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).

Illustration of vertebral endplates
Illustration of vertebral endplates.

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.

Modic Changes Illustrated by Type
Illustrations of Healthy Endplate Alongside Those With Modic changes: Healthy endplate, Type 1, Type 2, and Type 3 changes.

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.
Vertebrogenic pain is a distinct type of chronic low back pain caused by damage to vertebral endplates, the interface between the disc and the vertebral body. The basivertebral nerve (BSN) transmits pain signals to the brain from the endplates.

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.


  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]
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You may have heard of ‘degenerative disc disease.’ This term doesn’t actually refer to a disease, but instead to a condition in which a damaged spinal disc causes pain.

A Quick Review of Spine Anatomy

What role do discs play in our spines? Your spine is made up of a series of bones that run from the top to bottom of your back. Discs sit between each of these bones. They serve as shock absorbers and provide flexibility for your spinal column. Normally, each of your discs is directly adjacent to your spinal nerves.

Facet joints also play a key role in the spine. They are the connections between the bones of the spine. Thus, the spinal bones, discs, facet joints and nerves all function together to enable our mobility along with far more complex body functions.

What Is Degenerative Disc Disease?

With that quick spine anatomy review in-hand, we can now look at what exactly is degenerative disc disease. This condition is the progressive deterioration of spinal discs and arthritic changes in facet joints due to wear and tear with aging.

Bone spur overgrowth is related to degenerative disc disease. It can also cause a narrowing of the spinal canal, resulting in spinal stenosis, where the nerves running up that canal are compressed. This causes pain, numbness, and weakness in the legs.

There are a host of additional conditions associated with degenerative disc disease, including lumbar radiculopathy (also known as sciatica), neurologic claudication, and degenerative spondylolisthesis. They all are part of the challenges we face with our spine as we age and strive to remain active in our lives.

Illustration of lower back (lumbar) disc degeneration
Illustration of a spine with degenerative disc disease.

Non-Surgical and Minimally-Invasive Treatments for Degenerative Disc Disease

In most cases, the initial preferred path to treat degenerative disc disease are non-surgical and minimally-invasive options. These include:

  • Medications: Over-the-counter, nonsteroidal anti-inflammatory drugs (NSAIDs) can help control the inflammation, swelling and pain symptoms.
  • Physical Therapy: Some individuals experience disc problems due to excessive sitting or poor muscle development in the back. Physical therapy can help to improve and balance muscle mass, lower pressure on your back, and improve posture.
  • Weight Loss: If you are overweight, reducing your BMI can help significantly improve stress on discs and the spine, and reduce pain.
  • Epidural Steroid Injections: Flouroscopic-guided epidural steroid injections, precisely targeted near spinal nerves, discs, or joints, can reduce inflammation or pain.
  • Radiofrequency Neurotomy: This procedure uses radiofrequency waves to generate heat to target specific nerves. It temporarily disables those nerves’ ability to send pain signals. For some patients, radiofrequency ablation may reduce or eliminate pain for months.
  • Spinal Cord Stimulation: Spinal cord stimulators are medical devices that a doctor can implant in your body to manage chronic pain. They deliver electrical stimulation through thin leads to nerves along the spinal column. This modifies or blocks nerve activity to minimize the sensation of pain reaching the brain. A patient directly controls this stimulation activity by using a small external remote.

But what happens if these options prove to be ineffective or inappropriate for a patient?

Traditional Surgical Treatments for Degenerative Disc Disease

Until recently, the only options to treat degenerative disc disease other than non-surgical and minimally-invasive pain management have been surgical intervention and artificial disc replacement. Given the serious nature of this kind of back surgery, they traditionally are recommended only when all other alternatives have been exhausted.

Discectomy and Laminectomy Surgery

One of the first procedures developed for degenerative disc disease are a discectomy and laminectomy. In this surgery, a surgeon removes part of the bulging disc and part of the bone around the spinal canal.

There are two issues however that can result from this procedure. First, the removal of the disc material weakens the disc, so there is a risk for the disc to re-herniate. And second, the removal of bone can make the spine segment more unstable. As a result, pain can return in some instances. When it does, the resulting condition is called “Failed Back Surgery Syndrome.”

Spinal Fusion

In order to try to fix issues associated with discetomies and laminetomies, surgeons developed a procedure called spinal fusion. They targeted the issue of pain often being caused by spine instability. And spine instability was due to degeneration along with a loss of the height of a disc.

In the spinal fusion procedure, a spacer along with hardware is inserted to prop the disc up. The goal is to aleviate pain by preventing the degenerated spine segment from being able to move at all.

However, after spinal fusion, when one segment no longer can move, more force is exerted on other parts of the spine to compensate. As a result, new spine problems and sources of pain can crop up along adjacent parts of the spine due to the increased stress.

Artificial Disc Replacement (ADR)

To solve these problems, artificial disc replacement (ADR) emerged as an alternative. Rather than fuse two spine segments, the concept is to implant an artificial disc between them. This allows motion and props up disc height, alleviating the problems with fusion.

The artificial disc replacement technique however can have post-operative issues similar to that of spinal fusion surgery. In part, this is because the motion of an artificial disc joint isn’t natural. Stress on adjacent spine segments can still occur.

The Case for Surgical Spine Intervention and Artificial Disc Replacement

Despite the issues we’ve raised, there are circumstances where spine surgery is the most effective treatment to reduce pain and relieve symptoms. While spine surgery may limit flexibility, it can be successful in arresting pain.

If a medical professional or spine surgeon has recommended spine surgery to you, you should certainly consider it. Doctors evaluate many factors, and spine surgery may be the only viable alternative for a particular patient.

Physical Medicine and Rehabilitation doctors will normally recommend a spine surgeon when non-surgical and minimally-invasive spine pain management alternatives have been exhausted.

New, Non-Surgical Alternatives to Spine Surgery

Against this backdrop, two new alternatives to spine surgery have emerged: VIA Disc and the Intracept Procedure. These may be options for some patients seeking back pain relief and for who other non-surgical approaches have been ineffective or inappropriate.

What Is VIA Disc?

VIA Disc is a novel approach to address degenerated discs is to rebuild the disc biologically. In recent years, advances in regenerative medicine have advanced dramatically. They have taken their cue from the fact that the human body has a natural ability to heal itself in many ways. For example, skin cuts repair themselves, broken bones mend, and donated liver transplants regenerate.

Orthobiologic regenerative medicine is focused on taking this natural ability, directing it, and helping it along. The VIA Disc procedure uses biologic growth factors and cytokines extracted from intervertebral discs. These are enhanced with additional solutions to promote this therapy’s effectiveness. This procedure supplements tissue and cell loss that is associated with degenerative disc disease in the lower back.

During an outpatient, non-surgical procedure, this growth factor and cytokine mixture is injected into degenerated discs under imaging guidance with moderate sedation. The goal is for this supplement to stimulate the regeneration of the disc itself – and improve its functionality.

Studies have shown that those undergoing this procedure showed pain and function improvements that continued to be evident 12 months after the treatment.

What Is the Intracept Procedure?

Another option that has recently emerged is the Intracept Procedure.

Referencing back to our opening discussion about spine anatomy, at the point where discs meet the vertebrae bone is a layer called the vertebral endplate. This endplate is a mix of cartilage and bone that separates these two elements of your spine.

Research has shown that for some, back pain specifically originates in one or more of these endplates. If this is the source of your back pain, there is a new innovative way to treat it that doesn’t disturb the delicate function of your discs.

There is a nerve called the basivertebral nerve that interfaces with your vertebral endplates. The Intracept Procedure is a minimally invasive procedure that targets the basivertebral nerve to provide relief from chronic how back pain that originates in the endplate.

Prior to recommending the procedure, doctors who suspect the basivertebral nerve is the source of a patient’s pain will conduct a special imaging test to confirm their diagnosis.

This outpatient procedure is implant-free and preserves the structure of the spine. It ablates the basivertibral nerve with a radiofrequency probe to provide lasting pain relief.

Are You a Candidate for the Via Disc or Intracept Procedures?

While both VIA Disc and the Intracept Procedure show promise to address chronic back pain developed as a result of degenerative disc disease, they are only appropriate for some patients. You should discuss both options with your healthcare provider if you believe they may be appropriate options for your back pain.

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