Why Vertebrogenic Pain Is Often Missed — And What Actually Helps in Napa

A Pain Doctor's Guide to Vertebrogenic Pain and Basivertebral Nerve Ablation

By Jacqueline Weisbein, D.O.
Double Board-Certified in Physical Medicine & Rehabilitation and Pain Medicine

Quick Insights

Vertebrogenic pain originates from damaged vertebral endplates and inflamed bone marrow inside the spine. The basivertebral nerve carries pain signals from these injured areas, creating chronic low back pain that persists even when standard MRI reports appear normal. This condition affects the vertebral body itself rather than discs or nerves.

Key Takeaways

• Modic changes on MRI signal endplate inflammation that correlates with chronic pain and disability.
• Standard imaging reports often overlook subtle bone marrow changes that indicate vertebrogenic pain.
• Conservative treatments may fail because they don't address the nerve pathways inside the vertebral body.
• Basivertebral nerve ablation targets pain signals at their source with durable five-year outcomes.

Why It Matters

When your pain persists despite normal test results, vertebrogenic pain may be the missing diagnosis. Recognizing this condition opens the door to targeted interventions that address the underlying nerve pathways, potentially restoring your ability to work, sleep, and move without constant discomfort.

Introduction

As a double board-certified pain physician, I've treated hundreds of patients whose MRIs came back "normal" despite debilitating back pain. In Napa, many residents experience this frustration when standard imaging fails to reveal the true source of their chronic discomfort. Learn more about my expertise as Dr. Jacqueline Weisbein, DO—board-certified pain management physician at Napa Valley Orthopaedic Medical Group.

Vertebrogenic pain originates inside the vertebral body itself, where damaged endplates and inflamed bone marrow activate pain signals through the basivertebral nerve. Research shows that endplate defects create an inflammatory state that standard imaging reports often miss, leaving patients frustrated and without answers.

At Napa Valley Orthopaedic Medical Group, I perform targeted procedures that address these hidden pain generators. Serving clients from Yountville to American Canyon, I focus on accurate diagnosis before treatment, ensuring we address the actual source of pain rather than treating symptoms alone. When conservative care fails to resolve vertebrogenic pain, interventional options like basivertebral nerve ablation can restore function and quality of life.

This article explains why vertebrogenic pain is frequently overlooked and what evidence-based treatments can help.

What Is Vertebrogenic Pain and Why Does It Go Undiagnosed in Napa?

Vertebrogenic pain originates inside the vertebral body itself, where damaged endplates and inflamed bone marrow activate pain signals through the basivertebral nerve. In my practice, I see many patients whose standard MRI reports describe "mild degenerative changes" or "age-appropriate findings" despite debilitating pain that limits their ability to work, sleep, or exercise.

The problem lies in how imaging is interpreted. Radiologists often focus on disc herniations or nerve compression while overlooking subtle bone marrow changes called Modic changes. Research demonstrates that Modic changes correlate strongly with chronic low back pain and disability, yet many reports don't mention them at all. When your physician receives a report that says "normal," they may not investigate further, leaving the true pain generator unidentified.

I've found that careful diagnostic work often changes the treatment path. When I review imaging myself, I look specifically for endplate inflammation and bone marrow signal changes that indicate vertebrogenic pain. This condition affects approximately 40% of patients with chronic low back pain, yet it remains underdiagnosed because standard imaging protocols don't always highlight these findings.

The Role of Endplate Inflammation in Chronic Back Pain

The vertebral endplate sits between the disc and the vertebral body, acting as a nutrient gateway and structural support. When endplates develop defects from injury, degeneration, or repetitive stress, they trigger an inflammatory cascade inside the bone marrow. Studies show that endplate defects create an inflammatory state that activates nociceptors traveling through the basivertebral nerve, which runs directly through the center of the vertebral body.

This inflammation differs fundamentally from disc pain or nerve root compression. The pain signals originate from within the bone itself, creating a deep, aching discomfort that worsens with sitting, standing, or transitioning between positions. Patients often describe it as a constant background pain that flares with activity and never fully resolves with rest.

In my Napa practice, I focus on identifying the specific pain generator rather than treating symptoms alone. When endplate inflammation drives the pain, treatments targeting discs or nerves won't provide lasting relief. The basivertebral nerve becomes the key therapeutic target because it carries the pain signals from the inflamed endplate and bone marrow to the spinal cord.

How Modic Changes on MRI Signal Vertebrogenic Pain

Modic changes represent bone marrow alterations visible on MRI that correlate with endplate damage and inflammation. Type 1 Modic changes show active inflammation with increased fluid in the bone marrow. Type 2 changes indicate chronic fatty replacement of normal marrow. Both types can generate pain through basivertebral nerve activation.

Standardized MRI reporting guidelines from the International Society for the Study of the Lumbar Spine help identify these changes, but many radiologists don't routinely comment on them unless specifically asked. I review every MRI personally because subtle Modic changes at L4-L5 or L5-S1 often explain why patients haven't improved with previous treatments.

The challenge is that Modic changes can appear minor on imaging while causing significant pain. A small area of Type 1 change adjacent to the endplate may look insignificant compared to a large disc bulge, yet the Modic change may be the primary pain generator. When I correlate imaging findings with physical examination and pain patterns, I can often identify vertebrogenic pain even when previous physicians missed it.

Why Standard Treatments Often Miss the Mark

Physical therapy, medications, and epidural injections target different pain mechanisms than vertebrogenic pain. Physical therapy strengthens muscles and improves mobility but doesn't address inflammation inside the vertebral body. Anti-inflammatory medications may provide temporary relief but can't reach the bone marrow in therapeutic concentrations. Epidural injections deliver medication around nerve roots, not inside the vertebral body where the basivertebral nerve originates.

Evidence supports phenotype-based management approaches that match treatment to the specific pain generator. When vertebrogenic pain drives symptoms, treatments must target the basivertebral nerve pathway directly. I've observed that residents who fail multiple conservative treatments often have unrecognized vertebrogenic pain that requires a different therapeutic approach.

The frustration patients experience after failed treatments is understandable. When your pain persists despite doing everything recommended, it's natural to question whether anything will help. My approach emphasizes accurate diagnosis before treatment, ensuring we address the actual source of pain rather than treating symptoms alone. For many patients, exploring chronic pain treatment options can lead to more targeted care and lasting relief.

Basivertebral Nerve Ablation: A Targeted Solution

Basivertebral nerve ablation uses radiofrequency energy to interrupt pain signals traveling through the nerve inside the vertebral body. The procedure targets the nerve at its entry point into the vertebra, where it branches to supply the endplate and bone marrow. Clinical trials demonstrate that basivertebral nerve ablation significantly improved pain and function compared to standard care in patients with Modic changes, with benefits maintained at 12 months.

I perform this procedure using image guidance to precisely target the basivertebral nerve without affecting surrounding structures. The treatment takes approximately 60-90 minutes per level and is performed on an outpatient basis. Patients typically experience gradual improvement over 6-12 weeks as inflammation resolves and pain signals diminish.

Long-term data spanning five years shows sustained improvements in pain and function with a favorable safety profile. In my practice, I see many patients who regain the ability to work, exercise, and sleep without constant pain after basivertebral nerve ablation. The procedure doesn't work for everyone, but when vertebrogenic pain is accurately diagnosed and Modic changes are present, outcomes can be transformative. For those with spine-related pain, I also offer minimally invasive back pain procedures that can further support patient recovery.

What to Expect from Advanced Interventional Care in Napa

Evaluation for vertebrogenic pain begins with a detailed history and physical examination, followed by careful review of imaging. I look for specific patterns: pain worse with sitting or standing, minimal leg pain, failed conservative treatments, and Modic changes on MRI. When these factors align, basivertebral nerve ablation may be appropriate.

The procedure itself involves conscious sedation, image-guided needle placement, and radiofrequency ablation of the basivertebral nerve. Most patients go home the same day with activity restrictions for 6-8 weeks while the bone heals. Physical therapy typically begins around 6 weeks to restore strength and mobility as pain improves.

My approach emphasizes matching the procedure to the pain generator. Not every patient with back pain needs basivertebral nerve ablation, but when vertebrogenic pain is the primary driver and conservative care has failed, this targeted intervention addresses the underlying pathology. I work directly with each patient to determine candidacy based on their specific diagnosis, imaging findings, and treatment goals.

A Patient's Perspective

As a pain physician, I know that patient experiences reveal what clinical data alone cannot capture.

When someone lives with chronic pain despite being told their imaging looks normal, that frustration shapes every aspect of their life. Dave came to me after years of searching for answers to his persistent pain, and I was able to help him through dorsal root ganglion surgery—a targeted intervention that addressed his specific pain generator.

"Dr Weisbein is very caring and an excellent physician 😀. She performed dorsal root ganglion surgery and helped to markedly reduce my pain"

— Dave

This is one patient's experience; individual results may vary.

Dave's story reminds me why accurate diagnosis matters so much. When we identify the true pain generator—whether it's vertebrogenic pain, nerve root pathology, or another condition—we can offer treatments that actually address the underlying problem rather than just managing symptoms.

Conclusion

Vertebrogenic pain remains underdiagnosed because standard imaging reports often overlook the endplate inflammation and bone marrow changes that drive chronic discomfort. When your MRI comes back "normal" but your pain persists, expert consensus supports targeted evaluation for vertebrogenic pain using advanced imaging interpretation and phenotype-based management.

As a dual board-certified physician in Pain Medicine and Physical Medicine & Rehabilitation, I've helped many Napa residents reclaim their quality of life through precise diagnosis and interventional treatments like basivertebral nerve ablation. Real-world evidence demonstrates that these procedures deliver significant pain reduction and functional improvement with a strong safety profile, even in patients with reduced bone density.

Local medical facilities in the region, such as Providence Queen of the Valley Medical Center, serve the broader community. Nearby healthcare services are also available at Adventist Health St. Helena.

If you're ready to explore options beyond symptom management, I'd be honored to help you identify the true source of your pain and develop a personalized treatment plan. We proudly serve Napa and nearby communities such as St. Helena, Yountville, and surrounding areas. Schedule a consultation today to explore personalized pain management options at my practice at Napa Valley Orthopaedic Medical Group.

This article is for educational purposes only and should not be used as a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified healthcare provider with any questions you may have regarding a medical condition or treatment options. Never disregard professional medical advice or delay in seeking it because of something you have read in this article.

Frequently Asked Questions

How do I know if I have vertebrogenic pain instead of disc problems?

Vertebrogenic pain typically causes deep, aching discomfort that worsens with sitting or standing and doesn't radiate down your legs like nerve compression does. The key diagnostic clue is Modic changes on MRI showing endplate inflammation or bone marrow alterations, often at L4-L5 or L5-S1. Many patients with vertebrogenic pain have tried physical therapy, injections, and medications without lasting relief because those treatments don't address the basivertebral nerve pathway inside the vertebral body. A careful review of your imaging by a physician trained in interventional spine care can identify these subtle findings that standard radiology reports may miss.

What makes basivertebral nerve ablation different from other back pain treatments?

Basivertebral nerve ablation targets the specific nerve pathway that carries pain signals from inflamed endplates and bone marrow inside the vertebral body. Unlike epidural injections that treat nerve root compression or physical therapy that strengthens muscles, this procedure uses radiofrequency energy to interrupt pain signals at their source. Clinical trials show that patients with Modic changes experience significant improvements in pain and function that last five years or longer. The procedure is performed on an outpatient basis using image guidance, and most patients gradually improve over 6-12 weeks as inflammation resolves and the treated nerve pathway stops transmitting pain signals.

Can vertebrogenic pain be treated without surgery?

Conservative treatments like physical therapy, anti-inflammatory medications, and activity modification may provide temporary relief but often fail to resolve vertebrogenic pain because they don't address the underlying endplate inflammation and basivertebral nerve activation. Basivertebral nerve ablation is a minimally invasive outpatient procedure, not traditional open surgery, that specifically targets the pain generator inside the vertebral body. When conservative care hasn't worked and imaging shows Modic changes indicating vertebrogenic pain, this targeted intervention offers a mechanism-based solution. I evaluate each patient individually to determine whether conservative management might still help or whether moving to interventional treatment makes sense based on their specific diagnosis and functional goals.

Where can I find vertebrogenic pain treatment in Napa?

Dr. Jacqueline Weisbein at Napa Valley Orthopaedic Medical Group offers physician-guided vertebrogenic pain treatment tailored to your specific diagnosis and imaging findings. Located in Napa, our practice provides personalized interventional care including basivertebral nerve ablation in a professional, evidence-based environment. Schedule your consultation today to explore advanced pain management options.