Basivertebral Nerve Ablation: Anterior Column Procedure - Pratik Gandhi, D.O.

[00:00:03]So, we we're going to kind of take a switch here and jump into sort of the anterior elements.

[00:00:08]Um This was sort of a game-changer in the world of spine. You know, we had spine surgeons sending a lot of the axial back pain to us. You know, those the fusions that were happening that weren't successful, although there were definitely some successful ones.

[00:00:22]But the mantra in the past was, you know, axial back pain, treat the facets or, you know, try an SCS that sometimes works, sometimes didn't.

[00:00:30]Um and then this technology came about, you know, where we know that patients develop disc issues early on in life, in their 30s and 50s. That transitions into these Modic changes and then can become spinal stenosis later on. So, that degenerative cascade this procedure is sort of there to catch it early. Um So, again, there's always a big argument between discogenic pain, treating the discs versus treating the basivertebral nerve for with the Modic changes. Um but again, great, you know, data behind the procedure. You know, they have 5-year data, 10-year data coming soon. Um randomized control trials, which is a big thing for a level one randomized control trials. Um and the procedure is as a pretty safe safety profile, which is also big. Um when we kind of tell the patients about the procedure, we tell them it's it implant-free, no incisions.

[00:01:19]Um recovery is pretty quick. Um and that's why it's sort of changed the whole paradigm in how we treat this axial back pain. If you want to add.

[00:01:27]Yeah, perfect. Uh so, it has been a a real game-changer to be able to to proceed with this um with this procedure, you needs to have uh the description of Modic change on MRI. So, either Modic type one or type two. So, type one is a a refresher, so will be hypointense on T1. Um and so so Modic type one will be hyper and hyper, so both on T1 and T2 imaging.

[00:01:54]Um and um Modic type two will demonstrate uh swelling. So basically edema within within the vertebral um within the the end plates. Um so you're looking on physical examination those patients will present more frequently with anterior column pain. So they will be having difficulty sitting for a long period of time, bending forward, having difficulty with transition. In comparison to discogenic back pain has been demonstrated that vertebrogenic back pain will will be more central although it can creeps a little bit more on the side but typically a little bit is a little bit more of a centrally located pain.

[00:02:38]Um and yeah, so those patients will will be able to with the evidence of imaging and the clinical presentation to proceed with the vertebral plate stabilization. Um there's some groups such as uh in my practice will be performing also a discogram or an anesthetic discogram to confirm that this is the pain generator as well. Um other important thing to know on imaging the larger the Modic changes are. So if you have a very large Modic type one so lots of lots of edema within within the the end plates those patients tend to do better with with BVN. Um and if you have presence of facet joint fluid this is a factor that you know indicates that you may have some posterior element components as well. So this has been demonstrated as well. So those patients may benefit from the vertebral plate stabilization but may require also some facet rhizotomy afterwards. So we'll kind of we'll continue with the with the demo here.

[00:03:51]Yep. So we already kind of set up the view. Um We take an oblique view have that facet shadow at 50% or you know, sometimes less or more depending on how the pedicle sort of kind of elucidates itself. So this one here which we're treating L4 vertebral body.

[00:04:08]We're already on the midline of the pedicle. You know, the biggest thing here is the same mantra with the vertebralplasty and kyphoplasty. You know, don't want to breach the medial border of the pedicle. That's a no-no until you're in the posterior wall of the vertebral body. So we've already got purchase here on on the model.

[00:04:25]We're at mid pedicle here. Our lateral view shows us that's our AP mid pedicle and then our lateral view shows us that we're kind of even across the board.

[00:04:34]>> [snorts] >> So with this device we have you know, from the intercept device from Boston Scientific there's a bevel needle and a diamond shape needle.

[00:04:42]I almost exclusively use bevel just to give myself that directionality you know, if I'm getting too medial I can turn the needle outwards and turning the needle outwards will get me deeper without going without going deeper but still get me across midline.

[00:04:56]So right now we're kind of even but just to be safe I'm going to turn the needle outwards and that way I can still kind of make my trajectory towards the vertebral body.

[00:05:09]So we're right at the on the lateral view we're right at the medial border or sorry the posterior wall and then on the AP view we haven't breached but now if we want to get a little bit more aggressive we can turn the turn the needle again and dive and then we'll go back to lateral.

[00:05:24]So we'll go a little bit deeper.

[00:05:28]There.

[00:05:30]Just kind of down and again with the directionality you can kind of get the needle where you want it there.

[00:05:38]And then again so now we've gone through the posterior wall. We'll check an AP one more time.

[00:05:43]And so we're through the posterior wall and just through the medial border now.

[00:05:46]So, we're we're still even Steven you know with the with where we want to be.

[00:05:51]Um [snorts] we'll go back to lateral now.

[00:05:53]And then we're just going to go a little bit further in.

[00:05:58]Picture there.

[00:06:00]So, a little high, but this is about where we would do a tool exchange. Um kind of take out the needle there.

[00:06:06]And then we have this curved stylet.

[00:06:08]Good show it here.

[00:06:10]Right. So, right now the the actual curved cannula is covered, but if we were to bring this up, you know, it would come out.

[00:06:20]And so, what we do is we do a tool exchange, bring the cannula in, the J stylet, and kind of drop it there.

[00:06:28]Okay, so it's sitting there now.

[00:06:30]And then what I'll do is I'll bring this gear wheel up.

[00:06:35]Lock this in.

[00:06:44]Okay. I'm going to take a picture there.

[00:06:48]And then click that in. So, you can see the J stylet just kind of creeping out from the uh from the cannula there. So, in my opinion, we're a little high. So, I'm actually directing the J stylet downwards and medial.

[00:07:02]And so, we'll hold on to this.

[00:07:06]And you can see us making some some headway here.

[00:07:10]Going down.

[00:07:13]Down some more.

[00:07:14]And then I'll So, it doesn't dip too much, I'll just kind of change the trajectory again.

[00:07:20]Picture there. And so, now you can see that it kind of turned back on itself, but we're still towards the posterior wall, which is what we want. Um and we'll check how far across midline we are here.

[00:07:30]And we're already across, you know, we can take one more you know, one more tap here if we want.

[00:07:35]There. So, now we're definitely across.

[00:07:37]We're still posterior. So, this is where we will um bring the gear wheel down.

[00:07:46]And then pull the J-stop out.

[00:07:50]And then we insert the probe here.

[00:07:56]And then we also want to uncover this, so we'll bring the gear wheel back down.

[00:08:02]We'll take a picture there.

[00:08:04]And so we want these the the two prongs, so you see a light one and a dark one.

[00:08:08]We want that to kind of straddle the spinous process there.

[00:08:11]So we'll put it there.

[00:08:15]So we're pretty close there.

[00:08:16]Um, and that's where we would turn on the ablation. You know, if it's a targeted ablation, we do 7 minutes at you know, 85° and if we feel like we're a little off, we still have the option of doing the the 15-minute lesion as well. Um, either way, you know, the results are really good. Patient selection is big again. Um, you want to make sure you've If they're older patients, you really want to make sure that you've eliminated the facets or spinal stenosis as a big problem.

[00:08:40]Um, if they're younger, the likelihood is that they're having more disc-related issues including these uh Modic changes on their MRI if they've advanced, but we know that Modic is sort of a late finding on these MRIs. So we want to make sure that we're capturing these patients, you know, you can if you're really really not sure, like uh Dr. Clark said, you could do a discogram. Um, we don't do as many here, um, but all in all, if you know a person has pain and the physical exam correlates, um, this procedure, like I said, has a really good safety profile.

[00:09:10]Um, pretty easy to do and get the good results from it.

[00:09:21]Perfect.

[00:09:23]Do you want to show the lateral one there?

[00:09:25]>> Yeah.

[00:09:26]Yeah, perfect.

[00:09:27]>> are. Maybe just a a note here just in term of positioning of the anterior lateral anterior posterior depth of the ablation. So you want to be uh you know, between 30% and 50% of the AP dimension of the vertebral body. So, we're about that 30%. This is This is perfect. Um and you want to be about 50 the 50-yard line between the superior end plate and inferior end plate. So, right in the center. So, excellent positioning here. Um the time of ablation Yeah, most of the literature is at 15 minutes, but there's more and more push obviously to decrease the ablation time.

[00:10:06]It's an ablation time. It's an ablation at 85° C.

[00:10:11]Um and uh yeah, there's uh interest and and more more and more data toward shorter ablation time. Obviously, this makes a significant difference in the procedural time. So, this is uh we're we're interested to to have more follow-up on this data in the upcoming years as well.

[00:10:31]And so, we're going to pivot and also demonstrate a different system for BVNA.

[00:10:37]So, we'll work on that and then we'll ask questions after after we do that.