559- Vertebral Nerve Ablation for Chronic Low Back Pain After Lumbar Fusion Surgery

Welcome to The Evidence-Based Chiropractor, where each week we deliver the latest chiropractic research and marketing strategies, all in the time it takes to get to your office. Now here's your host, Dr. Jeff Langmaid.

Hello and welcome to The Evidence-Based Chiropractor. I'm your host, Dr. Jeff Langmaid. On today's episode, we're talking all about nerve ablation post-fusion. This is something you might not see every single day in your practice, but it is something that really matters. If you have people coming in post-surgically, chances are they are a constellation of challenges, and chances are they're also seeing multiple doctors— you, maybe the surgeon, maybe pain management. And And many of them are being recommended nerve ablations. Spoiler alert, nerve ablations are not my favorite thing. You're gonna hear much more about that and why on today's episode. We're gonna dive into a brand new study that talks all about this post— a nerve ablation post-fusion on today's episode. Now, before we get started, big shout out to a few partners of the podcast. Leander Tables, hooking you up with $750 off their Series 950 using the code EBC2026. As well as Shockwave Centers of America, $500 off and a free cart by connecting with their team and letting them know you're a listener. Big savings for being a listener of this podcast. Thank you so much for tuning in. But as I said at the top, today's episode, all about the research. We're gonna talk about something I think is interesting because it challenges an assumption. And that assumption is if a segment has been fused, then whatever's been happening at that level is kind of done. Motion's gone, surgery's been completed. If there's no hardware failure, it seems as though we'd look towards the adjacent segment. If it's in the lumbar spine, maybe the SI joints, the facets, maybe muscular pain. But what if the level fused itself can still generate pain? And more specifically, what if the vertebral end plates at that fused level can remain biologically active, can remain nociceptive and painful?

Right.

Even decades after the fusion. That's what we're looking at today. 2026 case report in the Journal of Spine Surgery. Title of it, we'll drop a link down below, L5-S1 Basal Vertebral Nerve Ablation for Chronic Vertebrogenic Low Back Pain Following Lumbar Fusion. So this is a case report. It's not like this randomized controlled trial. It's not looking back at thousands of cases. So you have to take that with a the limitation, but I thought it was a great opportunity to bring up post-surgical care as well as ablations in the context of the real world and ultimately be able to pull out what I think are some really useful lessons. So for context, chronic low back pain, not a single diagnosis. When we say low back pain, it can clinically represent an enormous amount of pain generators, as you are well aware. Discogenic pain, facet pain, SI joint pain, muscular pain, radiculopathy, stenosis, instability. All of that. And increasingly, I think in the literature and in maybe what you're seeing in practice, you might be paying more attention to vertebrogenic pain. So vertebrogenic pain is pain thought to originate from the vertebral end plates with nociceptive signals carried through the basal vertebral nerve. So one of the imaging findings, that might sound esoteric, so let's make it real. One of the imaging findings commonly associated with that pain is Modic changes. You probably see these all the time, particularly Modic 1 and 2 changes on an MRI. So the authors noted that vertebrogenic pain can clinically resemble discogenic pain. So the imaging is an important component in terms of being able to literally see what's going on. So if you followed spine research, followed this podcast over the last few years, you've probably heard of the BVNA, basal vertebral nerve ablation. And the idea is really, really straightforward.

Yeah.

Ablation is burning, basically. So if the vertebral— if the basal vertebral nerve is transmitting pain from the end plate, you can perform a radiofrequency ablation intended to interrupt or disrupt or disconnect that pain signal. So there have been a variety of these types of ablations have been done throughout the years. This one is the BVNA. So this does have a growing popularity. But there's a catch. Patients with previous lumbar fusion have been generally excluded from some of the trials that have come out. So it creates sort of this clinical blind spot. BVNA could be helpful in some carefully selected patients. I'll say why I say could in a few moments. But what happens if that level is already fused? 'Cause if that level is fused and there are no hardware changes, meaning the hardware's coming out, it's broken, et cetera, We're pretty limited. We can't get in there and deliver an adjustment. We can do things around that segment, of course, and should at the adjacent segments and with the muscular tissue and with the fascia. We can't get in there and move the segments, literally fused. Now, one important thing I just want to point out, I'd be remiss if I didn't. I believe that chiropractic care, maybe mandated might be a strong word, but after a fusion, Getting in there at the segments above and below after the fusion has taken, so to speak, and when there's no complications, all of those caveats apply. But I believe chiropractic care is probably the most important thing. You're going to rehab after a fusion. That's to get back to a baseline, right? Your standard PT rehab. But to be able to fend adjacent segment disease is so rampant that getting in there and ensuring that the segments above and below, which take an Overwhelming majority of the beating after a fusion, getting in there and ensuring that they're moving as well as they can. And chances are they're not perfect to begin with. Often when somebody has a fusion, there's a variety of things going on. It's not just one thing at one level. That is a rarity. So, and even when that's the case, there still is tremendous load. Even if the adjacent segments are in perfect shape, there's tremendous load. If they're suboptimal, and then a fusion's done at the level adjacent to it, that can dramatically accelerate the degenerative changes. And ultimately, this is where you start to see hardware stack up over time, which is not good for anybody. So really, I think, you know, there's an opportunity for us as chiropractors to tell this story. I don't think— I've seen almost nobody tell the story that post-surgery patients, post-fusion patients, after cleared by their surgeon, Should absolutely go in and at least be evaluated by a chiropractor at a consistent level, if not receive some ongoing care, just because the biomechanics, this is not a stretch. This is like just straight biomechanics, if nothing else. And there's a lot more that we can do as well, but I'll get off that soapbox for today. So let's go back to the vertebrogenic pain. What if the painful vertebra level that's already fused can actually have end plates that are causing pain? That's really the question. And that's what they were looking at. So this study was at a patient, 55-year-old guy, had an L5-S1 interbody fusion all the way back in the 1900s, as they say, in 1995. And he did not have pain continuously from 1995. He actually had about 15 to 20 years of no pain. And then he started to see things start to come back. So this wasn't somebody that woke up from a fusion, said, my back still hurts, and it's an immediate failed post, a failed post-surgery syndrome type case. He apparently did well for many, many years, and then had new, then basically new chronic pain emerged over time. So almost all of it was axial, interestingly. So this is where you start to piece these things together. If it's radicular, you're saying, ah, maybe there's an adjacent segment that has some nerve compression or some compressive pathology, whether it's foraminal stenosis, lateral recess, or central.

Right.

That's not really the case. He had 90% axial pain, less than 10% were leg symptoms. And it hurt him when he was sitting, driving, forward bending, lifting. So all of these things start to point towards maybe there's something going on at the spine, not necessarily to the nerve. So this guy had tried just about everything previous to the nerve ablation. NSAIDs, steroid injections, facet injections.

Yeah.

SI joint injections, you know, acupuncture, and even some chiropractic care as well. But this was longstanding refractory pain. So his disability index was 48%, pain scale 7 out of 10, and they kind of classified it as severe disability. He wasn't just like, well, you know, this hurts. This guy was in some really, you know, challenged situation.

Uh-huh.

The CT imaging showed a solid and stable L5-S1 fusion, no hardware complication, no pseudoarthrosis. looked pretty good, no instability. But when they looked at the MRI, they saw Modic Type 2 changes at 5-1 and immediately adjacent as well to those interbody cages. So they had a patient with predominantly axial pain, chronic, way after the surgery. It looked like it was axial loading causing it, stable fusion, no hardware issues, and massive Modic changes. So piecing this together is where they came up with the thought of this could be an end plate mediated vertebrogenic pain type situation going on. So they basically performed a BVNA. They performed a nerve ablation at that level. So again, findings pre, 7 out of 10 pain, 48%. At 2 weeks post-ablation, 5 out of 10 pain, disability 34%. At 3 months, 4 out of 10 pain. At 12 months, 3 out of 10 pain. So he continued to improve and had what he considered to be a 75% overall improvement, along with some functional benefits as well. He was able to get up and get moving. So let's dive into— that's kind of the study in a nutshell. And I thought the study was interesting, not as a promotional tool for ablations, as you're about to hear, by any stretch of the imagination, but as an opportunity to open up the conversation around ablations. And here's the reason why I am, in most cases, it's very rare there's absolutes, but in most cases, most of the time, I am vehemently against ablations. Ablations, in my opinion, often create a cascade of challenges. When you ablate the nerve, there's pain and motor control. And when you have dysfunction in an area and then you're reducing input and output from a nervous system perspective, You end up in a challenged situation. You need to have throughput, afferent and efferent input. And there's no way to just like snip the efferent or snip the afferent or ablate the— it kind of all goes. So what I have seen over time is that just like steroid injections, often, not always, just like steroid injections, ablations tend to be a fast track towards fusion surgery. So, you know, I don't believe there's this grand conspiracy to do them to automatically create. And then, you know, I don't believe there's this grand conspiracy It's just the biology and the physiology of how this works. So the interesting part I'll say is in this case, in a fused segment is probably the only time I would say maybe an ablation actually could work. Why do I say that? Because the segment's already fused. And if it's actually fused, no pseudoarthrosis, no hardware breaks, well, you don't need motion. Literally, you can't have motion. It's a fused segment. So ablating a nerve at a fused level to me, There's no loss associated with that. The loss would be if you're trying to have an area be stable due to muscle, tendon, ligament, and it's unfused, and then you're ablating a nerve to reduce pain. I have seen time and time again, those levels fall apart and then need subsequent surgical intervention. If a fusion's already taken place, and let me be very clear as well, if somebody's had a decompressive procedure, but not a fusion, A laminectomy, a laminotomy. Ablations absolutely make me cringe because then we're already talking about a level that was injured to begin with. Clearly, that's why they had a surgery. Had a surgery, so it's biomechanically and structurally compromised forever. And then ablating a nerve that provides efferent and afferent input is a really bad idea in my mind, with rare exception. However, in a fused segment, No motion at all. You don't really need muscle control at that level. Now, the real question becomes the next question that I don't know the answer to, which is when you ablate a nerve at a single level, how much overlap to the adjacent levels? Because clearly you would not, in an ideal world, want to ablate a nerve even at a fused level and then have it affect negatively the adjacent levels, which are going to be undergoing tremendous load due to the fusion. So— This starts to become relatively complex, as you can see, relatively quickly. But I think it's a really important point for us to take in and understand as chiropractors. Why? One, because the goal is to avoid all of this to begin with, but to help patients ultimately avoid all of this to begin with. But we are going to have patients come in. There's a lot of people that get steroid injections, millions, tens of millions per year. I think there's over a million elective surgeries performed each and every year. There are clearly probably millions of ablations performed each and every year. So there is a massive amount, a massive amount of these procedures being done each and every year. So there are people walking around in your town, chances are these procedures are being performed on people in your town, literally every single day that you're gonna be in practice, and every day before you're in practice, and many days after you're in practice. And they're going to be walking around your community having these procedures performed. So understanding not only what these procedures are, but potentially where you could intervene before or be helpful at the worst case, not ideal afterward, I think is a really important place for us to be as movement-based neuromusculoskeletal experts ultimately. So from a post-surgical case, I'm just gonna encourage you, if you have not told the story on social to your community, to the other providers in your community about the help you can provide people post-surgically, please do so. These people are in dire need of the care that you are performing. And of course, trying to get to them before they ever get to that point is the goal that all of us are after each and every day. So I thought this study was pretty cool. I'll drop a link down in the show notes. Big shout out to some of our other partners. Grant Elliott and the RehabFix Hybrid Program. If you want to extend your care beyond the 4 walls of your practice and ramp up revenue big time, Grant has done it himself. He can show you how to do it. That's the RehabFix Hybrid Program. Connect with his team, as well as the NovoPulse OA Recovery Program. No capital expense. You can get hooked up with the hardware and software to have an osteoarthritis recovery program that can help you help more people and make more money in your practice. And finally, Care Plan Pro. This is my baby. I've been working on it for over 6 months developing it, and we have— it's blown my mind. If you have not gone over to careplanpro.ai, please do so. I say it's blown my mind because we have hundreds of docs in the 90 days since we have released this, which we really haven't even talked about it publicly or that much. We have hundreds of docs on this platform. It is ramping up and scaling fast. The feedback is awesome, and the goal is really simple. Help patients get the care they need, help you deliver that care plan recommendation, membership plan recommendation, or concierge plan recommendation in a way that doesn't require sales. The software does the heavy lifting and enables you to do what you are supposed to do, which is confidently give a care plan, not chronically under-recommend care because of cost and pricing. Careplanpro.ai. A lot of bells and whistles there as well, but that is it in a nutshell. So if you have not left a rating or review for this podcast, I would love it if you would take a moment and do so. That helps more and more docs find out about us. Thank you so much for tuning in. Thank you for being a chiropractor. Have a fantastic week in practice, and I will talk to you soon.

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