which level do you inject for stenosis

[10KHertz]

I’m worried about your reading comprehension as no where did I mention a lateral foraminotomy, only a laminectomy.

So you have things backwards , not I.

And as NJPain stated, there is no good data demonstrating that MILD is equal to a surgical posterior laminectomy, only data that MILD is better than no decompression at all in old sick patients.

My reading comprehension is just fine Sport…

The only confusion here is your understanding of open lumbar decompression surgery or laminectomy. All lamis are coupled with lateral decompressions.

Mild is proven with appropriate data for LSS and NCS.read more, I posted the most recent study above . You can deny your patients the procedure , but you can’t deny the data . It’s a legit option in the LSS pathway …

Formal laminectomy and decompressive surgery always includes a foraminotomy/facetectomy. Read op notes .

If you can Post an operative note with a simple posterior laminectomy only( no facetectomy/lateral decompression) , I’ll Venmo you $500. If not , just admit you’re a talking trash punk.

---

Members don't see this ad.

 

[soccrwz]

Here is my understanding:

MILD is for ligamentum flavum hypertrophy which causes CCS, now a laminectomy can improve both a large disc herniation and/or LFH which would allow for a posterior decompression. And yes they do do laminectomies only without altering the ascending facet outside its attachment with the lamina. Laminectomy involve removal of lamina and the ligamentum flavum. Now if they have osteophytic overgrown on the facets causing lateral recess stenosis this involves wide laminectomy and partial facetectomy usually if not fusing or paracentral herniation causing LRS as well. As a bigger ie not partial facetectomy can cause instability and would likely require a fusion, Its important to note laminectomy involves "total" removal of lamina, laminotomy is a partial removal used often to gain access to disc via tubular retractor or endoscopic intralaminar approach to gain access to the disc. A MILD procedure often involves removal of the laminar bone to gain access to the LFH which is a laminotomy.

Now laminectomy by itself would only decompress the posterior component but wouldn't change the LRS just giving room more medially in the central, LRS can be treated with wide laminectomy and partial facetectomy combined with is the more standard approach.

 

[10KHertz]

Here is my understanding:

MILD is for ligamentum flavum hypertrophy which causes CCS, now a laminectomy can improve both a large disc herniation and/or LFH which would allow for a posterior decompression. And yes they do do laminectomies only without altering the ascending facet outside its attachment with the lamina. Laminectomy involve removal of lamina and the ligamentum flavum. Now if they have osteophytic overgrown on the facets causing lateral recess stenosis this involves wide laminectomy and partial facetectomy usually if not fusing or paracentral herniation causing LRS as well. As a bigger ie not partial facetectomy can cause instability and would likely require a fusion, Its important to note laminectomy involves "total" removal of lamina, laminotomy is a partial removal used often to gain access to disc via tubular retractor or endoscopic intralaminar approach to gain access to the disc. A MILD procedure often involves removal of the laminar bone to gain access to the LFH which is a laminotomy.

Now laminectomy by itself would only decompress the posterior component but wouldn't change the LRS just giving room more medially in the central, LRS can be treated with wide laminectomy and partial facetectomy combined with is the more standard approach.

Yes , both MILD and a partial laminectomy improve central stenosis with NCS. Some surgeons use : Minimally Invasive Surgical (MIS) techniques include laminotomy and microendoscopic laminotomy with tubular retractors. This may be similar to what we do.

They do not address radiculopathies with LRS. I implied this several posts above …
I have not seen a “pure open total laminectomy” without partial facetectomy/lateral decompression in my life. They tend to go hand in hand , maybe for billing purposes (skeptical).
The point I was making , is that pure NCS with posterior element HLF and intraspinous ligament decompression (this element of decompression is the most important actually) and partial laminectomy does work = MILD.

You don’t knee jerk have to have open surgery on all NCS patients . How many failed laminectomies , and subsequent fusions are performed out there? I see it all the time.

I appreciate the discussion…

 

[deleted875186]

Yes , both MILD and a partial laminectomy improve central stenosis with NCS. Some surgeons use : Minimally Invasive Surgical (MIS) techniques include laminotomy and microendoscopic laminotomy with tubular retractors. This may be similar to what we do.

They do not address radiculopathies with LRS. I implied this several posts above …
I have not seen a “pure open total laminectomy” without partial facetectomy/lateral decompression in my life. They tend to go hand in hand , maybe for billing purposes (skeptical).
The point I was making , is that pure NCS with posterior element HLF and intraspinous ligament decompression (this element of decompression is the most important actually) and partial laminectomy does work = MILD.

You don’t knee jerk have to have open surgery on all NCS patients . How many failed laminectomies , and subsequent fusions are performed out there? I see it all the time.

I appreciate the discussion…

We should be discussing if MILD is actually going to help this patient. This is a different patient than what is described in the MILD studies, younger, primarily disc causing compression, with a mildly hypertrophic ligament. The outcome we are looking for is probably something better than “improved ability to walk before needing to rest”

 

[soccrwz]

Yes , both MILD and a partial laminectomy improve central stenosis with NCS. Some surgeons use : Minimally Invasive Surgical (MIS) techniques include laminotomy and microendoscopic laminotomy with tubular retractors. This may be similar to what we do.

They do not address radiculopathies with LRS. I implied this several posts above …
I have not seen a “pure open total laminectomy” without partial facetectomy/lateral decompression in my life. They tend to go hand in hand , maybe for billing purposes (skeptical).
The point I was making , is that pure NCS with posterior element HLF and intraspinous ligament decompression (this element of decompression is the most important actually) and partial laminectomy does work = MILD.

You don’t knee jerk have to have open surgery on all NCS patients . How many failed laminectomies , and subsequent fusions are performed out there? I see it all the time.

I appreciate the discussion…

the coding for laminectomy/laminotomies includes alot more and bundles foraminatomy/facectomy as well also people use laminectomy/laminotomy interchangeable like interlaminar and sadly intralaminar or translaminar; all nomenclature issues ( sorry if this sounds pendantic)

someone once told me they shortened the study for MILD since the longer studies showed it reoccured within a short period of time, now I don't know if this is true or not; anyone know the long term data for older folks?

 

[soccrwz]

the coding for laminectomy/laminotomies includes alot more and bundles foraminatomy/facectomy as well also people use laminectomy/laminotomy interchangeable like interlaminar and sadly intralaminar or translaminar; all nomenclature issues ( sorry if this sounds pendantic)

someone once told me they shortened the study for MILD since the longer studies showed it reoccured within a short period of time, now I don't know if this is true or not; anyone know the long term data for older folks?

Also there are several papers regarding not taking down the facets on pubmed discussing preservation of stability vs iatrogenic instability; I think the issue involves how specific you want to be about laminotomy vs laminectomy vs hemilamectomy how much is which is which kind of thing. I don't see alot of laminectomy only type surgeries as much as I see fusions anterior and posterior vs posterior only bilateral vs unilateral vs interspinous rod stabilizing devices etc, lots of variation among specialist within the same field, which I think means the field is advancing to figure out which new techniques work for which patient etc.

 

[deleted875186]

Also there are several papers regarding not taking down the facets on pubmed discussing preservation of stability vs iatrogenic instability; I think the issue involves how specific you want to be about laminotomy vs laminectomy vs hemilamectomy how much is which is which kind of thing. I don't see alot of laminectomy only type surgeries as much as I see fusions anterior and posterior vs posterior only bilateral vs unilateral vs interspinous rod stabilizing devices etc, lots of variation among specialist within the same field, which I think means the field is advancing to figure out which new techniques work for which patient etc.

Or it means the field is leaning towards fusion because of increased RVUs

 

[epidural man]

Regarding where to put the steroid. I believe it doesn’t matter and they all work. I personally would do a caudal - mostly because I hate watching residents do inter-laminar and I think particulate works better than Dex.

What is really funny is we are spending a good amount of time arguing procedural minutia on a procedure that most of the world doesn’t even think works.

 

[epidural man]

Technically a lateral foraminotomy is not indicated with nonradicular symptoms . A MILD is equivalent to a posterior Lami for NEUROGENIC CLAUDICATION symptoms … thus your logic is reversed IMO. Ie Less is best …FYI Vertos has pretty decent literature for its technique and was well accepted by Medicare nationwide.

MILD clearly works as proven by the Medicare funded study.

My beef is with your statement about it being less - certainly not the ones I’ve done or seen.

A single level lami takes 30-45 minutes and is a definitive decompression. There is no reason a healthy 40 year old shouldn’t take this option.

A MILD is blind kind of choppy and partial decompression that takes forever and is quite dangerous with several cliffs that need avoided.

 

[10KHertz]

All good points …
MILD is only a Medicare >65yo patient with NCS. Not really geared for any younger .

I agree the term laminectomy is vague at best, esp within the surgical literature and so many surgical variations, training variants .

A wide lami does open the lateral recesses for sure. At this time most MILD operators are only decompressing centrally along the lateral spinous process or medial only . We could use the bone rongeur more laterally for a wider laminar and ligament decompression, but this is not allowable YET. Don’t do a MILD on spondylolisthesis , not worth it.

I tell all my patients , this procedure helps you walk longer and stand more erect for a few years only . It does not palliate axial lbp , radiculopathies , etc. it’s a staged procedure , prior to a wider lami/foraminotomy procedure .

 

[soccrwz]

All good points …
MILD is only a Medicare >65yo patient with NCS. Not really geared for any younger .

I agree the term laminectomy is vague at best, esp within the surgical literature and so many surgical variations, training variants .

A wide lami does open the lateral recesses for sure. At this time most MILD operators are only decompressing centrally along the lateral spinous process or medial only . We could use the bone rongeur more laterally for a wider laminar and ligament decompression, but this is not allowable YET. Don’t do a MILD on spondylolisthesis , not worth it.

I tell all my patients , this procedure helps you walk longer and stand more erect for a few years only . It does not palliate axial lbp , radiculopathies , etc. it’s a staged procedure , prior to a wider lami/foraminotomy procedure .

I honestly appreciate the variations of approach to this topic because it expands all of our thoughts/knowledge and options regardless if we do or don't do these procedures so we can speak intelligently to patients.

I don't think debulk the LFH is the right answer, now I'm not scanning through the all the cuts but the disc looks like it central with cephalad direction and the Ligamentum flavums main bulk is at the bottom part of the herniation. Now surgically this would require a full laminectomy and foraminatomy if you left the disk intact, which would require a fusion, depending on your neck of the woulds this would problem be a PLIF, diskectomy and IB spacer at L4-5 without foraminotomy.

Patient's young and some literature out there says 85% resorption in 12 months of disc protrusion, but you don't want to be in that 15%. That number has been debated many times over.

 

[bedrock]

Technically a lateral foraminotomy is not indicated with nonradicular symptoms . A MILD is equivalent to a posterior Lami for NEUROGENIC CLAUDICATION symptoms … thus your logic is reversed IMO. Ie Less is best …FYI Vertos has pretty decent literature for its technique and was well accepted by Medicare nationwide.

My reading comprehension is just fine Sport…

The only confusion here is your understanding of open lumbar decompression surgery or laminectomy. All lamis are coupled with lateral decompressions.

Mild is proven with appropriate data for LSS and NCS.read more, I posted the most recent study above . You can deny your patients the procedure , but you can’t deny the data . It’s a legit option in the LSS pathway …

Formal laminectomy and decompressive surgery always includes a foraminotomy/facetectomy. Read op notes .

If you can Post an operative note with a simple posterior laminectomy only( no facetectomy/lateral decompression) , I’ll Venmo you $500. If not , just admit you’re a talking trash punk.

1- there is no medical reason she can’t have a lami so if you have a complication from MILD, you are particularly vulnerable legally.

I'm just saying that you are making assumptions and then posting, so either you are rushing or your reading comprehension is the issue. I suspect you are just rushing. Read the OP's two posts before yours. They didn't clarify if the patient had radicular pain or not. My post simply stated a lami and you assumed the rest.

Yes US surgeons do laminoforaminotomy 95% of the time because they charge more for it, but the argument I was making, which you either missed or rushed through, was that a true surgical laminectomy is clearly superior to MILD and so surgery is the best treatment for a non sick patient.

MILD certainly has its place for sicker patients that cannot tolerate GA.

 

[10KHertz]

ASRA article:
“However, less-invasive options should be tried prior to offering surgery. Surgery is portrayed as a definite treatment option but is not always effective, and complication rates as high as 40% have been reported.[7] Patients often need another surgery (reoperation rate of 23% in one series) and may still have significant residual discomfort.[8] Not every patient is a good surgical candidate due to coexisting medical issues. The Mild procedure is a good option for patients who are not responsive to conservative or injection therapy and are either not good surgical candidates or do not want open surgical decompression.”

MILD or No MILD? New case, new axial cut, NC symptoms only, ‘failed conservative pain care’, no progressive neurological deficits. ASA grade 2-3 surgical risk. Patient hesistant to pursue formal surgery. Everyday patient you seen hourly… what do you do ?

Figure 2: Thickened ligamentum flavum outlined in red on axial view MRI lumbar spin

My additional read: Looks like a paracentral diffuse disc bulging with lateral recess foraminal narrowing with no clinical radiculopathy yet…

Refer for open lami , wide lami , covering lateral lamina for lateral recess ? MIS endoscopic lami? MILD? Rogue MILD along lateral lamina as well ( 😂) ?

 

[lobelsteve]

ASRA article:
“However, less-invasive options should be tried prior to offering surgery. Surgery is portrayed as a definite treatment option but is not always effective, and complication rates as high as 40% have been reported.[7] Patients often need another surgery (reoperation rate of 23% in one series) and may still have significant residual discomfort.[8] Not every patient is a good surgical candidate due to coexisting medical issues. The Mild procedure is a good option for patients who are not responsive to conservative or injection therapy and are either not good surgical candidates or do not want open surgical decompression.”

MILD or No MILD? New case, new axial cut, NC symptoms only, ‘failed conservative pain care’, no progressive neurological deficits. Patient hesistant to pursue formal surgery. Everyday patient you seen hourly… what do you do ?

Figure 2: Thickened ligamentum flavum outlined in red on axial view MRI lumbar spin

My additional read: Looks like a paracentral diffuse disc bulging with lateral recess foraminal narrowing with no clinical radiculopathy yet…

Refer for open lami , wide lami , covering lateral lamina for lateral recess ? MIS endoscopic lami? MILD? Rogue MILD along lateral lamina as well ( 😂) ? No excuses …

That’s not a lot of ligament to remove.

 

[deleted875186]

ASRA article:
“However, less-invasive options should be tried prior to offering surgery. Surgery is portrayed as a definite treatment option but is not always effective, and complication rates as high as 40% have been reported.[7] Patients often need another surgery (reoperation rate of 23% in one series) and may still have significant residual discomfort.[8] Not every patient is a good surgical candidate due to coexisting medical issues. The Mild procedure is a good option for patients who are not responsive to conservative or injection therapy and are either not good surgical candidates or do not want open surgical decompression.”

MILD or No MILD? New case, new axial cut, NC symptoms only, ‘failed conservative pain care’, no progressive neurological deficits. ASA grade 2-3 surgical risk. Patient hesistant to pursue formal surgery. Everyday patient you seen hourly… what do you do ?

Figure 2: Thickened ligamentum flavum outlined in red on axial view MRI lumbar spin

My additional read: Looks like a paracentral diffuse disc bulging with lateral recess foraminal narrowing with no clinical radiculopathy yet…

Refer for open lami , wide lami , covering lateral lamina for lateral recess ? MIS endoscopic lami? MILD? Rogue MILD along lateral lamina as well ( 😂) ?

When the facets are big i feel as though it’s difficult to know where ligament begins. I think removing the ligament in this case won’t do much.

 

[10KHertz]

I agree this wouldn’t be my ideal MILD candidate, although these ASRA investigators used this case as an appropriate MILD case. Maybe they are simply addressing NCS . I think the HLF 2.5mm is just met, more HLF seems midline and centrally. The confounding issues is the diffuse disc and hypertrophic facets .
To be honest, i wouldn’t expect a prolonged benefit with MILD. Again this was a appropriate MILD case, not in my book .

 

[soccrwz]

ASRA article:
“However, less-invasive options should be tried prior to offering surgery. Surgery is portrayed as a definite treatment option but is not always effective, and complication rates as high as 40% have been reported.[7] Patients often need another surgery (reoperation rate of 23% in one series) and may still have significant residual discomfort.[8] Not every patient is a good surgical candidate due to coexisting medical issues. The Mild procedure is a good option for patients who are not responsive to conservative or injection therapy and are either not good surgical candidates or do not want open surgical decompression.”

MILD or No MILD? New case, new axial cut, NC symptoms only, ‘failed conservative pain care’, no progressive neurological deficits. ASA grade 2-3 surgical risk. Patient hesistant to pursue formal surgery. Everyday patient you seen hourly… what do you do ?

Figure 2: Thickened ligamentum flavum outlined in red on axial view MRI lumbar spin

My additional read: Looks like a paracentral diffuse disc bulging with lateral recess foraminal narrowing with no clinical radiculopathy yet…

Refer for open lami , wide lami , covering lateral lamina for lateral recess ? MIS endoscopic lami? MILD? Rogue MILD along lateral lamina as well ( 😂) ?

contributor disc>LFH, and hypertrophied facets causing SARS/LAR due to DOC. Unpopular opinion here but If no mayor surgery Stabilink as this will limit the motion of the facets and expand the foramen and ccs improving the NCS. Even if you excise the LFH those facets will make it build back up, I'm not sure if if this has been studied but this is what make sense to be that the irritation causes LFH and the irritation will still be present.

 

[Taus]

contributor disc>LFH, and hypertrophied facets causing SARS/LAR due to DOC. Unpopular opinion here but If no mayor surgery Stabilink as this will limit the motion of the facets and expand the foramen and ccs improving the NCS. Even if you excise the LFH those facets will make it build back up, I'm not sure if if this has been studied but this is what make sense to be that the irritation causes LFH and the irritation will still be present.

So by that logic you’d rec a fusion (MIS or not) over a decompression?

 

[gaspasser127]

I agree this wouldn’t be my ideal MILD candidate, although these ASRA investigators used this case as an appropriate MILD case. Maybe they are simply addressing NCS . I think the HLF 2.5mm is just met, more HLF seems midline and centrally. The confounding issues is the diffuse disc and hypertrophic facets .
To be honest, i wouldn’t expect a prolonged benefit with MILD. Again this was a appropriate MILD case, not in my book .

1) Why not Vertiflex for this patient instead? Agree there isn’t a whole lot of LF to scoop out of there. While minimum LFH to qualify for MILD based on their studies is 2.5 mm i feel the patients I sign up for it and have seen done well have LFH > 4mm. Hypertrophied facets and broad disc bludge are significant contributors to stenosis at this level as well so that’s why I think Vertiflex would be a better option.

2) the fluid in the facets makes me wonder whether there’s a listhesis present and if there’s a dynamic component to it. Im not necessarily a big fan of minuteman but this may be an appropriate case for it

 

[NJPAIN]

When the facets are big i feel as though it’s difficult to know where ligament begins. I think removing the ligament in this case won’t do much.

I believe that the ligament is an extension of the facet capsule.

 

[10KHertz]

1) Why not Vertiflex for this patient instead? Agree there isn’t a whole lot of LF to scoop out of there. While minimum LFH to qualify for MILD based on their studies is 2.5 mm i feel the patients I sign up for it and have seen done well have LFH > 4mm. Hypertrophied facets and broad disc bludge are significant contributors to stenosis at this level as well so that’s why I think Vertiflex would be a better option.

2) the fluid in the facets makes me wonder whether there’s a listhesis present and if there’s a dynamic component to it. Im not necessarily a big fan of minuteman but this may be an appropriate case for it

Yes , probabaly good to get some
Flex/Ext plain films to evaluate for a stealth listhesis. Good idea … or an upright f/e MRI out of pocket 😆 (you guys have these ?)
Even though MILD allows for grade 1 spondis, ive heard of progressive instability after the procedure with post op flex/Ext films getting worse… just don’t bother with slips/spondi’s and refer for the fusion (unfortunately).

 

[NJPAIN]

Yes , probabaly good to get some
Flex/Ext plain films to evaluate for a stealth listhesis. Good idea … or an upright f/e MRI out of pocket (you guys have these ?)
Even though MILD allows for grade 1 spondis, ive heard of progressive instability after the procedure with post op flex/Ext films getting worse… just don’t bother with slips/spondi’s and refer for the fusion (unfortunately).

When we start talking about MinuteMan and Stabilink for LSS with NIC are these technologies really offering significant benefit over decompression without instrumentation? Especially regarding Stabilink and similar, are the anesthetic requirements and surgical dissection all that different from decompression without instrumentation?

 

[soccrwz]

So by that logic you’d rec a fusion (MIS or not) over a decompression?

The extent of decompression you need would likely cause iatrogenic instability given SARS/ CCS (Disc>>LFH), and there may be some discogenic pain (annular tears etc) but i don't have all the images. mind you an intralaminar or interspinous device doesn't prevent a more aggressive decompression being done later, so from that point it has an advantage. The intralaminar devices afix to the lamina which is more stable and less likely to subsist verses a vertiflex which is intra spinous, and probably much higher rate of subsistence. Plus an intralaminar or maybe minuteman fusion device would address not on extensive movement but flexion as well since a fusion/bone grafting is performed. The stabilink does well for these type of cases in the right patient, and doesn't prevent a large fusion if it is necessary down the line. Some of the literature notes 18-25% increase in both Foraminal size and cc. I agree get flex/ex with 6v makes sure no pars defect; now if dynamic instability your thinking full blown fusion which is 6-8 month recovery, adjacent level disease down the road, these ISD/IL fixation device recovery is much less. Plus with a stabilink you can use a cobb and expose the facets debride them to facilitate fusion there as well since you can access them if you dissect down the the lamina. Given more extensive dissection GA may be better for stabilinks. A laminectomy but itself wouldn't be sufficient to address the SARS/FS.

 

[Ducttape]

MILD is not equivalent to open lami. i tell patients that from the get go.

MILD is helpful for those older patients who cannot undergo surgical correction.

in that last patient, she should see a surgeon first. MILD would not be the first or second choice.

the surgeon should detail the specific reason why he would not offer surgery (the ones i refer are very good at doing this).