Vertebrogenic Back Pain: Why Your MRI Looks Normal
- Posted on: Jun 11 2026
If you’ve been told your MRI is “normal” — or that it shows only mild, age-appropriate wear and tear — and yet your low back pain hasn’t budged after months of physical therapy, medication, or rest, you’re not imagining it. For a specific group of patients, the explanation is a condition that standard imaging reports often overlook entirely: vertebrogenic back pain.
This article explains what vertebrogenic back pain is, why it doesn’t always show up the way patients expect on imaging, how it’s diagnosed, and what treatment options exist when conservative care hasn’t worked.
The Frustration of “Your MRI Looks Fine”
Few things are more frustrating than being in real, daily pain while a radiology report says everything looks normal — or close to it. Patients in this situation often hear phrases like “mild disc bulge, not clinically significant” or “age-related changes consistent with patient’s age.”
For some people, that’s reassuring. For others — especially those whose pain is constant, worse with sitting or bending forward, and centered in the lower back rather than radiating down the leg — it can feel dismissive. The pain is real. The MRI just wasn’t looking for the right thing.
That’s because a standard MRI is read primarily for discs, nerve roots, spinal canal width, and alignment. It’s an excellent tool for finding herniated discs, spinal stenosis, and nerve compression. But there’s another structure deep inside each vertebra that doesn’t always make it into the radiologist’s summary — even when the signal is sitting right there on the images.
What Standard MRI Reports Often Miss
Inside every vertebral body, just above and below the disc, are thin layers of bone and cartilage called the vertebral endplates. These endplates anchor the disc to the bone and play a role in disc nutrition and structural support.
When endplates are damaged — from repetitive mechanical stress, disc degeneration, or prior injury — they can develop a specific pattern of bone marrow changes called Modic changes, named after the radiologist who first described them. Modic changes are visible on MRI, but they’re frequently mentioned only in passing, or not flagged as a potential pain generator at all.
This is the gap that leads to vertebrogenic back pain being underdiagnosed. The findings are often present on the films a patient already has — they just weren’t connected to the clinical picture.
Dr. Amit Sharma & our minimally invasive pain & spine team.
What Is Vertebrogenic Back Pain?
Vertebrogenic back pain is chronic low back pain that originates from the vertebral endplates themselves, rather than from the disc, a nerve root, the facet joints, or surrounding muscles.
Running through the center of each vertebra is a small nerve called the basivertebral nerve (BVN). According to a clinical overview from the National Institutes of Health, the basivertebral nerve carries pain signals from damaged vertebral endplates, and research increasingly points to these endplates as an under-recognized source of chronic axial low back pain (NIH StatPearls, Basivertebral Nerve Ablation).
In other words: when the endplate is injured or inflamed, the basivertebral nerve transmits that pain signal — and that signal can be just as real and disabling as pain coming from a pinched nerve or herniated disc, even though it looks different on imaging.
How Vertebrogenic Pain Differs From Other Common Causes of Back Pain
Not all chronic low back pain has the same source, and the treatment approach depends heavily on getting that source right. Here’s how vertebrogenic pain typically presents compared to other common causes:
Disc-related pain (herniation or radiculopathy): Often radiates down one leg, may include numbness, tingling, or weakness following a specific nerve pattern. Worsens with activities that increase pressure on the disc, such as prolonged sitting or bending.
Facet joint pain: Tends to be more localized, often worsens with extension (arching backward) or twisting, and may be aggravated by standing for long periods.
Muscular or myofascial pain: Often follows a specific activity, injury, or period of deconditioning. Tends to respond well to physical therapy, stretching, and activity modification, and frequently improves over weeks.
Vertebrogenic pain: Typically a deep, central, band-like pain across the lower back. Often worse with sitting, bending forward, or transitioning from sitting to standing. It frequently does not improve significantly with physical therapy alone, and patients often describe having “tried everything” without lasting relief.
None of these patterns are diagnostic on their own — they’re clues. The Cleveland Clinic notes that low back pain has many overlapping causes, and a careful history combined with targeted imaging review is essential to sort them out (Cleveland Clinic, Lower Back Pain).
How Vertebrogenic Back Pain Is Diagnosed
Diagnosing vertebrogenic back pain starts with a thorough history and physical exam, but the key additional step is a focused re-review of existing MRI imaging — specifically looking for Modic type 1 or type 2 changes at the vertebral endplates.
A few features that raise suspicion for vertebrogenic pain include:
Pain that has been present for at least six months and has not responded adequately to physical therapy, medications, or epidural steroid injections.
Pain that is clearly worsened by flexion-based activities — sitting, bending forward, prolonged driving — and improved somewhat by lying down or standing.
MRI findings showing Modic type 1 or type 2 changes adjacent to the disc space, even if the disc itself looks relatively unremarkable.
Absence of significant nerve root compression that would otherwise explain leg pain, numbness, or weakness.
If you’ve had an MRI in the past year, it’s often worth having it specifically re-reviewed with this question in mind: are there endplate changes that were never discussed?
Treatment Options: From Conservative Care to Targeted Procedures
The good news is that vertebrogenic back pain doesn’t automatically mean surgery. Like most spine conditions, treatment generally follows a stepwise approach.
Conservative care first. Physical therapy, activity modification, anti-inflammatory medication, and weight management remain reasonable first steps for most patients with chronic low back pain, including those who may ultimately be diagnosed with a vertebrogenic component. If you haven’t yet explored a structured conservative pathway, our overview of stepwise spine pain treatment options walks through what a reasonable progression looks like.
When conservative care isn’t enough. For patients who have genuinely tried physical therapy, medication, and possibly injections without lasting relief — and whose imaging shows Modic changes consistent with vertebrogenic pain — a minimally invasive procedure called basivertebral nerve ablation (BVN ablation) may be an option.
BVN ablation uses a small probe, guided by imaging, to deliver controlled radiofrequency energy to the basivertebral nerve inside the vertebral body — interrupting the pain signal at its source rather than masking it. It’s typically performed as an outpatient procedure, often under light sedation, with most patients returning to normal activity within a few days.
A long-term study published in the European Spine Journal followed patients for five years after BVN ablation and found sustained improvements in both pain and function, with results that held up well over time (Fischgrund et al., European Spine Journal, 2020).
If you’re curious about the specific devices and protocols used for this procedure, we’ve also written a detailed comparison of the two most established systems in OptaBlate vs. Intracept: A Comparison of BVN Ablation Systems.
Dr. Amit Sharma & our minimally invasive pain & spine team.
What to Expect If You Move Forward With BVN Ablation
Before any procedure is recommended, a thorough evaluation is necessary — including a review of prior imaging, a physical exam, and confirmation that conservative treatments have genuinely been exhausted.
If BVN ablation is appropriate, the procedure itself is performed under imaging guidance (fluoroscopy), typically takes under an hour, and does not require general anesthesia for most patients. A small probe is advanced into the vertebral body through a narrow access channel, positioned near the basivertebral nerve, and radiofrequency energy is applied for a set duration.
Recovery is generally quick. Many patients notice some improvement within a few weeks, with continued improvement over the following months as inflammation around the treated nerve resolves.
As with any procedure, BVN ablation isn’t right for everyone. Patients with certain types of vertebral fractures, infections, or specific anatomical considerations may not be candidates — which is why imaging review and a hands-on evaluation matter so much before any decision is made.
When It’s Time to Ask for a Second Look
If your back pain has lasted more than six months, hasn’t meaningfully improved with physical therapy or injections, and your MRI report didn’t specifically address the vertebral endplates — it may be worth having your case reviewed by a physician who specializes in interventional spine care.
You don’t necessarily need new imaging. Often, the answer is already sitting in the MRI you already have — it just needs to be looked at with a different question in mind.
Dr. Amit Sharma & our minimally invasive pain & spine team.
Frequently Asked Questions
What is vertebrogenic back pain?
Vertebrogenic back pain is chronic low back pain that comes from the vertebral endplates — the bone and cartilage layers above and below each spinal disc — rather than from the disc, nerve roots, or facet joints. It’s transmitted through a nerve called the basivertebral nerve.
How is vertebrogenic pain different from a herniated disc?
A herniated disc often causes pain that radiates down one leg, sometimes with numbness, tingling, or weakness. Vertebrogenic pain is typically a deep, central, band-like ache across the lower back that worsens with sitting or bending forward, without the leg symptoms typical of nerve root compression.
Can an MRI actually diagnose vertebrogenic back pain?
An MRI can show the findings associated with vertebrogenic pain — specifically Modic type 1 or type 2 changes at the vertebral endplates — but these findings are often not highlighted in standard radiology reports. A focused review of existing imaging by a spine specialist, combined with your clinical history, is usually needed to make the diagnosis.
What are Modic changes?
Modic changes are a specific pattern of bone marrow signal changes seen on MRI at the vertebral endplates, caused by inflammation, degeneration, or prior injury to the endplate. They are one of the key imaging markers associated with vertebrogenic back pain.
Is basivertebral nerve (BVN) ablation a surgery?
No. BVN ablation is a minimally invasive, outpatient procedure performed under imaging guidance. It does not involve open surgery, and most patients go home the same day and resume normal activities within a few days.
How do I know if I’m a candidate for BVN ablation?
Candidacy depends on your symptom pattern, how long you’ve had pain, whether conservative treatments have been tried, and whether your imaging shows Modic changes consistent with vertebrogenic pain. A hands-on evaluation with a review of your existing MRI is the best way to find out.
Tagged with: basivertebral nerve ablation, Degenerative Disc Disease, Modic Changes, Vertebrogenic Pain
Posted in: Special Report, News
