The Problem Nobody Talks About
Basivertebral nerve (BVN) ablation — the Intracept procedure — is FDA-cleared at L3, L4, L5, and S1 for vertebrogenic chronic low back pain. The standard approach is transpedicular: a cannula traverses the pedicle to reach the posterior third of the vertebral body, where the BVN enters through the basivertebral foramen.
This approach assumes the pedicles are available. In a patient with prior instrumented lumbar fusion, bilateral pedicle screws occupy that corridor entirely. The published literature has no solution for this — no randomized trial of BVN ablation to date has included patients with a history of lumbar fusion surgery.
This case involved a patient with chronic vertebrogenic low back pain spanning L3-4 and L5-S1, with Modic changes at all four adjacent endplates — and a prior L4-5 TLIF with bilateral pedicle screw instrumentation and interbody cage. Four vertebral levels needed to be treated. The pedicles at L4 were fully occupied. A different solution was required.
Intraoperative Fluoroscopy
The Anatomy Everyone Avoids
The lateral vertebral wall is perceived as dangerous territory. Three structures demand respect here — but all are anatomically predictable:
Runs at the waist — mid-height — of the vertebral body along the lateral wall before branching posteriorly. Entry at mid-height risks arterial injury.
Connect the sympathetic chain to the spinal nerve. Course anterolaterally — a posterolateral trajectory stays posterior to these structures.
Re-enters the canal through the foramen to supply the posterior annulus and PLL. Distinct from the BVN but relevant context for the neighborhood.
The segmental artery is reliably at mid-vertebral height. Entering the lower third of the vertebral body places the cannula below this vascular level. The grey rami travel anterolaterally — a posterolateral entry at approximately the 5 o’clock position naturally avoids them.
Anatomical Diagrams
Original illustrations showing the posterolateral access corridor, relevant anatomy, and the four-level treatment strategy.
The Technique
Pre-procedure CT was obtained to characterize screw geometry at L4-5 and map the posterolateral wall corridor at each level. The patient was kept awake throughout — a deliberate choice, as the posterolateral corridor is non-standard and real-time neurological feedback during cannula passage provides a safety layer that sedation would eliminate.
Pre-procedure CT mapped screw positions and defined the posterolateral corridor at each of the four target levels. Non-negotiable in any post-fusion case.
Posterolateral wall (~5 o’clock), lower third of the vertebral body — below the segmental artery at mid-height, posterior to the grey rami.
Posterior-third/anterior-two-thirds junction — where the BVN arborizes toward both endplates. Same depth target as the standard Intracept procedure.
Patient remained awake throughout for continuous neurological monitoring. Any paresthesia during cannula advancement prompts immediate repositioning.
AP and lateral fluoroscopic confirmation at each level before RF energy delivery. GE OEC C-arm allowed real-time repositioning at every step.
L3, L4, L5, and S1 — all treated in a single session via the same posterolateral approach, entering each vertebral body in the lower third.
Why This Matters
Vertebrogenic pain does not become less painful because the patient had prior surgery. Adjacent-level degeneration after fusion is well recognized, and patients with failed back surgery syndrome are among the most challenging to treat. Yet the published Intracept trials excluded post-fusion patients entirely.
This creates a gap: a growing population with persistent or recurrent vertebrogenic pain adjacent to fusion levels has no described BVN ablation pathway — even though the pain mechanism and target anatomy are unchanged.
This is not a call to abandon standard technique where it applies. It is a recognition that instrumented fusion is common, adjacent-level vertebrogenic pain is common, and the intersection of these two realities requires a solution.