Chronic Low Back Vertebrogenic Pain Involves the Spinal Vertebral Endplates

Research shows chronic low back pain may be caused by lumbar vertebral endplate change involving the basivertebral nerve—and not disc-related or discogenic.

The cause of chronic low back pain can be notoriously hard to diagnose. The spine’s intervertebral discs are a common suspect, but when disc-related treatments don’t help ease the pain, could the root of the problem be something else? As researchers try to crack the code on chronic low back pain, they’ve explored a potential—and overlooked source—vertebral endplates that cause vertebrogenic chronic low back pain.

basivertebral nerve weaves through the vertebral body to the endplatesA type of intraosseous nerve called the basivertebral nerve (or BVN) weaves through the vertebral bodies to the endplates, and researchers have recently linked it as a cause of chronic low back pain. Copyrighted © image provided courtesy of Relievant Medsystems, Inc. (Minneapolis, MN). Researchers have found that more nerves source your vertebral endplates than your spinal discs—and more nerves means more potential for pain. And, just like other areas of your spine, like your discs and joints, your vertebral endplates can degenerate, upping the risk for pain.

Here, you’ll learn more about the vertebral endplates, including why they are emerging as a potential source of chronic low back vertebrogenic pain.

Spine Anatomy Lesson: Defining the Vertebral Endplates and the Basivertebral Nerve

The vertebral endplates line the top (superior) and bottom (inferior) of each vertebral body, which are the round, thick, weight-bearing bones in your spine. The vertebral endplates are made of cancellous (spongy) bone, and they serve as the barrier between each intervertebral disc and the vertebrae above and below it.

The vertebral endplates are more likely a possible source of chronic low back pain as opposed to chronic neck pain. Why? The low back, or lumbar spine, bears the most weight in your spine—and that puts pressure on the structures in your low back. Because your endplates are situated between a cushiony disc and the hard, bony vertebral body (both of which are under pressure, too), they are vulnerable to degeneration and nerve damage that contributes to chronic low back pain.

The endplates and vertebral bodies are sourced by a network of intraosseous nerves.

Intraosseous nerves are nerves that live within bone. A type of intraosseous nerve called the basivertebral nerve (or BVN) weaves through the vertebral bodies, and researchers have recently linked it as a possible cause of chronic low back pain.

The BVN feeds into each spinal bone through the back side (posterior) of the vertebral body, and then it branches out, sending nerves toward the top and bottom vertebral endplates. Research has shown that the BVN, despite living within bone, can transmit pain signals from the damaged vertebral endplates, which may result in vertebrogenic chronic low back pain.1

Nerve pain within the spine has long been linked to discs that have degenerated—your doctor may refer to this as “discogenic pain.” But as researchers understand the role vertebral endplates and the BVN play in the sensation of pain, including the fact that more nerves source your vertebral endplates and vertebral bodies than your spinal discs, a new term has emerged: “vertebrogenic pain.” If your doctor discovers that your endplates are the origin of your chronic low back pain, he or she may use this term to describe it.

Diagnosing Vertebral Endplate Pain: The Importance of “Modic Changes”

Diagnosing vertebral endplate pain is challenging, in large part because diagnostic imaging scans often don’t pick up subtle endplate damage. However, a relatively recent classification scale known as Modic changes has helped doctors identify signs of vertebrogenic pain in patients with chronic low back pain.

Modic changes are areas of bone marrow damage that have a link to low back pain and appear on magnetic resonance imaging (MRI).2

Modic changes are named after the doctor who classified them in 1988, Dr. Michael Modic. Modic changes help doctors understand the connection between endplate damage and chronic low back pain.

Dr. Modic identified 2 types of change that show a strong association between vertebral endplate damage and chronic low back pain:

  1. Type 1: Shows “vascular development” in the vertebral body, inflammation and edema (a collection of excess fluid), and vertebral endplate changes (such as a split or crack in the endplate)
  2. Type 2: Shows changes in the vertebral body’s bone marrow (fatty deposits have taken the place of bone marrow)

If your lumbar MRI results show Type 1 or Type 2 Modic changes, your doctor may recommend starting a course of conservative treatment (eg, physical therapy, medications) to address your pain. But if your pain does not ease with conservative treatment, your doctor may suggest targeting the BVN directly with a newer therapy.

Treating Vertebral Endplate Pain with Nerve Ablation

If your doctor discovers that vertebral endplate nerve dysfunction is the source of your chronic low back pain, he or she may recommend a treatment option called the Intracept® Intraosseous Nerve Ablation System (Relievant Medsystems), which addresses BVN nerve pain minimally invasively.

Your doctor may consider you a candidate for this procedure if you meet the following criteria:

  1. You’ve struggled with chronic low back pain for at least 6 months
  2. Your pain hasn’t reduced with at least 6 months of conservative therapy
  3. Your MRI results show Type 1 or Type 2 Modic changes (or similar) that correlate your symptoms of vertebrogenic low back pain

The procedure is performed using fluoroscopy (real time x-ray) and begins with the doctor’s insertion of a thin tube called a cannula into a vertebral pedicle. The pedicle is a stem-like structure that protrudes from the back of the vertebra (each vertebra has 2 pedicles).

The cannula creates a tunnel to the basivertebral nerve. The doctor then places the Intracept Radiofrequency Probe into the path to the nerve created by the cannula and ablates the nerve with the help of a radiofrequency generator.

Since it’s a minimally invasive procedure, Intracept can be performed in an outpatient facility—so you’ll be able to go home the same day. Plus, the devices used in the procedure do not stay implanted in your spine; they are removed at the completion of the procedure. Your doctor can help set expectations around how long you should expect your pain relief to last, though in one study, benefits were shown to be durable for up to two years.3

If you haven’t responded to months of nonsurgical treatment, talk to your doctor about the risks and benefits of basivertebral nerve ablation for your vertebrogenic chronic low back pain.

Endplate or Disc? Getting to the Root Cause Gives You a Better Outlook

The intervertebral discs may be the more common chronic low back pain culprit, but they aren’t the sole source of spine pain. Doctors and medical researchers are continuously learning more about the role your vertebral endplates play in back health. With more patients receiving earlier diagnoses of vertebrogenic pain, better long-term outcomes and freedom from long-lasting pain will follow.

Disclosure
Seton Brain and Spine Institute in Austin, TX received research funding from Relievant Medsystems.

Updated on: 11/13/19
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