Procedures · Axial back pain

Low back pain

Back pain that stays in the back, without pain running down the leg, usually comes from a different source than a pinched nerve, and most of it does not need surgery. Two of its most common sources can be treated through a needle without a fusion: the small facet joints at the back of the spine, and the nerve inside the vertebral body.

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Two pain generators

Facet joint pain and vertebrogenic pain

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 a fusion. Which one applies to you depends on your MRI and on how your back responds to a diagnostic block, and some people 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 backward or turning, and easier sitting or leaning forward. It can be done in the neck as well as the low back.
How it works
Each joint is supplied by tiny medial branch nerves that carry only sensation from the joint. A radiofrequency probe heats a short segment of those nerves so they stop carrying pain signals. The joint itself is left untouched.
How it is confirmed
By a diagnostic medial branch block, which always comes first. No scan can show that a facet joint is causing pain, because worn facets appear on almost every adult MRI, including in people with no pain. The test is to numb the nerves for a few hours and see whether the pain goes, and the ablation is only offered if it does.
The procedure
Outpatient, under live X-ray, local anesthetic with light sedation, usually under an hour. Home the same day with a driver.
How long it lasts
The nerves grow back, so relief is long-lasting but not permanent. Studies generally describe several months to a year or more in well-selected patients. It can be repeated when the pain returns, and a repeat treatment usually works as well as the first.
Who it is not for
Anyone whose diagnostic block did not help, and anyone whose main problem is leg pain from a compressed nerve, which needs a different treatment.

Basivertebral nerve ablation

For pain coming from the vertebral body

What it treats
Vertebrogenic low back pain, which comes from the vertebral body and its endplates. It is typically deep and in the middle of the back, worse with sitting and bending forward, 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. Unlike RFA, it is chosen from the MRI. Your symptoms have to match, and the pain must have lasted despite at least six months of nonsurgical 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 the nerve is treated where it cannot regrow, the aim is lasting relief from a single treatment. Randomized trials, comparing it with a sham procedure and with continued standard care, reported improvements in pain and function that lasted for years of follow-up.
Who it is not for
Anyone without those endplate changes on MRI, which is most people with back pain. Also anyone whose main problem is leg pain, and anyone with instability at the level, which needs a different operation.

Outcome statements on this page summarize the published literature and cannot be guaranteed for any one person. 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 backward and better sitting. Vertebrogenic pain is usually the reverse: worse sitting and bending forward, and often described as deep and central.
The MRI
Modic type 1 or 2 endplate changes point to the vertebral body. Facet arthritis on its own proves little, because nearly everyone over forty has some.
The block
Only a medial branch block can confirm facet pain. There is no equivalent block for the basivertebral nerve, which is why that treatment is chosen from imaging.
Both at once
Some people have both. The usual plan is to treat whichever one the history and the block point to most strongly, then reassess.

Treating back pain without a fusion

Fusing the spine for back pain alone, with no instability, deformity or compressed nerve, has much less predictable results than fusing for those problems. Both of these procedures treat a specific, identified source of pain without limiting the motion of the spine, and both leave every surgical option open if they do not work.

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