Extrapedicular approach for basivertebral nerve radiofrequency ablation: a conceptual review

BACKGROUND: Chronic axial low back pain (LBP) of vertebrogenic origin is increasingly recognized as a distinct clinical entity responsive to basivertebral nerve (BVN) radiofrequency ablation (RFA). This analysis synthesizes the anatomical, biomechanical, and safety considerations of both access routes and evaluates their clinical implications. METHODS: A literature review was conducted in PubMed for articles on BVNRFA anatomy, techniques, and access routes published through December 1, 2025. Given the limited literature on extrapedicular BVNRFA, studies from the vertebral augmentation literature were included if appropriate for access route considerations. RESULTS: The standard technique for BVNRFA utilizes a transpedicular trajectory to access the vertebral body, which provides a consistent trajectory using the pedicle but places the introducer in proximity to the facet joints, dorsal root ganglion, exiting spinal nerve, and paraspinal muscles. Emerging evidence has described the extrapedicular approach, which follows a lateral pathway, may be considered for select patients with anatomical challenges, such as narrow pedicles or preexisting pedicle instrumentation. CONCLUSION: Currently, there is no clinical evidence to suggest the superiority of the extrapedicular approach over the traditional transpedicular approach. Each has its own anatomical considerations, technical challenges, and risks to consider, which require imaging guidance and careful adherence to anatomical landmarks. Further biomechanical, cadaveric, animal model, and clinical studies are warranted to assess the relative efficacy, safety, and long-term implications of each approach.