mild procedure frustration

[velodoc]

I'm interested in others' experience with mild procedure. I've now done about 15. Have done weekend training, further training/observation of others, reading, etc. Have extensive spinal injection/intervention/implant experience, and have significant clinical success.

I have strictly selected my mild cases: 1) symptoms of neuroclaudication 2) MRI evidence of central canal lumbar stenosis 3) MRI evidence of thickened ligamentum flavum at site of stenosis, 4) no concomitant severe foraminal stenosis.

Getting good amount of tissue out, ie ligament and bone. Epidurogram lookes thicker in all cases. Really spending time in OR to get this right. Being aggressive.

My results are, thus far 50-50 and my success is a 3-4point reduction in pain, ie from 7/10 to 3/10. About half have minimal to no improvement. Have performed post-mild ILED on a few, with some noting improved longevity of symptom relief. Wondering if others are having similar results. Wondering if my expectations are too high.

Also, seeing a lot of pain docs ordering mild for the diagnosis of ligamentum flavum hypertrophy, ie no neuroclaudication and no stenosis (see these patients for second opinions). Similar to overutilization of IDET, etc. Removing ligament because "its there." Maybe these are the success stories? Kind of like removing "plica" from knee joint.

Sorry to sound cynical. I want this procedure to work. While its a pain to go to the hospital, these are patients that are either rejected by surgeons because of age, health or funding, or, if they are given the option of surgery, the proposed sugery consists of hardware placement for reasons I don't comprehend. In other words, if effective and not overutilized, mild could be a standard treatment in my practice.

Any comments, suggestions, and/or technical caveats would be appreciated.

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[mid|ine]

Was going to get trained, but High Mark released a statement that the decompression code couldn't be used. Now we can't get enough for the procedure to pay for the device. So I haven't trained.

Where are you and how are you billing?

Unfortunate to hear your results are less then those published with strict selection criteria...

 

[Mister Mxyzptlk]

Also, seeing a lot of pain docs ordering mild for the diagnosis of ligamentum flavum hypertrophy, ie no neuroclaudication and no stenosis (see these patients for second opinions). Similar to overutilization of IDET, etc. Removing ligament because "its there."

Gosh, what a surprise to learn that pain docs will put anything sharp into anything that has insurance. No good will come of this. When the malpractice hammer falls (and you know it will given all the cowboys out there) the spine surgeons will be lined up to testify.

 

[hyperalgesia]

Wondering if my expectations are too high.

Yes, I'm surprised your results are this good. There are too many confounding variables in the dx of neurogenic claudication, the identification of its anatomical/physiologic cause, and its resolution by dorsal debulking of the LF. I predict MILD will make some corporations and physicians some money and then disappear along with Silly Bandz and Obamacare.

 

[SleepIsGood]

First off...

This is the poster's first post. So buyer beware, he could just be indirectly bad mouthing it.

But let's just assume he isnt. Keep in mind that the company itself states there's a certain amount of patients that do not respond to it. As many of you all know there are various pain generators. mild takes care of some of the issues (lig flavum), but there's other problems as well --discs, facets, irritated nerve roots,etc.

I think it's a great tool, in the right hands.

In terms of billing.....I've also heard that there were some coding issues. It would be interesting to find out more details.

 

[drusso]

Cannot get paid for MILD. Can't get paid for peripheral Stim either. Can't get paid for percent discs or nucleoplasty. Epidural "lysis" of adhesions? Nope...no one asking for verts or kypho much either...

So, how do you guys get PAID for this stuff??? I can't even get a disco approved because it is "experimental."

 

[joshmir]

drusso-

where are you that you are not getting paid?

 

[Mister Mxyzptlk]

First off...

This is the poster's first post. So buyer beware, he could just be indirectly bad mouthing it.

If it's the same Velodoc from the ISIS forum he's a straight shooter and a welcome addition.

 

[SSdoc33]

First off...

This is the poster's first post. So buyer beware, he could just be indirectly bad mouthing it.

But let's just assume he isnt. Keep in mind that the company itself states there's a certain amount of patients that do not respond to it. As many of you all know there are various pain generators. mild takes care of some of the issues (lig flavum), but there's other problems as well --discs, facets, irritated nerve roots,etc.

I think it's a great tool, in the right hands.

In terms of billing.....I've also heard that there were some coding issues. It would be interesting to find out more details.

buyer beware? in one post, velodoc has made more sense than in the 2000 that sleep has made.

evidently, every procedure is a success in sleep's hands, so those on this forum should be a bit skeptical of his comments

 

[Jcm800]

buyer beware? in one post, velodoc has made more sense than in the 2000 that sleep has made.


im happy again this morning. I laughed my ass off...

 

[Jcm800]

i ahve 3 cases scheduled in late february. I will update. All medicare. All central stenosis with neurogenic claudication, one does have a fair amount of neural foraminal stenosis... all with significant flavum thickening. We will see. I dont think the first 5 are the best representation, but you have to start somewhere.

 

[hyperalgesia]

Getting good amount of tissue out, ie ligament and bone. Epidurogram lookes thicker in all cases. Really spending time in OR to get this right. Being aggressive.

I would love to see images of pre and post epidurograms if you have them.... Thanks for the post!

 

[lobelsteve]

buyer beware? in one post, velodoc has made more sense than in the 2000 that sleep has made.


im happy again this morning. I laughed my ass off...

 

[SleepIsGood]

buyer beware? in one post, velodoc has made more sense than in the 2000 that sleep has made.

evidently, every procedure is a success in sleep's hands, so those on this forum should be a bit skeptical of his comments

Wow. I thought you were supposed to be a "mature" and seasoned attending along with the other joker Steve. Remember with your arrogant, "I'm an attending, I'm better than thou" attitude. Settle down for a change.

If he's legit, he'll pass the test. IF he's a quack or troll he'll fall.

BTW..if you know how to read (that requires putting your arrogance aside for a second) my post. You will see that I wrote there is a non response rate to the procedure. The COMPANY even says that. Every procedure has a non response rate. However, based on their data and from what other studies have shown (pub med it) it's not 50% like the OP stated his was. Granted his "N" number is small. But if you are getting 50/50 results, there should be some further investigation into the technique and patient selection.

The published data in peer reviewed literature is promising. Before people start knocking it like they have IDET, biaculoplasty, etc more caution should be exercised.

Relax.

 

[lobelsteve]

Wow. I thought you were supposed to be a "mature" and seasoned attending along with the other joker Steve. Remember with your arrogant, "I'm an attending, I'm better than thou" attitude. Settle down for a change.

If he's legit, he'll pass the test. IF he's a quack or troll he'll fall.

BTW..if you know how to read (that requires putting your arrogance aside for a second) my post. You will see that I wrote there is a non response rate to the procedure. The COMPANY even says that. Every procedure has a non response rate. However, based on their data and from what other studies have shown (pub med it) it's not 50% like the OP stated his was. Granted his "N" number is small. But if you are getting 50/50 results, there should be some further investigation into the technique and patient selection.

The published data in peer reviewed literature is promising. Before people start knocking it like they have IDET, biaculoplasty, etc more caution should be exercised.

Relax.

I can only attack the science behind the procedure. Removing flavum is not the same as removing a bulbous medial facet, the ligamentum flavum, the lamina, and possibly some vertebral body foraminal osteophytes. The "incredible" results reported so far are "too good to be true". If we could limit the procedure to only those with stenosis secondary to flavum hypertrophy without disc bulges or facet hypertrophy- then we could make a case for doing this procedure only in those to frail for conventional decompressive laminectomy. As it stands, the procedure is already being abused. Pain physicians cannot restrain themselves from stabbing people with needles any chance they get. Patient selection is based more on insurance rather than on pathology matching potential therapeutic benefit.

Sleep: You will be a pain millionaire within 3 years.

 

[Jcm800]

those that are doing this procedure, which fluoro code is appropriate. there is truly an epiduragram, or is it the 76000 code...

 

[lobelsteve]

I'm betting fluoro is bundled in like in SCS and Vplasty.

 

[Jcm800]

I'm betting fluoro is bundled in like in SCS and Vplasty.

its not bundled, yet...

and i dont believe fluoro is bundled with vertebroplasty. The flouro code is 72291 isnt it...

 

[epidural man]

So 50% treatment success - that is an NNT of 2 (assuming a control group would have 0% success).

There isn't a single other intervention or medicine that we use in pain with a NNT of 2.

The best medicine we have, in the very best RCT for the perfect patient, for example Elavil for PHN, is like 6 or something (18% response rate).

I think it is somewhat funny how we always are so critical of interventions and expect such high response rates, and yet when we use extremely dangerous medicines (gabapentin, oxycodone, etc) that have response rates around 20% or less, we consider ourselfs the more responsible and conservative physicians.

MILD probably works because it free's up the ligament (provides more flexibility and movement) which decreases ischemia and symptoms and is probably less important than creating a ton of space - so even with enlarged facets and disc bulging, it should work in most patients with a hypertrophied and calcified ligament.