Case Study: Leading Interventionalist Makes the Move to mild® and Helps Patient (87) Find Lasting Relief
Published
July 17, 2024
mild® Provider, Dr. Youssef Josephson | Double Board-Certified PM&R and Pain Management Physician | Modern Spine and Pain
This case study explores the successful treatment of a patient, age 87, by Dr. Youssef Josephson. After he decided to move this patient to the mild® Procedure for lumbar spinal stenosis (LSS), Dr. Josephson found the procedure not only helped her avoid major surgery but also improve quality of life, regain functional ability, and discontinue use of opioids.
Patient History: Pre-mild®
An 87-year-old female patient presented with the following complaints during her consultation:
Poor quality of life marked by an inability to walk and stand for prolonged periods due to significant pain.
Heavy reliance on pain medication despite disliking the side effects, which left her feeling tired and unable to engage in daily activities.
Although she had undergone multiple interventions, her desired level of function remained unaddressed.
Dr. Josephson observed that despite her age, she exhibited considerable vitality and potential for functional improvement.
Past Treatments
The multiple and unsuccessful interventions included physical therapy, epidural injections, and extensive dependency on medication.
She consulted with a spine surgeon, who proposed a significant open surgery involving fusion. After discussing this route with her physician, she opted to pass on open surgery due to concerns regarding recovery time and extensive anesthesia requirements.
Despite her overall good health, she preferred minimal levels of general anesthesia.
MRI Findings, Neurogenic Claudication and MOVE2mild®
An MRI revealed buckling at the L4-L5 level along with ligamentum flavum hypertrophy.
Based on this imaging, the patient was diagnosed with spinal stenosis accompanied by intermittent neurogenic claudication, attributed to various risk factors and underlying health concerns.
Dr. Josephson determined the most appropriate treatment for her condition and desired outcome was mild®, with a focus on treating levels L4-L5.
Images submitted by Dr. Josephson
Procedure Details
The procedure was performed utilizing fluoroscopic guidance. The patient was treated at the L4-L5 segment to address the hypertrophic ligamentum flavum which was compressing the space in the spinal canal and putting pressure on the nerves in the lower back. A mild® Tissue Sculpter was utilized to extract excess ligamentum flavum. Once satisfactory decompression was achieved, small amounts of dye and cortisone were injected to visualize improved flow and overall results.
The case concluded with a small incision closure using glue and one Steri-strip, which minimized recovery time.
The Results
At the one-week postoperative follow-up, the patient reported feeling significantly better.
At the one-month follow-up, the patient handed over her pill bag, indicating she no longer needed the medication. This is notable given that, at 87 years old, she had been reliant on opioid medication.
Dr. Josephson described this moment as the “Holy Grail” of pain management, being able to help his patient regain their quality of life and functional abilities without medication.
Key Takeaway from Dr. Josephson:
“I call it the Holy Grail of pain management and that is when a patient who has been maintained on medications, walks in and hands you their pill bag and says ‘Doc, I don’t need this this anymore. I now have my quality of life back. I have my ability to function back,’ and that to me that is a slam dunk.”
Key Takeaways from Dr. Josephson on Why He Continues to Advocate for mild®
Dr. Josephson continues to treat spinal stenosis with mild® because the procedure provides outcomes that address both pain relief and structural issues without resorting to major surgery, interventions, or lengthy recovery periods.
As a minimally invasive procedure, mild® requires a short recovery time as well as a very minimal postoperative course. Usually within a matter of days, patients are back to themselves—indeed, a better version of themselves.
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.
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.
2012 data from Health Market Sciences report for Vertos Medical 2013.
Data on file with Vertos Medical.
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.
Based on mild® Procedure data collected in all clinical studies. Major complications are defined as dural tear and blood loss requiring transfusion.
MiDAS ENCORE responder data. On file with Vertos Medical.
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.
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.
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.
Treatment options shown are commonly offered once conservative therapies (e.g., physical therapy, pain medications, chiropractic) are not providing adequate relief. This is not intended to be a complete list of all treatments available. Doctors typically recommend treatments based on their safety profile, typically prioritizing low risk/less aggressive procedures before higher risk/more aggressive procedures, but will determine which treatments are appropriate for their patients.
The mild® Procedure is a minimally invasive treatment for lumbar spinal stenosis. As with most surgical procedures, serious adverse events, some of which can be fatal, can occur, including heart attack, cardiac arrest (heart stops beating), stroke, and embolism (blood or fat that migrates to the lungs or heart). Other risks include infection and bleeding, spinal cord and nerve injury that can, in rare instances, cause paralysis. This procedure is not for everyone. Physicians should discuss potential risks with patients. For complete information regarding indications for use, warnings, precautions, and methods of use, please reference the devices’Instructions for Use.
Patient stories on this website reflect the results experienced by individuals who have undergone the mild® Procedure. Patients are not compensated for their testimonial. The mild® Procedure is intended to treat lumbar spinal stenosis (LSS) caused by ligamentum flavum hypertrophy. Although patients may experience relief from the procedure, individual results may vary. Individuals may have symptoms persist or evolve or other conditions that require ongoing medication or additional treatments. Please consult with your doctor to determine if this procedure is right for you.
Reimbursement, especially coding, is dynamic and changes every year. Laws and regulations involving reimbursement are also complex and change frequently. Providers are responsible for determining medical necessity and reporting the codes that accurately describe the work that is done and the products and procedures that are furnished to patients. For this reason, Vertos Medical strongly recommends that you consult with your payers, your specialty society, or the AMA CPT regarding coding, coverage and payment.
Vertos Medical cannot guarantee coding, coverage, or payment for products or procedures. View our Billing Guide.
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Hall S, Bartleson JD, Onofrio BM, Baker HL Jr, Okazaki H, O’Duffy JD. Lumbar spinal stenosis. Clinical features, diagnostic procedures, and results of surgical treatment in 68 patients. Ann Intern Med. 1985;103(2):271-275. doi:10.7326/0003-4819-103-2-271.
Kalichman L, Cole R, Kim DH, et al. Spinal stenosis prevalence & association with symptoms: The Framingham Study. Spine J. 2009;9(7):545-550. doi:10.1016/j.spinee.2009.03.005.
Fukusaki M, Kobayashi I, Hara T, Sumikawa K. Symptoms of spinal stenosis do not improve after epidural steroid injection. Clin J Pain. 1998;14(2):148-151. doi:10.1097/00002508-199806000-00010.
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
Friedly JL, Comstock BA, Turner JA, et al. Long-Term Effects of Repeated Injections of Local Anesthetic With or Without Corticosteroid for Lumbar Spinal Stenosis: A Randomized Trial. Arch Phys Med Rehabil. 2017;98(8):1499-1507.e2. doi:10.1016/j.apmr.2017.02.029
Pope J, Deer TR, Falowski SM. A retrospective, single-center, quantitative analysis of adverse events in patients undergoing spinal stenosis with neurogenic claudication using a novel percutaneous direct lumbar decompression strategy. J Pain Res. 2021;14:1909-1913. doi: 10.2147/JPR.S304997
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
Abstract presented at: American Society of Pain and Neuroscience Annual Conference; July 22-25, 2021; Miami Beach, FL.
Mobility Matters: Low Back Pain in America, Harris Poll Survey, 2022. View data and full summary here.
Deer TR, Grider JS, Pope JE, et al. Best Practices for Minimally Invasive Lumbar Spinal Stenosis Treatment 2.0 (MIST): Consensus Guidance from the American Society of Pain and Neuroscience (ASPN). J Pain Res. 2022;15:1325-1354. Published 2022 May 5. doi:10.2147/JPR.S355285.
