Ken Chapman, MD, is a pain management physician with The Spine & Pain Institute of New York, in Manhattan and Staten Island. He is board certified in pain management and anesthesiology and serves as the director of pain management at Staten Island University Hospital, North Shore LIJ Health system as well as assistant clinical professor at SUNY Downstate. He discusses eight things to know about minimally invasive lumbar decompressions for patients with spinal stenosis.
Why MILD is different
1. How the procedure is performed. MILD is usually performed in a hospital setting by a pain management physician. The procedure is done under an X-ray unit to guide instrument placement. "You use a cannula to access the ligament that is causing the stenosis and you insert a trocar through the cannula, which is used to take out the ligament and open the stenosis at the appropriate levels," says Dr. Chapman. "With the X-ray and contrast, you can actually indirectly see yourself decompressing the ligament as the epidural space opens up."
2. Benefits of the new treatment. The minimally invasive lumbar decompression is an outpatient intervention for patients with spinal stenosis caused by ligamentous hypertrophy. These are patients who have undergone conservative treatment modalities without success, but are not yet ready to undergo surgical intervention. "In the past, after failing conservative treatment, these patients would go for surgery," says Dr. Chapman. "Now, we have an intermediary step which is really different than anything else out there. The patient can experience pain relief without surgery."
The treatment can take 20-45 minutes, depending on how extensive it is, and the recovery period is typically much faster than patients who undergo a laminectomy. "Patients are up and walking around the same day after surgery and they are able to resume normal activity within a week," he says. "There are some patients who need more bone removed or experience inflammation, but most of the time they are able to return 100 percent within a week after surgery."
3. No bridges are burned. Patients who don't experience pain relief after MILD can still undergo a laminectomy because MILD does not disrupt the anatomy. "Since this procedure can be offered before doing a laminectomy, it may become part of a surgeon's treatment algorithm," he says. "They may have their patients try this first before undergoing surgery."
Why more physicians aren't performing MILD
4. Physicians need extra training. While there are several advantages to performing minimally invasive lumbar decompressions, many pain management physicians aren't able to do so. One hindrance could be the advanced training physicians need in order to perform the procedure correctly. "It is an operator-dependent intervention and there is a learning curve involved," says Dr. Chapman. "Physicians need to take time to learn the treatment and understand which patients would benefit the most before incorporating it into their practices."
5. Intervention is performed in a hospital setting. Another road block to the widespread implementation of MILD is the operation setting. In most cases, physicians need to operate out of a hospital, but many pain management physicians don't have hospital privileges.
6. MILD CPT codes were recently released. Pain physicians have been able to receive reimbursement for performing MILD from insurance companies for a while, but up until July 1 physicians had to use unlisted codes. There are now specific codes out for MILD, which make it a more easily reimbursed treatment. "It takes time to receive the proper billing codes, and without that the hospital and physicians may not be compensated," says Dr. Chapman. "With these new codes coming out, word will get around and more pain specialists will be doing it."
Will it stick?
7. Studies show positive results. There have been a few studies examining the effectiveness of MILD showing good outcomes, says Dr. Chapman. "There is mounting evidence that this could be a very helpful treatment," he says. "I'm sure there will continue to be good evidence for this procedure in the future."
8. Trending away from surgery. Surgery may not be necessary for many patients with spinal stenosis and insurance companies are increasingly less willing to cover surgical intervention even after traditional conservative treatment is exhausted. For patients who don't respond to other types of non-surgical treatment, MILD may become the best treatment option.
"The MILD intervention is something completely different than what has been brought to the table before," says Dr. Chapman. "As we move away from surgical procedures, we can fine-tune MILD even more. I think it's here to stay."
Learn more about The Spine & Pain Institute of New York.
Related Articles on Spine Pain Management:
10 Biggest Trends in Spine Pain Management
5 Points on the Role of Pain Management in Spine Care
4 Points on Medication Management for Back Pain
Why MILD is different
1. How the procedure is performed. MILD is usually performed in a hospital setting by a pain management physician. The procedure is done under an X-ray unit to guide instrument placement. "You use a cannula to access the ligament that is causing the stenosis and you insert a trocar through the cannula, which is used to take out the ligament and open the stenosis at the appropriate levels," says Dr. Chapman. "With the X-ray and contrast, you can actually indirectly see yourself decompressing the ligament as the epidural space opens up."
2. Benefits of the new treatment. The minimally invasive lumbar decompression is an outpatient intervention for patients with spinal stenosis caused by ligamentous hypertrophy. These are patients who have undergone conservative treatment modalities without success, but are not yet ready to undergo surgical intervention. "In the past, after failing conservative treatment, these patients would go for surgery," says Dr. Chapman. "Now, we have an intermediary step which is really different than anything else out there. The patient can experience pain relief without surgery."
The treatment can take 20-45 minutes, depending on how extensive it is, and the recovery period is typically much faster than patients who undergo a laminectomy. "Patients are up and walking around the same day after surgery and they are able to resume normal activity within a week," he says. "There are some patients who need more bone removed or experience inflammation, but most of the time they are able to return 100 percent within a week after surgery."
3. No bridges are burned. Patients who don't experience pain relief after MILD can still undergo a laminectomy because MILD does not disrupt the anatomy. "Since this procedure can be offered before doing a laminectomy, it may become part of a surgeon's treatment algorithm," he says. "They may have their patients try this first before undergoing surgery."
Why more physicians aren't performing MILD
4. Physicians need extra training. While there are several advantages to performing minimally invasive lumbar decompressions, many pain management physicians aren't able to do so. One hindrance could be the advanced training physicians need in order to perform the procedure correctly. "It is an operator-dependent intervention and there is a learning curve involved," says Dr. Chapman. "Physicians need to take time to learn the treatment and understand which patients would benefit the most before incorporating it into their practices."
5. Intervention is performed in a hospital setting. Another road block to the widespread implementation of MILD is the operation setting. In most cases, physicians need to operate out of a hospital, but many pain management physicians don't have hospital privileges.
6. MILD CPT codes were recently released. Pain physicians have been able to receive reimbursement for performing MILD from insurance companies for a while, but up until July 1 physicians had to use unlisted codes. There are now specific codes out for MILD, which make it a more easily reimbursed treatment. "It takes time to receive the proper billing codes, and without that the hospital and physicians may not be compensated," says Dr. Chapman. "With these new codes coming out, word will get around and more pain specialists will be doing it."
Will it stick?
7. Studies show positive results. There have been a few studies examining the effectiveness of MILD showing good outcomes, says Dr. Chapman. "There is mounting evidence that this could be a very helpful treatment," he says. "I'm sure there will continue to be good evidence for this procedure in the future."
8. Trending away from surgery. Surgery may not be necessary for many patients with spinal stenosis and insurance companies are increasingly less willing to cover surgical intervention even after traditional conservative treatment is exhausted. For patients who don't respond to other types of non-surgical treatment, MILD may become the best treatment option.
"The MILD intervention is something completely different than what has been brought to the table before," says Dr. Chapman. "As we move away from surgical procedures, we can fine-tune MILD even more. I think it's here to stay."
Learn more about The Spine & Pain Institute of New York.
Related Articles on Spine Pain Management:
10 Biggest Trends in Spine Pain Management
5 Points on the Role of Pain Management in Spine Care
4 Points on Medication Management for Back Pain