Kevin “Buzz” Barrette, MD, MBA, Division of Interventional Pain at Scripps Clinic Medical Group in San Diego, California talks about treating back pain with a new technique.
Interview conducted by Ivanhoe Broadcast News in 2024.
It seems like everybody, sometimes in our life, ends up with a lower back problem, right?
Barrette: It’s pretty unfortunate, but the reality is most people, at some point in their lives, will have a low back problem. Unfortunately, our options have historically been pretty limited. So it’s a tough problem to treat and it’s going to affect everyone, pretty much, at some point in their lives.
It can become really debilitating to where back pain affects your physical state, your mental state, everything about it, right?
Barrette: No question – low back pain can absolutely impact your ability to do things that you want to be doing. Then in turn, it can certainly have effects on your mental well being, can affect your work, can affect your family life. It can really have a big impact on pretty much all aspects of a patient’s life. So it’s a really challenging problem to treat, and we’re making progress as time goes on at treating low back pain.
So, what is exactly vertebrogenic pain?
Barrette: Vertebrogenic low back pain is a relatively new subset of low back pain. So historically, we have attributed many cases of chronic low back pain to the intervertebral discs. The discs are a cushioning between the big bones in the back, and we have seen on MRI many cases in patients with discogenic or disc related low back pain. Changes in signal of the bone that led some people to believe, perhaps, it’s not actually the disc that’s causing pain rather the bones. So, vertebrogenic back pain – it’s actually pain emanating from the junction between the big bones in the back and the discs in your back.
What can you do to help it?
Barrette: So historically, again, this is a relatively new diagnosis, and historically, we haven’t had great treatment options. So if people have been dealing with chronic low back pain, our answers have been intermittent corticosteroid injections, which haven’t been helpful oftentimes. And sometimes a spinal fusion surgery, which is obviously a more invasive intervention for a lot of patients, and certainly can be associated with potential adverse events in the future. So more recently, there has been a new development, a procedure called a basivertebral nerve ablation, and this is a procedure for patients with a specific type of low back pain called vertebrogenic low back pain, pain coming from the big bones in your back.
How can you tell the difference between that and a disc problem?
Barrette: It’s a great question. Disc problems and problems from the bone, vertebrogenic back pain share many similarities. They both often cause chronic low back pain that persists for months, sometimes even years or decades, and they’re both associated with disc degeneration. Vertebrogenic, low back pain, however, specifically on magnetic resonance imaging on an MRI study, you see inflammation or increased signal within some of these bones in your back – these are called Modic changes. And that is the primary differentiating source between vertebrogenic low back pain and potentially other causes of low back pain.
How does nerve ablation work?
Barrette: I’ll just say what the Modic changes are – they are white marks that we see on certain sequences on an MRI. So, nerve ablations have existed for a very long time and are used throughout many aspects of medicine, many different fields. Ablate means to get rid of. So a nerve ablation, you’re essentially burning. You’re getting rid of certain nerves in the body. And what the basivertebral nerve ablation is, is it’s burning specifically the nerve that supplies the end plate of the bones in your back. So basically, those areas on the MRI that show up as white marks, this ablation actually burns the little nerve that supplies sensation to that specific area.
Is there any risk to this?
Barrette: There’s risk with really any spine intervention. This is a very safe procedure. It has been around in the research world for about a decade, at this point, and in the real clinical practice of medicine has been successful for several years now. Always potential risks, but the reality is this is a very safe procedure. It utilizes a tried and true method of accessing the vertebral body, similar to a procedure called the kyphoplasty that has existed for decades and decades. It’s essentially the same procedure with some slight modifications to actually cauterize and burn a specific nerve. So it’s a safe path to get to this area. But again, there are always theoretical potential risks with any spine intervention.
One point you made earlier was that it’s unlikely people would injure their backs and not feel it because the joints in the back have different pain signals so people can still feel the rest of their back. I thought that was a good point.
Barrette: That’s correct. So the basivertebral nerve supplies the end plates of the vertebral bodies. There are several other nerves that exist in the back that supply different structures. So you’re not getting rid of sensation to the discs in the back, you’re not getting rid of sensation to any of the major joints in the back or the spinal nerves. It’s very specific to the vertebral end plates. So for this reason you’re not at risk of developing some subsequent injury if we cauterize or get rid of this specific nerve.
So why would someone be a good candidate for this and not like a cortisone shot or an epidural in the back?
Barrette: Great question. So epidural steroid injections are typically what we think of as cortisone shots in the back, and these have actually never been shown in the literature to be efficacious for back pain. Now, in practice, they are used frequently for back pain. But really epidural steroid injections are helpful with patients who have sciatica. For isolated low back pain, typically we attribute this to the disc and more recently, the vertebral end plates. And the role of epidural steroid injections for these conditions is unclear at best, at worst, it’s not helpful for these conditions.
We talked to a patient of yours – Andrea Beagle. Can you tell me about when you first met her, what pain was she in?
Barrette: Unfortunately, Andrea had been dealing with low back pain for many years on the spectrum of decades, which is quite common with patients that are dealing with vertebrogenic back pain. She had lots of pain when she was sitting for a long period of time, bending forward, lifting objects, bending over to put on shoes, certain things like that. And unfortunately, it had gotten to a point where it was really impacting every aspect of her life. She had seen multiple different providers, had had a myriad of different injection procedures, and really nothing had helped. So when I took a look at her MRI, I saw these modic changes at L5/S1, the low level of her back, and really thought she’d be a great candidate for this procedure. And fortunately, it really worked for her and she had a great outcome from it.
What’s crazy is that we got her playing with her grandkids, and that was one thing that brought her to tears because she thinking that she was going to go through life and never be able to really play with her grandkids.
Barrette: It’s really remarkable. A lot of times, the key feature that we see with patients with vertebrogenic back pain, oftentimes, is bending forward and, specifically, if you’re down low playing with your grandkids, it can really be debilitating when you’re dealing with this pain. So it really is great that we have a potential treatment option now for this subset of patients.
And you see it every day if you’re doing that. But if you’re doing 30 procedures a day, you’re seeing life changing things happen. How long does this procedure take?
Barrette: So the procedure itself takes about an hour. It is a bit more invasive than other spine injections that we do. That being said, there are no stitches involved. There’s no real recovery time with this procedure. There’s no hospital stay. The procedure takes an hour. Sometimes there is some post operative soreness associated with this. Generally, it’s very well controlled with over the counter analgesics. Patients go home and there really isn’t a whole lot that we do in between.
So, is there a recovery period where you don’t do anything for a week or so?
Barrette: So it really depends on your provider. There are no official restrictions with this particular procedure. In my practice, I generally tell patients to avoid lifting anything 25, 50 pounds for a week or so. But aside from that, I typically have no strict restrictions for my patients.
Perfect. Anything we’re missing?
Barrette: I would say, in general, this is a subset of low back pain that has really been challenging for pain providers and spine providers to manage for decades. And this is really one of the first great breakthroughs we’ve had from a back pain standpoint. And I’ve seen amazing results with many patients from this procedure. I was lucky enough to be involved with this from the research phases and now in my actual practice, I get to see firsthand the tremendous change we can see in a patient’s life. So I’m really excited to be able to do this procedure and offer it to patients. And I’m really thankful to be part of Scripps Clinic where they are very excited about fostering innovative procedures. And I hope to continue to do this and really enjoy making a true difference in patients lives.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
Stephen Carpowich
Carpowich.stephen@scrippshealth.org
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