Vertebrogenic Low Back Pain: Symptoms, Types, Causes and Treatment

Vertebrogenic low back pain is an emerging clinical diagnosis that has gained significant attention in recent years. Understanding this condition is crucial for patients and providers alike, as it represents a unique source of chronic low back pain distinct from other common causes. This article draws on the latest scientific research to comprehensively explore the symptoms, types, causes, and treatment options for vertebrogenic low back pain.

Symptoms of Vertebrogenic Low Back Pain

Vertebrogenic low back pain can be challenging to distinguish from other forms of back pain. However, recent research has identified specific patterns and features that help differentiate it, leading to more accurate diagnosis and targeted treatment.

Symptom	Character	Key Diagnostic Aid	Source(s)
Chronic Pain	Persistent	MRI Modic Changes	1, 2, 6
Location	Centralized	Lumbar Spine (L3-S1)	1, 4, 6
Quality	Deep, aching	Not typically radicular	1, 2, 3
Aggravation	Activity	Movement, sitting	1, 4, 6

Table 1: Key Symptoms

Understanding the Core Symptoms

Vertebrogenic pain is often described as chronic, persistent low back pain that localizes primarily in the central lower back—usually between the L3 and S1 vertebral levels 1, 4, 6. Unlike radicular pain, which radiates down the legs, vertebrogenic pain is typically deep, aching, and confined to the back itself.

Modic Changes as Diagnostic Clues

A hallmark of vertebrogenic pain is the presence of Modic changes on magnetic resonance imaging (MRI). These changes—Type 1 and Type 2—are alterations in the vertebral endplates and adjacent bone marrow, signaling inflammation and degeneration 1, 2, 6. These MRI findings help differentiate vertebrogenic pain from other causes, such as discogenic or facet joint pain.

Aggravating and Relieving Factors

Patients often report that pain worsens with physical activity, prolonged sitting, or bending. It may improve with rest but rarely resolves completely 1, 4. Unlike acute injuries, vertebrogenic pain tends to persist for months or even years.

Symptom Variability and Overlap

It is important to note that while these are characteristic features, vertebrogenic pain may coexist with other pain generators. Clinical history alone—such as episodic versus continuous pain—has limited specificity or sensitivity for this diagnosis 3.

Types of Vertebrogenic Low Back Pain

Not all vertebrogenic pain is the same. Advances in imaging and research have helped categorize the condition into subtypes, primarily based on MRI findings and associated clinical features.

Type	MRI Feature	Clinical Implication	Source(s)
Type 1 Modic	Edema	Inflammatory, active pain	1, 2, 3, 6
Type 2 Modic	Fatty change	Chronic, less inflammatory	1, 2, 3, 6
Mixed/Other	Overlapping	Varies, may coexist	1, 3, 6

Table 2: Types of Vertebrogenic Pain

Modic Type 1: The Inflammatory Subtype

This type is defined by bone marrow edema and inflammation at the vertebral endplates, visible as bright signals on MRI. Patients with Type 1 Modic changes tend to have more active, sometimes severe pain, which may be more responsive to certain interventions 1, 2, 6.

Modic Type 2: The Chronic Subtype

Type 2 Modic changes represent fatty infiltration of the bone marrow at the endplates, indicating more chronic, less active inflammation. These patients still experience persistent pain, but it may be less intense than in Type 1 1, 2, 6.

Mixed and Other Types

Some patients exhibit a combination of both types or may transition from one to the other over time. The clinical significance can vary, and these mixed patterns highlight the spectrum of vertebrogenic pathology 1, 3, 6.

Clinical Relevance

Identifying the type of Modic change is important for prognosis and treatment planning. Studies show that radiofrequency ablation of the basivertebral nerve is effective for both Type 1 and Type 2 Modic changes, underscoring their relevance in therapeutic decision-making 2, 4, 5, 6, 7, 8.

Causes of Vertebrogenic Low Back Pain

Understanding what causes vertebrogenic low back pain is essential for effective prevention and management. The condition centers on the vertebral endplates and the nerves that innervate them.

Cause	Underlying Process	Key Structure	Source(s)
Endplate Damage	Degeneration, microtrauma	Vertebral Endplate	1, 2, 6, 8
Inflammation	Edema, cytokine release	Subchondral Bone	1, 2, 6, 8
Nerve Involvement	BVN pain transmission	Basivertebral Nerve	2, 4, 5, 8
Disc-Endplate Interaction	Disc degeneration	Intervertebral Disc	1, 6, 8

Table 3: Causes of Vertebrogenic Pain

Vertebral Endplate Damage

Chronic stress, repetitive microtrauma, or the natural aging process can damage the vertebral endplates—the thin layers of bone separating the intervertebral discs from the vertebral bodies. This damage leads to structural weakness and increased permeability, allowing for inflammation and pain signaling 1, 6, 8.

Inflammation and Modic Changes

Damaged endplates can trigger an inflammatory response in the adjacent bone marrow. This is seen on MRI as Modic Type 1 changes (edema) or, over time, as Modic Type 2 changes (fatty degeneration). This inflammation not only causes pain but can perpetuate a cycle of ongoing degeneration 1, 2, 6, 8.

The Basivertebral Nerve: The Pain Messenger

The basivertebral nerve (BVN) innervates the vertebral endplates and is now recognized as the primary pain pathway in vertebrogenic low back pain. When the endplates are damaged and inflamed, the BVN transmits pain signals to the central nervous system, resulting in chronic discomfort 2, 4, 5, 8.

Interplay with Disc Degeneration

While vertebrogenic pain is distinct from discogenic pain, the two often coexist. Disc degeneration can contribute to endplate damage, and vice versa, creating a complex interplay between the disc and vertebral bone 1, 6, 8.

Other Contributing Factors

• Genetics and age-related degeneration
• Mechanical overload (e.g., heavy lifting, obesity)
• Prior spinal surgery or trauma

Treatment of Vertebrogenic Low Back Pain

Recent advances in understanding vertebrogenic pain have revolutionized its management. While conservative therapies remain foundational, innovative minimally invasive options are now available and supported by robust clinical evidence.

Treatment	Approach	Outcome Effectiveness	Source(s)
Conservative Care	Physical therapy, medication	Modest, often inadequate	1, 4, 6, 7
Epidural Injections	Anti-inflammatory	Short-term relief	6, 7
Basivertebral Nerve Ablation (BVNA)	Minimally invasive, radiofrequency	Significant, sustained pain reduction	2, 4, 5, 6, 7, 8
Surgery	Structural repair	Rarely indicated	1

Table 4: Treatment Options

Conservative Management: The First Step

Most patients begin with non-surgical treatments such as:

• Physical therapy
• Anti-inflammatory medications
• Lifestyle modifications (weight loss, activity adjustment)
• Activity pacing

While these can help some, many patients with true vertebrogenic pain find only partial or temporary relief 1, 4, 6, 7.

Epidural Steroid Injections

Steroid injections can reduce inflammation and offer short-term symptom relief. However, their benefits are usually transient, especially when the underlying source is vertebrogenic 6, 7.

Basivertebral Nerve Ablation (BVNA): A Game-Changer

BVNA is a minimally invasive procedure that targets the basivertebral nerve using radiofrequency energy. By disrupting pain transmission from the damaged endplates, BVNA offers significant and durable pain relief.

Key Findings:

• Large randomized controlled trials have demonstrated that BVNA results in significant improvements in pain, function, and quality of life at 3, 12, 24, and even 60 months post-treatment 2, 4, 5, 6, 7, 8.
• Up to 75% of treated patients report meaningful improvements, with many experiencing over 50% pain reduction or complete pain resolution 5, 6, 7, 8.
• BVNA has an excellent safety profile, with very low rates of complications 6, 7, 8.
• The procedure is typically performed under local anesthesia, is CT- or fluoroscopy-guided, and is completed within an hour 8.

Surgery: Rarely Needed

Traditional spinal surgeries (such as fusion or disc replacement) are generally not indicated for isolated vertebrogenic pain, unless there is structural instability or other complicating factors 1.

The Importance of Accurate Diagnosis

Success with BVNA is highly dependent on appropriate patient selection, typically requiring:

• Chronic low back pain >6 months
• MRI evidence of Type 1 or 2 Modic changes between L3 and S1
• Exclusion of other pain generators (e.g., nerve root compression)

Conclusion

Vertebrogenic low back pain is a distinct and increasingly recognized cause of chronic low back discomfort. By focusing on the vertebral endplates and the basivertebral nerve, clinicians can now diagnose and treat this condition with greater accuracy and efficacy.

Key Takeaways:

• Symptoms: Persistent, centrally located low back pain, often with Modic changes on MRI.
• Types: Classified primarily by Modic Type 1 (inflammatory) and Type 2 (chronic, fatty) changes.
• Causes: Damage and inflammation of the vertebral endplates, with pain transmission via the basivertebral nerve.
• Treatment: While conservative care is the initial approach, basivertebral nerve ablation offers significant, long-term relief for appropriately selected patients.
• Future Directions: Continued research and improved imaging will likely refine diagnosis and expand treatment options for those suffering from vertebrogenic low back pain.

If you or someone you know is struggling with chronic low back pain, consider discussing vertebrogenic pain and its modern treatment options with your healthcare provider.