Procedural but non surgical stenosis options.

[bedrock]

Debating what to do with my lumbar stenosis patients that have failed PT/ESI, but are too sick for surgery.

I don’t do MILD , veritiflex etc so no profit motive for me. Just debating when and to whom to refer for which procedure….and also when not to bother.

I’ve seen plenty of failed spacers but a local doc swears by vertiflex, another for MILD, etc.

Is there a good review article or protocol someone can suggest?

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[runfastnow]

I only have experience with MILD. My anecdotal evidence and criteria on n=30.

3/30 no improvement
5/30 some improvement but on fence as if it was worth doing
22/30 happy with results

My MILD selection criteria (on top of the MILD LF hypertrophy stuff):
- 3 or fewer levels with moderate/severe stenosis without large disc protrusion/extrusion
- Primarily neuroclaudication symptoms without acute/hot radic. Counsel extensively that MILD will typically not improve acute radic pain.
- Patient mainly complains of standing/walking endurance and primarily wants to be able to do dishes, walk grocery store, etc. without needing rest breaks for claudication symptoms and patient can tolerate current pain level at rest (or has minimal pain at rest).
- Failed ESI.

 

[bedrock]

Is there no half decent study out there comparing the options ? MILD vs Vertiflex, etc??

 

[pmrmd]

MILD pairs well with interspinous devices in this older/sicker population. You can do them some good with both.

 

[lobelsteve]

Is there no half decent study out there comparing the options ? MILD vs Vertiflex, etc??

There is not. Fun procedures of potential benefit. Lots of anecdotal stuff and case reports.
Good studies will prove it does nothing. We should avoid good studies as we can still offer hope.
Nope, I don't do these. But I love watching the high five rep slaps on LinkedIn.

 

[Ducttape]

are reps for MILD high fiving on LinkedIn (i am not a member)?

half the time, i dont see the rep at all.

he sends me a text asking if everything goes okay, and i send back an emoji.



anecdotally, simlar to runfastnow, have had 3 out of the past 30 that was a failure and i have told them to get surgery.

most recent MILD in follow up danced a jig in the office.

 

[BobBarker]

Vertiflex works very well. I have done around 220 cases.

 

[Agast]

most recent MILD in follow up danced a jig in the office.

Tik Tok or it didn’t happen

 

[Ducttape]

not my patient, but...

 

[lobelsteve]

not my patient, but...

My patient and I from my first year in practice.

 

[manowar rules]

Vertiflex works very well. I have done around 220 cases.

Are you having issues with insurance coverage for Vertiflex, or has that situation improved?

 

[BobBarker]

Since 2019, it has been extremely difficult to do them on Medicare advantage. Basically all of my cases since then have been on traditional Medicare, employer TPA plans, or state employee insurance. I have heard from the rep that some Medicare advantage plans are approving again so I will start trying on everyone again.

 

[Espn123]

There is not. Fun procedures of potential benefit. Lots of anecdotal stuff and case reports.
Good studies will prove it does nothing. We should avoid good studies as we can still offer hope.
Nope, I don't do these. But I love watching the high five rep slaps on LinkedIn.

So for the patient who isn’t a surgical candidate, and they have maybe moderate to moderate/severe stenosis, and they fail PT/ESI, what do you do?

 

[swamprat]

So for the patient who isn’t a surgical candidate, and they have maybe moderate to moderate/severe stenosis, and they fail PT/ESI, what do you do?

Minuteman or zip .. duh

 

[Ducttape]

they can go see a surgeon. there is bound to be some cowyboy that will cut them open, but doesnt mean that it will help.


otherwise, same thing we do for all patients with other forms of chronic pain:
home exercise, stay active, focus on maintaining functionality and quality of life

lifestyle changes. it is okay to use the motorized cart at Wegmans. just keep going.

try meds if you like. but think twice (or three) times before starting opioids.

consider changing their perspective on pain and consider cognitive therapies. Acceptance and Commitment Therapy for example...

 

[lobelsteve]

So for the patient who isn’t a surgical candidate, and they have maybe moderate to moderate/severe stenosis, and they fail PT/ESI, what do you do?

What did we do before these lucrative and unproven procedures exist?

 

[SSdoc33]

they can go see a surgeon. there is bound to be some cowyboy that will cut them open, but doesnt mean that it will help.


otherwise, same thing we do for all patients with other forms of chronic pain:
home exercise, stay active, focus on maintaining functionality and quality of life

lifestyle changes. it is okay to use the motorized cart at Wegmans. just keep going.

try meds if you like. but think twice (or three) times before starting opioids.

consider changing their perspective on pain and consider cognitive therapies. Acceptance and Commitment Therapy for example...

starting to see how you can spend 30 minutes with a patient

 

[MitchLevi]

Can't fix everything. Pain is a part of life, especially back pain.