MILD Procedure - Minimally Invasive Lumbar Decompression

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likeaboss

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I have about 100 patients with severe spinal stenosis who are 70-90 years old and not a candidate for spine surgery. How long before we can start doing these??
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I have a friend that swears by this, but for some reason I have no interest in it.
 
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MILD? No way. Old LF. Old dura. No way a 90 year-old has stenosis from LF hypertrophy only. Doing a MILD on someone that old just seems like a bad idea to me. Vertiflex here.
 
Taus said:
Why are they not a candidate for a laminectomy? Age alone shouldn’t determine. I’m sure only a few truly cannot ie highly comorbid, major degenerative scoli
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Well many of them just don't want surgery, they would rather deal with the pain than go thru the long recovery of a decompression and fusion. And a lot of them are just deconditioned.
 
likeaboss said:
How did the patients do?
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I'll cut in and tell you my only experience with it - I had a new pt visit around 9 months ago with a woman who had MILD approx 5 yrs ago in California. She showed up and when I told her I don't do MILD she became irate with me and was mortified to hear I don't do it. She "settled" for bilateral S1 TFESI and did well. Every visit I tell her I still don't do MILD.
 
likeaboss said:
How did the patients do?
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Did about a dozen each of Vertiflex and MILD in fellowship. Overall I was more impressed with the Vertiflex but that’s purely my subjective impression. Of my 3 MILDs, one felt worse, one felt quite a bit better, and one felt only a tiny bit better. I tried to reach out to Vertiflex to get “trained” so I could do them out of fellowship but didn’t hear back.
 
Nice fellowship experience!

That should be more than sufficient to not have to go to training you would think
 
Does Medicare cover MILD again, now?

I did 5 or 6 back in fellowship but I never have done any in practice due the reimbursement limbo.
 
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callmeanesthesia said:
I tried to reach out to Vertiflex to get “trained” so I could do them out of fellowship but didn’t hear back.
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They are deliberately not offering training to everyone, possibly for the end goal of being bought out by a larger device company. Rep specifically told me not to tell my colleagues he was offering me training. Sad for the patients.
 
I think they are clearly positioning themselves to be bought. Why go to the expense of training everyone and the resultant increase in headcount, if the company is not going to exist in 6-12m?


They are trying to increase their future valuation too. “We have only trained 300 doctors and look at our numbers, imagine the possibilities...”

Would be a great fit for Stryker. A pretty good fit for ABT, better if they bought Pan Med kypho product as well.
 
emd123 said:
Does Medicare cover MILD again, now?

I did 5 or 6 back in fellowship but I never have done any in practice due the reimbursement limbo.
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Yeah. It’s technically under a research study so there’s a few extra codes you have to add but it’s covered by Medicare for patients over 65. Also supposedly by some work comp.
 
Curious if anyone who has done them has post op MRIs that show any difference. I’ve done a handful of procedures and got 2 post op MRIs a few months out for “different” pain. The central stenosis looks the exact same to me.
 
Those who need more information should try and go to a conference that has a lecture that speaks about both MILD and Vertiflex.

Most conferences these days should have this topic.
 
What is the reimbursement like for MILD?
 
unchockey21 said:
Curious if anyone who has done them has post op MRIs that show any difference. I’ve done a handful of procedures and got 2 post op MRIs a few months out for “different” pain. The central stenosis looks the exact same to me.
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Have not seen and not aware of any appreciable changes on MRI s/p MILD
 
I've performed a fair number of MILD procedures with mixed results, mostly fair to good with some no improvement. The problem is that it's only covered by Medicare currently. And as you all know, rarely in that patient population is spinal stenosis only due to LF hypertrophy. But if I feel that there is a large LF component on MRI I'll explain it to them and offer it. I have seen plenty of younger patients who would likely do well, however it's never approved. In the end Vertiflex has been a better option. I've performed Vertiflex on failed MILDs with success. If the OP has that many patients who you think could benefit, contact the local rep and tell them, I'm sure they'd be happy to train you. MILD success is very dependent on technique. You need to get a lot of LF and show improvement of contrast spread. It takes 2x the time of Vertiflex with 5x the fluoro exposure.
 
PainandGain said:
I've performed a fair number of MILD procedures with mixed results, mostly fair to good with some no improvement. The problem is that it's only covered by Medicare currently. And as you all know, rarely in that patient population is spinal stenosis only due to LF hypertrophy. But if I feel that there is a large LF component on MRI I'll explain it to them and offer it. I have seen plenty of younger patients who would likely do well, however it's never approved. In the end Vertiflex has been a better option. I've performed Vertiflex on failed MILDs with success. If the OP has that many patients who you think could benefit, contact the local rep and tell them, I'm sure they'd be happy to train you. MILD success is very dependent on technique. You need to get a lot of LF and show improvement of contrast spread. It takes 2x the time of Vertiflex with 5x the fluoro exposure.
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What’s outcome at 6, 12, 24 months?
 
DODOCSS said:
What’s outcome at 6, 12, 24 months?
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Good question. My practice just recently hired a research coordinator to track patients and better answer this question. I haven't had any Vertiflex patients come back yet with loss of therapy with the oldest coming on 12m. MILD is mixed I'm sure but I'd like to get some hard data.
 
MRI won’t change. You aren’t creating space. You are freeing up a very stiff and immovable ligament that now will theoretically bend and bow allowing more dynamic space and blood flow.

Outcomes with MILD are good- otherwise Medicare would not have agreed to pay for it. That was why they put them through the very rigorous trial period and MILD came out on top.

I will say that in the few cases I have done in 80+ year olds that also had severe foraminal stenosis, that after the MILD, the ESIs seemed to be more effective for the radicular symptoms.

However, I am not experienced and it took me forever to do a case (haven’t done one in a long time).

There guy in town I know that was involved in part of the Medicare study I think only does Vertiflex now - I think that says something. Apparently that is great technology.

One thing that bugged me about MILD was how the company was not honest about complications. There have been some absolutely horrible things happen, and they never said anything about it. Maybe they didn’t know about them but we are a small community and we hear things.
 
epidural man said:
MRI won’t change. You aren’t creating space. You are freeing up a very stiff and immovable ligament that now will theoretically bend and bow allowing more dynamic space and blood flow.

Outcomes with MILD are good- otherwise Medicare would not have agreed to pay for it. That was why they put them through the very rigorous trial period and MILD came out on top.

I will say that in the few cases I have done in 80+ year olds that also had severe foraminal stenosis, that after the MILD, the ESIs seemed to be more effective for the radicular symptoms.

However, I am not experienced and it took me forever to do a case (haven’t done one in a long time).

There guy in town I know that was involved in part of the Medicare study I think only does Vertiflex now - I think that says something. Apparently that is great technology.

One thing that bugged me about MILD was how the company was not honest about complications. There have been some absolutely horrible things happen, and they never said anything about it. Maybe they didn’t know about them but we are a small community and we hear things.
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What could go wrong when you repeatedly jab a crochet hook into the spine?
 
epidural man said:
MRI won’t change. You aren’t creating space. You are freeing up a very stiff and immovable ligament that now will theoretically bend and bow allowing more dynamic space and blood flow.

Outcomes with MILD are good- otherwise Medicare would not have agreed to pay for it. That was why they put them through the very rigorous trial period and MILD came out on top.

I will say that in the few cases I have done in 80+ year olds that also had severe foraminal stenosis, that after the MILD, the ESIs seemed to be more effective for the radicular symptoms.

However, I am not experienced and it took me forever to do a case (haven’t done one in a long time).

There guy in town I know that was involved in part of the Medicare study I think only does Vertiflex now - I think that says something. Apparently that is great technology.

One thing that bugged me about MILD was how the company was not honest about complications. There have been some absolutely horrible things happen, and they never said anything about it. Maybe they didn’t know about them but we are a small community and we hear things.
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Do tell. What kind of horrible things?
 
BobBarker said:
L5/S1
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Basically this. It's just rare to see a Medicare population patient who's spinal stenosis is solely due to LF hypertrophy. I also will recommend to patients with osteoporosis where I think a spinous process fracture from Vertiflex is a risk.
 
PainandGain said:
Basically this. It's just rare to see a Medicare population patient who's spinal stenosis is solely due to LF hypertrophy. I also will recommend to patients with osteoporosis where I think a spinous process fracture from Vertiflex is a risk.
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this makes sense. thank you
 
epidural man said:
One thing that bugged me about MILD was how the company was not honest about complications. There have been some absolutely horrible things happen, and they never said anything about it. Maybe they didn’t know about them but we are a small community and we hear things.
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absolutely horrible? please explain.
 
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