years.
Who it is not for
Backs without those endplate changes on MRI, which is most backs. Also anyone whose main problem is leg pain, and anyone with instability at the level, which is a different operation entirely.

Outcome statements on this page describe the general direction of the published literature, not a guarantee for any individual case. What applies to you depends on your imaging, your examination and how you respond to the diagnostic steps above.

Telling them apart

How the two are separated in clinic

The history
Facet pain is usually worse standing and arching backwards and better sitting. Vertebrogenic pain is usually the reverse — worse sitting and bending forwards, and often described as deep and central rather than off to one side.
The MRI
Modic type 1 or 2 endplate changes point to the vertebral body. Facet arthrosis on its own points at nothing in particular, because nearly everyone over forty has some.
The block
A medial branch block settles the facet question and nothing else settles it. There is no equivalent block for the basivertebral nerve, which is why that one is selected on imaging.
Both at once
It happens, and it is not a contradiction. Where both are present the usual order is to treat whichever the history and the block point to most strongly, then reassess what is left.

Neither of these is a fusion, and that is the point of them

Axial low back pain has historically been a poor reason to fuse a spine, and fusing for pain alone — without instability, without a deformity, without a compressed nerve — has a much less predictable result than fusing for those things. Both procedures on this page exist to treat a specific, identified pain generator without removing any motion, and both leave every surgical option open if they do not work.

The full RFA write-up →
The full basivertebral ablation write-up →