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Smuck M, McCormick ZL, Gilligan C, Hailey MK, Quinn ML, Bentley A, Metcalfe K, Bradbury B, Lukes DJ, Taylor RS. A cost-effectiveness analysis of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain. Spine J 2024:S1529-9430(24)01040-4. [PMID: 39332685 DOI: 10.1016/j.spinee.2024.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2024] [Accepted: 09/20/2024] [Indexed: 09/29/2024]
Abstract
BACKGROUND CONTEXT Randomized trials have demonstrated the superiority of intraosseous basivertebral nerve ablation (BVNA) compared with sham and standard care in terms of improvements in pain, disability, and health-related quality of life in patients with vertebrogenic chronic low back pain (cLBP). PURPOSE To assess the cost effectiveness of BVNA in patients with vertebrogenic cLBP compared to standard care alone. STUDY DESIGN/SETTING A model-based economic analysis. PATIENT SAMPLE Base case analysis used INTRACEPT, a randomized trial comparing BVNA with standard care in 140 patients with vertebrogenic cLBP, recruited from 23 sites across the United States, with a follow-up, up to 5 years. Scenario analyses compared data from the Surgical Multi-center Assessment of Radiofrequency Ablation for the Treatment of Vertebrogenic Back Pain (SMART) randomized trial against a sham control, and a single-arm study. OUTCOME MEASURES Costs and quality-adjusted life years (QALYs) were calculated to determine the incremental cost-effectiveness ratio (ICER). METHODS A cost-effectiveness model was built in Microsoft Excel® to evaluate the costs and health outcomes of patients undergoing BVNA using the Intracept Procedure (Relievant Medsystems) to treat vertebrogenic cLBP from a US payor perspective. Alternative scenario sensitivity analyses and probabilistic sensitivity analyses were conducted to assess the robustness of the model results. QALYs were discounted at 3.0% per year. RESULTS Base case analysis showed that BVNA relative to standard care alone was a cost-effective strategy for the management of patients with vertebrogenic cLBP, with an ICER of US$11,376 per QALY at a 5-year time horizon from introduction of the procedure. Modeling demonstrated a >99% probability that this was cost effective in the US, based on a willingness-to-pay threshold of US$100,000 to US$150,000. Various sensitivity and scenario analyses produced ICERs that all remained below this threshold. CONCLUSIONS BVNA with the Intracept Procedure offers patients with vertebrogenic cLBP, clinicians, and healthcare systems a cost-effective treatment compared to standard care alone.
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Key Words
- BMI, body mass index
- EQ-5D, EuroQol 5-Dimension 5-level
- ESI, epidural steroid injection
- MCS, mental component summary
- N/A, not applicable
- ODI, Oswestry Disability Index
- PCS, physical component summary
- QALY, Quality adjusted life year,APC, Ambulatory Payment Classification
- SD, standard deviation
- SF36v2®, Short Form 36 Version 2
- SMART, Surgical Multi-center Assessment of Radiofrequency Ablation for the Treatment of Vertebrogenic Back Pain
- VAS, visual analog scale,BVNA, Basivertebral nerve ablation
- WTP, Willingness to pay
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Affiliation(s)
- Matthew Smuck
- Department of Orthopaedic Surgery, Division of Physical Medicine & Rehabilitation, Stanford University, 430 Broadway Street, Redwood City, CA, 94063, USA.
| | - Zachary L McCormick
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, UT 84108, USA
| | - Chris Gilligan
- Office of the Chief Medical Officer, Robert Wood Johnson University Hospital, New Brunswick, NJ 08903, USA
| | - Mary K Hailey
- Relievant Medsystems, Inc. Corporate Headquarters, 7201 Metro Blvd #300, Edina, MN 55439, USA
| | - Michelle L Quinn
- Relievant Medsystems, Inc. Corporate Headquarters, 7201 Metro Blvd #300, Edina, MN 55439, USA
| | | | | | | | | | - Rod S Taylor
- MRC/CSO Social and Public Health Sciences Unit & Robertson Centre for Biostatistics, University of Glasgow, Glasgow, G12 8QQ, UK
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Sayed D, Beall DP, Gulati A, Hyman E, Block JE. Computed Tomographic Characterization for Basivertebral Nerve Ablation Utilizing a Radiofrequency Multitined Expandable Electrode. MEDICAL DEVICES (AUCKLAND, N.Z.) 2024; 17:323-337. [PMID: 39301449 PMCID: PMC11412689 DOI: 10.2147/mder.s487201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2024] [Accepted: 09/09/2024] [Indexed: 09/22/2024]
Abstract
Background A growing body of clinical evidence has demonstrated that intraosseous minimally invasive basivertebral nerve (BVN) ablation results in significant and durable improvements in vertebrogenic back pain. Thus, it is important to develop, refine and validate new and additional devices to accomplish this procedure. Methods Using reconstructions of 31 patient computed tomography (CT) scans of the lumbosacral spine (L1-S1), the primary objective was to simulate the intravertebral placement of a novel multitined expandable electrode in bipolar configuration at the targeted ablation site and determine if the proper trajectories could be achieved in order for the device tips to be in the correct position for lesion formation at the BVN plexus. Successful device deployment required that the distance between tips was between 10 mm and 20 mm. Results The mean distances between device tips ranged from 11.35 mm (L5) to 11.87 mm (L3), and there were no statistically significance differences across the six vertebral levels (F = 0.72, p = 0.61). The percentage of successful intraosseous device placements within the tip distance acceptable range (≥ 10 mm to ≤ 20 mm) was 90% (162 of 180), with no tip-to-tip distances > 20 mm. There was a notable association between decreasing vertebral level and mean degree of angulation between contralateral devices ranging from 50.90° at L1 to 91.51° at S1, and the difference between across the six vertebral levels was significant (F = 89.5, p < 0.01). Conclusion Feasibility evidence is provided from real world CT imaging data that validates using the multitined electrode for proper intraosseous placement within the vertebral body to effectively ablate the BVN plexus.
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Lee E, Kim J, Rahman S, Daksla N, Caldwell W, Bergese S. Basivertebral Nerve Ablation for Treatment of Lower Back Pain. Biomedicines 2024; 12:2046. [PMID: 39335559 PMCID: PMC11429079 DOI: 10.3390/biomedicines12092046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Revised: 08/24/2024] [Accepted: 08/28/2024] [Indexed: 09/30/2024] Open
Abstract
Lower back pain (LBP) is a widely prevalent global health issue, affecting over half a billion people and remaining the leading cause of years lived with disability (YLDs). LBP significantly impacts healthcare systems, with substantial costs related to surgical procedures and lost workdays. Vertebrogenic back pain (VBP), characterized by specific clinical symptoms and associated with Modic changes (MC) in vertebral endplates, best seen on MRI, is a significant subset of LBP. This paper explores the pathophysiology, diagnosis, and current reports and studies focusing on VBP and the role of basivertebral nerve (BVN) ablation as a therapeutic intervention. Multiple studies, including randomized controlled trials (RCTs) and meta-analyses, demonstrate the efficacy of BVN ablation in reducing pain and improving function in patients with chronic LBP associated with MC.
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Affiliation(s)
| | | | | | | | | | - Sergio Bergese
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY 11794, USA (J.K.); (S.R.); (N.D.); (W.C.)
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Helgeson MD, Pisano AJ, Fredericks DR, Wagner SC. What's New in Spine Surgery. J Bone Joint Surg Am 2024; 106:1035-1040. [PMID: 38662809 DOI: 10.2106/jbjs.24.00133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Affiliation(s)
- Melvin D Helgeson
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, Maryland
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Alfred J Pisano
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, Maryland
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Donald R Fredericks
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, Maryland
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Scott C Wagner
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, Maryland
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Stolzenberg D, Issa TZ, Boyd J, Boctor MJ, Tran D, Kitei PM, Schroeder GD. Basivertebral Nerve Radiofrequency Ablation (Intracept): Procedural Technique. Clin Spine Surg 2024; 37:223-229. [PMID: 38832706 DOI: 10.1097/bsd.0000000000001622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 02/28/2024] [Indexed: 06/05/2024]
Abstract
Intraosseous basivertebral nerve ablation is indicated for the treatment of chronic vertebrogenic low back pain with failure of at least 6 months of conservative treatment. This article details patient positioning and setup, step-by-step instructions for the procedure, and postoperative management. Pearls and pitfalls are also discussed. In addition, an instructional procedure video accompanies this paper and can be found online (at https://vimeo.com/791578426/de0e90cfbe).
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Affiliation(s)
- David Stolzenberg
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | - Tariq Z Issa
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | - Jeffrey Boyd
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | - Michael J Boctor
- Department of Plastic Surgery, Loma Linda University, Loma Linda, CA
| | - David Tran
- Axion Spine and Neurosurgery, Alpharetta, GA
| | - Paul M Kitei
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | - Gregory D Schroeder
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
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Hirsch JA, Sahr DM, Brook AL, Chandra RV, Manfre L, Marcia S, Milburn J, Muto M. Basivertebral nerve ablation meets neurointervention-déjà vu? J Neurointerv Surg 2024:jnis-2024-021484. [PMID: 38653523 DOI: 10.1136/jnis-2024-021484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2024] [Indexed: 04/25/2024]
Affiliation(s)
- Joshua A Hirsch
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Diane M Sahr
- Perceive Medical LLC, Minneapolits, Minnesota, USA
| | - Allan L Brook
- Director of Interventional Neuroradiology, Montefiore Medical Center, Bronx, New York, USA
| | - Ronil V Chandra
- Interventional Neuroradiology, Monash Medical Center and Monash University, Clayton, Victoria, Australia
| | - Luigi Manfre
- ESNR Secretary of State, Department Head Minimally Invasive Spine, IOM Mediterranean Oncology Institute, Viagrande-Cantania, Sicily, Italy
| | - Stefano Marcia
- Departmento dei servizi, Radiologia Area Ospedaliera ASL Cagliari, SS Trinita Hospital, Cagliari, Sardinia, Italy
| | - James Milburn
- Department of Radiology, Ochsner Medical Center, New Orleans, Louisiana, USA
| | - Mario Muto
- Chairman Diagnostic and Interventional Radiology, Cardarelli Hospital, Naples, Italy
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7
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McCormick ZL, Curtis T, Cooper A, Wheatley M, Smuck M. Low back pain-related healthcare utilization following intraosseous basivertebral nerve radiofrequency ablation: a pooled analysis from three prospective clinical trials. PAIN MEDICINE (MALDEN, MASS.) 2024; 25:20-32. [PMID: 37643639 PMCID: PMC10765157 DOI: 10.1093/pm/pnad114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/21/2023] [Accepted: 08/21/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND The effectiveness and safety of intraosseous basivertebral nerve ablation (BVNA) for treating vertebrogenic pain is established, but low back pain-related healthcare utilization (LBPr-HU) following BVNA continues to be defined. METHODS LBPr-HU data were pooled from 3 prospective studies. LBPr-HU categories of interest included non-invasive conservative care, opioid utilization, lumbosacral spinal injection (LSI), lumbosacral radiofrequency ablation (LRFA), and lumbosacral spinal surgery. Pre- and post-BVNA LBPr-HU were compared at both 1- and 5-years using McNemar's test for proportions and paired t-tests for means. RESULTS Two hundred forty-seven patients received BVNA and had 1-year follow-up; 205 had long-term follow-up (mean of 5.3 ± 1.33 years). Twenty-seven percent fewer participants initiated conservative care in the year post-BVNA compared to the year preceding BVNA (P < .001; 95% CI 19.8-34.5). Of 77/247 participants taking opioids at baseline, 40.3% and 61.7% fewer were taking them at one-year and 5.3 ± 1.33 years post-BVNA, respectively (P < .001). Of participants receiving LSIs in the year preceding BVNA, 81.2% fewer received LSI(s) in the year post-BVNA (P < .001; 95% CI 70.7-90.7); a 76.4% reduction in LSIs was maintained through a mean of 5.3 ± 1.33 years post-BVNA. LRFA rates were 1.6% at 1-year post-BVNA and 8.3% at 5.3 ± 1.33 years post-BVNA. Lumbar fusion surgery was 0.8% at 1-year post-BVNA and 6.5% at 5.3 ± 1.33 years post-BVNA. CONCLUSIONS In this aggregate analysis of patients with vertebrogenic pain, utilization of conservative care, opioids, LSIs, and LRFA were substantially reduced through 5 years post-BVNA compared to baseline. Lumbar fusion rates were less than half the published value at 5 years in similar populations.
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Affiliation(s)
- Zachary L McCormick
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, UT 84108, United States
| | - Timothy Curtis
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, UT 84108, United States
| | - Amanda Cooper
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, UT 84108, United States
| | - Margo Wheatley
- Health Economist, Technomics Research, LLC, Medina, MN 55356, United States
| | - Matthew Smuck
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Redwood City, CA 94063, United States
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8
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Smuck M, Truumees E, Macadaeg K, Jaini AM, Chatterjee S, Levin J. Intraosseous basivertebral nerve ablation: Pooled long-term outcomes from two prospective clinical trials. INTERVENTIONAL PAIN MEDICINE 2023; 2:100256. [PMID: 39238665 PMCID: PMC11373002 DOI: 10.1016/j.inpm.2023.100256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 05/08/2023] [Accepted: 05/09/2023] [Indexed: 09/07/2024]
Abstract
Background Vertebrogenic pain is an established source of anterior column chronic low back pain (CLBP) resulting from damaged vertebral endplates with pain signals transmitted by the basivertebral nerve (BVN). Type 1 or Type 2 Modic changes on magnetic resonance imaging (MRI) are objective biomarkers for vertebrogenic pain. Radiofrequency ablation of the BVN (BVNA) has demonstrated both efficacy and effectiveness for the treatment of vertebrogenic pain in two randomized trials. Here, we report 3-year aggregate results from two prospective studies of BVNA-treated patients. Methods Pooled results at 3 years post-BVNA are reported for two studies with similar inclusion/exclusion criteria and outcomes measurements: 1) a prospective, open label, single-arm follow-up of the treatment arm of a randomized controlled trial (RCT) comparing BVNA to standard care (INTRACEPT Trial), and 2) a prospective, open label, single cohort long-term follow-up study of BVNA-treated patients. Paired datasets (baseline and 3-years) for mean changes in Oswestry disability index (ODI) and numeric pain scores (NPS) were analyzed using a two-sided t-test with a 0.05 level of significance. Results There were 95/113 (84%) BVNA patients who completed a 3-year visit across 22 study sites. At baseline, 71% of patients reported back pain for ≥5 years, 28% were taking opioids, 34% had spinal injections in the prior 12 months, and 14% had prior low back surgery. Pain and functional improvements were significant at 3 years with a mean reduction in NPS of 4.3 points from 6.7 at baseline (95% CI 3.8, 4.8; p<0.0001) and a mean reduction in ODI of 31.2 points from 46.1 at baseline (95% CI 28.4, 34.0; p<0.0001). Responder rates, using minimal clinically important differences of ≥15-points for ODI and ≥50% reduction in NPS from baseline to three years, were 85.3% and 72.6%, respectively (combined response 69.5%), with 26.3% of patients reporting 100% pain relief at 3 years. There was a 74% reduction in the use of opioids and 84% reduction in the use of therapeutic spinal interventions from baseline to 3 years. There were no serious device or device-procedure related adverse events reported through three years. Conclusion Intraosseous BVNA demonstrates statistically significant, clinically meaningful, and durable improvements in pain and function through 3 years in patients with primary vertebrogenic low back pain. BVNA-treated patients significantly reduced opioid use and interventions for low back pain.
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Affiliation(s)
- Matthew Smuck
- Department of Orthopaedic Surgery, Division of Physical Medicine & Rehabilitation, Stanford University, 430 Broadway Street, Pavilion C 4th For, Redwood City, CA, 94063, USA
| | - Eeric Truumees
- Ascension Texas Spine & Scoliosis, 1004 W 32nd St Suite 200, TX, 78705, USA
| | - Kevin Macadaeg
- Indiana Spine Group, 13225 N Meridian St, Carmel, IN, 46032, USA
| | - Ashwin M Jaini
- Department of Orthopaedic Surgery, Division of Physical Medicine & Rehabilitation, Stanford University, 430 Broadway Street, Pavilion C 4th For, Redwood City, CA, 94063, USA
| | - Susmita Chatterjee
- Department of Orthopaedic Surgery, Division of Physical Medicine & Rehabilitation, Stanford University, 430 Broadway Street, Pavilion C 4th For, Redwood City, CA, 94063, USA
| | - Joshua Levin
- Department of Orthopaedic Surgery, Division of Physical Medicine & Rehabilitation, Stanford University, 430 Broadway Street, Pavilion C 4th For, Redwood City, CA, 94063, USA
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Nwosu M, Agyeman WY, Bisht A, Gopinath A, Cheema AH, Chaludiya K, Khalid M, Yu AK. The Effectiveness of Intraosseous Basivertebral Nerve Ablation in the Treatment of Nonradiating Vertebrogenic Pain: A Systematic Review. Cureus 2023; 15:e37114. [PMID: 37034146 PMCID: PMC10075185 DOI: 10.7759/cureus.37114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 04/03/2023] [Indexed: 04/05/2023] Open
Abstract
Intraosseous basivertebral nerve ablation has shown sustained efficacy in treating chronic axial low back pain (LBP) in patients with type 1 or 2 Modic changes. This systematic review aims to determine the efficacy of intraosseous basivertebral nerve radiofrequency ablation in treating nonradiating axial chronic LBP compared to standard therapy, sham, or without contrast. The population of interest is individuals greater than or equal to 18 years old with chronic nonradiating vertebrogenic pain. The key outcome was the percentage of patients with greater than or equal to 50% pain reduction, greater than or equal to 10-point improvement in function and disability measured by the Oswestry Disability Index (ODI), greater than or equal to two-point pain reduction in the visual analog scale (VAS) or numerical pain rating scale, and a decrease in opioid utilization by 10 morphine milligram equivalents. Three databases, PubMed, MEDLINE, and Google Scholar, were used to retrieve the studies for the review. Two independent reviewers assessed the studies for inclusion using the validated tools for quality appraisal. There were 286 articles in total; however, only 11 publications with extensive data on 413 participants matched the inclusion criteria and were used for this review. At three months, a majority of the participants reported greater than or equal to 10-point improvement in the ODI, a measure of functional and disability improvement on a 10-point scale, and greater than or equal to two-point improvement in the VAS. A good number of patients in the basivertebral nerve ablation (BVNA) arm reported complete pain resolution demonstrating therapy success and the superiority of BVNA over sham and standard treatment. Basivertebral nerve radiofrequency ablation, among other criteria, is a safe and minimally invasive therapy that significantly lowers pain and impairment in individuals with vertebrogenic pain with distinct Modic type 1 and 2 changes at lumbar vertebra three-sacral vertebra one (L3-S1) vertebral levels. Proper patient selection and exact procedural methods are essential to the success of basivertebral nerve neurotomy. The findings of the existing investigations require confirmation by nonindustry-funded, large-scale, high-quality trials using generalizable study participants.
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Affiliation(s)
- Marcellina Nwosu
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- Interventional Pain Management and Primary Care, El Paso Pain Center, EL Paso, USA
| | - Walter Y Agyeman
- Internal Medicine, Piedmont Athens Regional Medical Center, Athens, USA
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Aakash Bisht
- Medicine, Government Medical College, Amritsar, IND
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Ankit Gopinath
- Internal Medicine, Kasturba Medical College, Manipal, IND
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Ameer Haider Cheema
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Keyur Chaludiya
- Internal Medicine, Doctors at Doorstep, Surat, IND
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Maham Khalid
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Ann Kashmer Yu
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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Sayed D, Grider J, Strand N, Hagedorn JM, Falowski S, Lam CM, Tieppo Francio V, Beall DP, Tomycz ND, Davanzo JR, Aiyer R, Lee DW, Kalia H, Sheen S, Malinowski MN, Verdolin M, Vodapally S, Carayannopoulos A, Jain S, Azeem N, Tolba R, Chang Chien GC, Ghosh P, Mazzola AJ, Amirdelfan K, Chakravarthy K, Petersen E, Schatman ME, Deer T. The American Society of Pain and Neuroscience (ASPN) Evidence-Based Clinical Guideline of Interventional Treatments for Low Back Pain. J Pain Res 2022; 15:3729-3832. [PMID: 36510616 PMCID: PMC9739111 DOI: 10.2147/jpr.s386879] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 11/17/2022] [Indexed: 12/12/2022] Open
Abstract
Introduction Painful lumbar spinal disorders represent a leading cause of disability in the US and worldwide. Interventional treatments for lumbar disorders are an effective treatment for the pain and disability from low back pain. Although many established and emerging interventional procedures are currently available, there exists a need for a defined guideline for their appropriateness, effectiveness, and safety. Objective The ASPN Back Guideline was developed to provide clinicians the most comprehensive review of interventional treatments for lower back disorders. Clinicians should utilize the ASPN Back Guideline to evaluate the quality of the literature, safety, and efficacy of interventional treatments for lower back disorders. Methods The American Society of Pain and Neuroscience (ASPN) identified an educational need for a comprehensive clinical guideline to provide evidence-based recommendations. Experts from the fields of Anesthesiology, Physiatry, Neurology, Neurosurgery, Radiology, and Pain Psychology developed the ASPN Back Guideline. The world literature in English was searched using Medline, EMBASE, Cochrane CENTRAL, BioMed Central, Web of Science, Google Scholar, PubMed, Current Contents Connect, Scopus, and meeting abstracts to identify and compile the evidence (per section) for back-related pain. Search words were selected based upon the section represented. Identified peer-reviewed literature was critiqued using United States Preventive Services Task Force (USPSTF) criteria and consensus points are presented. Results After a comprehensive review and analysis of the available evidence, the ASPN Back Guideline group was able to rate the literature and provide therapy grades to each of the most commonly available interventional treatments for low back pain. Conclusion The ASPN Back Guideline represents the first comprehensive analysis and grading of the existing and emerging interventional treatments available for low back pain. This will be a living document which will be periodically updated to the current standard of care based on the available evidence within peer-reviewed literature.
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Affiliation(s)
- Dawood Sayed
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA,Correspondence: Dawood Sayed, The University of Kansas Health System, 3901 Rainbow Blvd, Kansas City, KS, 66160, USA, Tel +1 913-588-5521, Email
| | - Jay Grider
- University of Kentucky, Lexington, KY, USA
| | - Natalie Strand
- Interventional Pain Management, Mayo Clinic, Scottsdale, AZ, USA
| | | | - Steven Falowski
- Functional Neurosurgery, Neurosurgical Associates of Lancaster, Lancaster, PA, USA
| | - Christopher M Lam
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
| | - Vinicius Tieppo Francio
- Department of Rehabilitation Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | | | - Nestor D Tomycz
- AHN Neurosurgery, Allegheny General Hospital, Pittsburgh, PA, USA
| | | | - Rohit Aiyer
- Interventional Pain Management and Pain Psychiatry, Henry Ford Health System, Detroit, MI, USA
| | - David W Lee
- Physical Medicine & Rehabilitation and Pain Medicine, Fullerton Orthopedic Surgery Medical Group, Fullerton, CA, USA
| | - Hemant Kalia
- Rochester Regional Health System, Rochester, NY, USA,Department of Physical Medicine & Rehabilitation, University of Rochester, Rochester, NY, USA
| | - Soun Sheen
- Department of Physical Medicine & Rehabilitation, University of Rochester, Rochester, NY, USA
| | - Mark N Malinowski
- Adena Spine Center, Adena Health System, Chillicothe, OH, USA,Ohio University Heritage College of Osteopathic Medicine, Athens, OH, USA
| | - Michael Verdolin
- Anesthesiology and Pain Medicine, Pain Consultants of San Diego, San Diego, CA, USA
| | - Shashank Vodapally
- Physical Medicine and Rehabilitation, Michigan State University, East Lansing, MI, USA
| | - Alexios Carayannopoulos
- Department of Physical Medicine and Rehabilitation, Rhode Island Hospital, Newport Hospital, Lifespan Physician Group, Providence, RI, USA,Comprehensive Spine Center at Rhode Island Hospital, Newport Hospital, Providence, RI, USA,Neurosurgery, Brown University, Providence, RI, USA
| | - Sameer Jain
- Interventional Pain Management, Pain Treatment Centers of America, Little Rock, AR, USA
| | - Nomen Azeem
- Department of Neurology, University of South Florida, Tampa, FL, USA,Florida Spine & Pain Specialists, Riverview, FL, USA
| | - Reda Tolba
- Pain Management, Cleveland Clinic, Abu Dhabi, United Arab Emirates,Anesthesiology, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - George C Chang Chien
- Pain Management, Ventura County Medical Center, Ventura, CA, USA,Center for Regenerative Medicine, University Southern California, Los Angeles, CA, USA
| | | | | | | | - Krishnan Chakravarthy
- Division of Pain Medicine, Department of Anesthesiology, University of California San Diego, San Diego, CA, USA,Va San Diego Healthcare, San Diego, CA, USA
| | - Erika Petersen
- Department of Neurosurgery, University of Arkansas for Medical Science, Little Rock, AR, USA
| | - Michael E Schatman
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, New York, USA,Department of Population Health - Division of Medical Ethics, NYU Grossman School of Medicine, New York, New York, USA
| | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
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Kasitinon D, Williams R, Gharib M, Flowers R, Raiser S, Jain NB. What's New in Orthopaedic Rehabilitation. J Bone Joint Surg Am 2022; 104:1961-1967. [PMID: 36126120 DOI: 10.2106/jbjs.22.00732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Donald Kasitinon
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Reed Williams
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Mahmood Gharib
- Department of Physical Medicine and Rehabilitation, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Ryan Flowers
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sara Raiser
- Department of Orthopaedics, Emory Healthcare, Atlanta, Georgia
| | - Nitin B Jain
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, Texas
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12
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Lorio M, Clerk-Lamalice O, Rivera M, Lewandrowski KU. ISASS Policy Statement 2022: Literature Review of Intraosseous Basivertebral Nerve Ablation. Int J Spine Surg 2022; 16:1084-1094. [PMID: 36266051 PMCID: PMC9807041 DOI: 10.14444/8362] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
The index 2020 ISASS Guideline Statement "Intraosseous Ablation of the Basivertebral Nerve for the Relief of Chronic Low Back Pain" was generated in response to growing requests for background, supporting literature, evidence, as well as proper coding for intraosseous basivertebral nerve ablation. Since the guideline was published, the American Medical Association has added Current Procedural Terminology category I codes for basivertebral nerve ablation: 64628 and 64629. Additionally, the has recognized a need for greater specificity in differentiating various types of low back pain and has designatedthe International Classification of Diseases, 10th revision, Clinical Modification code M54.51, vertebrogenic low back pain, to ensure correct diagnosis. The timing of these additions provides an opportunity to refresh the ISASS Guideline to ensure proper diagnosis and procedural coding and to update the supporting literature and evidence.
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Affiliation(s)
- Morgan Lorio
- Advanced Orthopedics, Altamonte Springs, Florida, USA, Morgan Lorio, Advanced Orthopedics, 499 E Central Parkway, Altamonte Springs, FL 32701, USA;
| | | | - Milaris Rivera
- Universidad Autónoma de Guadalajara, School of Medicine, Zapopan, Jalisco, USA
| | - Kai-Uwe Lewandrowski
- Center for Advanced Spine Care of Southern Arizona, Surgical Institute of Tucson, Tucson, AZ, USA
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13
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Sherwood D, Haring RS, Schirmer D, Modic M. The interrater reliability of Modic changes among a potential basivertebral nerve ablation population: Why AC1 may be preferred to kappa. J Orthop Res 2022; 41:1123-1130. [PMID: 36200411 DOI: 10.1002/jor.25449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 08/30/2022] [Accepted: 10/01/2022] [Indexed: 02/04/2023]
Abstract
Interrater reliability of Modic changes is subject to variables which affect consistency in reporting. Given the importance of Modic change identification for basivertebral nerve ablation (BVNA) candidacy, interrater reliability for this specific cohort has not yet been reported. Twenty lumbar magnetic resonance images of potential basivertebral nerve candidates were independently reviewed by two neuroradiologists and two interventional spine physiatrists for the presence and characterization of Modic changes. The kappa value of their agreement on the presence of Modic changes was 0.52 (95% confidence interval [CI] 0.37-0.67), whereas agreement on the type of Modic change was 0.51 (95% CI 0.37-0.65). Using an alternative methodology for measuring interrater reliability (Gwet's AC1) yielded the identification of the presence of Modic changes at AC1 0.51 (95% CI 0.36-0.66), whereas agreement on the type of Modic change was AC1 0.75 (95% CI 0.66-0.83). While less common, AC1 may be preferred in the appropriate cohort to kappa as it mitigates some of the pitfalls to which kappa values may be victim. Ultimately, our results are in-line with previous reports of interrater reliability results for Modic changes in other cohorts and should serve to caution those who perform BVNA regarding interrater agreement of the imaging crux of the procedure.
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Affiliation(s)
- David Sherwood
- Department of Orthopedics, University Health Lakewood Medical Center, Kansas City, Missouri, USA
| | - Richard Sterling Haring
- Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Derek Schirmer
- Stanford University Medical Center, Physical Medicine and Rehabilitation Division, Redwood City, California, USA
| | - Michael Modic
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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14
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Santifort KM, Glass EN, Meij BP, Bergknut N, Pumarola M, Gil VA. Anatomic description of the basivertebral nerve and meningeal branch of the spinal nerve in the dog. Ann Anat 2022; 245:152000. [PMID: 36183940 DOI: 10.1016/j.aanat.2022.152000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/22/2022] [Accepted: 08/26/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE The existence of the basivertebral nerve and meningeal branch of the spinal nerve has not been proven in dogs to date. The objectives of this study are to 1) determine whether dogs have a meningeal branch of the spinal nerve (MBSN) and a basivertebral nerve (BVN) and to (2) describe anatomical characteristics of these two nerves. Authors also put forward a discussion on the possible clinical relevance of these findings. MATERIAL AND METHODS Dissections were performed on six embalmed dogs at the Veterinary Faculty of Barcelona with the use of stereomicroscopy and microsurgery equipment. RESULTS The MBSN (grossly) and BVN (grossly and histologically) were identified in the cervical, thoracic, and lumbar region in all dog specimens. In addition, other small fibers (suspected nerves) entering the vertebral body through small foramina close to the end plates were identified. Histological examination of the tissues confirmed the presence of nerve fibers (myelinated and unmyelinated) in suspected BVN samples. Results of the present study indicated that dogs have BVNs. Also, suspected nerve fibers were identified among the epidural fat, running from the intervertebral foramina, that likely represent the MBSN. CONCLUSION These findings open up the discussion on extrapolation of treatment options employed in human medicine for "low back pain", such as BVN ablation, which is discussed in this article. Further anatomic and clinical studies of the innervation for the vertebral body, periosteum, vasculature, dorsal longitudinal ligament and anulus fibrosus are necessary to elucidate possible anatomical variants and breed differences as well as potential clinical (e.g., therapeutic) relevance.
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Affiliation(s)
- K M Santifort
- Evidensia Small Animal Hospital Arnhem, Meander 10, 6825 MB Arnhem, the Netherlands; Evidensia Small Animal Hospital Hart van Brabant, Eerste Zeine 112, 5144 AM Arnhem, the Netherlands.
| | - E N Glass
- Red Bank Veterinary Hospital, Section of Neurology and Neurosurgery, 197 Hance Ave, Tinton Falls, NJ 07724
| | - B P Meij
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Yalelaan 108, 3508 TD Utrecht, the Netherlands
| | - N Bergknut
- Evidensia Small Animal Hospital Arnhem, Meander 10, 6825 MB Arnhem, the Netherlands; Evidensia Small Animal Hospital Hart van Brabant, Eerste Zeine 112, 5144 AM Arnhem, the Netherlands
| | - M Pumarola
- Unit of Compared and Murine Pathology, Department of Animal Medicine and Surgery, Faculty of Veterinary Medicine, Universitat Autònoma de Barcelona, Campus UAB, Travessera dels turons s/n, 08193 Bellaterra (Barcelona), Spain
| | - V Aige Gil
- Department of Sanitat i Anatomía Animal, Faculty of Veterinary Medicine, Universitat Autònoma de Barcelona Campus UAB, Travessera dels turons s/n, 08193, Bellaterra (Barcelona), Spain
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15
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Sayed D, Naidu RK, Patel KV, Strand NH, Mehta P, Lam CM, Tieppo Francio V, Sheth S, Giuffrida A, Durkin B, Khatri N, Vodapally S, James CO, Westerhaus BD, Rupp A, Abdullah NM, Amirdelfan K, Petersen EA, Beall DP, Deer TR. Best Practice Guidelines on the Diagnosis and Treatment of Vertebrogenic Pain with Basivertebral Nerve Ablation from the American Society of Pain and Neuroscience. J Pain Res 2022; 15:2801-2819. [PMID: 36128549 PMCID: PMC9482788 DOI: 10.2147/jpr.s378544] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 08/26/2022] [Indexed: 12/05/2022] Open
Abstract
Chronic low back pain is a worldwide leading cause of pain and disability. Degenerative disc disease has been the presumptive etiology in the majority of cases of chronic low back pain (CLBP). More recent study and treatments have discovered that the vertebral endplates play a large role in CLBP in a term defined as vertebrogenic back pain. As the vertebral endplates are highly innervated via the basivertebral nerve (BVN), this has resulted in a reliable target in treating patients suffering from vertebrogenic low back pain (VLBP). The application of BVN ablation for patients suffering from VLBP is still in its early stages of adoption and integration into spine care pathways. BVN ablation is grounded in a solid foundation of both pre-clinical and clinical evidence. With the emergence of this therapeutic option, the American Society of Pain and Neuroscience (ASPN) identified the need for formal evidence-based guidelines for the proper identification and selection of patients for BVN ablation in patients with VLBP. ASPN formed a multidisciplinary work group tasked to examine the available literature and form best practice guidelines on this subject. Based on the United States Preventative Task Force (USPSTF) criteria for grading evidence, gives BVN ablation Level A grade evidence with high certainty that the net benefit is substantial in appropriately selected individuals.
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Affiliation(s)
- Dawood Sayed
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
| | - Ramana K Naidu
- Anesthesiology, California Orthopedics & Spine, Marin, CA, USA.,Pain Management, MarinHealth Medical Center, Marin, CA, USA
| | - Kiran V Patel
- Interventional Pain Management/ Anesthesiology, The Spine & Pain Institute of New York, New York City, NY, USA
| | - Natalie H Strand
- Interventional Pain Management, Mayo Clinic, Scottsdale, AZ, USA
| | - Pankaj Mehta
- Clinical Research, Pain Specialists of Austin, Austin, TX, USA
| | - Christopher M Lam
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
| | - Vinicius Tieppo Francio
- Department of Rehabilitation Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Samir Sheth
- Interventional Pain Management, Sutter Health, Roseville, CA, USA
| | - Anthony Giuffrida
- Cantor Spine Center, Paley Orthopedic and Spine Institute, Fort Lauderdale, FL, USA
| | - Brian Durkin
- Pain Institute of Long Island, Port Jefferson, NY, USA
| | - Nasir Khatri
- Interventional Pain Medicine, Novant Health, Charlotte, NC, USA
| | - Shashank Vodapally
- Physical Medicine and Rehabilitation, Michigan State University, East Lansing, MI, USA
| | - Christopher O James
- Department of Physical Medicine and Rehabilitation, University of Kentucky, Lexington, KY, USA
| | | | - Adam Rupp
- Department of Rehabilitation Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Newaj M Abdullah
- Pain Medicine and Anesthesiology, University of Utah, Salt Lake City, UT, USA
| | - Kasra Amirdelfan
- Clinical Research, IPM Medical Group, Inc, Walnut Creek, CA, USA
| | - Erika A Petersen
- Department of Neurosurgery, University of Arkansas for Medical Science, Little Rock, AR, USA
| | | | - Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
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16
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McCormick ZL, Sperry BP, Boody BS, Hirsch JA, Conger A, Harper K, Lotz JC, Burnham TR. Pain Location and Exacerbating Activities Associated with Treatment Success Following Basivertebral Nerve Ablation: An Aggregated Cohort Study of Multicenter Prospective Clinical Trial Data. PAIN MEDICINE (MALDEN, MASS.) 2022; 23:S14-S33. [PMID: 35856332 PMCID: PMC9297150 DOI: 10.1093/pm/pnac069] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 02/25/2022] [Accepted: 04/11/2022] [Indexed: 11/14/2022]
Abstract
OBJECTIVE Develop pain location "maps" and investigate the relationship between low back pain (LBP)-exacerbating activities and treatment response to basivertebral nerve radiofrequency ablation (BVN RFA) in patients with clinically suspected vertebral endplate pain (VEP). DESIGN Aggregated cohort study of 296 patients treated with BVN RFA at 33 centers in three prospective trials. METHODS Participant demographics, pain diagrams, and LBP-exacerbating activities were analyzed for predictors using stepwise logistic regression. Treatment success definitions were: (1) ≥50% LBP visual analog scale (VAS), (2) ≥15-point Oswestry Disability Index (ODI), and (3) ≥50% VAS or ≥15-point ODI improvements at 3 months post-BVN RFA. RESULTS Midline LBP correlated with BVN RFA treatment success in individuals with clinically-suspected VEP. Duration of pain ≥5 years (OR 2.366), lack of epidural steroid injection within 6 months before BVN RFA (OR 1.800), lack of baseline opioid use (OR 1.965), LBP exacerbation with activity (OR 2.099), and a lack of LBP with spinal extension (OR 1.845) were factors associated with increased odds of treatment success. Regressions areas under the curve (AUCs) were under 70%, indicative of low predictive value. CONCLUSIONS This study demonstrates that midline LBP correlates with BVN RFA treatment success in individuals with VEP. While none of the regression models demonstrated strong predictive value, the pain location and exacerbating factors identified in this analysis may aid clinicians in identifying patients where VEP should be more strongly suspected. The use of objective imaging biomarkers (Type 1 and/or 2 Modic changes) and a correlating presentation of anterior spinal element pain remain the most useful patient selection factors for BVN RFA.
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Affiliation(s)
- Zachary L McCormick
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Beau P Sperry
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | | | - Joshua A Hirsch
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Aaron Conger
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | | | - Jeffrey C Lotz
- Department of Orthopaedics, University of California San Francisco, San Francisco, California, USA
| | - Taylor R Burnham
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
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17
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Conger A, Burnham TR, Clark T, Teramoto M, McCormick ZL. The Effectiveness of Intraosseous Basivertebral Nerve Radiofrequency Ablation for the Treatment of Vertebrogenic Low Back Pain: An Updated Systematic Review with Single-Arm Meta-analysis. PAIN MEDICINE (MALDEN, MASS.) 2022; 23:S50-S62. [PMID: 35856331 PMCID: PMC9297160 DOI: 10.1093/pm/pnac070] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 04/18/2022] [Accepted: 04/18/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To provide an estimate of the effectiveness of basivertebral nerve (BVN) radiofrequency ablation (RFA) to treat vertebrogenic low back pain (LBP). DESIGN Systematic review with single-arm meta-analysis. POPULATION Persons ≥18 years of age with chronic LBP associated with type 1 or 2 Modic changes. INTERVENTION Intraosseous BVN RFA. COMPARISON Sham, placebo procedure, active standard care treatment, or none. OUTCOMES The proportion of patients treated with BVN RFA who reported ≥50% pain score improvement on a visual analog scale or numeric rating scale. The main secondary outcome was ≥15-point improvement in Oswestry Disability Index score. METHODS Three reviewers independently assessed articles published before December 6, 2021, in MEDLINE and Embase. The Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) framework was used to evaluate the overall quality of evidence. RESULTS Of the 856 unique records screened, 12 publications met the inclusion criteria, representing six unique study populations, with 414 participants allocated to receive BVN RFA. Single-arm meta-analysis showed a success rate of 65% (95% confidence interval [CI] 51-78%) and 64% (95% CI 43-82%) for ≥50% pain relief at 6 and 12 months, respectively. Rates of ≥15-point Oswestry Disability Index score improvement were 75% (95% CI 63-86%) and 75% (95% CI 63-85%) at 6 and 12 months, respectively. CONCLUSION According to GRADE, there is moderate-quality evidence that BVN RFA effectively reduces pain and disability in most patients with vertebrogenic LBP. Further high-quality studies will likely improve our understanding of the effectiveness of this procedure.
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Affiliation(s)
- Aaron Conger
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah, USA
| | - Taylor R Burnham
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah, USA
| | - Tyler Clark
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah, USA
| | - Masaru Teramoto
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah, USA
| | - Zachary L McCormick
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah, USA
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18
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McCormick ZL, Conger A, Smuck M, Lotz JC, Hirsch JA, Hickman C, Harper K, Burnham TR. Magnetic Resonance Imaging Characteristics Associated with Treatment Success from Basivertebral Nerve Ablation: An Aggregated Cohort Study of Multicenter Prospective Clinical Trials Data. PAIN MEDICINE (MALDEN, MASS.) 2022; 23:S34-S49. [PMID: 35856328 PMCID: PMC9297152 DOI: 10.1093/pm/pnac093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 06/09/2022] [Accepted: 06/09/2022] [Indexed: 12/08/2022]
Abstract
OBJECTIVE Investigate associations between endplate and motion segment magnetic resonance imaging (MRI) characteristics and treatment outcomes following basivertebral nerve radiofrequency ablation (BVN RFA) in patients with clinically suspected vertebral endplate pain (VEP). DESIGN Aggregated cohort study of 296 participants treated with BVN RFA from three prospective clinical trials. METHODS Baseline MRI characteristics were analyzed using stepwise logistic regression to identify factors associated with treatment success. Predictive models used three definitions of treatment success: (1) ≥50% low back pain (LBP) visual analog scale (VAS), (2) ≥15-point Oswestry Disability Index (ODI), and (3) ≥50% VAS or ≥15-point ODI improvements at 3-months post-BVN RFA. RESULTS The presence of lumbar facet joint fluid (odds ratio [OR] 0.586) reduced the odds of BVN RFA treatment success in individuals with clinically suspected VEP. In patients with a less advanced degenerative disc disease (DDD) profile, a > 50% area of the endplate with bone marrow intensity changes (BMIC) was predictive of treatment success (OR 4.689). Both regressions areas under the curve (AUCs) were under 70%, indicating low predictive value. All other vertebral endplate, intervertebral disc, nerve roots facet joint, spinal segmental alignment, neuroforamina, lateral recesses, and central canal MRI characteristics were not associated with BVN RFA success. CONCLUSIONS In patients with vertebrogenic low back pain with Modic changes, the presence of degenerative findings of the anterior and posterior column was not associated with a clinically important impact on BVN RFA treatment success. None of the models demonstrated strong predictive value, indicating that the use of objective imaging biomarkers (Type 1 and/or 2 Modic changes) and a correlating presentation of pain remain the most useful patient selection factors for BVN RFA.
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Affiliation(s)
- Zachary L McCormick
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Aaron Conger
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Matthew Smuck
- Department of Orthopedics, Stanford University, Palo Alto, California, USA
| | - Jeffrey C Lotz
- Department of Orthopedics, University of California San Francisco, San Francisco, California, USA
| | - Joshua A Hirsch
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Colton Hickman
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | | | - Taylor R Burnham
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
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19
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Boody BS, Sperry BP, Harper K, Macadaeg K, McCormick ZL. The Relationship Between Patient Demographic and Clinical Characteristics and Successful Treatment Outcomes After Basivertebral Nerve Radiofrequency Ablation: A Pooled Cohort Study of Three Prospective Clinical Trials. PAIN MEDICINE (MALDEN, MASS.) 2022; 23:S2-S13. [PMID: 35856330 PMCID: PMC9297161 DOI: 10.1093/pm/pnac050] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 03/29/2022] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Multiple studies have demonstrated the safety and effectiveness of basivertebral nerve radiofrequency ablation (BVN RFA) for improving low back pain related to the vertebral endplate. However, the influence of patient demographic and clinical characteristics on treatment outcome is unknown. DESIGN Pooled cohort study of three clinical trials of patients with vertebral endplate pain identified by Type 1 and/or Type 2 Modic changes and a correlating presentation of anterior spinal element pain. SETTING Thirty-three global study centers. SUBJECTS Patients (n = 296) successfully treated with BVN RFA. METHODS Participant demographic and clinical characteristics were analyzed with stepwise logistic regression to identify predictors of treatment success. Three definitions of treatment success were defined: 1) ≥50% visual analog scale pain improvement, 2) ≥15-point Oswestry Disability Index (ODI) improvement, and 3) ≥50% visual analog scale or ≥15-point ODI improvement from baseline. RESULTS Low back pain of ≥5 years' duration and higher ODI scores at baseline increased the odds of treatment success, whereas baseline opioid use and higher Beck Depression Inventory scores reduced these odds. However, the three regression models demonstrated receiver-operating characteristics of 62-70% areas under the curve, and thus, limited predictive capacity. CONCLUSIONS This analysis identified no demographic or clinical characteristic that meaningfully increased or reduced the odds of treatment success from BVN RFA. On the basis of these findings and the high response rates from the three analyzed trials, we recommend the use of objective imaging biomarkers (Type 1 and/or 2 Modic changes) and a correlating presentation of anterior spinal element pain to determine optimal candidacy for BVN RFA.
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Affiliation(s)
| | - Beau P Sperry
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | | | | | - Zachary L McCormick
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
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20
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Conger A, Smuck M, Truumees E, Lotz JC, DePalma MJ, McCormick ZL. Vertebrogenic Pain: A Paradigm Shift in Diagnosis and Treatment of Axial Low Back Pain. PAIN MEDICINE (MALDEN, MASS.) 2022; 23:S63-S71. [PMID: 35856329 PMCID: PMC9297155 DOI: 10.1093/pm/pnac081] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 04/22/2022] [Accepted: 05/01/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Aaron Conger
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT, USA
| | - Matthew Smuck
- Department of Orthopaedics, Stanford University, Redwood City, CA, USA
| | - Eeric Truumees
- The University of Texas Dell Medical School, Ascension Texas Spine and Scoliosis, Austin, TX, USA
| | - Jeffrey C Lotz
- Department of Orthopaedics, University of California San Francisco, San Francisco, CA, USA
| | | | - Zachary L McCormick
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT, USA
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21
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Sherwood D, Miller S, Epps A, Gill B, Zhivotenko O, Khan S, Swenson T, Gardner J, Roehmer C, Martin D, Kennedy DDJ, Modic M, Schneider BJ. A First Estimate of the Annual Prevalence of Basivertebral Nerve Ablation Candidates in a Spine Clinic. PAIN MEDICINE 2022; 23:1858-1862. [PMID: 35652735 DOI: 10.1093/pm/pnac088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 04/29/2022] [Accepted: 05/19/2022] [Indexed: 11/14/2022]
Abstract
Emerging literature purports the use of basivertebral nerve ablation (BVNA) for a specific cohort of patients with chronic low back pain and Type 1 or Type 2 Modic changes from vertebral levels L3-S1. The early literature warrants further evaluation. Studies establishing the efficacy of BVNA use highly selective patient criteria. The population which fulfills these criteria in our practice is small. Our study suggests it is perhaps 3% (11/338, 95% CI 1-5%).
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Affiliation(s)
- David Sherwood
- University Health-Lakewood Medical Center. Department of Orthopedics. 7900 Lee's Summit Rd, Kansas City, MO, 64139. USA
| | - Scott Miller
- Vanderbilt University Medical Center. Department of Physical Medicine and Rehabilitation. 2201 Children's Way, Suite 1318, Nashville, TN, 37212. USA
| | - Adam Epps
- Vanderbilt University Medical Center. Department of Physical Medicine and Rehabilitation. 2201 Children's Way, Suite 1318, Nashville, TN, 37212. USA
| | - Benjamin Gill
- University of Missouri, Columbia. Department of Physical Medicine and Rehabilitation. 1 Hospital Drive DC046.00, Columbia, MO, 65212. USA
| | - Oksana Zhivotenko
- Orthopedic Partners. Department of Physical Medicine and Rehabilitation. 82 New Park Ave, North Franklin, CT, 06254. USA
| | - Samir Khan
- Vanderbilt University Medical Center. Department of Physical Medicine and Rehabilitation. 2201 Children's Way, Suite 1318, Nashville, TN, 37212. USA
| | - Theodora Swenson
- Vanderbilt University Medical Center. Department of Physical Medicine and Rehabilitation. 2201 Children's Way, Suite 1318, Nashville, TN, 37212. USA
| | - James Gardner
- Vanderbilt University Medical Center. Department of Physical Medicine and Rehabilitation. 2201 Children's Way, Suite 1318, Nashville, TN, 37212. USA
| | - Christian Roehmer
- Vanderbilt University Medical Center. Department of Physical Medicine and Rehabilitation. 2201 Children's Way, Suite 1318, Nashville, TN, 37212. USA
| | - Dann Martin
- Vanderbilt University Medical Center. Department of Radiology. 1211 Medical Center Drive, Nashville, TN, 37232. USA
| | - David D J Kennedy
- Vanderbilt University Medical Center. Department of Physical Medicine and Rehabilitation. 2201 Children's Way, Suite 1318, Nashville, TN, 37212. USA
| | - Michael Modic
- Vanderbilt University Medical Center. Department of Radiology. 1211 Medical Center Drive, Nashville, TN, 37232. USA
| | - Byron J Schneider
- Vanderbilt University Medical Center. Department of Physical Medicine and Rehabilitation. 2201 Children's Way, Suite 1318, Nashville, TN, 37212. USA
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22
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Koreckij T, Kreiner S, Khalil JG, Smuck M, Markman J, Garfin S. Prospective, randomized, multicenter study of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: 24-Month treatment arm results. NORTH AMERICAN SPINE SOCIETY JOURNAL 2021; 8:100089. [PMID: 35141653 PMCID: PMC8820067 DOI: 10.1016/j.xnsj.2021.100089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Revised: 10/18/2021] [Accepted: 10/20/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Vertebral endplates, innervated by the basivertebral nerve, can be a source of vertebrogenic low back pain when damaged with inflammation, visible as types 1 or 2 Modic changes. A randomized controlled trial (RCT) compared basivertebral nerve ablation (BVNA) to standard care (SC) showed significant differences between arms at 3 and 6-months. At 12-months, significant improvements were sustained for BVNA. We report results of the BVNA arm at 24-months. METHODS Prospective, open label, single-arm follow-up of the BVNA treatment arm of a RCT in 20 US sites with visits at 6-weeks, and 3, 6, 9, 12 and 24-months. Paired comparisons to baseline were made for the BVNA arm at each timepoint for Oswestry Disability Index (ODI), Visual Analog Scale (VAS), Short Form Health Survey (SF-36), EQ-5D-5L, and responder rates. RESULTS 140 patients were randomized, 66 to BVNA. In the 58 BVNA patients completing a 24-month visit, 67% had back pain for >5 years, 36% were actively taking opioids at baseline, 50% had prior epidural steroid injections, and 12% had prior low back surgery. Improvements in ODI, VAS, SF-36 PCS, and EQ-5D-5L were statistically significant at all timepoints through 2 years. At 24 months, ODI and VAS improved 28.5±16.2 points (from baseline 44.5; p < 0.001) and 4.1±2.7 cm (from baseline 6.6; p < 0.001), respectively. A combined responder rate of ODI≥15 and VAS≥2 was 73.7%. A ≥50% reduction in pain was reported in 72.4% of patients and 31.0% were pain-free at 2 years. At 24 months, only 3(5%) of patients had BVNA-level steroid injections, and 62% fewer patients were actively taking opioids. There were no serious device or device-procedure related adverse events reported through 24 months. CONCLUSION Intraosseous BVNA demonstrates an excellent safety profile and significant improvements in pain, function, and quality of life that are sustained through 24 months in patients with chronic vertebrogenic low back pain.
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Key Words
- AE, Adverse Events
- ANCOVA, Analysis of Covariance
- BVN, Basivertebral Nerve
- BVNA, Basivertebral Nerve Ablation
- Basivertebral nerve
- Basivertebral nerve ablation
- CLBP, Chronic Low Back Pain
- Chronic low back pain
- DMC, Data Management Committee
- ESI, Epidural Steroid Injection
- LS, Least Squares
- MCID, Minimal Clinically Important Difference
- Modic
- ODI, Oswestry Disability Index
- QOL, Quality of Life
- RCT, Randomized Controlled Trial
- RDQ, Roland-Morris Disability Questionnaire
- Radiofrequency ablation
- SC, Standard Care
- VAS, Visual Analog Scale
- Vertebrogenic pain
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Affiliation(s)
- Theodore Koreckij
- Department of Orthopedic Surgery, Kansas City Othropedic Alliance, Kansas City, MO, USA
| | - Scott Kreiner
- Department of Interventional Spine and Sports, Barrow Brain and Spine, Phoenix, AZ, USA
| | - Jad G Khalil
- Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak, MI, USA
| | - M Smuck
- Physical Medicine & Rehabilitation Division, Stanford University, Redwood City, CA, USA
| | - J Markman
- Department of Neurosurgery, Translational Pain Research Program, University of Rochester School of Medicine, Rochester, NY, USA
| | - Steven Garfin
- Department of Orthopaedic Surgery, University of California-San Diego, La Jolla, CA, USA
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Tieppo Francio V, Gill B, Rupp A, Sack A, Sayed D. Interventional Procedures for Vertebral Diseases: Spinal Tumor Ablation, Vertebral Augmentation, and Basivertebral Nerve Ablation-A Scoping Review. Healthcare (Basel) 2021; 9:1554. [PMID: 34828599 PMCID: PMC8624649 DOI: 10.3390/healthcare9111554] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 11/09/2021] [Accepted: 11/11/2021] [Indexed: 12/13/2022] Open
Abstract
Low back pain is consistently documented as the most expensive and leading cause of disability. The majority of cases have non-specific etiologies. However, a subset of vertebral diseases has well-documented pain generators, including vertebral body tumors, vertebral body fractures, and vertebral endplate injury. Over the past two decades, specific interventional procedures targeting these anatomical pain generators have been widely studied, including spinal tumor ablation, vertebral augmentation, and basivertebral nerve ablation. This scoping review summarizes safety and clinical efficacy and discusses the impact on healthcare utilization of these interventions. Vertebral-related diseases remain a top concern with regard to prevalence and amount of health care spending worldwide. Our study shows that for a subset of disorders related to the vertebrae, spinal tumor ablation, vertebral augmentation, and basivertebral nerve ablation are safe and clinically effective interventions to decrease pain, improve function and quality of life, and potentially reduce mortality, improve survival, and overall offer cost-saving opportunities.
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Affiliation(s)
- Vincius Tieppo Francio
- Department of Rehabilitation Medicine, The University of Kansas Medical Center (KUMC), Kansas City, KS 66160, USA;
| | - Benjamin Gill
- Department of Physical Medicine and Rehabilitation, The University of Missouri, Columbia, MO 65212, USA;
| | - Adam Rupp
- Department of Rehabilitation Medicine, The University of Kansas Medical Center (KUMC), Kansas City, KS 66160, USA;
| | - Andrew Sack
- Department of Anesthesiology, The University of Kansas Medical Center (KUMC), Kansas City, KS 66160, USA; (A.S.); (D.S.)
| | - Dawood Sayed
- Department of Anesthesiology, The University of Kansas Medical Center (KUMC), Kansas City, KS 66160, USA; (A.S.); (D.S.)
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