For years, interventional pain management specialists have followed a traditional path to treat patients with chronic, severe lower back pain. This path typically includes physical therapy, anti-inflammatories, opioids or even epidural spinal injections.
Jonathan Droessler, MD, an interventional spine care specialist at UCLA Health, has seen scores of patients whose pain doesn’t quite respond to these conventional, non-surgical therapies. These are patients who are also poor candidates for major spinal surgery.
“Surgery means prolonged recovery periods,” he said. “But more importantly, for this group, surgery doesn’t guarantee success.”
An effective solution for nagging pain
This is where basivertebral nerve ablation, or BVNA, has fundamentally changed patients’ options. Dr. Droessler specializes in this minimally invasive, 90-minute outpatient procedure, which targets a distinct, often overlooked source of chronic lower back pain – vertebogenic pain. This is a specific type of pain that originates deep within the bones of the spine and their protective cartilages, rather than from muscles or pinched nerves. It’s a common diagnosis and a problem that affects quality of life for many, he said.
Dr. Droessler explains that by delivering precise thermal energy to the sensory nerves within the vertebrae, this procedure offers a solution without the need for major surgery.
“There are not a lot of great options for it,” Dr. Droessler said. “I’ve been doing more and more of basivertebral nerve ablation because it’s been probably one of the most effective things I do for patients in my practice.”
Why BVNA works for some
To understand why this procedure works so well, he says, it helps to look at what is actually causing the back pain.
Doctors used to think that almost all lower back pain came from pulled or strained muscles, worn-out spinal joints or degenerated discs. But, more recent medical research shows that this pain may originate in the vertebral bones adjacent the degenerated discs. The discs that sit between the bones and act like shock absorbers naturally wear down, getting thinner and losing their cushioning.
When that happens, the body’s mechanical load shifts directly onto the vertebral bones. It’s this pressure that causes inflammation inside the bone tissue – which is usually visible in an MRI. The basivertebral nerve is a tiny sensory nerve that sits inside each of the spinal bones. When the bone tissue gets inflamed, this nerve acts like a trip wire, sending continuous pain signals to the brain.
Dr. Droessler says the pain can flare up during daily activities such as bending or leaning forward.
“When patients tell me their lower back bugs them when they lean over to do the dishes, put on their shoes or play golf, those are the exact people we can help with this procedure,” he said. “And there are a lot of patients out there living with this pain and discomfort.”
But, this procedure is not for everyone, Dr. Droessler said. Only some qualify. First, he said, they must have suffered lower back pain for at least six months that refuses to get better with physical therapy or anti-inflammatory medications.
“The pain must be strictly in the lower back and get worse when bending forward,” he said. “It should not be shooting down the legs, which is usually a sign of a pinched nerve or sciatica. Patients must have an MRI that shows inflammation in the bone for me to consider this procedure as an option for them.”
How the procedure works
Once the patient checks these boxes, the actual procedure is quite simple, with minimal risks, Dr. Droessler said. It takes about 90 minutes from start to finish and is done during an outpatient visit, which means the patient can go home the same day.
Patients are typically given sedation to fall asleep comfortably, similar to the anesthetic used during a routine colonoscopy. The doctor then inserts a small probe into the vertebral body using a special live X-ray screen for guidance, until it reaches the nerve. They then use controlled heat to burn or stun the nerve so it can no longer send those pain signals to the brain.
“The procedure itself is very safe,” he said. “They wake up and don’t usually need to take any prescription pain medicines afterward.”
Even if patients need them, he recommends over-the-counter pain medications to manage any discomfort. And because the nerve is only used to send pain signals, he said, the ablation doesn’t weaken or change the structure of the spine, or affect functionality in any way.
‘One and done’ long-term solution
Healing is quick, unlike major open surgery, which requires months of painful recovery, Dr. Droessler said. His instructions for the first week are typically for patients to do light activities and “ramp it up” slowly and gradually.
The real win here is a study tracking patients up to five years after this procedure shows positive, long-term outcomes and even improvement, he said. Many patients experience significant, long-term pain relief that is durable and lasts for years because this specific nerve doesn’t show an ability to grow back after the treatment.
“A lot of my patients don’t really want to have surgery,” he said. “So, it’s a nice in-between. It appeals to a lot patients who don’t want to get a spinal surgery.”
Are patients who get this procedure then pain-free? Dr. Droessler says “pain-free is the Holy Grail.”
“That’s what is sought, but very rarely does a patient get to that level of being without any pain,” he said. “So, the real question is how much more are you able to do functionally? Pain levels can fluctuate on a day-by-day basis. But what were you not able to do before that you are able to do now? And are you able to do it without limitations?”
The goal of this procedure, Dr. Droessler said, is to get patients anywhere between 50% to 70% of pain reduction where they are able to return to activities such as golf, hiking, working out or simply doing yard work or household chores without significant limitations.
Dr. Droessler said he does 25 to 30 of these procedures a year. He feels good about offering this as a viable solution for patients when appropriate because it’s the closest they have to a permanent solution for this type of pain.
“The nice thing about this procedure is also that it’s a one-time thing because the nerve does not come back,” he said. “And five-year data actually shows that people continue to get better after the procedure.”
