A Fourth Source of Low Back Pain and a Procedure to Treat It

There is no single magic treatment that works for all forms of chronic low back pain. The first key in successfully treating it is to determine the source and cause. Then with a diagnosis, your medical professional can evaluate appropriate alternatives to relieve the symptoms.

Until about 20 years ago, the medical community believed there were only three primary sources for low back pain. Today, doctors recognize a fourth source of low back pain that involves damaged vertebral endplates.

We’ll bring you up to speed on what you should know about this pain source and a treatment option to consider if you are suffering from it.

What are three of the sources of low back pain?

For years, medical specialists believed the sources of low back pain were rooted in three spine structural components:

1. The zygapophyseal joints. These both allow and limit rotation and bending movements in the spine. Degenerative changes in the facet joints can lead to low back pain.
2. The sacroiliac joints. These joints link the hip and the lower spine. Low back pain can result from joint damage or injury.
3. The intervertebral discs. These provide cushioning and flexibility for the spinal column during everyday activities. Disc degeneration can pinch spinal nerves, leading to low back pain that may radiate into the legs.

There are many different conditions across these three sources that can cause problems for patients. The complexity of diagnosing them usually requires an in-depth examination by a medical professional.

What is a fourth source of low back pain?

The more recenlty discovered fourth source of low back pain can arise from a damaged vertebral endplate.

What are vertebral endplates?

The spine has a series of stacked small bones called vertebrae that form the spinal canal. Between adjacent vertebrae are intervertebral discs that provide cushioning and flexibility.

At the top and bottom of each vertebra are vertebral endplates. These endplates serve as the interface between each vertebra and the adjacent disc. (In the image below, the vertebral endplates are illustratated by the lighter yellow rings).

What is vertebrogenic pain?

As intervertebral discs deteriorate with wear and tear with age, stress occurs on the vertebral endplates. With this stress, the endplates may become damaged.

Damaged vertebral endplates can become inflamed, leading to vertebrogenic pain. The basivertebral nerve (BSN) transmits pain signals to the brain from the endplates.

What are the symptoms of a damaged vertebral endplate?

The symptoms of a damaged vertebral endplate are similar to that of a damaged intervertebral disc.

In both cases, patients describe:

• The source of the pain is in the middle of the low back.
• Pain that worsens with physical activity, prolonged sitting, bending, and lifting.

This similarity presents a challenge when identifying the difference between the two. A damaged vertebral endplate requires distinctly different treatments than a damaged intervertebral disc.

How do doctors determine if a patient has vertebrogenic pain?

To confirm that a patient has vertebrogenic pain, doctors use an MRI to look for specific changes that occur with endplate inflammation. These are called Modic changes.

They look for two of the three types of bone marrow changes: type 1, inflammation and edema, and type 2, fatty infiltration, which each indicate vertebrogenic pain.

What indicates if someone might be a good candidate for the Intracept Procedure to relieve vertebrogenic lower back pain?

A patient may be a good candidate for the Intracept Procedure if:

• They have had chronic back pain for at least 6 months; and
• They have failed to respond to conservative care for a period of at least 6 months; and
• An MRI has shown that they have Type 1 or Type 2 Modic changes in at least one vertebrae from L3 to S1.

The Intracept Procedure

The Intracept Procedure is a minimally-invasive outpatient procedure for patients with vertebrogenic pain. The procedure targets the basivertebral nerve to relieve this chronic pain. It may be considered after other conservative options fail to relieve pain.

• A doctor uses fluoroscopic guidance to target a radiofrequency probe. The probe heats the basivertebral nerve, stopping it from sending pain signals to the brain.
• The Intracept procedure typically lasts an hour and takes place in an outpatient surgery center using local anesthetic and light sedation.
• The Intracept back procedure is minimally invasive and preserves the overall structure of the spine.
• The Intracept procedure recovery time, when most patients feel pain relief, is within two weeks after the procedure.

What’s the Intracept Procedure success rate? A recent study on Intracept showed function and pain relief improvements that lasted more than five years¹.

Wrapping it up, there are two key takeways if you have lower back pain:

1. Vertebral endplate damage should always be considered as a possible alternate pain source in addition to spinal disc degeneration.
2. For appropriate patients with vertebrogenic low back pain, the Intracept Procedure can be an effective option.

Reference

1. Fischgrund J. Ryne A. Macadaeg K. et al. Long-term outcomes following intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: 5-year treatment arm results from a prospective randomized, double-blind sham-controlled multi-center study. Eur Spine J. 2020 Aug;29(8):1925-1934. doi: 10.1007/s00586-020-06448-x [PubMed]