Vertiflex vs MILD vs Lami vs ESI: Ethics, SOS, and Role of the Pain Physician

IPSIS: Formerly the Spine Intervention Society
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I don't do Vertiflex or MILD (or Lami), but in my neck of the woods there seems to be a high correlation between ASC ownership and these procedures. I like the idea though since ESI band-aids only help for so long.
 
Ferrismonk said:
I don't do Vertiflex or MILD (or Lami), but in my neck of the woods there seems to be a high correlation between ASC ownership and these procedures. I like the idea though since ESI band-aids only help for so long.
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Can you elaborate on how ASC ownership or HOPD SOS could impact medical judgment related to caring for patients?
 
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Are people getting good results with MILD?
 
Agast said:
Are people getting good results with MILD?
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Do you know how generalizable Tim Deer's clinical experience is with this procedure?


“This is very exciting to show that we can use minimally invasive procedures like MILD to improve function and improve pain scores,” said Timothy R. Deer, MD, a clinical professor of anesthesiology and pain medicine at West Virginia University School of Medicine, in Morgantown, who was not involved in the research. Given the short-term relief or complete lack of relief from epidural steroids, Dr. Deer said, “MILD should be moved earlier in the algorithm.” Dr. Deer is the president and CEO of The Spine and Nerve Center of The Virginias, in Charleston"

Dr. Deer serves as a consultant to Cornorloc, Vertiflex and Vertos.
 
honestly, I do not ever think of ASC v HOPD when I am discussing injections with patients.

I think of risks, benefits, potential complications and whether the patient would reasonably be able to tolerate the procedure...

but since you bring it up, I will consider whether to scam the system and have all procedures done at HOPD from here on out.

(even though all procedures are ASC at this system, and all the major carriers have set price fees for all the major procedures....)
 
Ducttape said:
honestly, I do not ever think of ASC v HOPD when I am discussing injections with patients.
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Exactly.

IMHO, overwhelmingly, whichever facility/entity the physician is associated with is where they will tend to perform there procedures/surgeries. It's a simple matter of economy of time.
 
drusso said:
Who, what, where, when, and why?
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The sad thing about Vertiflex is the study which notes that Vertiflex "is not inferior" to X-stop (which of course, did not work). We did a bunch of X-stop in our practice and it never seemed to work; there is a reason Medtronics dumped it.

I am amazed that people continue to ignore Jim Wienstein's article on surgery vs conservative care for lumbar stenosis. We have a great, very effective means of treating lumbar stenosis. ALL of the alternative treatments have inferior results (in any) compared to a lumbar laminectomy.

Unfortunately, we have hubris, a desire for cash, and a culture of physicians who will perform the newest procedure (despite marginal evidence) for fear of being viewed as passé.
 
drusso said:
Do you know how generalizable Tim Deer's clinical experience is with this procedure?


“This is very exciting to show that we can use minimally invasive procedures like MILD to improve function and improve pain scores,” said Timothy R. Deer, MD, a clinical professor of anesthesiology and pain medicine at West Virginia University School of Medicine, in Morgantown, who was not involved in the research. Given the short-term relief or complete lack of relief from epidural steroids, Dr. Deer said, “MILD should be moved earlier in the algorithm.” Dr. Deer is the president and CEO of The Spine and Nerve Center of The Virginias, in Charleston"

Dr. Deer serves as a consultant to Cornorloc, Vertiflex and Vertos.
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The fact that Tim Deer embraces this procedure should be a substantial reason to avoid it.

"MILD" should be eliminated from any rational "algorithm".
 
drusso said:
Can you elaborate on how ASC ownership or HOPD SOS could impact medical judgment related to caring for patients?
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HOPD SOS has nothing to do with it. Sorry about that one.

What I was saying is that I don't see hospital employed pain docs in my area doing MILD or Vertiflex. Surgeons just do the lami. I see independent pain docs with ASC ownership doing them and I'm sure it is at least partially related to the facility reimbursement.
 
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paindoc007 said:
What’s your reasoning for this?
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He is the current Ken Allo- the guy promotes dubious treatments at meetings and is a schill for the equipment companies. I am sure he is so happy about his arrangements he can barely count.

Yes- mild is commonly known as "minimally effective lumbar decompression" (MELD). It is nearly impossible to provide any significant decompression via this method. The vast majority of true stenosis (8mm or less in the lumbar spine) requires a bony decompression which can only be done via laminectomy. This is just another scam promoted by the pain field; there is a very good reason the insurers do not cover this. If you have scrubbed in on a number of lumbar laminectomies, this becomes quickly apparent.

Vertiflex has been shown to be "no less effective" than X-stop (which did not work). However, I am going to go to the course for this and then hang out with someone who does this. Why? Even though I think it is marginally effective, it is good to know how to do it to be well informed and be able to show others if the need arises. Surgery will get more and more minimally invasive, but I am skeptical of widespread implementation of a marginally effective procedure just to serve that purpose as a "stepping stone". I was skeptical about x-stop (rightfully so), but that did not stop our group from dropping many of those in; I don't think I saw significant relief in anyone who had x-stop longer term.

However, there are people here who feel vertiflex is very effective. These docs have evaluated the treatment and have implemented it in good faith. We all know there is more than one way to skin a cat, and we must accept that our personal views may not always be correct and in many instances may not be shared by others.
 
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Ferrismonk said:
I don't do Vertiflex or MILD (or Lami), but in my neck of the woods there seems to be a high correlation between ASC ownership and these procedures. I like the idea though since ESI band-aids only help for so long.
Click to expand...

Have you not found Vertiflex effective? Just curious.
 
hawkeye2009 said:
He is the current Ken Allo- the guy promotes dubious treatments at meetings and is a schill for the equipment companies. I am sure he is so happy about his arrangements he can barely count.

Yes- mild is commonly known as "minimally effective lumbar decompression" (MELD). It is nearly impossible to provide any significant decompression via this method. The vast majority of true stenosis (8mm or less in the lumbar spine) requires a bony decompression which can only be done via laminectomy. This is just another scam promoted by the pain field; there is a very good reason the insurers do not cover this. If you have scrubbed in on a number of lumbar laminectomies, this becomes quickly apparent.

Vertiflex has been shown to be "no less effective" than X-stop (which did not work). However, I am going to go to the course for this and then hang out with someone who does this. Why? Even though I think it is marginally effective, it is good to know how to do it to be well informed and be able to show others if the need arises. Surgery will get more and more minimally invasive, but I am skeptical of widespread implementation of a marginally effective procedure just to serve that purpose as a "stepping stone". I was skeptical about x-stop (rightfully so), but that did not stop our group from dropping many of those in; I don't think I saw significant relief in anyone who had x-stop longer term.

However, there are people here who feel vertiflex is very effective. These docs have evaluated the treatment and have implemented it in good faith. We all know there is more than one way to skin a cat, and we must accept that our personal views may not always be correct and in many instances may not be shared by others.
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I don't think they're teaching Vertiflex anymore?
 
drusso said:
I don't think they're teaching Vertiflex anymore?
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Really? Why not?

I contacted the rep to go learn about it. Too many guys trained in it?

I personally am not enthusiastic about it as a strong option for people with stenosis, but like to learn as much about new procedures as I can, whether I am going to use them or not.
 
Was offered to train a couple weeks ago
 
I have been doing MILD for about one year. Non employed and non-owner doing in hospital for patients who can't or don't want to have surgery. We have had good results for many of our patients. Our success rate is probably closer to 60% rather than the 80% stated in the study.
 
Learned some Vertiflex and MILD in my training. With Vertiflex, a lot of patients got excellent results. I am contemplating it in the future for some patients after epidurals stop working. With me personally, while I am salaried currently, even if I have ASC ownership, I will never allow profit to drive my thought process. At the end of day, you will be successful and lucrative in your career if you're the guy who does the right thing for the patient and has proven success and results because you identified the pathology, and gave an appropriate treatment plan that worked. I've seen some people letting RVUs or reimbursement influence their treatment process, those people are not only A) un-ethical, but they're also B) dumb and short-sighted. Good luck when your results are trash and word spreads that you're an "mediocre doctor."
 
people seems to hate personal experience and anecdotes on this board but i'll give mine anyways - vertiflex - definitely not for everyone. i truely do think laminectomy is best for decompression - but with the caveat that it is significantly more invasive than vertiflex. vertiflex is not a cure all and i've had a range of homeruns to not effective. ones i do are usually old patients with comorbities or patients who absolutely refuse surgery.
i've sometimes obtained pre and post MRI to prove it did decompress - and yes it does decompress.
ones that i did recently that are memorable - 65 yo guy with mechanical aortic valve on forever warfarin - L4-L5 3mm severe stenosis. surgeon didn't want to touch it due to risk of valve clotting off of warfarin. i've arranged with his cardiologist to bridge with lovenox - hold 24 hours - vertiflex - and resume warfarin and lovenox until therapeutic - his sciatica/claudication is gone with some residual back pain.
i also did 95 yo L4-L5 under no sedation - just local only - neurogenic claudication gone.
you can call it anecdotes but for me it has its roles and you just have to deploy it in the right people in the right settings.
i can't attest for MILD since i don't do those.
 
I think you can push the envelope on the anticoagulants with vflex. I have done them on ASA/plavix and INR around 1.6 (separate patients). Had to use the bovie on the first one. Only time I have ever used it on a vflex.
 
Speaking of which...I spoke to a cardiologist yesterday about Lovenox bridging with Coumadin patients and he said definitely DO NOT ever bridge with Lovenox anymore.

The bleeding associated with the procedure is too great, and the risk is much higher than just being on Coumadin.

He's talking about pacemakers obviously, but that's what the cardio literature shows.

Aortic valve patient on Coumadin needs to stay on Coumadin.
 
I had a kypho that bridged pretty aggressively with lovenox (resuming lovenox and Plavix after the procedure for a couple days while the plavix reaches efficacy) and was on ASA and she went to the ER as her tiny incision started bleeding quite a bit on post op day 2. They stopped the lovenox and everything resolved. Her bandage was dry In recovery and she had no bleeding during the procedure.
 
Skrillex said:
Learned some Vertiflex and MILD in my training. With Vertiflex, a lot of patients got excellent results. I am contemplating it in the future for some patients after epidurals stop working. With me personally, while I am salaried currently, even if I have ASC ownership, I will never allow profit to drive my thought process. At the end of day, you will be successful and lucrative in your career if you're the guy who does the right thing for the patient and has proven success and results because you identified the pathology, and gave an appropriate treatment plan that worked. I've seen some people letting RVUs or reimbursement influence their treatment process, those people are not only A) un-ethical, but they're also B) dumb and short-sighted. Good luck when your results are trash and word spreads that you're an "mediocre doctor."
Click to expand...

i agree with you 100%, but thats a pretty naive take. some one the worst, most "mediocre" docs around are the busiest and make the most money. just b/c you do a crappy job, doesnt mean that you wont be busy or make a ton of money. i know a surgeon who takes out every lamina that walks in his door, and he always has a full waiting room...... not that im advocating for that type of practice.
 
SommeRiver said:
Speaking of which...I spoke to a cardiologist yesterday about Lovenox bridging with Coumadin patients and he said definitely DO NOT ever bridge with Lovenox anymore.

The bleeding associated with the procedure is too great, and the risk is much higher than just being on Coumadin.

He's talking about pacemakers obviously, but that's what the cardio literature shows.

Aortic valve patient on Coumadin needs to stay on Coumadin.
Click to expand...

even though you stop lovenox for 24 hours? interesting. this is news to me. my pt did bleed like stink even though he stopped lovenox btw..
 
That's what he said, and apparently the cardio literature supports it. I haven't looked it up myself, but this guy was pretty straight forward about Lovenox simply being too potent...Again, that's pacemaker placement in the cardio world and not an epidural, but it is something to think about...

I can't REMEMBER an issue in my experience with Lovenox, but I've only done it a few times.

Edit - Can we PLEASE get a few societies to recommend staying on AC for lumbar TFESI?
 
SSdoc33 said:
i agree with you 100%, but thats a pretty naive take. some one the worst, most "mediocre" docs around are the busiest and make the most money. just b/c you do a crappy job, doesnt mean that you wont be busy or make a ton of money. i know a surgeon who takes out every lamina that walks in his door, and he always has a full waiting room...... not that im advocating for that type of practice.
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That's at least better than all the surgeons that fuse, fuse, fuse
 
I’ve done less than 10 Superion spacers. Overall, patient experience has been very positive if you manage their expectations and optimize patient selection. I do realize this is all anecdotal.
 
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BobBarker said:
I think you can push the envelope on the anticoagulants with vflex. I have done them on ASA/plavix and INR around 1.6 (separate patients). Had to use the bovie on the first one. Only time I have ever used it on a vflex.
Click to expand...
Do you make 2 separate small incisions when you have a 2 level Vertiflex, or one long incision? I just did my first cases and for my 2 level, I made one long incision from the mid top spinous process to the mid bottom process. I used cerebellar retractors, a little bovie, and a 3 layer closure, even closing fascia around the supraspinous ligament. The patient has done great but I think I’m the future I would just make 2 small incisions instead to make closure a lot easier.
 
Two small incisions unless the patient is just the right amount obese and then you can probably do it through one small incision. I typically throw just one vicryl deep and two simple sutures to close the skin.
 
On a related note, did anyone else hear that the reimbursement on VERTIFLEX is going down 22% solely because of "billing errors" by a hospital in south central US that did nearly 20% of the cases in the nation??
 
NJPAIN said:
On a related note, did anyone else hear that the reimbursement on VERTIFLEX is going down 22% solely because of "billing errors" by a hospital in south central US that did nearly 20% of the cases in the nation??
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That sucks, where did you find that out? I don't have a surgery center or hospital stake, so I actually lose money leaving clinic to implant these things, but I think that Vertiflex will turn out to be a game-changing procedure for poor laminectomy candidates.
 
I think it’s a great procedure in the appropriate candidate as well.

The info regarding reimbursement was both from a rep and a news story posted on the internet. Apparently Vertiflex has attempted to do damage control but they are getting no where.

Perhaps others here know more details?


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Post the news story. It sounds unlikely.

Can’t see too many ways to make a billing “error”. Billing 22867 instead of 22869 only increases the physician fee. Billing 22612 and keeping them inpatient a day would be fraud.
 
I’m saying the hospital billing error story is unlikely. The reimbursement cut is accurate. They stepped it back to what it was in 2017.
 
That is really interesting. Thanks for finding that.
So a hospital was not recording the device code appropriately making their cost look much less than what it actually was, thereby skewing the data to make the procedure look more profitable that it actually was.
 
One hospital screwed vertiflex. I wonder who the doctor and hospital is to blame here. Oh wait, we all know that answer
 
I don’t think there is any dr to blame. I don’t know any dr’s that are involved with that aspect of coding. It wasn’t a CPT issue. Which doctor do you think is to blame?
 
NJPAIN said:
On a related note, did anyone else hear that the reimbursement on VERTIFLEX is going down 22% solely because of "billing errors" by a hospital in south central US that did nearly 20% of the cases in the nation??
Click to expand...
Yes this is the official company line.
 
NJPAIN said:
On a related note, did anyone else hear that the reimbursement on VERTIFLEX is going down 22% solely because of "billing errors" by a hospital in south central US that did nearly 20% of the cases in the nation??
Click to expand...

that bobbarker screwed us all

jk
 
i've been noticing a trend this year people are schilling/promoting MILD over vertiflex. i'm guessing the company got a new investor and is trying to influence key figures.. any thoughts on this? why is a procedure that went away reviving at this point? does it really work? in my opinion it's more invasive than vertiflex but feel free to educate me.
 
TIVAndy said:
i've been noticing a trend this year people are schilling/promoting MILD over vertiflex. i'm guessing the company got a new investor and is trying to influence key figures.. any thoughts on this? why is a procedure that went away reviving at this point? does it really work? in my opinion it's more invasive than vertiflex but feel free to educate me.
Click to expand...

How would we know it works if it did? Kypho deuce...
 
TIVAndy said:
i've been noticing a trend this year people are schilling/promoting MILD over vertiflex. i'm guessing the company got a new investor and is trying to influence key figures.. any thoughts on this? why is a procedure that went away reviving at this point? does it really work? in my opinion it's more invasive than vertiflex but feel free to educate me.
Click to expand...

Looks like they are trying to ride the Vertiflex coattails. Seems to be a strong connection to ASPN.

It’s a company and a procedure that has taken so many hits but never seems to die.


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