The Role of Vertebral Endplates

in Chronic Low Back Pain


Vertebral Endplate Pain

Historically, intervertebral discs have been the presumed source of most chronic low back pain. However, treatments focused on the disc have not produced the desired success rates and did not correlate with disc degeneration on MR imaging or on discography results. Recent research has concluded that vertebral body endplates are a significant source of chronic low back pain.


The Role of the Basivertebral Nerve

Intraosseous nerves within the vertebral body were described in 1998 by Antonacci et al.1. The existence and distribution of these intraosseous nerves within the vertebral body were subsequently further detailed by Fras et al.2 in 2003 and Bailey et al.3 in 2011, who also described the source of the intraosseous nerves as the basivertebral nerve (BVN). The BVN enters the posterior vertebral body via the basivertebral foramen (Figure 1) and arborizes near the center of the vertebral body, sending branches to innervate the superior and inferior endplates. These nerve endings have been shown to proliferate in damaged and degenerated endplates4 and are more innervated than the intervertebral discs5.

In 2003, Fras et al.2 reported on the presence of Substance P within the BVN, concluding that these nerves have the potential for transmitting pain signals. Subsequently in 2011, Bailey et al.3 showed that the basivertebral nerves are PGP 9.5-positive, establishing their role in pain transmission.

Modic Changes and Chronic Low Back Pain

Modic changes and associated endplate damage strongly correlate with chronic low back pain, as reported by the following:

  • Modic et al.6 described intraosseous MR imaging observed changes adjacent to the vertebral endplates in patients with CLBP. He described these changes as a “Type 1” or “Type 2” based on their appearance on MR imaging.
  • Carragee et al.7 determined that vertebral body and endplate MRI signal changes, indicative of intraosseous edema or inflammation, were well correlated with clinical low back pain.
  • Weishaupt et al.8 reported 100% specificity to pain in patients with Modic Type 1 and Type 2 changes.
  • Kuisma et al.9 found a 2.28 odds ratio for the presence of Modic changes at L5-S1 in patients with CLBP.
  • Mok et al.10 noted that Modic changes were associated with the presence and severity of low back pain.

Collectively, these findings validate vertebral endplates as a significant source of chronic low back pain in patients with Type 1 or Type 2 modic changes, also referred to as vertebrogenic pain, and this pain is transmitted via the basivertebral nerve.

1 Antonacci MD, Mody DR, Heggeness MH. Innervation of the human vertebral body: a histologic study. Journal of Spinal Disorders 1998; 11(6):526-31.

2 Fras C, Kravetz P, Mody DR, Heggeness MH. Substance P-containing nerves within the human vertebral body: an immunohistochemical study of the basivertebral nerve. The Spine Journal: Official Journal of the North American Spine Society. 2003;3(1):63-7.

3 Bailey JF, Liebenberg E, Degmetich S, Lotz JC. Innervation patterns of PGP 9.5-positive nerve fibers within the human lumbar vertebra. Journal of Anatomy 2011;218(3):263-70.

4 Lotz JC, Fields AJ, Liebenberg EC. The Role of the Vertebral End Plate in Low Back Pain. Global Spine J 2013;03:153-64.

5 Fields AJ, Liebenberg EC, Lotz JC. Innervation of pathologies in the lumbar vertebral endplate and intervertebral disc. The Spine Journal: Official Journal of the North American Spine Society 2014;14(3):513-521.

6 Modic MT, Steinberg PM, Ross JS, Masaryk TJ, Carter JR. Degenerative disk disease: assessment of changes in vertebral body marrow with MR imaging. Radiology 1988;166:193-9.

7 Carragee EJ, Alamin TF, Miller JL, Carragee JM. Discographic, MRI and psychosocial determinants of low back pain disability and remission: a prospective study in subjects with benign persistent back pain. The Spine Journal: Official Journal of the North American Spine Society. 2005; 5(1):24-35.

8 Weishaupt D, Zanetti M, Hodler J, et al. Painful Lumbar Disk Derangement: Relevance of Endplate Abnormalities at MR Imaging. Radiology 2001; 218(2):420-7.

9 Kuisma M, Karppinen J, Niinimaki J, et al. Modic changes in endplates of lumbar vertebral bodies: prevalence and association with low back and sciatic pain among middle-aged male workers. Spine 2007; 32(10):1116-22.

10 Mok K, Samartzis D, Karppinen J, et al. Modic changes of the lumbar spine: prevalence, risk factors, and association with disc degeneration and low back pain in a large-scale population-based cohort. The Spine Journal: Official Journal of the North American Spine Society 2016;16(1):32-41.