Extrapedicular approach for basivertebral nerve radiofrequency ablation: a conceptual review

Area of Science:

• Pain Management
• Minimally Invasive Spine Procedures
• Interventional Radiology

Background:

• Chronic axial low back pain (LBP) of vertebrogenic origin is a recognized clinical entity.
• Basivertebral nerve radiofrequency ablation (BVN RFA) is an effective treatment for this condition.
• Understanding different access routes for BVN RFA is crucial for patient selection and procedural success.

Purpose of the Study:

• To synthesize anatomical, biomechanical, and safety considerations of transpedicular and extrapedicular access routes for BVN RFA.
• To evaluate the clinical implications of these distinct approaches.
• To compare the emerging extrapedicular approach with the standard transpedicular technique.

Main Methods:

• Conducted a literature review of PubMed articles on BVN RFA anatomy, techniques, and access routes.
• Included studies on vertebral augmentation for access route considerations due to limited extrapedicular BVN RFA literature.
• Focused on publications up to December 1, 2025.

Main Results:

• The standard transpedicular approach offers a consistent trajectory but involves proximity to sensitive structures.
• The extrapedicular approach provides a lateral pathway, potentially beneficial for patients with anatomical challenges like narrow pedicles or instrumentation.
• Emerging evidence describes the extrapedicular technique for specific patient populations.

Conclusions:

• No current clinical evidence demonstrates the superiority of the extrapedicular approach over the transpedicular approach for BVN RFA.
• Both approaches have unique anatomical considerations, technical challenges, and risks requiring imaging guidance and precise landmark adherence.
• Further biomechanical, cadaveric, animal, and clinical studies are needed to compare the efficacy, safety, and long-term outcomes of each approach.