A 55-year-old female presents with 18 months of chronic axial low back pain rated 5-7/10. Pain is constant with a deep, aching quality centered in the low back. It is aggravated by prolonged sitting, standing, and any sustained posture. She describes morning stiffness lasting 30-45 minutes. She has failed extensive conservative treatment including physical therapy (12 weeks), NSAIDs, duloxetine, lumbar medial branch blocks (negative - less than 50% relief), and SI joint injections (negative). She is not a surgical candidate per spine surgery evaluation.

Midline lumbar tenderness over the L4-5 spinous processes. Pain with axial loading. No radicular findings. Negative facet loading maneuvers. Negative SI joint provocation tests. Full strength and intact reflexes.

MRI lumbar spine shows Modic Type 1 changes (bone marrow edema pattern) at L4-5 endplates bilaterally. L4-5 disc shows moderate desiccation and loss of height. No significant disc herniation or stenosis. Facet joints are mildly arthritic without significant pathology.