John Hong, MD, Medical Director of Gateway Spine & Pain Physicians in Bolingbrook, Ill., offers five points on the procedure itself as well as what it means for the interventional pain management field.
1. MILD is less invasive than traditional back surgery. Spinal stenosis is traditionally treated with conservative measures — such as epidural steroid injections, medication and physical therapy — or more aggressive treatment such as spine surgery. Now, MILD provides another option other than surgery when more conservative options fail.
“It’s a revolutionary procedure because it allows treatment of spinal stenosis without more invasive, traditional back surgery,” Dr. Hong says.
The procedure generally takes one hour, is performed with only a local anesthetic using very small incisions, and patients go home that same day with just “a couple bandages on their back.” The improvement in back pain can be dramatic and immediate. Spinal stenosis tends to develop in older populations often with multiple medical issues, and for many, surgery is not an option, he says. Now, there is a viable option.
2. Patient selection is the most important thing. As with any procedure, selecting appropriate patients is critical for a good outcome, Dr. Hong says. He says this treatment is appropriate for patients with evidence of moderate to severe symptomatic spinal stenosis as a result of thickened ligamentum flavum in the mid to lower lumbar region. These are patients that have lower back and leg pain and numbness usually worse with standing. Pain is typically improved with bending forward.
“Patients with symptomatic spinal stenosis are often reluctant to consider spine surgery,” he says. “For these patients, surgery was never really an option for them. They often have many co-morbid medical risks. Because MILD is minimally invasive and can be performed with small incisions with only local anesthetics, we now have a treatment alternative.”
3. Reimbursement has been a challenge but improving. MILD has been around for a few years, but beginning July 1, 2011, CPT codes for the procedure were released. Pain physicians were able to receive reimbursement for performing MILD before the update, but they had to use unlisted codes. Even though CMS recognizes the procedure now, Dr. Hong says reimbursement may continue to be challenge.
“With any new procedure, there’s always difficulty getting reimbursed,” he says.
4. Interventional pain specialists are well-suited to perform MILD. Dr. Hong says the reason why interventional pain specialists are being targeted to perform this procedure is because they already are adept at performing X-ray guided spine procedures.
“Interventional pain specialists are already experts in performing many of the skills necessary for MILD,” he says. “The learning curve for someone who is already proficient at interventional pain techniques is accelerated.”
However, there are certain new skills and techniques that have to be learned. Dr. Hong trained at Vertos Medical’s headquarters in California in a cadaver lab.
“As interventional pain specialists, we perform fluoroscopically guided spine injections daily,” he says. “We likely do this more than most other specialists. This comfort level is necessary since the accurate and safe application of the tissue remover using a fluoroscopic techniques and an epidurogram is essential to a successful procedure.”
5. MILD represents an expansion of traditional pain management procedures. MILD represents a new idea in the field of interventional pain management, Dr. Hong says. What makes this procedure different from more conventionally performed procedures is that the pain specialist is actually surgically removing tissue from within the spine itself, he says.
“This procedure is intriguing and revolutionary because it breaks new ground for what is traditionally performed by interventional pain specialists,” he says. “The field of interventional pain management continues to evolve. Most of our procedures involve injecting medications in and around the spine, delivering heat energy to ablate nerves, and implanting spinal cord stimulators or intrathecal pumps. Intradiscal procedures have been performed to reduce disc hernations and tears with mixed results. MILD is the first procedure that percutaneously decompresses the spinal cord by means of removing excess ligamentum flavum.”
Because this procedure is expanding the realm of what interventional pain management physicians have traditionally done, spine surgeons have been monitoring early outcomes of the procedure closely. Fortunately early outcomes and research studies have been favorable.
“When a new procedure is developed that blurs the lines between interventionalists and surgeons, controversy typically arises,” Dr. Hong says.
For that reason, Dr. Hong encourages physicians performing MILD to work collaboratively with surgeon colleagues to determine the safest, most cost effective way to maximize quality of life.