Abstract
Background
Patients with psychiatric conditions experience higher rates of chronic low back pain (LBP) compared to the general population and frequently face worse outcomes, including delayed diagnosis, higher rates of opioid dependence, and suboptimal pain management. Despite the high burden of chronic LBP on patients with psychiatric illnesses, the effectiveness of interventional pain management procedures in this population remains understudied.
Objective
This study sought to evaluate early pain reduction and functional outcomes following BVN ablation in patients with psychiatric conditions.
Methods
A retrospective chart review was conducted on patients who underwent BVN ablation at our institution from November 2019 to January 2025. For patient group designation and comparison, we identified Patients with Psychiatric Conditions (PCC, N = 52) and Patients without Psychiatric Conditions (Non-PPC, N = 82). Psychiatric diagnoses included anxiety disorders, major depressive disorder, bipolar disorder, Tourette's syndrome, and substance use disorders. Pain severity was assessed using the Visual Analog Scale (VAS) at baseline and at the 4–6-week post-procedure follow-up visit, and functional improvement was determined based on documented patient-reported outcomes at the same time point.
Results
A statistically significant decrease in VAS was observed in the PPC cohort (7.4 vs. 3.71, p = 0.006) and the Non-PPC cohort (6.82 vs. 3.82, p = 0.017). When comparing the PPC cohort to the Non-PPC cohort, no statistically significant difference was observed in the percentage of patients reporting improvement in functional status after the procedure (80.8% vs. 78.0%, p = 0.706).
Conclusions
At 4–6-weeks post procedure, patients with psychiatric conditions experienced significant pain relief and improvement in functional status comparable to patients without psychiatric conditions. These findings suggest that having a documented psychiatric condition does not significantly alter early pain relief or functional improvement outcomes after BVN ablation.
Keywords: Basivertebral nerve ablation, Chronic low back pain, Psychiatric conditions, Depression, Anxiety, Mental health
1. Introduction
Low back pain (LBP) is a leading cause of prolonged disability and morbidity, as well as substantial healthcare and societal costs. LBP is defined as discomfort, muscle tightness, or stiffness in regions between the lower ribs and the gluteal folds, in some cases radiating to the legs. [1]. The lifetime prevalence of LBP is estimated to range from 49% to 90%, and approximately 25% of patients who seek care for LBP experience a recurrence within one year [2]. Overall, chronic LBP affects 13% of the US adult population, and approximately one-third of these individuals report moderate to severe symptoms [3].
Chronic LBP can be caused by damage to vertebral endplates, which express nociceptors innervated by the basivertebral nerve. These endplate changes are visible on MRI as alterations in vertebral endplate and bone marrow signal intensity, known as Modic changes. Endplate damage leads to transmission of pain signals to the central nervous system, causing a syndrome known as vertebrogenic LBP [[4], [5], [6]]. Therefore, radiofrequency ablation of the basivertebral nerves has emerged as a minimally invasive therapeutic option for patients with chronic vertebrogenic LBP, indicated for those with Modic Type 1 or 2 changes on MRI who have failed conservative management [7]. Several studies, including the SMART trial and the INTRACEPT trial, have demonstrated significant pain reduction and improved functional status within three months of BVN ablation, with sustained improvements at 12-month follow-up [[8], [9], [10], [11], [12]].
Psychiatric conditions are common among patients with chronic LBP and can negatively impact outcomes following interventional procedures for chronic pain. For instance, one study demonstrated that depression significantly shortened the duration of treatment success after lumbar facet radiofrequency denervation [13]. Similarly, the presence of psychiatric conditions has been associated with lower postoperative compliance rates, reoperation, and readmission rates following spinal cord stimulator replacement [14]. Preoperative depression has also been associated with more severe symptoms and worse functional outcomes in patients undergoing elective surgery for lumbar spinal stenosis [15]. Preoperative depression was also associated with prolonged time to return to work in patients undergoing transforaminal lumbar interbody fusion for lumbar spondylolisthesis [16]. A recent meta-analysis of 44 studies found that patients with depression had worse disease severity before and after lumbar spine surgery, although the magnitude of postoperative improvement in pain, disability, and physical function was similar to patients without depression [17].
In clinical practice, many insurers require documentation of a patient's psychological history and an assessment of the patient's ability to tolerate and benefit from interventional procedures such as spinal cord stimulators, and more recently, basivertebral nerve ablation [18,19]. Although these requirements are designed to guide patient selection, they may create additional administrative steps, thus creating potential delays to effective pain management. Despite the literature demonstrating that psychiatric conditions are associated with higher symptom burden and may affect functional outcomes after interventional spine procedures, no studies have examined the impact of psychiatric conditions on outcomes after BVN ablation. Given the high prevalence of psychiatric conditions among patients with chronic LBP and their known influence on pain perception and recovery, this presents a critical gap in the literature [3,20]. This study aims to evaluate the outcomes of BVN ablation in patients with psychiatric conditions, further improving our understanding of how mental health factors impact treatment effectiveness.
2. Methods
2.1. Ethics statement
This retrospective chart review study was approved by the Stony Brook University Hospital Committee on Research in Human Subjects via a waiver of consent (IRB2025-00033).
2.2. Subject selection and patient group designation
Adult patients (age ≥18) who underwent BVN ablation at our institution from November 2019 to January 2025 were included in this retrospective chart review study. Patient demographics, baseline clinical characteristics, and outcome data were extracted from the electronic medical record (EMR). For patient group designation and comparison, we identified Patients with Psychiatric Conditions (PPC) and Patients without Psychiatric Conditions (Non-PPC). Patients with Psychiatric Conditions were defined as those with at least one psychiatric diagnosis documented in the EMR; these diagnoses included, but were not limited to, anxiety disorders, mood disorders, trauma-related disorders, and substance use disorders.
2.3. Clinical and procedural data collection
Demographics, baseline clinical characteristics, and intra-procedure data for all included patients were extracted from the EMR. Baseline opioid use was determined through EMR review and defined as an active opioid prescription documented at the time of the BVN ablation procedure. Intra-procedure data included the number of vertebral levels treated, the type of anesthesia used, and ablation parameters. Pain severity was assessed using the Visual Analog Scale (VAS) at baseline and again at the 4–6-week post-procedure follow-up visit, and functional improvement was determined based on documented patient-reported outcomes at the same time point. During this follow-up visit, patients were typically asked about their ability to perform daily activities, including walking, standing, sitting, bending, and returning to work or hobbies. Functional improvement was defined as any clinical documentation of increased activity levels, enhanced mobility, return to work, or general improvement in performing activities of daily living as recorded in the clinical notes at the 4–6-week follow-up visit. The 4–6-week follow-up visit was selected as it aligns with standard follow-up practices and assessment of early clinical improvement at our institution, allowing for standardization of outcome data collection for all patients in the study. Post-procedure complications, including vertebral compression fractures, were monitored until the most recent available follow-up. Patients were monitored for vertebral compression fractures based on clinical evaluation at follow-up appointments; routine post-procedure imaging was not performed. The length of follow-up was recorded for each patient. Primary outcome measures included the change in VAS and patient-reported functional status.
2.4. Statistical analysis
All statistical analyses were performed using IBM SPSS Statistics 26™ (IBM Corp.). Two-sided P values ≤ 0.05 were considered statistically significant. We utilized chi-square tests and Fisher's exact tests for categorical variables and independent samples t-tests or Mann-Whitney tests for continuous variables.
3. Results
3.1. Baseline demographics and clinical characteristics
Baseline demographics and clinical characteristics are presented in Table 1. A total of 134 patients were included, of whom 52 (38.8%) had a documented psychiatric condition. Outcome data were available for all 134 patients at the 4–6-week follow-up visit. The mean age was 69.80 ± 11.43 years for the overall cohort; there was no significant difference in mean age between PPC and Non-PPC patients. Overall, 46.3% of patients were female, with a significantly higher proportion of females in the PPC cohort compared to the Non-PPC cohort (59.6% vs. 37.8%, p = 0.014). Opioid use at baseline was more common in PPC compared to the Non-PPC cohort (15.4% vs. 3.7%, p = 0.016). There was no significant difference in baseline VAS when comparing PPC to patients in the Non-PPC cohort. There were no significant differences in smoking history, insurance status, mean BMI, and race or ethnicity distribution when comparing PPC and Non-PPC cohorts.
Table 1.
Baseline demographics and clinical characteristics.
| All Patients (N = 134) | PPC (N = 52) | Non-PPC (N = 82) | p | |
|---|---|---|---|---|
| Age (Years), Mean ± SD (Range) | 69.80 ± 11.43 (36-90) | 68.10 ± 10.85 (36-89) | 70.88 ± 11.71 (37-90) | 0.838 |
| Sex | ||||
| Male | 72 (53.7%) | 21 (40.4%) | 51 (62.2%) | 0.014 |
| Female | 62 (46.3%) | 31 (59.6%) | 31 (37.8%) | 0.014 |
| BMI (Mean ± SD) | 28.93 ± 5.20 | 28.55 ± 4.65 | 29.17 ± 5.53 | 0.147 |
| Obese | 48 (35.8%) | 17 (32.7%) | 31 (37.8%) | 0.548 |
| Smoking History | 75 (56.0%) | 26 (50.0%) | 49 (59.8%) | 0.268 |
| Diabetes History | 19 (14.2%) | 9 (17.3%) | 10 (12.2%) | 0.408 |
| Bone Density Status | ||||
| Normal Bone Density | 5 (3.7%) | 3 (5.8%) | 2 (2.4%) | |
| Osteopenia | 23 (17.2%) | 10 (19.2%) | 13 (15.9%) | |
| Osteoporosis | 9 (6.7%) | 5 (9.6%) | 4 (4.9%) | |
| Not Assessed | 97 (72.4%) | 34 (65.4%) | 63 (76.8%) | |
| Overall p-value | 0.424 | |||
| Race | ||||
| Black or African American | 2 (1.5%) | 0 (0.0%) | 2 (2.4%) | |
| Unknown/Prefer Not to Say | 1 (0.7%) | 0 (0.0%) | 1 (1.2%) | |
| White | 131 (97.8%) | 52 (100.0%) | 79 (96.3%) | |
| Overall p-value | 0.378 | |||
| Ethnicity | ||||
| Hispanic or Latino | 1 (0.7%) | 0 (0.0%) | 1 (1.2%) | |
| NOT Hispanic or Latino | 128 (95.5%) | 51 (98.1%) | 77 (93.9%) | |
| Unknown/Prefer Not to Say | 5 (3.7%) | 1 (1.9%) | 4 (4.9%) | |
| Overall p-value | 0.488 | |||
| Insurance Status | ||||
| Private Insurance | 19 (14.2%) | 11 (21.2%) | 8 (9.8%) | |
| Medicare | 103 (76.9%) | 36 (69.2%) | 67 (81.7%) | |
| Medicaid | 2 (1.5%) | 1 (1.9%) | 1 (1.2%) | |
| Veterans Affairs (VA) | 1 (0.7%) | 1 (1.9%) | 0 (0.0%) | |
| Worker's Comp | 5 (3.7%) | 2 (2.8%) | 3 (3.7%) | |
| No Fault/MVA | 4 (3.0%) | 1 (1.9%) | 3 (3.7%) | |
| Overall p-value | 0.351 | |||
| Baseline Visual Analog Scale (Mean ± SD) | 7.04 ± 2.18 | 7.40 ± 2.01 | 6.82 ± 2.26 | 0.129 |
| Opioid Use at Baseline | 11 (8.2%) | 8 (15.4%) | 3 (3.7%) | 0.016 |
| Duration of Low Back Pain in Years (Mean ± SD) | 8.31 ± 18.08 | 5.97 ± 5.48 | 9.79 ± 22.63 | 0.113 |
3.2. Distribution of psychiatric conditions
The distribution of psychiatric conditions in the PPC cohort is presented in Table 2. Among the 52 patients in the PPC cohort, anxiety was reported in 43 patients (82.7%), depression in 24 (46.2%), substance use disorder in 6 (11.5%), bipolar disorder in 3 (5.8%), and obsessive–compulsive disorder in 3 (5.8%). Adjustment disorder, Tourette's syndrome, and post-traumatic stress disorder were each reported in one patient (1.9%).
Table 2.
Psychiatric conditions.
| Psychiatric Condition | n (%) of PPC |
|---|---|
| Depression | 24 (46.2%) |
| Anxiety | 43 (82.7%) |
| Bipolar Disorder | 3 (5.8%) |
| OCD | 3 (5.8%) |
| Substance Use Disorder | 6 (11.5%) |
| Adjustment Disorder | 1 (1.9%) |
| Tourette's Syndrome | 1 (1.9%) |
| PTSD | 1 (1.9%) |
3.3. Intraoperative data
All patients underwent BVN ablation with ablation parameters of 85 °C for 15 min. The median number of vertebral levels treated for the overall cohort was 3.5, with no significant difference between the PPC cohort and the Non-PPC cohort. Most procedures (98.5%) were performed under general anesthesia, with one patient each in the PPC cohort and Non-PPC cohort receiving monitored anesthesia care (MAC).
3.4. Patient-reported outcomes and complications
Patient-reported outcomes at 4–6 weeks post-procedure are presented in Table 3. The overall cohort demonstrated a mean decrease in VAS of 3.27 ± 2.61; there was no significant difference in the VAS decrease when comparing the PPC and Non-PPC cohorts. A statistically significant decrease in VAS was observed for PPC (7.4 vs. 3.71, p = 0.006) and the Non-PPC cohort (6.82 vs. 3.82, p = 0.017). A significantly greater proportion of patients in the PPC cohort experienced a ≥ 2-Point VAS decrease compared to the Non-PPC cohort (84.6% vs. 68.3%, p = 0.034). Functional improvement was reported by 79.1% of patients in the overall cohort; there was no significant difference when comparing the rates of functional improvement reported by the PPC and Non-PPC cohorts (80.8% vs. 78.0%, p = 0.706). Post-procedure opioid use remained unchanged from baseline and was higher in PPC than in the Non-PPC cohort (15.4% vs. 3.7%, p = 0.016).
Table 3.
Patient-reported outcomes at 4–6 Weeks post-procedure.
| All Patients (N = 134) | PPC (N = 52) | Non-PPC (N = 82) | p | |
|---|---|---|---|---|
| Follow-up Visual Analog Scale (Mean ± SD) | 3.78 ± 2.23 | 3.71 ± 2.29 | 3.82 ± 2.21 | 0.913 |
| Decrease in VAS (Mean ± SD) | 3.27 ± 2.61 | 3.69 ± 2.41 | 3.00 ± 2.71 | 0.163 |
| % Decrease in VAS (Mean ± SD) | 41.56 ± 56.21 | 50.11 ± 29.66 | 36.14 ± 67.51 | 0.200 |
| ≥50% Decrease in VAS | 68 (50.7%) | 29 (55.8%) | 39 (47.6%) | 0.354 |
| Patients with ≥ 2-Point VAS Decrease | 100 (74.6%) | 44 (84.6%) | 56 (68.3%) | 0.034 |
| Reported Improvement in Functional Status | 106 (79.1%) | 42 (80.8%) | 64 (78.0%) | 0.706 |
| Self-Reported % Pain Reduction (Mean ± SD) | 57.28% ± 30.12 | 63.73% ± 27.60 | 53.60% ± 31.11 | 0.463 |
| Post-Procedure Opioid Use | 11 (8.2%) | 8 (15.4%) | 3 (3.7%) | 0.016 |
Post-procedure complications were monitored until the most recent available follow-up visit, and duration of follow-up was documented for each patient. No post-procedure vertebral compression fractures were observed in the entire cohort, with a mean follow-up length of 18.07 ± 11.71 months. There was no significant difference when comparing the mean length of follow-up in months for the PPC and Non-PPC cohorts. Four complications were reported by patients in the Non-PPC cohort, including left foot drop, transient lower extremity muscle spasms, paraspinal muscle spasms, and left foot paresthesia, all of which resolved by the end of follow-up. No complications were reported by patients in the PPC cohort.
4. Discussion
This study evaluated the safety and effectiveness of BVN ablation in a cohort of 134 patients, including 52 patients with documented psychiatric conditions. We performed a retrospective EMR review of all adult patients who underwent BVN ablation at our institution from November 2019 to January 2025. Demographic data, baseline clinical characteristics, intraoperative data, outcomes, and complications were analyzed for the full cohort and for a subset of patients with psychiatric conditions, which included patients with depression, anxiety, PTSD, OCD, bipolar disorder, substance use disorder, adjustment disorder, and Tourette's syndrome.
In our cohort, 38.8% of patients had a documented psychiatric condition, a rate considerably higher than that observed in the general U.S. adult population, where the estimated prevalence of major depressive disorder and anxiety disorders is approximately 17% and 21%, respectively [21]. The psychiatric burden observed in our cohort is similar to that of adults with chronic pain, where clinical depression and anxiety affect 39.3% and 40.2% of individuals, respectively [22]. These findings highlight the significant psychiatric burden in this population and reaffirm the well-established association between psychiatric disorders and chronic pain. The PCC cohort was predominantly female (59.6%), consistent with population-level data indicating that women are approximately 1.7 times more likely than men to experience anxiety and are disproportionately affected by depressive disorders [23].
Although baseline opioid use was more common among PPC, opioid use remained unchanged following BVN ablation in both cohorts. The lack of change in opioid use following the procedure may be explained by the comparatively low baseline prevalence in our cohort (8.6%) compared to prior studies like the SMART trial, in which approximately 30% of patients reported opioid use [10]. Given the low opioid use in our overall cohort and the lack of post-procedural change, opioid use is unlikely to have confounded pain and functional outcomes.
The VAS decreases observed in the PPC and Non-PPC cohorts are comparable to outcomes reported in prior studies of BVN ablation. The INTRACEPT trial reported a mean VAS decrease of 3.46 at 3 months post-procedure, and the SMART trial reported a mean VAS decrease of 2.97 at 3 months post-procedure [8,12]. These findings suggest that patients with psychiatric conditions experience pain and functional improvements comparable to those without psychiatric conditions, and that both groups achieved outcomes consistent with prior BVN ablation studies.
A significantly greater proportion of patients in the PPC cohort experienced a ≥ 2-Point VAS decrease compared to the Non-PPC cohort). While this was the only outcome measure to reach statistical significance, it suggests the BVN ablation can provide comparable — and potentially even greater — pain relief in patients with psychiatric conditions, a patient population often considered at higher risk for poor clinical outcomes. However, given the limited number of statistically significant differences and the potential for type I error, this finding should be interpreted cautiously and warrants confirmation in larger, prospective studies.
Importantly, no vertebral compression fractures or persistent complications were observed in our cohort, underscoring the overall safety of BVN ablation in a real-world patient population. These findings align with our prior work, which demonstrated an absence of post-procedure vertebral compression fractures among patients with reduced bone density undergoing BVN ablation, further supporting the procedure's safety across a broad spectrum of patients [24].
While existing Medicare LCDs do not mandate a particular psychological evaluation prior to BVN ablation, they do require an assessment of the patient's ability to tolerate and benefit from the procedure [18,19]. These requirements are designed to guide patient selection, especially given prior studies demonstrating poorer outcomes for patients with psychiatric conditions after interventional spine procedures [[13], [14], [15], [16]]. Our findings, however, demonstrate that patients with psychiatric conditions achieved comparable early pain relief to patients without psychiatric conditions. These findings may help inform clinician judgment and patient selection, as the presence of a psychiatric condition alone does not appear to significantly alter early pain and functional outcomes after BVN ablation.
5. Limitations
Our cohort of 134 patients represents a comparatively large sample size relative to previous studies on BVN ablation, but certain limitations remain. As a retrospective analysis, our results are inherently constrained by the observational nature of the study design. Objective measures of functional status and overall well-being, such as the Oswestry Disability Index and Short Form Health Survey, were not routinely collected by office staff at our institution, limiting direct comparison to prior studies that employed these metrics. Consequently, functional improvement was assessed via subjective patient reports obtained at follow-up visits. Detailed information regarding psychiatric treatments, including psychotherapy and pharmacotherapy, was inconsistently recorded in the EMR, limiting our ability to assess the potential impact of specific treatments. Additionally, the prevalence of psychiatric conditions in our cohort may have been under- or overestimated due to overlapping diagnoses on chart review rather than standardized psychiatric evaluations or screening tools. Future prospective studies incorporating standardized outcome and screening measures can further characterize both functional recovery and the influence of psychiatric conditions on BVN ablation outcomes.
6. Conclusions
In this retrospective cohort study, BVN ablation demonstrated significant early pain reduction and functional improvement in the overall patient population and in patients with psychiatric conditions. Despite prior evidence demonstrating higher baseline symptom burden and poorer outcomes in this subgroup after interventional spine procedures, our PPC cohort achieved comparable pain relief to those without psychiatric conditions at 4–6 weeks post-procedure. These findings suggest that the presence of psychiatric conditions may not adversely impact early clinical response to BVN ablation, although studies with longer follow-up may help clarify treatment durability and long-term outcomes. Conducted independently and without industry support, this study adds real-world evidence supporting the effectiveness of BVN ablation in a diverse patient population, including those with psychiatric conditions.
CRediT authorship contribution statement
Emily Bellow: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Visualization, Writing - Original Draft, Writing - Review & Editing. Jennifer Bae: Formal Analysis, Investigation, Methodology, Visualization, Writing - Original Draft, Writing - Review & Editing. Jeffrey Zhang: Formal Analysis, Investigation, Methodology, Visualization, Writing - Original Draft, Writing - Review & Editing. Sandi Bajrami: Formal Analysis, Investigation, Methodology, Visualization, Writing - Original Draft, Writing - Review & Editing. Derek Johnson: Data Curation, Formal Analysis, Investigation, Methodology, Visualization, Writing - Original Draft, Writing - Review & Editing. William Caldwell: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Resources, Software, Supervision, Validation, Visualization, Writing - Original Draft, Writing - Review & Editing.
Funding statement
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Declaration of competing interest
William Caldwell reports a relationship with Boston Scientific Corporation that includes consulting or advisory, speaking and lecture fees, and travel reimbursement.
Acknowledgements
We would like to thank the Stony Brook Center for Pain Management and the Department of Anesthesiology for their role in patient care and their support of our research.
Footnotes
Presentations: This work was presented as an E-Poster at the American Society of Anesthesiologists Annual Meeting on October 11, 2025.
Data availability
Investigators can contact the corresponding author to request access to de-identified clinical data in this study.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Investigators can contact the corresponding author to request access to de-identified clinical data in this study.