A New Era for IPM: Elevating Your Practice & Your Community Through mild^®

(00:00) I’m Dr. David Dickerson. I’m an anesthesiologist and pain specialist in Chicago. I’m here with some esteemed colleagues that’ll introduce themselves. But first we’re going to click over and as we talk about the new era for interventional pain management. We’re going to talk about these specific objectives today. I think we’ll accomplish these, specifically we’re going to look at how we bridge this gap between our beloved epidural steroid injections for treating spinal stenosis and the mild^® Procedure, and really how in many practices now we’re seeing that the role of epidural steroid injections and the efficacy of those is something that we can talk about because we have something to offer when it’s not working.

(00:47) We’re going to talk about how you integrate this procedure, this treatment, into your busy practice and how it enhances and elevates the work that you’re already doing. Now, these patients are already there and we’re going to talk about how you bring the patients in from your community that aren’t already there, and how we do that with both our surgical partners and our non-surgical partners that currently have forgotten about these patients or perhaps aren’t aware that there are treatments to change the symptoms these patients have. We’re going to want to really have everyone leave here excited to be involved in this pipeline in delivering this care, this evidence-based treatment. And what do I mean, excited? I mean willing to recognize that a mild^® clinician or a mild^®-aware clinician is able to grant access to patients that needs something that’s not just about movement, mobility and relief, but also can drive things like their brain health through better socialization and more steps.

(01:47) So what we’re talking about downstream of this, while we’re talking about better walking, better relief, what that amounts to is effectively dementia risk for many patients when we look at the data around the importance of socialization and steps. So if that doesn’t get us all interested as people who, if we’re all lucky enough will be aged, we need to normalize this therapy as soon as possible. Otherwise, it’s not going to be something that’s around for us when we’re looking to keep going. So my colleagues are going to introduce themselves, and I can promise you based on the conversations leading here, this will be a very valuable part of your day. And if it’s not, come find me afterwards because I want to be held accountable for that as the moderator.

(02:32) Hello, good afternoon. My name is Zohra Hussaini. I am a nurse practitioner working in Kansas City at the University of Kansas Health System, and I’ve been there for a little over 10 years. Hi everyone. I’m Rebecca Sanders. I’m her neighbor to the south in Joplin, Missouri. I’m a hospital employee, but anesthesia, interventional pain is my background. And I’m Dr. Peter Pryzbylkowski. I’m anesthesia-boarded interventional spine based in the Philadelphia area. Did my first mild^® and fellowship in 2012.

(03:04) Excellent. A lot of experience up here, and I think that that will come through very quickly. But first we want to understand where we’re starting as a group because you’re all a part of this. We’re not here to talk at you. We really want to have some interaction during this talk. So we’re going to do some surveys and we’re going to get a sense of really where our audience is in regards to their amount of exposure to the mild^® Procedure. So if you’re not someone who performs the mild^® Procedure, answer this as if you’re someone who schedules, refers, evaluates, or is participating in identifying candidates. So on average in a month, how many patients are you recommending for the mild^® Procedure? And there’s a QR code, you’ll click that it’ll allow you to put the answer in and we’ll be able to see those right up here.

(4:00) Alright. And it looks like folks are having a couple. And if you’re a provider or a physician that performs these, how many do you do in a month? Alright, we see some heavy hitters in there. Five plus, I mean, and again, part of this is it’s a pipeline. We’re going to refer in, we’re going to select, we’re going to perform the treatment. So there’s going to be some range here, but I’m glad to see that there’s a lot of experience in the room. And so even around your table, while we want you interacting with us, by all means have a little bit of side conversation about–is what they’re saying true? Do you believe that? Is that what you see? It’s a great way to put us to the test. So let’s talk a little bit about why this matters. We’re going to set the stage from an evidence-based standpoint and talk a little bit about first, what is this treatment? Dr. Sanders.

(4:51): All right, I think that’s my cue. Hi everybody. We’re going to talk about the mild^® Procedure. I’m going to go over to some of the basic science, and this is a wonderful procedure that’s changed all of our practices and we really stand on a very solid foundation of evidence. And I’ll review that a little bit today with you guys. Oh, thank you.

(05:11) Alright, so you’re all here because you probably see neurogenic claudication in your clinics on a daily basis. These patients typically are on the older side. So if you look at this 60-year-old population and older 20% of them are actually going to have neurogenic claudication, and a lot of times they’ll present to our clinic with back pain. And when you start to talk to ’em, you’ll realize, oh, this patient has really changed how they live and it’s actually their stenosis. We might see arthritic changes in their spine for sure, but it all started with that stenosis, they’re sitting more, they’re not able to walk as much, they’re not going on trips because they’re afraid they’re going to have to walk and there might not be a bench. So very, very common problem. And the studies show that when you see stenosis on an MRI, more than 90% of those patients are going to be symptomatic.

(06:03) So if you think about our diagnostic codes, we have lumbar spinal stenosis with or without neurogenic claudication. So that means with or without symptoms, more than 90% of your patients are going to be symptomatic. And it’s kind of our job to ask them the right questions to see if indeed they are symptomatic and that’s something we can treat. If indeed they have symptoms, a lot of times they’re going to describe some numbness in their back, their buttock or their legs, and that’s going to improve when they sit down. Or a lot of times they will say bending forward like on a shopping cart that will relieve their symptoms. They’re like, oh yeah, I’m always looking for that shopping cart. The reason this procedure works so well is because ligamentum flavum hypertrophy is a huge player in spinal stenosis. A lot of times patients will have multifactorial stenosis, but in 85% of the cases of stenosis, the ligamentum flavum is a large player. That’s why this can be broadly used for a lot of patients with stenosis. So this is for patients who have neurogenic claudication and then their ligament has hypertrophied up to 2.5 millimeters or more.

(07:09) So when we do the mild^® Procedure, what we’re doing is we’re debulking the ligament, we’re removing the attachments of where the ligament attaches to the lamina, and that makes it more pliable and that basically will remove that kink where the stenosis occurs. The advantages is it’s a very short outpatient procedure. It has a safety profile that’s equivalent to an epidural steroid injection¹. So a lot of these patients have already had an epidural. They understand it’s a very low risk procedure. This has actually been proven to have the exact same safety profile as a lumbar epidural steroid injection. It can be performed with local anesthesia and or light sedation. So it’s an excellent option for patients who might not be good surgical candidates and are not good candidates for general anesthesia. Very light sedation is all that’s needed. You don’t have any suturing or anything that you need more than just a small incision the size of a baby aspirin.

(08:06)* Let’s talk a little bit about the evidence. So one of my favorite things about the mild^® Procedure, why I used it so readily as a new pain physician was the level of evidence. So there’s actually Level 1A guideline evidence for the mild^® Procedure. There’s now three randomized control trials with long-term data to support the use of the mild^® as both a functional and pain improvement procedure that is also durable. So we’re seeing studies that are now out to three years actually showing both ODI improvement that are pretty dramatic improvements in ODI as well as standing time, walking time. And of course VAS pain scores have improved as well.

*Speaker comments; please review publications/references for accuracy.

(08:50) Lastly, there’s five-year durability data. So a common question patients ask us is, doctor, how long is this epidural going to last? How often am I going to have to have this? And so a lot of times they’ll say, how often am I going to have to have the mild^® Procedure? Well, I love telling them that we now have five-year durability data saying that the vast majority, over 80% of these patients have avoided surgery. So that’s very attractive to say this is not only short-term fix, but we’re actually going to where the root of the problem is and fixing that problem.

 

References:

(06:27) 1. Jain S, Deer TR, Sayed D, et al. Minimally invasive lumbar decompression: a review of indications, techniques, efficacy and safety. Pain Manag. 2020;10(5). https://doi.org/10.2217/pmt-2020-0037. Accessed June 1, 2020.

(06:27) 2. Hansson T, Suzuki N, Hebelka H, Gaulitz A. The narrowing of the lumbar spinal canal during loaded MRI: the effects of the disc and ligamentum flavum. Eur Spine J. 2009;18(5):679-686. doi:10.1007/s00586-009-0919-7.

(07:22) 1. Hansson T, Suzuki N, Hebelka H, Gaulitz A. The narrowing of the lumbar spinal canal during loaded MRI: the effects of the disc and ligamentum flavum. Eur Spine J. 2009;18(5):679-686. doi:10.1007/s00586-009-0919-7.

(07:22) 2. Benyamin RM, Staats PS, MiDAS ENCORE Investigators. mild^® is an effective treatment for lumbar spinal stenosis with neurogenic claudication: MiDAS ENCORE Randomized Controlled Trial. Pain Physician. 2016;19(4):229-242.

(08:19) 1. Staats PS, Chafin TB, Golvac S, et al. Long-term safety and efficacy of minimally invasive lumbar decompression procedure for the treatment of lumbar spinal stenosis with neurogenic claudication: 2-year results of MiDAS ENCORE. Reg Anesth Pain Med. 2018;43:789-794. doi:10.1097/AAP.0000000000000868.

(08:19) 2. Mekhail N, Costandi S, Nageeb G, Ekladios C, Saied O. The durability of minimally invasive lumbar decompression procedure in patients with symptomatic lumbar spinal stenosis: Long-term follow-up [published online ahead of print, 2021 May 4]. Pain Pract. 2021;10.1111/papr.13020. doi:10.1111/papr.13020

(08:19) 3. Benyamin RM, Staats PS, MiDAS ENCORE Investigators. mild^® is an effective treatment for lumbar spinal stenosis with neurogenic claudication: MiDAS ENCORE Randomized Controlled Trial. Pain Physician. 2016;19(4):229-242.

(08:34) 1. Benyamin RM, Staats PS, MiDAS ENCORE Investigators. mild^® is an effective treatment for lumbar spinal stenosis with neurogenic claudication: MiDAS ENCORE Randomized Controlled Trial. Pain Physician. 2016;19(4):229-242.

(08:34) 2. Mekhail N, Costandi S, Abraham B, Samuel SW. Functional and patient-reported outcomes in symptomatic lumbar spinal stenosis following percutaneous decompression. Pain Pract. 2012;12(6):417-425. doi:10.1111/j.1533-2500.2012.00565.x.

(08:34) 3. Mekhail N, Costandi S, Nageeb G, Ekladios C, Saied O. The durability of minimally invasive lumbar decompression procedure in patients with symptomatic lumbar spinal stenosis: Long-term follow-up [published online ahead of print, 2021 May 4]. Pain Pract. 2021;10.1111/papr.13020. doi:10.1111/papr.13020

(00:00) Once again, my name is Peter Pryzbylkowski. I’m an interventional spine doctor in Philadelphia. I’ve been doing the mild^® since 2012. When I came back to market 2017, 2018, I got heavily involved. Again, I deal with an elderly patient population. I’m at the Jersey Shore. I have patients who live in Florida for six months, come back up to see me for six months. And what I found is a lot of my older patients Medicare beneficiaries were getting in a rut where they were just wanting epidural after epidural after epidural. So I’ll go over some things later on in the presentation to how I’ve really introduced mild^® to that patient population to kind of get you out of the rut of just doing repeated serial epidurals on Medicare beneficiaries. One of the things that has helped, if you aren’t already aware, is CMS only allows you to do an epidural once every 90 days now.

(00:49) So some of these patients come in, maybe they’re again, epidurals in the 90’s, early 2000’s, they would get a series of three. I tell them now the series of three is gone. We have to think about other options now to treat your spinal stenosis. And I’m going to go out on a limb here and say, no one’s curing spinal stenosis with a lumbar epidural steroid injection. This is one of the few procedures we have in interventional spine where you can fix one of the root causes of spinal stenosis. Not many things we have in our field can fix a pain generator. This is one of ’em. We’re very good at putting Band-Aids on things. So this is one of the more durable procedures I do for my patient population. So we’re going to kind of go over here some evidence we have in terms of just epidural steroid injections. How many are you doing in your practice typically for lumbar spinal stenosis with neurogenic claudication, once again, have a QR code up there. If you scan it, we’ll be able to look live, see what some of these numbers are.

(01:47) So I say for my own practice I do in-office epidurals every other Friday, I do about 30 lumbar epidural steroid injections every other Friday in the office under local. So it’s a decent amount. I have a large Medicare patient population, so we can see the numbers here. They’re pretty high over 15, about 60% over 15. So it’s a lot. So this is where we can make some headway with the conference today. And our panel presentation is how do you change going from serial repeated epidurals to explaining to the patient you have a therapy available to you that’s as safe as an epidural steroid injection¹ that requires no suturing and is truly minimally invasive without burning any bridges. So we see a lot of the newer things on market. You have large posterior constructs that are put in between spinous processes. That’s not this procedure, right? My opinion is you need to jump through a mild^® before you do a posterior fusion device. Why? This is a lot easier procedure to do prior to putting a posterior fusion device in. So you want to make it look easy, make it look simple. So that’s why you want to do the most conservative thing first and work your way up that algorithm for treating spinal stenosis patients.

(03:02) So how many of you find serial epidurals for stenosis patients with neurogenic claudication to be effective? Sometimes I’d agree it does provide benefit, but the benefit tends to be transient. The question I get asked repeatedly in my office is, how long is this going to help me? And I’m honest, I say everyone’s different. I don’t have a magic crystal ball. You might have relief for a few weeks, a month, maybe two or three months, but on average, I’d say stenosis patients, when we do a lumbar epidural steroid injection or maybe getting four to six weeks of relief, they come back into the office, they want another injection. I say, Medicare’s not going to approve another injection. We have to wait 90 days from your last epidural to do another epidural. Why not think about fixing the root cause for your stenosis with a procedure? Then the next question I get asked is, I don’t want surgery on my back. So you have to explain to the patient, this is not surgery on their spine. It’s an outpatient minimally invasive procedure, same day procedure, minimal sedation you could do under local like Dr. Sanders said with a small Band-Aid you put on the back before they leave.

(04:11) So we have some data here. Just going over epidural steroid injections. So we had a couple clinics I was involved with one of them. And does the use of multiple epidural steroid injections prior to the minimally invasive lumbar decompression, does it affect outcomes? Long-term, meaning if you do one epidural versus five epidurals prior to a mild^®, is there any difference in terms of the VAS score after a mild^® Procedure? And what we found was that there is no difference. It doesn’t matter if you do one, do zero, do multiple, five or more, the outcomes are still there for this procedure. Patients will be able to stand and walk longer than they can prior to doing a mild^® Procedure, which is great. So we encourage physicians who do epidurals to think about this sooner in your algorithm, try to get out of the rut of doing repeated epidurals. I can tell you I’ve had to really train my APPs to get out of the rut of just ordering the same procedure over and over again. We know what the benefit of that procedure is, and it’s not long lasting to think about this more sooner in the algorithm.

(05:19) So this is a chart I do like to show my patients in the office. So obviously we do conservative care therapies first, physical therapy, chiropractic care, acupuncture, plus or minus conservative care with medications, they tend to not work as we know for stenosis patients. So then we’re heading towards an epidural. What’s next after an epidural? So I set my patients up from the first visit with me so they know what step A, step B, step C is. Why is that important? If you do an epidural and that patient does not have any relief whatsoever, you don’t want to lose that patient. So they need to know that you have a game plan in place as an interventional spine doctor to treat stenosis. So I go over step A, step B, step C, and let me tell you, you look like a hero when you say we’ll do an epidural, it’s going to help you for a few weeks and the pain’s going to come back.

(06:09) Then you have someone who’s engaged and wants to listen to you about the next steps in care to treat their stenosis. Most patients, almost all my patients want to avoid the major open operations. Even patients that need a decompressive laminectomy, when I look at their MRI, they have severe stenosis. They can’t walk one city block. They still do not want a laminectomy. They want whatever option you have, doc, I trust you, I believe in you. Whatever you can do for me to help with these symptoms, please do it. And then if patients do go on to these more invasive procedures, they know they’ve done everything they can with an interventional spine doctor before they got into the OR with a scalpel to the back.

(06:53) That’s great. I want to build a little bit on this practical experience. I think that all of us have put this into our ecosystem, and like I said, it really has elevated what we’re offering our patients and it really differentiates our practice from peer practices in the communities. Building a little bit on what you said, Dr. Pryzbylkowski, you mentioned sort of the talk track you have, how’s your practice set up in order to really support that process? Doing a whole lot of stuff and patients are coming and going. It sounds like you have a really big first meeting, but what’s the setup that then happens as people are having the care that you described?

(07:30) Yeah, so good question. So definitely tell them step A, B and C at the consult. Anyone that’s a Medicare beneficiary who I do an epidural steroid injection on when they’re checking out of my office, they get a pamphlet. Vertos has a really nice index card with a QR code on it and it says, injection stop working, think about mild^®. So I give that to everyone 65 and older who I do a lumbar epidural steroid injection on in the office, not at the ASC, but in the office. I do most of my lumbar epidurals in the office under local. So that just reiterates that if you don’t have durable benefit from what I just did for you two, three minutes ago, this would be the next option. So they scan the QR code, they learn more about the procedure when they come back into the office, you’re already discussing this as the next step in care. If the epidural you did, which more likely than not, did not provide any long-term benefit,

(08:22) That’s great. I think that’s such a practical tool. Patients need to hold onto something and tell ’em, put it on your fridge, give it to a family member, don’t lose it. But if you lose it, we got more. We actually do the same, but we have ’em take the picture of it so that they can walk with that. And the packets are great. Also, the people in the Vertos packets I will say, look very, very happy. So I sometimes make light of that. I say, I don’t know if you’re much of a dancer, but this procedure might get you back on the dance floor because on the front cover of one of the packets is people doing things that I can’t do well even without stenosis, Dr. Sanders. So tell me a little bit about when we were talking getting ready for this, you had mentioned that there are instances where you might go straight to mild^® and not doing epidural surgery. Can you tell me about that sort of patient-centered approach you’ve developed? Right.

(09:13) I never thought of myself as an aggressive person, but I’m like this person that’s like sometimes just don’t even do an epidural. I feel like I’m aggressive. And some of that’s because I think we see our patients and literally I had a guy I did three years ago and he brought back his new girlfriend. He wants me to do the same procedure for her. So we see these great results and I think it gets us excited about this procedure and it gives us satisfaction as a physician. So with that foundation of these good results, sometimes she’ll have patients in your office that they’ve had a stroke, maybe they’ve had a heart attack, maybe they have peripheral vascular disease, maybe they have all three and they really need their anticoagulant. And to me, I mean we’re somewhat putting them at a risk if three times a year, year after a year we’re stopping their anticoagulants.

(10:01) And if I have the alternative of the mild^® Procedure and I say, let’s stop your anticoagulant one time, let’s do this procedure and then you might not need more invasive treatments. I think we’ve done them a tremendous service. I think we sometimes forget how important it’s to treat neurogenic claudication from the standpoint of longevity for these patients, like you said, their mental health and their cardiovascular health. So if I see a clear diagnosis of neurogenic claudication, when you start to measure these ligaments, you’re going to see, wow, this is 6, 8, 10 millimeters. You’re seeing some very large ligaments. And like you said, if we go to the problem and we treat it, we feel like we’ve actually fixed something long-term for these people.

(10:41) So I’ll throw this out based on Dr. Pryzbylkowski’s data, that epidurals are a delay of game to real outcomes. Could the best epidural you ever do for spinal stenosis be one that also has a mild^® with it? For the first one. That’s your favorite way to do it. That’s why, and that’s what I’ll a shared conversation with the patient, of course. So a lot of times I’ll say we can start with an epidural. That would be the least invasive thing to do. Or we can do a mild^® Procedure and we could even do the epidural at the time of the procedure. And a lot of times when you present that safety profile as the equivalent to an epidural, I think patients are very excited about it.

(11:16) We’re going to get back to that a little bit later when we talk about long-term outcomes with this procedure and really circle back on is this the end of epidurals or not or is it the way to make epidurals work better than they ever have? And I think as I look around the audience, I’ve had a lot of conversations with folks that this doesn’t kill epidurals, but as we get to long-term outcome data, we’ll talk a little bit about life after mild^®. Zohra, a couple of questions for you. I think in my practice, my PAs and nurse practitioners really are this missing link in terms of making sure that the patient moves from that great talk track and planning stage to actually delivering the care. Can you talk a little bit about how you interact and follow up with the patients that are receiving epidural steroid injections for spinal stenosis and how you chat through those next steps versus really pivoting towards it doesn’t sound like we’re meeting your needs and what that conversation looks like.

(12:09) Sure. So I mean obviously I think a lot of practices apps are really doing the follow-up to procedures, assessing patients for procedures. And that’s really key to understand how you’re going to progress to the next step with whatever your physician and collaborative is doing. So it’s important to understand when is the patient exhausted in what you’re offering or you come on as an APP and you’re seeing a patient that the physician has seen for many years and maybe has gone through multiple treatments with epidurals. At what point do you have a discussion that says, okay, maybe there’s other things we can offer for you. We have other tools. Is this really working? And I think the key thing for me when I’m assessing a patient is really understanding what their goals are. What are we trying to accomplish for you? If you’re just looking at the pain score, that pain score may never change, but their function might be better even though you’ve tried a treatment and they come and they say, well, I’m still at a 10, but I’m walking to the mailbox or I’m able to play with my kids.

(13:06) So I try to establish what are your goals? What are you here for and what are you trying to accomplish? And then that helps me know, well, here’s what this treatment can do, here’s what this treatment is not going to do for you. And be able to then elicit that pathway to say this is an option. We can start with epidurals being one of them, but if this is not working well for you, if you’re not reaching those goals, if you’re not able to come off your pain medications as you would like to or increase that functionality, there are other things that we might be able to do to supplement that that don’t require the same three month step process that might actually not even be working for three months. But again, it’s identifying to the patient that there are things available so they don’t feel like they give up and not come back because you didn’t give them another option that they think that they could have. So I think that’s one aspect that can help.

(13:55) That’s great. It’s really nice to see the variance and practice, but also there’s a lot of similarities between the way we’re building our ecosystems to deliver this.

References:

(04:20) 1.Pryzbylkowski, Pain Manag., 2021.

(04:42) 1. Pryzbylkowski P, Bux A, Chandwani K, et al. Minimally invasive direct decompression for lumbar spinal stenosis: impact of multiple prior epidural steroid injections [published online ahead of print, 2021 Aug 4]. Pain Manag. 2021;10.2217/pmt-2021-0056. doi:10.2217/pmt-2021-0056

(05:21) 1. Deer TR, Grider JS, Pope JE, et al. The MIST Guidelines: the Lumbar Spinal Stenosis Consensus Group guidelines for minimally invasive spine treatment. Pain Pract. 2019;19(3)250-274. doi:10.1111/papr.12744.

(00:00) So we’re going to talk about bringing the patients in that maybe aren’t in our practice and how we are going to bring this into our team-based approach. And one of the elephants in the room is, a lot of us are, people talk about practicing at top of license. What’s that look like for interventional spine specialists? It means we were in the procedure suite as much as we can be while still making sure that everything is running the way as if we were in all of the rooms doing the exams, doing the talk tracks. Sometimes he’s even better by having other people there doing it who maybe have those softer skills. How much of your time are you spending in the procedure room?

(00:37) So I’d say I spend 60 to 70% of my time in the procedure room. But like you said, it’s about getting your APPs, knowing what your talk track is, knowing what your algorithm is. And that might be difficult. I’m going to practice with 12 other pain doctors who don’t all think and act the same way I do. So I give kudos to my APPs because if they’re seeing one of my patients versus one of my colleagues, the talk tracks might be different. And it’s a lot for them to keep in their head of what is the doctor that this is the patient of willing to do and not willing to do.

(01:10) So, let’s drill down on that because clearly you and I and Rebecca are not the people we’ll be talking about this. Will you talk a little bit about APP education for us? Because I think APP preparation education makes that 60 to 70% not a disaster makes it a success. And so tell us a little bit about how we can educate our APPs.

(01:28) Yeah, absolutely. I mean, I think education is a passion of mine. When I started the practice, we are not well-trained in pain management to begin with as APPs. Obviously we have limited training and we don’t have fellowship in pain and we don’t get much pain management education under the belt training. So what does empowerment mean when you ask how can you empower a team member or an APP? It’s support, right? It’s support. It’s providing tools, it’s being there to help grow that individual, to train them in a way that fits and aligns with the way you practice and sharing that philosophy of how you work. So the training is really key. So do you offer educational videos, are you providing them access to conferences or networking opportunities with other peers or with yourself in a way that the APP can learn what it is they need to understand to identify the patient?

(02:27) Are they watching you do the procedure? Can you show them how to do the procedure in the way that they see it? Not for the APP to do it, but to at least identify an understanding of how to talk to the patient about what to expect with the procedure. Because if I can’t help the patient understand that it’s not a major surgical spinal procedure, they may never agree to go to the next step. And if I’ve never seen it be done and I don’t understand the process of it, I’m not going to be able to educate, help the patient understand post-op or expectations in any way. So being able to empower someone I think all comes down to the support. What tools are you providing? Are you helping that APP learn how to read an MRI enough to get the idea of whether they’re going to be a candidate in the first place to then refer to the physician to say, Hey, I want you to further look at this patient. I think they’re a candidate. And all of these are essential to be able to work collaboratively and effectively with someone in your team, whether it’s your APP, the nurse or another physician colleague. I think you have to really be able to support each other in that way.

(03:29) That’s great. And Vertos has a lot of opportunities to create those bridges as well. So if you’re not as creative as Zohra, then please reach out to the Vertos team because there are a lot of opportunities to bring durable education opportunities to the team and then also to the care environment.

(00:00) Yeah, so the initial talk track with me four or five years ago with the spine friend, so I’m good friends with I golf with these guys, is give me your patient that has AFib, has a COP date, has all these comorbid conditions you don’t want to operate on anyway. They might need a laminectomy, but you don’t know if they’re going to get off the table. So I worked my way up from the sickest patients now to healthy patients who they’ll to me now they know a laminectomy is a big procedure, so it takes time. It’s that initial explanation of what you’re doing is not burning bridges for them. I’m not putting in an implant that they have to remove, that there’s going to be evidence that I did something in the spine. When you see these patients back three months and you look at their scar, it’s barely visible.

(00:52) It’s the size of a baby aspirin like Rebecca said. So the talk track was different at first. I’m not burning any bridges. Give me your sickest patients talk track is different now. So all the patients that did well who are sick, I fax all my results back to my referring colleagues. I’m a big believer in the more times they see my name on their desk, even when they’re on Facebook or social media, I like all their posts. They know I’m thinking in the back of their head if Oh, I’m going to send a patient to Pryz, man, I’m going to send a patient to Pryz. I keep seeing his name on my desk all the time and the patients are doing well. So in big believer, when you have good outcomes, you got to send ’em back to your referral source, know whoever it is, chiropractor, family doctor, spine surgeon. So the talking tracks gotten easier where now I have colleagues of mine who are now on board, but I’m not going to lie, when I first started doing these heavily again in 2017, 2018, I was worried about burning bridges because these are the guys who are referring me on my stim trials and implants. So it took some time, but it does get better once you show them the outcome and you’re not really burning any bridges for ’em.

(01:56) Absolutely. I think that’s a great answer. Great. So I think setting this landscape of this two year data was presented last year by Dr. Staatz as a data release at this meeting. And I remember sitting and listening to it and at first I was like, okay, this is really interesting. And I was a little disappointed. I was like, man, I wanted mild^® to just smoke laminectomy. I wanted it to be this thing that all of a sudden all of us that were out there that weren’t saying it, but the elephant in the room is like, is this better than laminectomy? Is it better than laminectomy? Then I thought, man, I would have a hard conversation back at the office if all of a sudden I had this thing that was better than laminectomy that I was because I’ve never said it right. But if the data then brought that, so this non-inferiority data that shows that effectively between patients and the mild^® Procedure, which think about that, those are different patients.

(02:49) They had access to a treatment that had no more harms than laminectomy in this large data set of Medicare patients. So that access is a big part of this story that you don’t get when you just look at the table and see that the harms were similar, the re-operations were similar, what happened after mild^® versus laminectomy was very similar. It really levels of playing field and it puts us in a position to pick the right treatment for the right patient at the right time. And I think that that’s what this Medicare data shows me. Knowing that a hundred thousand Medicare patients have received this treatment says a lot. It says a ton. It means that in our communities, people receiving these therapies and the interventional spine specialists for the most part haven’t been run out of town with pitchforks and torches, but so it’s happening. It’s happened and it’s been a decade of development here that leads to this data and the Medicare dataset, but I think this is very important.

(03:39) We’ll go to the next slide. And I think that to me disarms this conversation of like, well, what happens when there are studies shows that this is better than laminectomy, we should stop doing laminectomy. What it says is pick the right patient for the right treatment. And that data shows that as we’re doing that we’re actually not inducing more harms and we’re creating access to people that have decompression. I think that’s really great. So we’re going to talk about, I think something that I’m hinting at throughout this talk track, which is interventional pain anxiety with our surgeons. And I think that data helps pacify some events says, look, it’s all about picking the right treatment for our patients. I totally agree with you. The first place that I start is mild^® is always an option for patients without other spine surgical options. It’s always an option.

(04:29) Build your practice there, celebrate your wins, show that it works even in those challenging patients that didn’t have another option, I think initially we wanted to say, look, it’s not just for that part of the Venn diagram, it’s for everybody true statement, but how do you actually implement change? And change management can come through comfort, data, relationships and time. And I think that if you lean into that and you build a practice, that anxiety starts to go away because you then start to be able to treat people like one of my spine surgeon’s grandfathers who was a paratrooper and needed a mild^® Procedure. And it’s interesting because he actually was a fellow at Rush and wasn’t practicing, but I spoke to him because his dad was a primary care physician. The grandfather was getting the mild^® Procedure and they said, would you talk to my son?

(05:16) He’s a spine fellow. I said, absolutely. I talked to him two years later, he’s now working as one of my partners. He’s building a spine practice. It’s very interesting the conversation that we have around this treatment for his grandfather had no other options. And you know what he says? I would be happy to take every patient who still needs something after a mild^® Procedure and offer them whatever their spine surgery is that they need. He’s one of the only surgeons in my practice, in our integrated group that has a wide open door that says, I’m not going to send this case for a quality review. I understand the treatment, what it is and what it isn’t. And I am glad to be your first surgical resource because when those patients walk in the door, they leave scheduled for surgery. So maybe the question is finding the right team members that are at a different point in their career that are building that can understand what the mild^® Procedure is and isn’t, which is the first step, and I use the important term, understand in my community, I hear a lot of surgeons come back to me and say, I don’t believe in the procedure, is what we do about belief or is about understanding.

(06:21) And that’s where evidence and science set this apart. So while I don’t throw that back in their face and say, I think what you mean to say is you don’t understand the procedure, I go ahead and have a conversation with someone who is ready to understand it. And that’s just important. And that’s about change management as well is let’s not waste our time. We have treatments that we could be doing. And that’s my little pearl for dealing with the anxiety is sometimes don’t provoke it. Find where it’s not happening. Lean in there. Dr. Sanders, you want to talk a little bit about some experience with the surgeon referral-APP dynamic and really how you report back to them with how the patients are doing?

(06:56) Right. I think that’s a great point. So first of all, I think it’s important. We talked a lot about our team model in our office. We just have a kind of almost like an understanding that nerve pain, radicular pain, that’s going to be our first priority. We’re going to treat that first because that’s going to help the patient. And in many ways then we’ll address their mechanical issues thereafter. So that goes from literally my receptionist, to my nurses, to my nurse practitioner. And we all in terms of the providers are looking at imaging. And I think when our surgeons see that we are really doing our due diligence to give patients a true adequate diagnosis. And when I see a surgical lesion or a surgical need, I’m going to be the first to recognize it and refer them to you. I think that gives us a lot of credibility.

(07:48) And then like you said, I mean it’s collaborative. Patients are literally being marketed medical treatments and patients are oftentimes looking for a minimally invasive treatment to their back pain or their urgent claudication. You want to be the center that offers the gamut of treatments and what you’re going to capture. If I do a mild^® Procedure, I’m also going to capture their friends who maybe aren’t a candidate for the mild^® Procedure and they’re going to ask me for it. I’m going to review their imaging and I’m going to give them to the surgeon. So really you’re going to be building adequate spinal care in your community and that’s everybody wins in that case.

(08:32) Zohra, I think that you’ve described for me how bridges that you build to surgeon’s offices with their APPs have been a untapped resource to really socialize and normalize what we’re talking about here. Can you talk a little bit about some of the success there?

(08:47) Sure. I’ll share actually an example of opportunity that we had where one of our past fellows, we’ve had multiple fellows come through our program over the years, went on to his own practice and in their community, I believe there was like seven miles done per year by a particular person that was trained in it. So obviously compared to Dr P. over here, that’s like nothing but over the course of the development of this particular provider within that institution, and he was trained in mild^®, brought that to the facility, majority of the conflict was the surgical team that they were working with who it was a little bit of a, can we do this and are we burning bridges? Are we building them? And they had a very large practice of APPs who in the surgical area would assess their patients and then move them onto the surgical schedule.

(09:44) But a lot of these patients weren’t candidates for surgery and they started to reach out to the pain team and said, Hey, we can’t do surgery on this patient. Can you guys at least offer some pain management, some injections or whatever you guys do. So there was a very large gap, or not a connective, cohesive relationship of what the pain docs could do and what the surgeons didn’t understand were available. And so I was actually asked to come out and have a conversation with that team of APPs in the surgical area because all of those referrals to pain management were coming from the physicians on the surgical side and their colleagues in the APP world to where are we going to send them. So sometimes they weren’t sent anywhere and they’re like, sorry, you’ve got a bad spine, there’s not a surgical option and there’s not much else we can do.

(10:31) And so we were able to work together to say, if that’s the case where you are not wanting to operate, what is it that we on this site can do? And we work in the same facility, let’s collaborate. So physician to APP dynamic is one where we build that capacity to learn and grow and be efficient. But APP to APP collaboration is key as well. So I might learn or be able to connect to another APP in a practice better than I can to a physician. Our physicians might be able to connect to the physicians better than an APP, but who’s assessing and who’s referring. And if you can kind of create that pathway, it really helps to build the bridge and make those opportunities available.

References:

(03:01) Staats P, Dorsi M, Reece D, Strand N, Poree L, Hagedorn J, Percutaneous image-guided lumbar decompression and outpatient laminectomy for the treatment of lumbar spinal stenosis: a 2-year Medicare claims benchmark study, Interventional Pain Medicine, Volume 3, Issue 2, 2024, 100412, ISSN 2772-5944, https://doi.org/10.1016/j.inpm.2024.100412.

(00:00) Bridge building. This is one of my favorite things to talk about with mild^®. And let’s see who can be creative. What are, give me one or two referring specialties that have been surprising sources that aren’t surgeons or aren’t spine surgeons.

(00:22) So for me it’s been chiropractors. I’ve had a lot of chiropractors in my area take interest in this and want me to actually educate them on this procedure, which was profound to me. I mean, I come from academics. I never worked with chiropractors until I went to private practice seven years ago, but they’re a large referral source for me now. And the more I can explain the different types of things I do that just aren’t facet blocks and epidurals, the more engaged they’ve been. So that’s been a huge win-win for me.

(00:50) That’s great. Rebecca? Good one. Good. I’m sorry I already gave you the mailman. I think word of mouth. I mean I think of all the procedures I do, this is the one that patients come in the most just asking me for this procedure by name. So I think like you said these, I mean I have been so surprised how much we help people’s mental health because they’re able to do more. They’re traveling. Someone told me last week I was able to go to Alaska because of this. Thank you. So I think people like to talk about it. So I would say word of mouth,

(01:22) I would have to agree with patients themselves. We actually leave the pamphlets and the booklets out in the clinical area. So when patients are waiting for their half hour sometimes to BC that they’ve got some resources to look at and not everyone’s a candidate. So you have to take caution and not telling patients about things that’s not for them. But having that there and having the patient advocate to go to their colleagues or their physicians that they’re seeing and say, Hey, I heard about this. Can you offer this? And sometimes that’s what comes to us, whether it’s by a surgeon or another doctor or somewhere that they heard by a friend that had it that, Hey, I heard about this option, can I do that? So I think that goes a long way even when patients themselves have knowledge about it.

(02:05) That’s great. So you mentioned these patients that the surgeons decide were too sick and they can’t have it and they just go somewhere. Well, I found where one of those places is they’re too sick because they usually have cardiopulmonary disease. So I go to my pulmonologist, I go to my cardiologist because what they’re tracking on is walking tolerance testing for a lot of these patients and they’re not doing it in the office, but that’s what they ask. And these patients can’t do cardiac rehab. So I went to the cardiac rehab PTs as well and I said, what do people complain about when they don’t have dyspnea but they can’t walk and it’s claudication, but they’re not candidates for spine surgery. What are you talking about? And that’s been a massive referral source for me being able to take those patients and knowing also that I’m not going into the epidural space.

(02:45) Those patients, I’m not doing this on blood thinners, but I keep them on their baby aspirin. I still perform the procedure less than a hundred milligrams. And they say, wait, they can stay on the baby aspirin. That’s not something that’s happening in the rest of the decompression world. It shouldn’t happen. And so I throw that out as those are my two. And then those patients tell all their other friends that have orthopnea and dyspnea about me. Go to the next slide.

(00:00) So the go-to provider for interventional pain care, that’s the goal here. This is something that is like that center of excellence, that plaque on the wall, we do mild^® here. And what does that tell you about these practices? Well, it tells you they think differently and that perhaps they’ve, they’re willing to make mobility matter above lots of other things that we’re thinking about on a daily basis.

(00:28) So we’re going to talk a little bit about how this word of mouth concept and differentiation, and I’m just going to throw out one idea that as I went and talked to my surgical colleagues about nonsurgical back pain with all the data that came out around spinal cord stimulation, they said, great, now you’re going to be doing stim for all these patients who need spine surgery. And we went over those studies and what I said was, we’re not talking about the super sick patients that do have spinal pathology. Those are the patients I want to offer a mild^® for. So while I’m talking about nonsurgical back pain stim, and they’re like, wow, you think about things really differently. Maybe you aren’t trying to take my business. Maybe you’re trying to take care of the patients that I can’t help and my team can’t help. So to me, that was the biggest differentiator.

(01:09) And it’s really great to see that things that don’t seem related are actually a part of the same conversation around advancing and advanced procedures. So I use nonsurgical back pain as a great way for me to build the world of mouth amongst the surgeons that I still want to win over because they are my partners and they do great work. They do great work to help many of our patients. And when I trained, you wouldn’t do half the stuff we would do without knowing that surgeon was going to back you up and speak highly of the care you delivered. We can’t let go of that. It is a team. So what would you say, Pryz, in terms of the differentiating factors and how you preserve that or deliver it?

(01:46) Yeah, I mean it’s meeting with these physicians. It’s having the one-to-one dinners with them. It’s building the relationships. And like Rebecca said earlier, when you see a surgical candidate, don’t pretend to do something that you think is going to help when it’s not. So get ’em in front of the provider. I like to text the surgeon I work with all the time, a picture of the MRI and the demographics and say, here you go. And it goes both ways. When they see people, they can’t help. They’re referring to me when I see people, when I know it’s surgical right away, I’m referring back to them.

(02:18) Love that. Clear boundaries and also speaking out loud things that maybe they don’t know as part of your process. Just getting that out there. Dr. Sanders.

(02:30) So very similar to what you said when it comes to seeing these patients, our goal is to get the adequate diagnosis. And I’m always, I’m very honest with my patients. I like to show ’em their MRI and sometimes a trick is to have ’em come here, stand up and look at your MRI and then go see if they’re looking for their chair to sit back down. And I’ll show them and I’ll say, you have a lot of things causing your stenosis. I’m not going to fix all of that. I’m not going to necessarily make your MRI look pretty, but my goal is to make you more functional and it’s going to happen in a very minimally invasive way where the risks are small. So I don’t promise something, I don’t promise a new MRI. I’m certainly looking for dynamic instability or other things that would maybe exclude the patient.

(03:21) And I think doing that due diligence is what’s going to keep our outcomes looking good. And then I tell patients, this is not a hundred percent success rate. If you look at the studies, it’s 80%, which is phenomenal. I think that is remarkable that we get 80% success rate from such a minimally invasive procedure. But I say if I do five of these on one person, unfortunately it’s not going to work. And that’s why I do the epidural at the same time. So at least they feel better for a little while while we’re getting them to the surgeon.

(03:49) And in terms of practices that have made these leaps, made these developments, Zohra, I’ll ask how are APPs the differentiator in delivering this care?

(04:04) Dr. Sanders mentioned a point about patients looking at their MRI, and it’s funny, and I always give my docs a hard time that my patients said that I was the best care provider because I actually took the time to go over their MRI with them. And it was the first time anybody ever explained to me what was going on. And I think that really, I mean in and of itself helps the individual, the patient to really feel empowered about their care, to understand what the next steps could provide. But it comes down to just, again, empowerment of your team to be able to work at the best of their scope so that you can work as a physician to the best of your capacity, doing the procedures that you need to do and having the right team to be able to help facilitate those patients to come through to you through proper training. Obviously ASPN has an APP track, so I’ll throw that plug out there starting at one o’clock if anybody in the room wants to join to learn about the various new advances in all the different spaces of pain. And so just being there to support them, to advocate, to help them learn so that they can eventually help you learn and get the patients the care that they need.