In this episode, Dr. Jacob Fleming interviews Dr. Olivier Clerk-Lamalice about basivertebral nerve ablation for vertebrogenic back pain, including indications, procedure technique and exciting tech on the horizon in minimally invasive spine interventions.

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SHOW NOTES

Dr. Clerk-Lamalice trained in Canada, first in engineering, and then medicine and diagnostic radiology at the Université de Sherbrooke in Calgary. He then completed a neuroradiology fellowship at Harvard, and a fellowship in interventional pain at The Spine Fracture Institute in Oklahoma City with Dr. Douglas Beall. Furthermore, he obtained his credentials as a fellow of interventional pain practice (FIPP), which is a widely recognized international designation. He now works at a comprehensive outpatient radiology center, where he practices both diagnostic and interventional radiology daily. They offer intrathecal drug administration, spinal cord stimulators, vertebral augmentation, Spine Jack, disc augmentation, nucleolysis, and various nerve blocks and ablations in and out of the spine. Their goal was to create a one stop shop for patients to come for consultation, imaging, expert advice and treatment.

Next, we discuss vertebrogenic back pain and the basivertebral nerve (BVN). The BVN is a nonmyelinated, intraosseous nerve, while most other peripheral nerves are myelinated, meaning they can regenerate. The BVN cannot, so ablation of this nerve is a permanent treatment. It is located within the central portion of the vertebral body midway between the superior and inferior end plates, one third ventral to the posterior wall of the vertebral body. On a sagittal T2 sequence on MRI, there is a triangle at the posterior aspect at the midpoint of the vertebral body called the basivertebral canal, which contains the nerve, artery and vein. The BVN is responsible for vertebrogenic back pain, which is a form of anterior column pain characterized by low back pain worsened by flexion and sitting. It is diagnosed via MRI using the Modic classifications. Modic type 1 (edematous), and type 2 (fibrofatty end plate) changes can be seen in this disease. It can be difficult to distinguish vertebrogenic from discogenic pain due to the fact that the sinuvertebral nerve (SVN), responsible for discogenic pain, crosses paths with the BVN. However, with MRI and an anesthetic discogram, it is possible to determine the etiology and choose the right treatment.

Finally, we discuss the steps of the procedure. Dr. Clerk-Lamalice uses an 8 gauge needle via a transpedicular approach, as is common for other spine procedures. He ensures the probe is positioned in the center of the vertebral body, parallel to the endplates. The nerve is ablated for 15 minutes at 85 C. The procedure takes 45 minutes, which includes an epidural steroid injection to bridge pain control during the periprocedural period. Patients usually go home within one hour after the procedure, and begin to experience the results within a couple days. There have been two trials for BVN ablation, which have made this intervention the most minimally invasive and evidence-based treatment for vertebrogenic pain. These studies indicated 25% of patients had a 50% reduction in pain, while 75% of patients had a 75% reduction of pain. Within that 75%, 30% reported being almost entirely pain free. To date, the study has followed participants to 8 years, and the results show the treatment is durable.

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RESOURCES

Ep 210: Modern Vertebral Augmentation
https://www.backtable.com/shows/vi/podcasts/210/modern-vertebral-augmentation

Ep 94: Spine Interventions
https://www.backtable.com/shows/vi/podcasts/94/innovation-in-spine-interventions

Relievent device for BVN ablation:
https://www.relievant.com/intracept/procedure-details/

Find this episode on backtable.com to view the full list of resources.