Why Do Some People Develop Deep, Persistent Back Pain That Doesn’t Respond to Anything?
If you’ve lived with chronic low back pain that feels deep, achy, centered, and stubborn, but not sharp, and not shooting down the leg, you may be dealing with a specific diagnosis that many patients haven’t even heard of yet:
This type of pain arises from inflammation of the vertebral endplates (the bone–disc interface) and irritation of the basivertebral nerve (BVN), a small nerve within the vertebra (Khalil et al., 2019; Fischgrund et al., 2018). When that nerve becomes sensitized, it can keep sending pain signals even after you’ve tried the usual fixes.
The next questions are the ones our patients always ask our spine team at Vertrae®:
“Why me?”
“Who tends to develop this?”
“And how do I know if I’m a candidate for BVN ablation?”
Let’s break it down, simply and clearly.
Quick Snapshot: Who’s Most at Risk for Vertebrogenic Pain?
- Vertebrogenic pain represents one of the most important advances in understanding chronic low back pain in the last decade (Fischgrund et al., 2018).
- Vertebrogenic pain is most common in adults ages 40–80, especially when disc degeneration and endplate inflammation overlap.
- Key risk factors include: Modic Type 1 or 2 changes on MRI, prior back injury, low bone density, smoking, obesity, and repetitive heavy work.
- Ideal candidates for BVN ablation usually have:
- 6+ months of deep, midline low back pain
- Little or no leg pain
- Modic changes at L3–S1 that match their pain pattern
- Many patients try PT and injections with limited success—because the pain source is inside the vertebra, not the muscle or nerve.
“Vertebrogenic pain is endplate-driven back pain, often visible as Modic changes on MRI, and BVN ablation treats that pain at its source.”
So… Why Me? Who Gets This Kind of Pain?
How Age, Disc Changes, and Genetics Set the Stage
Vertebrogenic pain is most common in adults between 40 and 80, not because age itself causes pain, but because the spine naturally undergoes wear over time. Discs lose hydration. Endplates absorb more force (Modic et al., 1988; Jensen et al., 2008). And when inflammation builds up around the BVN, that’s when deep, persistent pain can start.
Sometimes it’s labeled “degenerative disc disease,” but that doesn’t tell the full story. The disc may be involved, but the real pain source is often the endplates themselves.
Genetics can also play a role. Some people simply inherit spines that are more reactive to stress. If your endplates or discs are less durable, or if your body tends to stay inflamed longer after injury, vertebrogenic pain may be more likely to develop.
As Dr. Woods often tells patients:
“Aging doesn’t mean you’re breaking down. It just means certain patterns become more likely.”
Can Pain Show Up Years After an Old Injury?
Absolutely. Some patients remember a specific injury: a fall, a car accident, or a heavy lift. Others don’t. That part doesn’t always matter.
What matters is that even a small injury to the endplate can create a subtle fracture or irritation (Fields et al., 2019). Over time, that damage can evolve into chronic inflammation and hypersensitivity in the BVN.
The result? Pain that doesn’t feel muscular or sharp, but more like an ache “deep in the bone.”
As Jen, PA-C, often hears:
“I thought I pulled a muscle years ago… it got better… but it never felt quite right again.”
Bone Density and Lifestyle: Quiet Contributors
You don’t need osteoporosis to be at risk. Even mild bone thinning can make the vertebral endplates more vulnerable to stress, and we often see this in (Wang et al., 2020; Samartzis et al., 2013):
- Postmenopausal women
- Older adults
- Patients with long-term steroid use or certain metabolic conditions
Lifestyle and work exposures can also quietly accelerate stress on the endplates. It’s not about one wrong move or bad posture. It’s more about cumulative strain over time.
We see vertebrogenic pain more often in people who:
- Lift heavy objects repeatedly
- Spend long hours driving or operating machinery
- Smoke or use nicotine (which affects disc and bone nutrition)
- Carry extra weight
- Live a mostly sedentary lifestyle
None of these things guarantee you’ll develop pain. But they can add fuel to the fire if your spine is already inflamed or vulnerable. The good news? Once we identify the contributing factors, we can make targeted changes.
Clinical Snapshot: Are You a Good Candidate for BVN Ablation?
Vertebrogenic pain follows a pretty recognizable pattern, and once you know what to look for, it becomes much easier to identify.
You might be a candidate for BVN ablation if your pain:
- Feels deep, centered, and stubborn (not sharp or radiating)
- Gets worse with sitting, standing, or bending
- Comes with morning stiffness and never fully goes away
- Has lasted longer than six months
- Hasn’t responded well to PT, medications, or injections
If leg pain isn’t a major part of your symptoms, and your MRI shows Modic Type 1 or 2 changes (even if it’s just labeled “degenerative disc disease”), that’s a strong clue the pain may be coming from inside the bone, specifically, the basivertebral nerve (Khalil et al., 2019; Becker et al., 2021).
At Vertrae®, we connect the dots between your symptoms, exam, imaging, and history, and we only recommend BVN ablation when the whole picture fits.
Important: BVN ablation isn’t for every type of back pain. It’s for the right pattern, in the right patient, at the right time.
Final Thoughts
Vertebrogenic pain is one of those diagnoses that explains what nothing else quite could. The deep, central ache. The treatments that never seem to stick. The frustration of vague answers.
At Vertrae®, we take the time to connect the dots between your pain, your MRI, and your story, so you’re not left guessing.
BVN ablation isn’t right for everyone. But if your pain fits the pattern, it could be a real turning point.
Let’s find out what’s possible and what’s next.
Vertrae® | Let’s Get You Back on Track!
References
Becker, S., Hadjipavlou, A., Heggeness, M. H., & Khalil, J. G. (2021). Ablation of the basivertebral nerve for the treatment of chronic low back pain: Five-year outcomes from a prospective randomized controlled trial. European Spine Journal, 30(11), 3319–3327.
https://doi.org/10.1007/s00586-021-06988-4
Fields, A. J., Liebenberg, E. C., Lotz, J. C., & Hsieh, A. H. (2019). Innervation of pathologic vertebral endplates by sensory nerves. Spine, 44(4), E231–E238.
https://doi.org/10.1097/BRS.0000000000002827
Fischgrund, J. S., Rhyne, A., Franke, J., Sasso, R., Kitchel, S., Bae, H., … Yeung, C. (2018). Intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: A randomized, double-blind, sham-controlled trial. European Spine Journal, 27(5), 1146–1156.
https://doi.org/10.1007/s00586-018-5496-1
Jensen, T. S., Karppinen, J., Sorensen, J. S., Niinimäki, J., & Leboeuf-Yde, C. (2008). Vertebral endplate signal changes (Modic changes): A systematic literature review of prevalence and association with non-specific low back pain. European Spine Journal, 17(11), 1407–1422.
https://doi.org/10.1007/s00586-008-0770-2
Khalil, J. G., Smuck, M., Koreckij, T., Keel, J. C., Beall, D., Goodman, B., … Fischgrund, J. S. (2019). Prospective randomized controlled trial of basivertebral nerve ablation for chronic low back pain: Twelve-month results. The Spine Journal, 19(10), 1620–1632.
https://doi.org/10.1016/j.spinee.2019.05.598
Modic, M. T., Steinberg, P. M., Ross, J. S., Masaryk, T. J., & Carter, J. R. (1988). Degenerative disk disease: Assessment of changes in vertebral body marrow with MR imaging. Radiology, 166(1), 193–199.
https://doi.org/10.1148/radiology.166.1.3336678
Samartzis, D., Karppinen, J., Mok, F., Fong, D. Y. T., Luk, K. D. K., & Cheung, K. M. C. (2013). A population-based study of lumbar disc degeneration and its association with overweight and obesity. Spine, 38(5), 402–410.
https://doi.org/10.1097/BRS.0b013e31826f0c89
Wang, Y. X. J., Griffith, J. F., Deng, M., Leung, J. C. S., Kwok, A. W. L., Leung, P. C., & Ahuja, A. T. (2020). Vertebral endplate changes and their association with bone mineral density and disc degeneration. European Radiology, 30(5), 2654–2663.
https://doi.org/10.1007/s00330-019-06601-4
