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When “How Many Levels?” Is the Wrong Question
A recent discussion in a physician group posed what seemed, on the surface, like a technical question: If money were no option, how many spinal levels would you radiofrequency ablate in one day for a patient with extensive spondylosis and facetogenic pain throughout the spine? Would the limiting fac
When “How Many Levels?” Is the Wrong Question
Nikhil Verma M.D.
Board Certified Physiatrist | Interventional Spine & Regenerative Medicine | MSK Specialist | Physician Advocate | Healthcare Educator | Host – “Things I Didn’t Learn in Med School”
January 14, 2026
A recent discussion in a physician group posed what seemed, on the surface, like a technical question: If money were no option, how many spinal levels would you radiofrequency ablate in one day for a patient with extensive spondylosis and facetogenic pain throughout the spine? Would the limiting factor be local anesthetic dosing, post-operative concerns, or simply patient discomfort?
Most responses landed in a similar place. A few levels at a time. Space treatments out. Be mindful of tissue destruction. Be cautious about multifidus dysfunction. Implicitly, many acknowledged that ablating the entire spine is not a great option, even if technically possible.
And yet, the framing of the question itself reveals a deeper issue in how we approach complex, degenerative spinal pain.
Radiofrequency ablation is not a benign intervention. I learned this in residency in 2016. We are intentionally destroying tissue. Repeated denervation of facet joints alters spinal biomechanics, impairs segmental stability, and contributes to multifidus atrophy and dysfunction. Over time, we may reduce pain signals, but we often do so at the cost of resilience, proprioception, and likely, long-term spinal health. Even when spaced out and carefully selected, serial RFAs across multiple regions of the spine should give us pause.
In the same discussion, many clinicians pivoted toward peripheral nerve stimulation. That conversation followed a familiar pattern. There is currently one system with FDA approval for motor stimulation, while many others are being used off-label for sensory or mixed applications. The logic is understandable. I actually love motor stim for multifidi malfunction. I talked about here:
If burning nerves is problematic, perhaps stimulating them is more elegant.
But this still leads us down the same procedural path. Instead of destroying everything, we stimulate everything. Instead of ablation, we implant devices. We trade one intervention-heavy solution for another, often without stepping back to ask a more fundamental question.
Why are we not approaching these patients differently from the start?
Patients with diffuse spondylosis and widespread facetogenic pain are not failing because they lack enough procedures. They are often living in a state of chronic inflammation, deconditioning, immuno-cardio-metabolic dysfunction, poor recovery, and altered movement patterns that have accumulated over decades. Treating every painful spinal level as an isolated electrical problem misses the broader biological and mechanical context.
A more thoughtful approach begins with fundamentals that are too often sidelined. Nutrition matters. An anti-inflammatory diet and attention to gut health can meaningfully alter systemic inflammation and pain sensitivity. Sleep quality, alcohol intake, and stress physiology directly influence nociception and tissue healing, yet are rarely addressed with the same seriousness as a procedure.
Movement matters just as much. Progressive resistance training, cardiovascular conditioning, and, for some patients, aquatic therapy can restore load tolerance and confidence in movement. High-quality physical therapy that emphasizes motor control, spinal stability, and graded exposure is not interchangeable with passive modalities or generic exercise handouts. Manual therapies, when used appropriately, can help restore motion and reduce guarding, particularly when paired with active rehabilitation. There is so much more, that I made a multipart series, which I will continue to add to, about how to better address these pains in patients on my Substack- Essentials of Healing | Nikhil Verma, MD | Substack.
There is also a role for biologic and regenerative strategies when applied thoughtfully. MLS laser therapy, platelet-rich plasma, and prolotherapy may help modulate inflammation, support connective tissue health, and improve function in select patients. These are not miracle cures, and they should not be oversold, but they represent an attempt to support tissue health rather than simply silence nerves. In some cases, orthobiologic approaches may allow patients to reduce their reliance on repeated RFAs or implanted devices.
None of this is to say that interventional procedures have no role. They absolutely do. RFAs, nerve blocks, and even neuromodulation can be powerful tools. I would never say they don't work either. We should make sure we are doing them for the right patient, at the right time. The problem arises when they become the default strategy rather than one component of a broader plan.
When the primary options presented to patients are “burn everything” or “stim everything,” we have narrowed the conversation too much. We owe it to our patients to slow down and ask what else can be done to improve their capacity, reduce systemic inflammation, and restore function. That requires time, education, and a willingness to step outside a purely procedural identity.
The real challenge is not determining how many spinal levels can be treated in a single day. The real challenge is redefining success in chronic spine care and being willing to have deeper, more honest conversations with patients about healing, adaptation, and long-term outcomes.
