Methods of detecting and treating back pain
Described herein are various implementations of systems and methods for accessing and modulating tissue (for example, systems and methods for accessing and ablating nerves or other tissue within or surrounding a vertebral body to treat chronic lower back pain). Assessment of vertebral endplate degeneration or defects (e.g., pre-Modic changes) to facilitate identification of treatment sites and protocols are also provided in several embodiments. Several embodiments comprise the use of biomarkers to confirm or otherwise assess ablation, pain relief, efficacy of treatment, etc. Some embodiments include robotic elements for, as an example, facilitating robotically controlled access, navigation, imaging, and/or treatment.
1. A method of detecting and treating back pain of a subject, the method comprising:
identifying a candidate vertebral body for treatment based on a determination that the vertebral body exhibits one or more symptoms or defects associated with vertebral endplate degeneration,
wherein the one or more symptoms or defects associated with vertebral endplate degeneration comprise pre-Modic change characteristics, wherein the one or more symptoms or defects are selected from the group consisting of edema, inflammation, damage, tissue changes, and bone marrow lesions within the vertebral body or along a portion of a vertebral endplate of the vertebral body, and wherein the pre-Modic change characteristics comprise characteristics prior to a formal characterization or diagnosis as a Modic change; and
ablating a basivertebral nerve within the identified candidate vertebral body by applying a thermal treatment dose to a location within the vertebral body of at least 240 cumulative equivalent minutes (“CEM”) using a CEM at 43 degrees Celsius model.
2. The method of claim 1 ,
wherein the determination is based on images of the candidate vertebral body,
wherein the images comprise magnetic resonance imaging images; and
wherein applying the thermal treatment dose comprises delivery of radiofrequency energy using a radiofrequency energy delivery device including a bipolar pair of electrodes, and
wherein the radiofrequency energy is continuous and/or pulsed.
3. The method of claim 2 , wherein the determination involves application of one or more filters to the MRI images.
4. The method of claim 1 , wherein the determination is based on obtaining biomarkers from the subject.
5. The method of claim 4 , wherein the biomarkers are obtained from one or more blood serum samples.
6. The method of claim 4 , wherein the biomarkers are obtained over an extended period of time or at a single instance in time.
7. The method of claim 4 , wherein the biomarkers include one or more of: substance P, cytokines, and other compounds associated with inflammatory processes and/or pain.
8. The method of claim 1 , wherein identifying a candidate vertebral body for treatment based on a determination that the vertebral body exhibits one or more symptoms or defects associated with vertebral endplate degeneration comprises determining a quantitative or qualitative endplate score based on severity, extent, and/or quantity of the pre-Modic change characteristics.
9. The method of claim 1 , wherein the pre-Modic change characteristics comprise one or more of mechanical characteristics, bacterial characteristics, and pathogenetic mechanisms.
10. The method of claim 1 , wherein the pre-Modic change characteristics comprise one or more of focal defects, erosive defects, rim defects, and corner defects of the vertebral endplate of the vertebral body.
11. The method of claim 1 ,
wherein the thermal treatment dose is configured to achieve a target temperature of between 70 degrees Celsius and 90 degrees Celsius;
wherein the thermal treatment dose is delivered with a temperature ramp of between 0.1 and 5 degrees per second,
wherein the thermal treatment dose is configured to form a targeted lesion zone having an elliptical shape, a football shape, a disc shape, or a dumbbell shape,
wherein the method is performed without the use of any cooling fluid,
wherein applying the thermal treatment dose comprises delivery of one or more of radiofrequency energy, ultrasound energy, microwave energy, and laser energy,
wherein the location within the vertebral body is in a posterior half of the vertebral body or a geometric center of the vertebral body, and/or
wherein the location is at least 5 mm from a posterior border of the vertebral body.
12. The method of claim 1 ,
wherein the thermal treatment dose is configured to form a targeted lesion zone having a maximum cross-sectional dimension of less than 15 mm,
wherein the thermal treatment dose is configured to form a targeted lesion zone having a length to width ratio of at least 2:1,
wherein the thermal treatment dose is configured to form a targeted lesion zone having a maximum width of 20 mm and a maximum length of 30 mm, or
wherein the thermal treatment dose is configured to form a targeted lesion zone having a major axis length to minor axis length ratio between 1.5:1 and 3:1.
13. The method of claim 1 , further comprising:
advancing at least a distal end portion of a bipolar radiofrequency energy delivery probe comprising two electrodes to the location;
forming a passageway through a pedicle and into the vertebral body;
then advancing at least the distal end portion of the bipolar radiofrequency energy delivery probe along the passageway to the location; and
applying the thermal treatment dose to the location using the bipolar radiofrequency energy delivery probe.
14. A method of detecting and treating back pain of a subject, the method comprising:
obtaining images of a vertebral body of the subject;
analyzing the images to determine whether the vertebral body exhibits one or more symptoms associated with a pre-Modic change,
wherein the one or more symptoms comprise initial indications or precursors of edema or inflammation at a vertebral endplate prior to a formal characterization or diagnosis as a Modic change; and
ablating a basivertebral nerve within the vertebral body if it is determined that the vertebral body exhibits the one or more symptoms associated with a pre-Modic change.
15. The method of claim 14 ,
wherein ablating the basivertebral nerve within the vertebral body comprises advancing at least a distal end portion of a bipolar radiofrequency energy delivery probe comprising two electrodes to a target treatment location within the vertebral body and applying radiofrequency energy to the location to generate a thermal treatment dose sufficient to ablate the basivertebral nerve,
wherein the radiofrequency energy has a frequency between 400 kHz and 600 kHz,
wherein the thermal treatment dose is configured to achieve a target temperature of between 70 degrees Celsius and 90 degrees Celsius at the location, and
wherein the thermal treatment dose is delivered with a temperature ramp of between 0.1 and 5 degrees Celsius per second.
16. The method of claim 15 ,
wherein the radiofrequency energy is applied for an active energy delivery time of between 10 minutes and 20 minutes,
wherein the radiofrequency energy is continuous and/or pulsed,
wherein the temperature ramp is between 0.5 and 3 degrees Celsius per second, and
wherein the thermal treatment dose forms a targeted lesion zone having a major diameter along a long axis of between 20 mm and 30 mm and a minor diameter along a short axis of between 5 mm and 15 mm.
17. The method of claim 14 , wherein:
ablating the basivertebral nerve within the vertebral body comprises applying a thermal treatment dose to a location within the vertebral body of at least 240 cumulative equivalent minutes (“CEM”) using a CEM at 43 degrees Celsius model, and
the thermal treatment dose forms a targeted lesion zone at the location having a maximum cross-sectional dimension of less than 15 mm.
18. The method of claim 17 , wherein applying the thermal treatment dose comprises delivery of one of radiofrequency energy, ultrasound energy, microwave energy, or laser energy.
19. The method of claim 14 , wherein the images are obtained using an MRI imaging modality or a CT imaging modality.
20. The method of claim 14 , wherein ablating the basivertebral nerve comprises:
generating a targeted ablation zone having a maximum cross-sectional dimension of less than 15 mm;
generating a targeted ablation zone having a major diameter along a long axis of between 20 mm and 30 mm and a minor diameter along a short axis of between 5 mm and 15 mm,
generating a targeted ablation zone having a length to width ratio of at least 2:1,
generating a targeted ablation zone having a maximum width of 20 mm and a maximum length of 30 mm, or
generating a targeted ablation zone having a major axis length to minor axis length ratio between 1.5:1 and 3:1.