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lobelsteve

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    I refuse to do a procedure that I could not recommend for my own family.

    Taking chunks of ligament using nothing more than fluoro and contrast does not seem reasonable when the surgeon can do this with direct visualization.

    We either need training in endoscopic spine or they need to become more in favor of minimally invasive.

    Though I do believe outcomes favor decompressive lami.
     

    101N

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      I refuse to do a procedure that I could not recommend for my own family.

      Taking chunks of ligament using nothing more than fluoro and contrast does not seem reasonable when the surgeon can do this with direct visualization.

      We either need training in endoscopic spine or they need to become more in favor of minimally invasive.

      Though I do believe outcomes favor decompressive lami.

      1+ The only reason to perform this unsafe, unproven procedure is because you are greedy
      and don't want to send the patient for a definative, proven and safer open decompression. This says something about ethics of the guys that are promoting in in the literature.
       
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      Jcm800

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        1+ The only reason to perform this unsafe, unproven procedure is because you are greedy
        and don't want to send the patient for a definative, proven and safer open decompression. This says something about ethics of the guys that are promoting in in the literature.

        i did some cases. I disagree with the greedy part. It is a long procedure with lots of fluoro, and it doesnt pay well for an hour compared to what you could do. I did it, because i thought it might work well, and is less invasive.

        My outcomes were not great, and i have basically stopped doing it, but if the literature shows better results, i may try again.
         

        Tenesma

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          it's all fun and games until
          a) pt has a big dural tear
          b) pt has a vascular injury - that goes un-noticed - and has a cauda 5 hours later...
           

          PinchandBurn

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            Havent seen/heard about any complications yet. Definitely not publishes.

            The literature seems pretty robust on it's safety profile...thus far....

            Just like with anything complications will surface no doubt.

            Also...in terms of the 'greedy' thing. It's a LOT of fluro and doesnt really reimburse all that well..... I have heard that on pts that are somewhat recalcitrant to ESIs for SS. One could do the MILD, then the patinet's become responsive to ESIs again. Seems to me to be a better option than full blown out surgery. If MILD fails, atleast 'surgery still remains an option.
             

            Jcm800

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              i did some cases. I disagree with the greedy part. It is a long procedure with lots of fluoro, and it doesnt pay well for an hour compared to what you could do. I did it, because i thought it might work well, and is less invasive.

              Doc shark just curious, how many did you do?

              1 million!!!!!

              7 or 8. at least half were two levels... probably not enough for the learning curve...
               

              101N

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                1 million!!!!!

                7 or 8. at least half were two levels... probably not enough for the learning curve...

                Let's talk through this.

                You read your own MRIs right? How many times in your career have you seen a patient with claudication due to a hypertrophied ligamentum flavum exclusively. That is, with no concomitant medial facet hypertrophy, lateral recess stenosis, and/or a calcified/ossified PLL/disc and anterior osteophytic ridge?

                MILD uses faulty logic, it's a contrived fix - like x-stop- for a problem that was cured years ago with decompression. You can not perform a laminectomy without visualization and this is simply a poor substitute for a laminectomy/laminotomy.
                 

                Jcm800

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                  Let's talk through this.

                  You read your own MRIs right? How many times in your career have you seen a patient with claudication due to a hypertrophied ligamentum flavum exclusively. That is, with no concomitant medial facet hypertrophy, lateral recess stenosis, and/or a calcified/ossified PLL/disc and anterior osteophytic ridge?

                  MILD uses faulty logic, it's a contrived fix - like x-stop- for a problem that was cured years ago with decompression. You can not perform a laminectomy without visualization and this is simply a poor substitute for a laminectomy/laminotomy.

                  i picked patients that had neurogenic claudication with spinal stenosis whos major contributor to their stenosis ligamentum flavum hypertrophy, without much NF stenosis. It took over 1 year to find 7 patients. I thought these were the best candidates. my results were 50-50. it took a long time, it was a lot of fluoro, but nobody was worse, but only 50% were much better. Thus i have taken a break. procedures evolve, and sometimes they are good, sometimes they are not.
                   

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                    i picked patients that had neurogenic claudication with spinal stenosis whos major contributor to their stenosis ligamentum flavum hypertrophy, without much NF stenosis.

                    I understand the lack of NF stenosis, what I would argue is that the lateral canal, and disc/pll, are bigger contributors to most cases of stenosis than the yellow ligament. How many times is unroofing the canal alone - laminectomy - sufficient to ameliorate radicular symptoms? In many or most instances it's accompanied by a medial facetectomy. With MILD you not only can't unroof the canal - not a true lami -, but you ignore lateral canal stenosis entirely.
                     

                    Jcm800

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                      I understand the lack of NF stenosis, what I would argue is that the lateral canal, and disc/pll, are bigger contributors to most cases of stenosis than the yellow ligament. How many times is unroofing the canal alone - laminectomy - sufficient to ameliorate radicular symptoms? In many or most instances it's accompanied by a medial facetectomy. With MILD you not only can't unroof the canal - not a true lami -, but you ignore lateral canal stenosis entirely.

                      i dont think it is as good as a decompressive lami, but i do believe it is MUCH less invasive, with significantly less downtime and recovery, not necessitating GA. The question is, in which patients, if any, is debulking the ligament ENOUGH? Some say many, I dont think thats true, or i would be doing 2 a week. But if i could pick and choose a few patients that i thought were good candidates, and have 75% good outcomes, i would do it, but i cant. So i currently am not. However, others, good honest people, say they can... i dont knwo
                       
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                      101N

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                        i dont think it is as good as a decompressive lami, but i do believe it is MUCH less invasive, with significantly less downtime and recovery, not necessitating GA. The question is, in which patients, if any, is debulking the ligament ENOUGH? Some say many, I dont think thats true, or i would be doing 2 a week. But if i could pick and choose a few patients that i thought were good candidates, and have 75% good outcomes, i would do it, but i cant. So i currently am not. However, others, good honest people, say they can... i dont knwo

                        I think your answers are honest and I respect that. IMO, this procedure doesn't pass the momma test.
                         

                        ParaVert

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                          MILD - good idea, needs some work. I've done 6, all > age 80, all reporting symptom improvement initially but only half are better at 6 months. I take significant issue with the thought that people doing MILD are somehow shady. My last MILD was 94, single level of stenosis, did well and is happy. She had a very thick ligament and a 5mm pseudolisthesis from facet widening. She would have fallen apart after a lami, but who in their right mind would PLIF her? As I saw/see it, it was MILD or nothing for her.

                          Agree with the idea of endoscopic spine, too bad 2012 CPT coding changes has essentially killed endoscopic spine surgery. An endoscopically-performed microdiscectomy, even if performed via interlaminar approach with hemilaminotomy, can only be billed as a 62287 (percutaneous discectomy) or perhaps 0275T, not a 63030.

                          Regarding coding for MILD, only 0275T is acceptable. Palmetto GBA, my CMS carrier in SC, is not paying a dime for it. I've done three since July, haven't seen a penny yet for any of them. Guess that makes me something other than greedy. Maybe stupid!
                           

                          epidural man

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                            Someone posted on an earlier thread about MILD that he knew of a case where nerve root went with the ligamentum flavum. That doesn't sound good to me.

                            That was me. 2 cases (bad dural tear and nerve damage) in arizona - unreported as far as I know.

                            I'm a little surprised that people are so against this procedure however. Personally, I think the more LESS invasive we go, the better. I'm not arguing that MILD is the answer - because I agree, if you can accomplish a lami under local/sedation in 30 min (as some really good neursurgeons can do) then MILD makes less sense. However, I think it is a good goal - kind of like moving to placing paddle leads percutaneously. Less invasive is good. Rhizotomies of medial brancehs used to be done. Holy crap!

                            Finally, MILD probably works - not because of real spinal decompression, but because you free up a previouisly immobile ligament and restore it's pliability. So it may make sense in some who have more than just ligamentum hypertrophy.

                            Don't fear change. ;) Be a force for good.

                            Oh, and vote Ron Paul.

                            http://www.youtube.com/watch?v=Tb5aGgQXhXo&feature=related
                             

                            PinchandBurn

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                              MILD - good idea, needs some work. I've done 6, all > age 80, all reporting symptom improvement initially but only half are better at 6 months. I take significant issue with the thought that people doing MILD are somehow shady. My last MILD was 94, single level of stenosis, did well and is happy. She had a very thick ligament and a 5mm pseudolisthesis from facet widening. She would have fallen apart after a lami, but who in their right mind would PLIF her? As I saw/see it, it was MILD or nothing for her.

                              Agree with the idea of endoscopic spine, too bad 2012 CPT coding changes has essentially killed endoscopic spine surgery. An endoscopically-performed microdiscectomy, even if performed via interlaminar approach with hemilaminotomy, can only be billed as a 62287 (percutaneous discectomy) or perhaps 0275T, not a 63030.

                              Regarding coding for MILD, only 0275T is acceptable. Palmetto GBA, my CMS carrier in SC, is not paying a dime for it. I've done three since July, haven't seen a penny yet for any of them. Guess that makes me something other than greedy. Maybe stupid!

                              Hey Paravert, did you ever try doing ESIs on these patients AFTER the MILD procedure? Just wanted to know what your thoughts were if you did. People claim , pts become responsive to ESIs again once the ligamentum is debulked and venous flow is opened up more.
                               

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                                NOSfan

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                                  i dont think it is as good as a decompressive lami, but i do believe it is MUCH less invasive, with significantly less downtime and recovery, not necessitating GA. The question is, in which patients, if any, is debulking the ligament ENOUGH? Some say many, I dont think thats true, or i would be doing 2 a week. But if i could pick and choose a few patients that i thought were good candidates, and have 75% good outcomes, i would do it, but i cant. So i currently am not. However, others, good honest people, say they can... i dont knwo

                                  MILD is a useful tool to have. My personal 2 year unpublished data shows about an 70-80% 'responder rate' (pain reduction by > 50%) with overall about 40-50% completely pain-free of neurogenic claudication symptoms.

                                  It does work, but just like with ANY intervention, you try and select the proper patient. Yes, I have had the patient that I was convinced from a clinical and technical standpoint that they would be helped by this intervention, but they were not.

                                  I have a good number of patients that the surgeon does not want to operate on for various reasons and many of these turn out to be amiable for the procedure. I have found that the symptoms may return after a year or arise at other levels likely due to the natural course and history of the pathology.

                                  In regard to complications, I believe that with > 15,000 levels addressed there have been only published reports of 2 dural tears, that apparently responded to blood patch and epidural man's nerve root through the ligamentum flavum.
                                   
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                                  lobelsteve

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                                    MILD is a useful tool to have. My personal 2 year unpublished data shows about an 70-80% 'responder rate' (pain reduction by > 50%) with overall about 40-50% completely pain-free of neurogenic claudication symptoms.

                                    It does work, but just like with ANY intervention, you try and select the proper patient. Yes, I have had the patient that I was convinced from a clinical and technical standpoint that they would be helped by this intervention, but they were not.

                                    I have a good number of patients that the surgeon does not want to operate on for various reasons and many of these turn out to be amiable for the procedure. I have found that the symptoms may return after a year or arise at other levels likely due to the natural course and history of the pathology.

                                    In regard to complications, I believe that with > 15,000 levels addressed there have been only published reports of 2 dural tears, that apparently responded to blood patch. I have not seen any other published complications.

                                    You failed to mention your N.
                                    And lack of awareness regarding the complications does not mean they do not exist. It means we do not find out about them until we are hired for the plaintiff/defense side or the case settles. The logic/science behind the procedure fails to impress me as being as safe as or as effective as lami.
                                     

                                    NOSfan

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                                      You failed to mention your N.
                                      And lack of awareness regarding the complications does not mean they do not exist. It means we do not find out about them until we are hired for the plaintiff/defense side or the case settles. The logic/science behind the procedure fails to impress me as being as safe as or as effective as lami.

                                      n=36 with (about half with multiple levels addressed)

                                      No lack of awareness....just going by the literature and my experience. Of course anything can happen with any procedure.

                                      Logic and science seems pretty good to me (<15,000 levels addressed and a number of peer reviewed articles) ...you don't work for the insurance companies on the side, do you......."We do not cover experimental procedures, so your payment for your SIJ block is denied!" :D
                                       

                                      drrosenrosen

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                                        My senior partner (been doing pain for twelve years very well) has done a couple. He said during the training he took, he tried to puncture dura on the cadaver with the instruments and couldn't. He's excited about it, but I'm going to wait and see what his experience is with it for a year or so before I consider doing the course.
                                         

                                        Tenesma

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                                          there is a big difference between real live dura and cadaveric dura...cadaveric dura is harder and there is no CSF to prop it up... and how did he know if he punctured dura - did he dissect the cadaver.
                                           

                                          101N

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                                            My senior partner (been doing pain for twelve years very well) has done a couple. He said during the training he took, he tried to puncture dura on the cadaver with the instruments and couldn't. He's excited about it, but I'm going to wait and see what his experience is with it for a year or so before I consider doing the course.

                                            Yea boys, we gotta do these procedures early on, while they still work.
                                             

                                            PinchandBurn

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                                              there is a big difference between real live dura and cadaveric dura...cadaveric dura is harder and there is no CSF to prop it up... and how did he know if he punctured dura - did he dissect the cadaver.


                                              For what it's worth. Typically at these courses they have a Dyed Blue normal saline under pressure hooked up in the intrathecal space somewhere in the thoracic/cervical region. This way if someone were to 'accidentally' pierce the dura, dyed blue solution would come out. I've seen this at a few cadaver courses now.

                                              Obviously not a perfect reproduction...But does the job in some regards.
                                               

                                              clubdeac

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                                                My senior partner (been doing pain for twelve years very well) has done a couple. He said during the training he took, he tried to puncture dura on the cadaver with the instruments and couldn't. He's excited about it, but I'm going to wait and see what his experience is with it for a year or so before I consider doing the course.

                                                I went to the course (actually back at Newport Beach this very moment) and purposefully and successfully punctured right through the dura. I knew I was through based on feel and fluoro. However to get through, I had to rotate the "tissue sculptor" 180 degees and apply significant force - more than possible for most normal humans. I wasn't able to puncture dura keeping the instrument properly aligned with the blunt edge of the sculpture facing the dura. So from that stand point, it seemed pretty safe.
                                                 

                                                ParaVert

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                                                  Hey Paravert, did you ever try doing ESIs on these patients AFTER the MILD procedure? Just wanted to know what your thoughts were if you did. People claim , pts become responsive to ESIs again once the ligamentum is debulked and venous flow is opened up more.

                                                  Yes. On 2 or 3 of my post-mild patients came back within 3-6 months with residual pseudoclaudication symptoms. CLO interlaminar epidurogram confimed that the improved epidural flow achieved intraoperatively was maintained.

                                                  Yes, it seems that patients had more lasting pain improvement after ESIs post-MILD. My "N" is too low to make sweeping statements, but those few patients did well post-ESI for >3 months. Those same patients were getting 2 weeks worth of relief from pre-MILD ESIs.
                                                   

                                                  lurkingrue

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                                                    Please, I'd ask that we all keep the politics out of the discussion. Personally, I think both parties have sold out to moneyed interests, and the alternatives (e.g.:crazy-man Paul) are one step away from Lord of the Flies. But, this isn't a political forum -- we're discussing MILD. I'd humbly request that we move back on track.

                                                    I very much respect the technical skill, the knowledge, professionalism and service-mindedness that most posters here exhibit. Political and religious discussions just detract from that.
                                                     

                                                    Tenesma

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                                                      that's a brilliant idea to inject pressurized blue dye into the thecal sac... i have never seen that at any of the courses I have been to... but a great idea none the less... however, i would assume that once one person nicks the dura, the whole concept is down the drain for any subsequent trainee.
                                                       

                                                      emd123

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                                                        that's a brilliant idea to inject pressurized blue dye into the thecal sac... i have never seen that at any of the courses I have been to... but a great idea none the less... however, i would assume that once one person nicks the dura, the whole concept is down the drain for any subsequent trainee.

                                                        No, actually not because they have an IV bag full of blue dye hanging up connected to an intrathecal catheter. They had this at the last Medtronic neuromodulation course I went to. Pretty cool.
                                                         
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