If you experience chronic low back pain (CLBP), you may have questions: What’s causing it? What do my symptoms mean? Will my condition worsen as I age? How can I find relief?

You’re looking for answers—and you’re not alone. Unlike other debilitating conditions, researchers have never truly known how many people suffer from CLBP. Until recently, many patients have been left in the dark about the cause of their pain or their options for treatment.

As revealed in the Mobility Matters: Landmark Survey on Chronic Low Back Pain in America, created in partnership with The Harris Poll, there are many misconceptions about chronic low back pain, including its potential causes, symptoms, and treatment options.

Before this survey, we didn’t know which patients were suffering the most, or how the CLBP experience may change through life’s decades. In this blog, we’ll share the results of the survey, explore a common, yet often undiagnosed, cause of CLBP, and discuss some of the treatment options available for patients seeking relief.

According to Mobility Matters: Landmark survey on chronic low back pain in America, an infographic. More than 72 million US adults report experiencing CLBP. 27 millions have never been told exactly what's causing their CLBP. More than 8 in 10 wish there were better treatment options for CLBP. Silhouette image of a woman with shopping cart syndrome leaning on a shopping cart to alleviate back pain symptoms. Silhouette image of a man sitting down on a chair to alleviate his back pain.

See more insights from the survey here >

Introducing the Mobility Index

As we grow older, it can be difficult to assess which mobility challenges are a normal part of aging, and which ones may indicate a condition such as CLBP. The Mobility Index, developed as part of the national Know Your Back Story campaign, was designed to demonstrate how older adults could be moving through life if chronic low back or leg pain was not a limiting factor.

Through the Decades: How Does Your Mobility Measure Up?

Poll results show that with age, CLBP patients experience significantly greater challenges performing physical tasks and making it through the day without pain than their peers who do not suffer from low back pain.

Infographic - Mobility Index through the decades. Comparing pain and mobility differences between people with and without chronic low back pain (CLBP) in their 50s. Stand for 30+ minutes: 76% without CLBP, 33% with CLBP. Walk 1+mile: 75% without CLBP, 36% with CLBP. Dance through entire song: 77% without CLBP, 41% with CLBP. Often make it through day without any physical pain: 70% without CLBP, 30% with CLBP. Infographic - Mobility Index through the decades. Comparing pain and mobility differences between people with and without chronic low back pain (CLBP) in their 60s. Stand for 30+ minutes: 77% without CLBP, 35% with CLBP. Jogging: 50% without CLBP, 13% with CLBP. Satisfied with how well my body gets around: 80% without CLBP, 45% with CLBP. Often make it through day without any physical pain: 73% without CLBP, 31% with CLBP.Infographic - Mobility Index through the decades. Comparing pain and mobility differences between people with and without chronic low back pain (CLBP) 65 and older. Going up and down stairs: 79% without CLBP, 44% with CLBP. Walk 1+ mile: 70% without CLBP, 35% with CLBP. Satisfied with how well my body gets around: 81% without CLBP, 42% with CLBP. Often make it through day without any physical pain: 76% without CLBP, 31% with CLBP.Infographic - Mobility Index through the decades. Comparing pain and mobility differences between people with and without chronic low back pain (CLBP) in their 70s. Stand for 30+ minutes: 73% without CLBP, 36% with CLBP. Go up and down stairs: 80% without CLBP, 46% with CLBP. Gt up and down from floor: 66% without CLBP, 28% with CLBP. Often make it through day without any physical pain: 77% without CLBP, 31% with CLBP.

What Could You Do With Fewer Limitations?

If you’re suffering from CLBP, you’re already familiar with the limits your pain can put on daily tasks and activities. But do you know just how much you could be doing without these obstacles?

Image: A physician in a white doctor's coat smiles and reassures an elderly patient, a smiling woman wearing a sweater. Text: Standing for 30+ Minutes. Among adults who don't suffer from CLBP, nearly 3 in 4 individuals aged 50-79 are able to easily stand for 30 minutes or longer. In contrast, the number of CLBP patients in the same age range who can do the same is just over 3 in 10.

Mobility In Your 50s

For CLBP patients in their 50s, having difficulty doing physical activities that were once a regular part of life, such as walking a mile or dancing for the duration of one song, can feel especially discouraging.

Image: Silhouettes of people walking lengthening distances on a chart. CLBP patients in their 50s that can easily walk for one mile or more, only 36%. Can easily dance through an entire song, only 41%. 50-somethings without CLBP that report being able to do these activities with ease, over 75%.

Mobility In Your 60s

For people in their 60s, there are some activities like—jogging—that aren’t for everyone. Even among individuals without CLBP, only 50% of respondents in their 60s reported the ability to jog with ease. However, for patients suffering with chronic low back pain, this number plummets to only 13%.

2 circle graphs. One shows 50% complete, the other only shows 13% complete.

And whether jogging, walking, or doing anything else, fewer than half of CLBP patients in their 60s say they feel satisfied with how their body gets around. In contrast, 80% of 60-somethings without CLBP are satisfied with their mobility.

2 circle graphs. One shows 80% complete, the other only shows 45% complete.

Image: Elderly woman holding coffee mug, with glasses on her head, looking in the distance. Text: 7 in 10 patients between 50 and 79 say they are often unable to make it through the day without pain. Graph description: 10 body silhouettes, 7 out of 10 are colored in blue. 3 remain grey. 2nd graph description: 10 body silhouettes, 3 out of 10 are colored in navy blue. 7 remain grey. Text: Among their peers, this number drops to 3 in 10.

Mobility In Your 70s

Did you know that 80% of people in their 70s without CLBP are able to easily go up and down the stairs? If you are a CLBP sufferer in your 70s, you may have a much different experience, as fewer than half of CLBP patients in their 70s reported the same mobility using stairs.

Image: Elderly Hispanic couple walking down a staircase, hands on the banister, both smiling. Text: I can go up and down the stairs with ease. Graph: 80% shows non-CLBP, 45% shows CLBP.

Getting up from the floor is another activity that impacts CLBP sufferers much more than their peers who don’t experience chronic pain. While 66% of 70-somethings without CLBP reported ease in getting up or down from the floor, only 28% of those with CLBP were able to say the same.

Image: White man in his 60s, sitting on the floor, receiving a helping hand, smiling and getting pulled up. Text: I can get up or down from the floor with ease. Non-CLBP 66%. CLBP 28%.

Could An Enlarged Ligament Be Causing Your Low Back Pain?

Image: White man in his 60s, sitting, hunched over in pain, with his hand on his lower back. Text: 84% of people suffering from CLBP report moderate or severe pain

One cause of low back pain that often goes undiagnosed is an enlarged ligament, which can contribute to lumbar spinal stenosis (LSS), a common, yet overlooked, condition that millions of people may be unaware of.

Image: White woman in her 60s, sitting, hunched over in pain, with her hand on her lower back. Text: 78% of adults with chronic low back pain don't know that an enlarged ligament could be the cause.

What Is Lumbar Spinal Stenosis?

Lumbar spinal stenosis (LSS) is a common, yet overlooked, condition that is prevalent in nearly 20% of patients over the age of 60.

LSS is often caused by an enlarged ligament in the back, which compresses the space in the spinal canal and puts pressure on the nerves in the lower back. This pressure around the spinal cord can cause pain, numbness, heaviness, or tingling in the low back, legs, and buttocks.

How CLBP Impacts Daily Life

Unsurprisingly, the chronic low back pain that may be caused by LSS has negative impacts on nearly every aspect of a patient’s life, most commonly in their abilities to exercise, stand or walk for long periods of time, and get a good night’s sleep.

US adults say CLBP has interfered with their ability to complete every day tasks: Exercising 63%, Standing 63%, Walking 58%, Getting a good night's sleep 55%

Low Back Pain & LSS Treatments

Due to its minimally invasive nature and long-lasting durability, many interventional pain management doctors are making the move to mild® as an alternative to epidural steroid injections (ESIs), which may only work in the short-term and may require repeat injections to maintain relief.

More invasive courses of treatment can include procedures such as spacer implants or open surgery, though nearly 80% of CLBP sufferers have concerns about undergoing surgery.

The mild® Procedure, or minimally invasive lumbar decompression, is considered a gold standard of care among treatments for low back pain. By addressing the root cause of pain, the enlarged ligament, mild® has helped 88% of patients avoid back surgery for at least 5 years while providing lasting relief.

For Many Sufferers of CLBP, It Doesn’t Just Go Away On Its Own.

89% of patients have been experiencing CLBP for1 year or more, with more than half (57%) experiencing it for more than 5 years. Circle graphs: 89% 1 year or more vs 57% more than 5 years.

If you’re looking for answers about your chronic low back pain, a spine health doctor can help you determine the cause and provide you with treatment options that fit your needs.

Find a spine health doctor in your area

Learn more about Mild

When patients present complaining of chronic low back pain (CLBP), they’re relying on you, as their provider, to help them find answers. Many patients want to know what’s causing their pain, how their condition will progress over time, and perhaps most importantly, how they can find relief.

As revealed in the Mobility Matters: Landmark Survey on Chronic Low Back Pain in America, created in partnership with The Harris Poll, many CLBP patients feel that they have been left in the dark about the cause of their pain or their options for treatment; as a provider, you’re all too familiar with the challenges and frustrations that can come with chronic pain.

According to Mobility Matters: Landmark survey on chronic low back pain in America, an infographic. More than 72 million US adults report experiencing CLBP. 27 millions have never been told exactly what's causing their CLBP. More than 8 in 10 wish there were better treatment options for CLBP.

In this blog, we’ll share some of the results of the groundbreaking survey, including new insights into how CLBP can impact patients’ lives as they age. We’ll also explore a common, though often undiagnosed, cause of CLBP and discuss some of the treatment options available for patients seeking relief.

By staying informed about the causes of low back pain, educating patients about their treatment options, and encouraging patients to seek help from spine health specialists, healthcare providers can play a key role in improving patients’ quality of life.

See more insights from the survey here >

78% of Adults With Chronic Low Back Pain Don’t Know That An Enlarged Ligament May Be the Cause.

One cause of CLBP that often goes undiagnosed is an enlarged ligament in the lower back, which can contribute to lumbar spinal stenosis (LSS). LSS is a common, yet overlooked, condition that is prevalent in nearly 20% of patients over the age of 60.

LSS is often caused by an enlarged ligament in the back, which compresses the space in the spinal canal and puts pressure on the nerves in the lower back. This pressure around the spinal cord can cause pain, numbness, heaviness, or tingling in the low back, legs, and buttocks.

By recognizing the symptoms and understanding the treatment options, you may be able to identify the condition sooner in your patients with chronic low back pain and get them on the path to lasting relief.

84% of people suffering from CLBP report moderate or severe pain

Unsurprisingly, CLBP that may be caused by LSS has negative impacts on nearly every aspect of a patient’s life—most commonly in the ability to exercise, stand or walk for long periods of time, or get a good night’s sleep.

US adults say CLBP has interfered with their ability to complete every day tasks: Exercising 63%, Standing 63%, Walking 58%, Getting a good night's sleep 55%

Introducing the Mobility Index

As patients age, it can be difficult to assess which mobility challenges are a normal part of aging, and which may have an explanation, such as an enlarged ligament.

The Mobility Index was designed to demonstrate just how different life could be for older adults if chronic low back or leg pain was not a limiting factor.

Results from the Mobility Matters survey indicate that adults with CLBP face significantly more difficulties performing physical activity and making it through the day without pain than their peers without chronic pain.

Infographic - Mobility Index through the decades. Comparing pain and mobility differences between people with and without chronic low back pain (CLBP) in their 50sInfographic - Mobility Index through the decades. Comparing pain and mobility differences between people with and without chronic low back pain (CLBP) in their 60sInfographic - Mobility Index through the decades. Comparing pain and mobility differences between people with and without chronic low back pain (CLBP) 65 and older.Infographic - Mobility Index through the decades. Comparing pain and mobility differences between people with and without chronic low back pain (CLBP) in their 70s

What Could Your Patients Do With Fewer Limitations?

Patients who suffer from CLBP are already familiar with the limits their pain can put on carrying out daily tasks and activities. But they may not even realize just how much they’re missing out.

When it comes to activities such as walking, dancing, using the stairs, and more, the Mobility Index can be a great tool for educating patients. By reviewing the differences in mobility between individuals with and without CLBP, you can help your patients understand more about their mobility and their options for relief.

Standing for 30+ Minutes. Among adults who don't suffer from CLBP, nearly 3 in 4 individuals aged 50-79 are able to easily stand for 30 minutes or longer. In contrast, the number of CLBP patients in the same age range who can do the same is just over 3 in 10.

Mobility By the Decades: 50s

For CLBP patients in their 50s, having difficulty doing physical activities that were once a regular part of life, such as walking a mile or dancing for the duration of one song, can feel especially discouraging.

CLBP patients in their 50s that can easily walk for one mile or more, only 36%. Can easily dance through an entire song, only 41%. 50-somethings without CLBP that report being able to do these activities with ease, over 75%.

Mobility By the Decades: 60s

For patients in their 60s, there are some activities—like jogging—that aren’t especially popular. Even among individuals without CLBP, only 50% of respondents in their 60s reported the ability to jog easily. However, for patients suffering with CLBP, this number plummets to only 13%.

 

Chart: 50% vs 13%

Fewer than half of CLBP patients in their 60s say they feel satisfied with how their body gets around. In contrast, 80 percent of 60-somethings without CLBP are satisfied with their mobility. Non-CLBP 80%, CLBP 45%

Mobility By the Decades: 70s

80% of people in their 70s without CLBP are able to easily go up and down the stairs. But the experience may be significantly more challenging for CLBP patients of the same range, as fewer than half of those with CLBP were able to say the same.

I can go up and down the stairs with ease. Non-CLBP 80%. CLBP 45%.

Getting up from the floor is another activity that impacts CLBP sufferers much more than their peers who don’t experience chronic pain. While 66% of 70-somethings without CLBP reported ease in getting up or down from the floor, only 28% of those with CLBP were able to say the same.

I can get up or down from the floor with ease. Non-CLBP 66%. CLBP 28%.

Options for Low Back Pain & LSS Treatment

If you think lumbar spinal stenosis could be causing a patient’s low back pain, and common conservative treatment options such as physical therapy, pain medication, and epidural steroid injections (ESIs) are no longer providing adequate relief, it may be time to move to mild®.

The mild® Procedure, or minimally invasive lumbar decompression, is considered a gold standard of care among treatments for lumbar spinal stenosis. By addressing the root cause of pain, the enlarged ligament, mild® has helped 88% of patients avoid back surgery for at least 5 years while providing lasting relief.

The difference mild makes: stand 7x longer, walk 16x farther. Patients increased average standing time from 8 minutes to 56 minutes with less pain over one year. Patients increased average walking distance from 246 feet to 3,956 feet with less pain over one year.

Due to its minimally invasive nature and long-lasting durability, many interventional pain management physicians are making the move to mild® as an alternative to epidural steroid injections (ESIs), which may only work short-term and may require repeat injections to maintain relief.

More invasive courses of treatment can include procedures such as spacer implants or open surgery, though nearly 80% of CLBP sufferers have concerns about undergoing surgery.

CLBP Doesn’t Go Away On Its Own

For patients experiencing chronic low back pain, it’s never too early to act. Without addressing the root cause of pain—such as the enlarged ligament in cases of LSS—patients can often go years without finding relief.

89% of patients have been experiencing CLBP for1 year or more, with more than half (57%) experiencing it for more than 5 years. 89% 1 year or more vs 57% more than 5 years.

The Know Your Back Story campaign, a national public health awareness campaign, educates and encourages millions of people with CLBP to learn more about their “back story” and encourages providers to educate patients about LSS and the enlarged ligament that may be the source of this pain.

If your patients are seeking answers for chronic low back pain, they may benefit from the mild® Procedure as a first course of treatment. By referring patients to a local interventional pain management physician, you can help get them on the path to lasting relief.

Learn more about Mild.

Access more resources about the Know Your Back Story Campaign and the Mobility Matters Poll

As an Advanced Practice Provider (APP), you are an integral part in helping patients with lumbar spinal stenosis (LSS) get on the path to lasting relief.

In this webinar workshop, led by our panel of mild® experts, APPs Ashley Comer, NP, Marie Zambelli, NP, Kelsey Kimball, PA, Lauren Cote, NP, Patrick McGinn, PA, Kristen Klein, NP, discuss how patient education and proper outcomes assessment play an important role in optimizing patient outcomes after the mild® Procedure.

Access the webinar here:

Looking for more info on mild® patient identification criteria?
Check out our blog: Identifying & Educating mild® Patients – APP Guidance

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According to our Advanced Practice Provider (APP) Advisory Board, imaging review, a key aspect of mild® patient candidate identification, is often not included in initial schooling. To help APPs learn the basics of image review, become more familiar with identifying anatomical landmarks, and understand how to confirm if a patient is a candidate for the mild® Procedure, we asked James Lynch—an APP with the Pain Consultants of San Diego—to walk us through his tips and techniques for magnetic resonance imaging (MRI) review. In the following article, he shares pearls for becoming confident in imaging review and provides a series of videos so you can follow his step-by-step approach to determine if patients with lumbar spinal stenosis (LSS) should make the move to mild®.

As an APP in an Interventional Pain Medicine practice that offers the mild® Procedure, reviewing MRI images to determine the presence of hypertrophic ligamentum flavum (HLF) is a critical aspect of my role. Prior to joining this practice, I had very little experience reviewing MRI images. It was not part of the core curriculum while training to become an APP, and it was not an area that I felt very confident in. I’ve become more familiar and proficient with imaging review; however, I can say that it’s much more straightforward than it may initially seem. Through hands-on experience, by sharing clinical pearls among peers, and by watching step-by-step videos like those included in this article, I became competent, comfortable, and confident performing image reviews to identify mild® patient candidates—and I know other APPs can too.

Why Is Imaging Review Important?

We know that up to 85% of spinal canal narrowing is caused by thickened ligament. When we see patients with symptomatic LSS, if HLF is present, we will likely advance to mild® to provide patients long-term relief using a therapy that has a safety profile equivalent to an epidural steroid injection (ESI), but with lasting results. Being able to review a basic MRI empowers me to identify patients who may benefit from the mild® Procedure and confidently present my recommendations to them. This confidence helps build trust between me and my patients, and makes them feel more comfortable and assured prior to scheduling their mild® Procedure. Having more patients move to mild® means that I’m giving my patients a chance to achieve clinically meaningful, statistically significant improvements in mobility, Oswestry Disability Index (ODI), and pain reduction on the Numeric Pain Rating Scale (NPRS). It’s also incredibly rewarding to hear patients tell me about what they’re able to do now that they can walk further and do more activities than they could before.


Getting Started: Reviewing the MRI Report

LSS is highly recognizable by the signs and symptoms patients commonly exhibit, including pain, numbness, or heaviness when standing or walking, and finding relief by sitting, bending forward, or sleeping curled in the fetal position. When we see these signs in our patients, we’ll order an MRI to confirm the diagnosis and determine whether the patient is a good candidate for the mild® Procedure.

When we request an MRI, we’ll get a report and the imaging back for that patient. During my review of the report, I look line-by-line, specifically confirming whether the report notes central canal stenosis. It is also helpful to make note of other contributors to central canal stenosis (such as enlarged facets, disc bulge, etc.) in order to properly prepare a patient for potential follow-up expectations.

Light bulb illustration icon

Tip: As you gain comfort with image review, practice reviewing the MRI first and report second to confirm their diagnoses.

In the example shown here, I would note the following:

  • At L2 or L3, the patient has mild-to-moderate bilateral facet and ligamentum hypertrophy; however, the central canal remains patent and the patient does not have central canal stenosis at this level.
  • At L3-L4, the patient has moderate to severe central canal stenosis with a residual canal diameter of 6 mm.

Light bulb illustration

Reminder: You can also request that the radiology report include a measurement of the HLF, which can make it easier to review.

Because I have confirmed the presence of central canal stenosis in the report, I’ll then review the imaging to determine whether the patient is a candidate for the mild® Procedure. You can also take the reverse approach and review the imaging first, and then use the radiology report as a confirmation of your own findings.


Step 1: Linking the Sagittal and Axial Views

A note on software: While the specific software demonstrated in this blog is Ambra Health, much of the imaging software used today is similar in function and review procedures. Whether you’re using Ambra Health, Sharp, or another software option, the tips and tricks demonstrated in this blog should be consistent, regardless of the software you’re using.

In pulling up the images, I typically begin setting up the images to facilitate a clear and efficient review process. Begin by adjusting the layout of the software to show 2 images at the same time.

On the left-hand side, we will show the sagittal view, or vertical cross-section of the patient. On the right-hand side, the axial view, or horizontal cross-section of the patient, will be displayed.

Press the “Link” command in the system software to correlate the images together and select the STIR images (T2 weighted images).

star illustration

Tip: The reason I use the T2 image is because the cerebral spinal fluid actually brightens up, making it a lot easier to assess the spinal canal.


Step 2: Identifying Anatomical Landmarks

Image showing Vertebral Body

  1. Vertebral Body
  2. Central Canal
  3. Epidural Fat
  4. Ligamentum Flavum
  5. Spinous Process
  6. Exiting Nerve Root Space Under Pedicle Facet Joint
  7. Facet

image showing ligamentum flavum in patient suffering from lumbar spinal stenosis

My specific area of interest in evaluating the mild® patient candidate is the small black area, which is the ligamentum flavum, highlighted in the image here.

image showing hypertrophic ligamentum flavum compressing the nerves

In the small white area, we can see the central canal where the nerves are housed. In this image, we can see that the canal is very small, with very little white showing. This is consistent with central canal stenosis, and in this case, we can see clearly that the hypertrophic ligamentum flavum is compressing the nerves.

image showing comparison of the healthy central canal

By moving our image up to L2-L3, we can see an excellent comparison of the healthy central canal. The large white area shows that at this level, the thin black ligament is not compressing the nerves.

sagittal view showing where the spinal canal narrows where the central canal is stenosed

In the sagittal view, you’ll be able to see clearly where the spinal canal narrows, and this is helpful in identifying all levels where the central canal is stenosed.

We can also see here that the patient has a disc bulge, indicative of multi-factorial central canal stenosis.

It’s important to remember that comorbidities are common among LSS patients—in fact, a Level-1 clinical study of mild® patients demonstrated that just 5% of patients presented with central canal stenosis only. The presence of comorbidities, such as foraminal narrowing, lateral recess narrowing, or facet hypertrophy DO NOT RULE OUT patients as mild® Procedure candidates. Indeed, the same clinical study found that the majority of patients with comorbidities achieved an ODI improvement of ≥10 points at 2-year follow-up.


Step 3: Measuring the Ligamentum Flavum

Using the length tool in the software, I can draw a line across the ligament (the dark area indicated in the image below) to obtain the ligament measurement.

image showing an HLF measurement of 6.38 mm

Here, the measurement clearly shows an HLF of 6.38 mm. I will then repeat this measurement process at each of the levels that are affected by central stenosis (per the report, and as seen in the sagittal view).

star icon

Tip: As a reminder, any patients with HLF ≥2.5 mm may be considered a candidate for the mild® Procedure.


My Pearls for Easier Imaging Review

Once you become familiar with imaging review, you’ll develop your own tips and tricks that make the process easier and more efficient for you. Here are a few things that I suggest that can help when you’re just getting started:

  1. Request an HLF measurement in the report. If I see a patient that is suffering from “Shopping Cart Syndrome” and exhibiting symptoms consistent with lumbar stenosis with neurogenic claudication, I’ll put the primary diagnosis code as “lumbar stenosis with neurogenic claudication” on the MRI request. I’ll also add a note to the order for the radiologist to measure the ligamentum flavum at the levels that are being affected and are stenotic. This can also be programmed into your EMR system as an automated note for every lumbar MRI request.
  2. Scroll to find the best view. When the MRI is capturing images, it’s going to be at different depths, and may vary depending on the position of the patient. After I select the level of interest, I’ll typically scroll through several images (using the up and down arrow keys on my keyboard) to make sure I have the clearest view of the ligament and central canal.
  3. Find your level by starting at the sacrum. It’s possible to determine which level you’re looking at by counting from the sacrum. I also keep in mind that L5-S1 is where the spine really starts to have curvature.
  4. Focus on restoring functionality. If HLF is present in the MRI, we can feel confident about a decision to move to mild®, to provide LSS patients long-term relief using a therapy that has a safety profile equivalent to an ESI, but with lasting results. It’s common that you’ll see comorbidities that will need to be addressed eventually, but we’ll often begin with the mild® Procedure to restore functionality and help patients get back on their feet.

An Ideal mild® Procedure Candidate

In this video, you can see an end-to-end example of the imaging review for an ideal mild® case. In under 5 minutes, you can see how I:

  • Review the report: Start going line-by-line. At L4-L5, the patient appears to have bulking of the ligamentum flavum, resulting in narrowing of the central canal with no other noted comorbidities.
  • Link sagittal and axial images: After selecting a 2-image layout, select the T2 images, where cerebral spinal fluid brightens up, making it easier to identify the spinal canal.
  • Evaluate the level of central canal stenosis: Even though the radiologist has provided a report, I like to review the nuances of the images, knowing that I’m looking specifically to determine whether the patient is a good candidate for mild®.
  • Measure the ligamentum flavum: With my length tool, I can measure the ligament to make sure the HLF is ≥2.5 mm. In this case, an HLF of 4.18 mm confirms the patient is a candidate for mild®.

What if MRI isn’t an Option?

When a patient can’t have an MRI, we will instead send them in for a computed tomography (CT), ideally with a myelogram. A myelogram will highlight these relevant anatomical structures, so you can see the ligament and determine the patient’s candidacy. Even if a myelogram is not an option, be sure to indicate a primary diagnosis for lumbar stenosis when you order the CT, and the radiologist will then assess that patient for lumbar stenosis and HLF.

Using Imaging to Support Patient Education

When patients are in the office, I’ll often bring my laptop into the exam room and show them their imaging on screen. Being able to see their own anatomy, and specifically the hypertrophic ligament pressing on the nerves, is incredibly helpful to demonstrate this root cause of their LSS.

Then, I can also use the imaging to clearly point out how mild® addresses a major root cause of LSS by removing excess ligament tissue and leaving no implants behind. I’ll also show them where the nerves are being compressed and educate them about how mild® restores space in the spinal canal, which reduces the compression of the nerves. Most patients understand how the mild® Procedure works much more easily when they can see the images themselves, and it also helps them realize how the mild® Procedure can provide long-term relief and restore mobility.

Embracing Imaging Review: Don’t Be Intimidated­­—Practice Makes Perfect!

When I first started with imaging review, I was much less comfortable and confident than I am today. Knowing that our practice is committed to helping more patients move to mild®, I recognized that becoming comfortable with imaging review was a critical aspect of my role. Even though MRI review was not something included in my initial APP education, I realized that becoming proficient gave me an opportunity to bring additional value to our patients and practice.

The best way I found to get comfortable with imaging review was to dive in and review previous cases so I could become familiar with the anatomy and structures. Beyond hands-on experience, there are resources that offer additional support, including:

  • Online video resources: There are many videos available online that walk you through MRI reviews and will help you become more familiar with some of the structures.
  • Clinicians in your practice: Work with other physicians and APPs in your practice to hone your skills. I’d often review an MRI, and then share my findings with the physician I work with to confirm that they were seeing the same diagnosis that I saw.
  • Webinars: View webinars geared towards APP education, especially in imaging, such as The APP Imaging Workshop—A Collaborative Approach to mild® Patient Selection here.
  • Your Vertos representative: Our Vertos representative has been a great resource for our practice and is especially supportive when it comes to imaging. Connect with your representative to schedule a lunch-and-learn or meeting to review images together and access the latest educational materials.

With additional practice and experience, you’ll quickly become much more comfortable with imaging review. You’ll also notice how many of your patients with LSS have HLF and are candidates for the mild® Procedure. By putting more patients on the path to lasting relief with mild®, you’ll get to see first-hand how regaining mobility can be a life-changing improvement for the patients in your care.

Advanced Practice Providers (APPs) play a vital role in helping patients understand their lumbar spinal stenosis (LSS) diagnosis and treatment recommendations. By developing strong provider-patient communication, you’re taking the first step towards achieving positive outcomes and enhancing the patient experience.

Why is patient education so important?

  • Limited health literacy is linked to a spectrum of suboptimal health outcomes, including increased reports of poor physical functioning, pain, limitations in activities of daily living, and poor mental health status (Source)
  • Only about 12 percent of U.S. adults demonstrate proficient health literacy skills (Source)
  • Limited health literacy disproportionately affects adults aged 65 and older (Source)

Based on the data above, it is clear that patients over 65 years of age–the group most likely to suffer from LSS–may need more support to understand their condition and treatment plan. With the recognition that both lumbar spinal stenosis and poor health literacy can increase your patients’ susceptibility to poor physical functioning, pain, and limitations in activities of daily living, APPs should feel especially empowered to engage patients. This includes helpful education and dialogue that supports their understanding and helps them feel more comfortable taking the next step on their path to lasting relief.

In the following article, you will find step-by-step guidance and pragmatic suggestions that you can start using today, to help you ensure that your patients leave their consultation feeling confident and excited about their opportunity to make the move to mild®.

Watch: See APP Ashley Comer’s complete talk track for presenting mild® to her LSS patients.

Teach Patients About mild® in 3 Easy Steps

Use the mild® patient brochure as a tool and follow these simple steps to help your patients better understand their lumbar spinal stenosis diagnosis and the benefits of the mild® Procedure.

Do you experience back and leg pain when you stand or walk? Have steroid injections stopped working? Get back on your feet with the mild® procedure

STEP 1: Explain LSS in Plain Language

LSS is a complex condition that can be challenging for patients to understand. It is important that patients comprehend the cause of their LSS symptoms, so they feel informed and confident in moving forward with a treatment plan.

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Skip the Medical Jargon

Instead of using complex medical terms or acronyms, simplify your explanation with common words, phrases, and analogies to help patients understand their diagnosis and treatment options.

According to the CDC, nearly 9 out of 10 adults struggle to understand and use personal health information when it’s filled with unfamiliar or complex terms. (Source)

On the first page of the mild® patient brochure, you’ll find helpful illustrations that demonstrate the anatomical changes associated with LSS and the symptoms patients typically experience. During your patient consultation, be sure to highlight:

Infographic showing the symptoms of lumbar spinal stenosis (LSS)

  • Compression of the nerves in the lower back.
    • LSS can develop as a result of aging and natural wear and tear on the spine
    • Thickened ligament is a major root cause of lumbar spinal stenosis
    • Symptoms are caused by pressure on spinal nerves
  • LSS symptoms affect daily life, causing pain and limited mobility. ASK YOUR PATIENT:
    • Do you feel pain, numbness, tingling, or heaviness when standing or walking?
    • Are your symptoms relieved by sitting, bending forward, or sleeping in the fetal position?

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Relate LSS to Common, Lived Experiences

Many APPs and physicians use common, real-life analogies to help patients identify and understand their LSS symptoms. A common analogy that many patients may relate to is the “shopping cart syndrome.” Explaining that patients with lumbar spinal stenosis often feel relief when bending over a shopping cart (because it reduces pressure on the compressed nerves) can help patients recognize how this condition impacts their daily life.

STEP 2: Make the Discussion Specific to Your Patient

Once you’ve established the common signs and symptoms of LSS, demonstrate what the MRI shows for that specific patient. Turn to the last page of the mild® patient brochure, where you can use the diagrams provided. Drawing directly on the patient brochure, indicate the following:

What does your imaging show?

  • In the sagittal view on the left, note which level(s) are affected
  • In the axial view on the right, show how their thickened ligament appears in the MRI, being sure to draw over the nerves to demonstrate the impact on the central canal

Watch: See how APP Ashley Comer uses the illustrations in the mild® patient brochure to demonstrate her patients’ specific areas of stenosis.

You can also accompany the spinal illustrations in the mild® patient brochure with an added tool, such as a spine model or the patient’s MRI to reinforce the anatomical positioning of the problem or validate the diagnosis, respectively.

STEP 3: Highlight how the mild® Procedure Works

Once patients fully understand their condition, walk them through all of the reasons why you recommend they make the move to mild®. If you turn back to the beginning of the brochure (or access the same information in the mild® patient flip chart) and review the remaining pages, you can quickly cover the advantages of mild® relative to other treatment options, and prepare your patients for what to expect during and after their mild® Procedure.

Page 2: Comparing Treatment Options

Infographic showing the benefits of the mild® procedure compared to other treatments for lumbar spinal stenosis

  • The chart in the center of the page quickly presents mild® benefits in comparison to other treatment options for LSS, such as epidural steroid injections, spacer implants, or open surgery
  • Below the chart, the call out reinforces the unique advantages of mild® as the only treatment with a safety profile similar to an injection, and the lasting relief expected from back surgery

MOVE2mild®

Because epidural steroid injections (ESIs) were historically the standard of care for lumbar spinal stenosis patients, your patient may be expecting you to recommend another injection. You can explain that the data shows that there is no benefit to giving more than one ESI before mild®, and that giving more than one ESI delays the patient from receiving the longer-lasting, more effective mild® Procedure.

Page 3: How mild® Removes the Problem and Leaves Nothing Behind

Infographic showing an illustrations of spinal compression before and after the mild® procedure

  • mild® addresses a major root cause of LSS by removing excess ligament tissue
  • mild® reduces compression on the nerves to restore mobility and relieve pain
  • mild® doesn’t eliminate future treatment options, as no major structural anatomy of the spine is altered

Page 4: What to Expect on the Day of the mild® Procedure

Infographic explaining what a patient can expect the day they will receive the mild® procedure

  • Short outpatient procedure
  • Can be performed using local anesthetic and light sedation
  • Incision smaller than the size of a baby aspirin
  • Patients typically resume normal activity within 24 hours with no restrictions

Page 5: What to Expect After the mild® Procedure

Infographic showing proven results of the mild® procedure in treating lumbar spinal stenosis

  • mild® has an 85% patient satisfaction rate
  • mild® continues to improve patient functionality over time
    • Over one year, average standing time increased 7x from 8 to 56 minutes with less pain
    • Over one year, average walking distance increased 16x from 246 to 3,956 feet with less pain
  • mild® helped 88% of patients avoid back surgery for at least 5 years, while providing lasting relief
  • mild® is covered by Medicare (including Medicare Advantage), the VA, U.S. Military, & IHS. Commercial coverage varies.

Setting Expectations Supports Patient Success

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Every year, thousands of lumbar spinal stenosis patients are able to stand longer and walk farther with less pain thanks to the mild® Procedure, but those results aren’t achieved overnight. Improvements in patient functionality are typically achieved over time, with patients gradually increasing standing time and walking distance. If you set expectations in advance, patients may be more excited and satisfied to see their own functional improvements over time.

BONUS: Tips to Make Patient Education More Impactful
  1. Project confidence. When you showcase your knowledge and present information in ways patients can easily understand, they may feel more comfortable making decisions and following your recommendations.
  2. Encourage patients to ask questions. Take a moment between steps to confirm your patient understands the key points before moving to the next point.
  3. Discuss the benefits of reconditioning. When setting expectations around recovery, discuss the ways that patients can participate in improving their functionality. Help your patients get back on their feet by suggesting progressively longer walks, or even physical therapy.

Better Patient Education Helps Drive Success with mild®

LSS patients rely on APPs as critical members of their care team. Across the patient journey from diagnosing your patients’ LSS to finding relief with the mild® Procedure, APPs are key in supporting patients, helping them understand their condition, and feeling confident about their decision to make the move to mild®.

At Vertos, we recognize and support the role of APPs and are committed to providing education and resources that help you put more LSS patients on the path to lasting relief.

Don’t miss out on the latest and greatest tips and tools from Vertos.

  1. Register as an APP to stay informed of new peer-to-peer learning and other educational opportunities
  2. Follow us on social
  3. Connect with your Vertos rep for educational resources

Interventional Pain Management is a fast-growing specialty. As new lumbar spinal stenosis (LSS) procedures become available, practices are evolving the way they collaborate and work together to optimize patient care. The mild® Procedure’s patient selection process is quite simple, but requires imaging review, which is often not a part of Advanced Practice Providers’ (APP) traditional education.

The Vertos APP Advisory Board has emphasized the need for educational tools for APPs who would like to develop their image review skillset. Two of the esteemed Vertos APP Board Members, James Lynch, PA and Kelsey Kimball, PA, partnered with their physicians Dr. Michael Verdolin and Dr. Ajay Antony to provide an interactive workshop focused on enhancing imaging review skillsets. View the interactive workshop where they cover imaging basics, navigating software, measuring the ligament, and more!

  • LSS & mild® Patient Identification Overview (2:20)
  • MRI Basics (9:59)
  • Anatomical Review (15:58)
  • Navigating Imaging Software (27:24)
  • mild® Case Studies (1:02:26)
  • Benefits of Incorporating Image Review Into Your Practice (1:09:12)
  • Additional Educational Resources Available (1:12:43)
  • Q&A (1:15:13)

Looking for more info on mild® patient identification criteria? Check out our blog: Identifying & Educating mild® Patients – APP Guidance.

Also, be sure to connect with us to stay informed of upcoming APP-specific educational and peer engagement opportunities. Sign up and receive the latest updates!

Sign Up Now

Interventional Pain Management is a fast-growing specialty. As new lumbar spinal stenosis (LSS) procedures become available, practices are evolving the way they collaborate and work together to optimize patient care. The mild® Procedure’s patient selection process is quite simple, but requires imaging review, which is often not a part of Advanced Practice Providers’ (APP) traditional education.

Although image review can be intimidating, APPs report that the learning curve is relatively short and there are resources available to help you get started. Below are some tips from mild® APPs on how they quickly established comfort with imaging review in their practice, allowing them to “look for the ligament,” identify hypertrophic ligamentum flavum (HLF), and educate mild® patients independently. You can access a CME webinar on the topic below as well.

Standardize MRI requests to request HLF be listed and measured: if it isn’t on the report, review and measure yourself.

Ashley Comer, NP
The Spine & Nerve Centers of the Virginias
Charleston, WV

Get comfortable with your imaging system and work alongside your physician to identify anatomical landmarks using the measuring tools.

Jane Hartigan, PA
Evolve Restorative Center
Santa Rosa, CA

Get comfortable with your imaging system and work alongside your physician to identify anatomical landmarks using the measuring tools.

Jane Hartigan, PA
Evolve Restorative Center
Santa Rosa, CA

Don’t rely on the MRI report alone: HLF is often overlooked, so be sure to look at the images yourself.

Kelsey Kimball, PA
The Orthopaedic Institute
Gainesville, FL

Practice reviewing imaging with patients. Usually, no one has explained their condition to them using imaging, so once you establish comfort with image review, incorporate this step into your patient education routine.

Christine Christensen, NP
Spine & Pain Institute of Florida
Lakeland, FL

Practice reviewing imaging with patients. Usually, no one has explained their condition to them using imaging, so once you establish comfort with image review, incorporate this step into your patient education routine.

Christine Christensen, NP
Spine & Pain Institute of Florida
Lakeland, FL

Use each image review as a training opportunity. Review the image yourself, then compare it with the report.

CME Webinar: Reviewing MRIs: A Collaborative Approach to Patient Selection

Webinar - ASPN CME Webinar Series: Reviewing MRIs: A Collaborative Approach to Patient Selection

In this American Society of Pain & Neuroscience (ASPN) webinar, moderators Timothy Deer, MD; Dawood Sayed, MD and faculty members Navdeep Jassal, MD; Eugene Paik, MD; Ashley Comer, NP-C; Christine Christensen, APRN; and Zohra Hussaini, MSN, FNP-BC, MBA, APRN discuss how physicians and APPs can match more patients with the right treatments sooner by working together.

Access the Webinar

Educational activity is jointly provided by Evolve Medical Education, LLC and Mantra Meetings, and is available for CME credit until its expiration date of June 23, 2022.

Looking for more info on mild® patient identification criteria? Check out our blog: Identifying & Educating mild® Patients – APP Guidance. Interested in APP-focused education and events? Sign up to stay informed and receive the latest updates!

Sign Up Now

Injections falling short? Advanced IPM practices are moving beyond epidural steroid injections (ESIs) to offer the gold standard of care for lumbar spinal stenosis (LSS) patients. Review the new data where study researchers compared the medical records of participants who had received either just one or no steroid injection prior to the mild® Procedure, to participants who received two or more epidural steroid injections prior to mild®. Similar outcomes in both treatment groups in this study proved that giving more than one ESI prior to the mild® Procedure did not improve how well patients did and may have delayed patient care. Based on the results of the study, it is recommended that the standard treatment process for LSS patients be changed to give the mild® Procedure either as soon as LSS is diagnosed or after the failure of the first ESI.

Congratulations to authors and mild® physicians Peter Pryzbylkowski, Anjum Bux, Kailash Chandwani, Vishal Khemlani, Shawn Puri, Jason Rosenberg and Harry Sukumaran for the first ever plain language article to be published in Pain Management!

Access Digital Articles

View the original article and share the plain language version with your community.

Image of article about minimally invasive direct decompression for lumbar spinal stenosis

Key Takeaways from New Data:

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mild® has been shown to provide superior clinical performance to ESIs, a similar safety profile and substantially better cost–effectiveness

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There is no clinical benefit in performing multiple ESI procedures and delaying long-lasting treatment with mild®

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Elimination of multiple ESIs and utilizing mild® immediately upon diagnosis of neurogenic claudication with hypertrophic ligamentum flavum (HLF), or after failure of the first ESI procedure is recommended as part of a modified algorithm

Take Action

  • Update your algorithm: Patients who do not experience relief after their ESI may become frustrated or lose hope. Educate LSS patients early about their care options.
  • Inform your community that you offer more: Educate patients & referral practices who are searching for alternative solutions to ESIs, pain meds, or back surgery.

If your lumbar spinal stenosis (LSS) treatment algorithm relies on serial epidural steroid injections (ESIs) to relieve chronic lower back and leg pain associated with neurogenic claudication, data supports a different approach—­performing the mild® Procedure immediately upon diagnosis of LSS or moving to mild® after the first ESI fails may help your patients avoid “ESI Exhaustion.”

We already know that epidurals are not capable of “curing” neurogenic claudication, a major root cause of lumbar spinal stenosis which is present in 94% of patients. The steroids in the injection are believed to reduce inflammation to relieve pain; however, injections are only treating the symptoms of LSS. For long lasting relief, debulking the ligament is required. Injections results typically last less than six months. To provide ongoing relief, patients often require 2-3 injections on average per year.

ESI results last less than 6 months. Patients require 2-3 epidural injections per year.
ESI results last less than 6 months. Patients require 2-3 epidural injections per year.

Due to the temporary nature of epidural steroid injection relief, and the requirement for repeat injections, many practices encounter patients with what is increasingly becoming known as “ESI Exhaustion.” ESI Exhaustion can be spotted in patients at any stage of LSS treatment or stenosis severity. Once you start recognizing the signs of ESI Exhaustion in your lumbar spinal stenosis patients, you’ll see why so many leading clinicians are moving to mild® earlier in their treatment algorithm.

ESI Exhaustion Sign #1: Feelings of Hopelessness

“I went through three rounds of injections. I had heard ‘we’ve had pretty good results with this.’ But when you go through so many, it’s like ‘okay, I’ve heard this one before.’” -Ronnie, mild® Patient

When patients experience short-term relief for a condition as challenging as LSS, it can be easy for them to become frustrated and lose hope. Patients can become tired from needing to return for repeat injections. Other patients may start to feel hopeless if the injection is not effective or if it is only effective for a very short time. It’s important to remember that LSS patients often experience debilitating pain and loss of mobility that can have a devastating impact on their quality of life.

To help your patients remain optimistic and aligned to your treatment plan, educate your new and existing LSS patients about your treatment options early. Make sure they know that there is a procedure that offers the safety equivalence of an ESI, but with lasting results. If you are starting their treatment plan with a single epidural, inform them about the mild® Procedure during that first visit, so they know that if the ESI is not effective, there are other options that can help restore mobility by addressing a major root cause of LSS.

ESI Exhaustion Sign #2: Decreasing Durability of Relief

“The first epidural lasted about three months and then the pain was back. I went for the second epidural, and it didn’t last two weeks. My physician said, ‘Well you can have one more’ I said, ‘No, I’m finished with them.’”
-Lynn, mild® Patient

Lynn - Mild patient

One of the more common questions patients have about a steroid injection is “how long will the results last?” Unfortunately, with ESIs, efficacy can vary by patient, and it can be difficult to predict the degree of relief or durability of effect for each. While studies have shown pain relief for up to six months in some lumbar spinal stenosis patients receiving steroid injections, other studies have demonstrated limited effectiveness.

Dante - Mild patient

“They gave me the first one and it worked for two weeks. I had to get a second shot, and within a week it had already worn off.” -Dante, mild® Patient

Even more vexing for some patients is that the durability of effect of an initial ESI may not be experienced with subsequent injections. To achieve effectiveness over two to three years, five or more injections per year may be required.

Rather than offering patients a series of injection after injection with short-term results, move to mild® after the first ESI fails. The mild® Procedure offers a clinically proven safety profile equivalent to ESIs, but with lasting results. A 5-year study completed by the Cleveland Clinic showed that mild® helped 88% of patients avoid back surgery for at least 5 years while providing lasting relief.

Image comparing the
Image comparing the

ESI Exhaustion Sign #3: Solution Shopping

“The orthopedic surgeon gave me two options, back surgery with metal plates or more shots. I wanted something simple that would make me better.” -Faye, mild® Patient

If patients are dissatisfied with their results and feel they’ve run out of options in your practice, they may start to search for another solution. By offering mild® as an early intervention, you can avoid losing patients and actually increase productivity in your practice. Upon diagnosis of LSS, inform patients that you offer mild®, a minimally invasive treatment option that offers durable relief.

If you have already treated a patient with an ESI and it failed, or the patient received an injection in another practice, there is no reason to continue to offer another injection. Most patients I’ve seen are excited to learn that there is another option. Moving to mild® gives them new hope in finding lasting relief.

How to Avoid ESI Exhaustion? Move to mild®.

While “ESI Exhaustion” is highly common among LSS patients, it is also completely avoidable. Recognizing that serial injections are often the standard of care when conservative care methods like exercise and physical therapy have failed to provide relief, we published a study in Pain Management that evaluated whether LSS patients benefit from multiple ESIs prior to mild®.

The article, ‘Minimally invasive direct decompression for lumbar spinal stenosis: impact of multiple prior epidural steroid injections’ compares outcomes between 145 patients receiving either 0/1 injections or 2+ injections at 6 centers in the United States. In reviewing results between the two groups, we concluded that there is no benefit to performing multiple epidural steroid injections before the mild® Procedure and that doing so delays the patient from receiving a longer-lasting, more effective mild® treatment.

Based on this study and other favorable data, we recommend performing the mild® Procedure for lumbar spinal stenosis patients immediately upon diagnosis of neurogenic claudication with hypertrophic ligamentum flavum, or after the first ESI fails.

Does your practice offer the mild® Procedure? Do you manage patient identification and education? Follow these 3 steps to optimize your practice routine:

1. Start with the Symptoms

ID Shopping Cart Syndrome

Shopping Cart Syndrome – lumbar spinal stenosis (LSS) with neurogenic claudication (NC). These patients will often be the first ones to find chairs in your waiting room or use the walking aids, such as a shopping cart, to establish a flexed position. The flexed posture is a common sign of NC because it opens up the spinal canal to alleviate the pressure on the central canal to avoid pain that comes with being straight, upright, or mobile.

Silhouettes of four individuals: A man hunched over with lower back pain, a woman walking with pain in her upper legs, an elderly person holding a shopping cart to alleviate lower back pain, a person sitting to relieve back pain.

Ask patients

Ask patients the following questions to better understand how LSS with neurogenic claudication is limiting their mobility and when they experience symptom onset. Patients commonly report pain, so it is essential to talk about their functional limitations (eg, desire to walk the dog, get the mail, play with their grandchildren, etc.).

Consider incorporating these questions into your EMR or intake process so patients are routinely screened for neurogenic claudication.

Large question mark icon

  • How does your pain disrupt your life?
  • How long can you stand before you need to rest?
  • How far can you walk before you need to rest?

Ask patients

Ask patients the following questions to better understand how LSS with neurogenic claudication is limiting their mobility and when they experience symptom onset. Patients commonly report pain, so it is essential to talk about their functional limitations (eg, desire to walk the dog, get the mail, play with their grandchildren, etc.).

Consider incorporating these questions into your EMR or intake process so patients are routinely screened for neurogenic claudication.

Large question mark icon

  • How does your pain disrupt your life?
  • How long can you stand before you need to rest?
  • How far can you walk before you need to rest?

2. Confirm Candidacy:

Look for the ligament

Hypertrophic ligamentum flavum (HLF) contributes up to 85% of spinal canal narrowing

Hypertrophic ligamentum flavum (HLF) >= 2.5mm

What to look for?

  • LSS at levels L1-S1
  • Hypertrophic ligamentum flavum (HLF) – 2.5mm is the starting point

Need additional help establishing comfort with imaging review?

  • View the CME course on reading MRIs hosted by Advanced Practice Providers (APPs) Ashley Comer, NP-C; Christine Christensen, MSN, APRN; and Zohra Hussaini, MSN, FNP-BC, MBA, APRN
  • Contact your Vertos representative to set up an onsite or virtual educational session

If HLF is present, confirm candidacy…even in patients with comorbidities. mild® is an option for a broad spectrum of patients.

Candidates may have:

Medical comorbidities:

  • Osteoporosis
  • BMI >40

Spinal comorbidities:

  • Grade 1-2 spondylolisthesis
  • Foraminal narrowing
  • Degenerative disc disease
  • Lateral recess narrowing

Confirm coverage

mild® is covered by Medicare (all ages, all plan types, including Medicare Advantage), the VA, U.S. Military, and IHS. Commercial coverage varies.

3. Educate Patients & Establish Appropriate Outcomes and Expectations

Educate early – move to mild® after the first ESI fails

Illustration of a syringe with text label: "Safety profile similar to an ESI." Second illustration shows the size of the incision with text label: "No implants left behind, only a Band-Aid."

Establish appropriate outcomes and expectations

mild® helps patients stand longer and walk farther with less pain.

Infographic titled "Increased Mobility Over Time."  The infographic shows a graph indicating how a person's standing time improves 7x over the 12 months following the mild® procedure.  The second graph shows that a person can walk 16x farther after 12 months following the mild® procedure.

Optimize outcomes with reconditioning

Illustration of a person walking. Caption says: "Patients typically resume normal activity within 24 hours with no restrictions. Functionality improves over time."

  • At-home reconditioning walking program can be initiated immediately, as tolerated
  • Assess outcomes at 2-weeks and 4-6 weeks, then monthly. Assess mobility and Quality of Life (QOL) improvements, such as:
    • Transfer ability: Getting in and out of the bed/seat/car
    • Walking and standing times
    • Activities of daily living: Ability to get dressed, take off shoes, household chores, and grocery shopping

Optimize outcomes with reconditioning

Illustration of a person walking. Caption says: "Patients typically resume normal activity within 24 hours with no restrictions. Functionality improves over time."

  • At-home reconditioning walking program can be initiated immediately, as tolerated
  • Assess outcomes at 2-weeks and 4-6 weeks, then monthly. Assess mobility and Quality of Life (QOL) improvements, such as:
    • Transfer ability: Getting in and out of the bed/seat/car
    • Walking and standing times
    • Activities of daily living: Ability to get dressed, take off shoes, household chores, and grocery shopping

Illustration of a shopping cart explaining how "Shopping Cart Syndrome" is a sign of a patient suffering from lumbar spinal stenosis (LSS) with neurogenic claudication.

An image of a shopping cart that provides details about comorbidities and candidate eligibility for the mild® Procedure.

Illustration of a shopping cart explaining how "Shopping Cart Syndrome" is a sign of a patient suffering from lumbar spinal stenosis (LSS) with neurogenic claudication.

An image of a shopping cart that provides details about comorbidities and candidate eligibility for the mild® Procedure.

If you would like a mild® Quick Reference Card for your office or to learn more about APP-specific educational opportunities, please contact us and let us know what you need.

The following study, “Patients with Foraminal Narrowing Benefit from mild® Treatment” investigates procedural outcomes for mild® patients with and without foraminal narrowing as an adjunctive spinal comorbidity. Ninety-one patients from three sites were accepted for analysis and VAS scores were compared within each group over time and between groups. Responder rates were 86.4% in the group with foraminal narrowing, compared to 75.0% in the group having no foraminal narrowing. Though the amount of pain improvement between groups was not significantly different, this study confirms that lumbar spinal stenosis (LSS) patients with a narrowed foramen can benefit from the mild® Procedure and should not be excluded from treatment. View the abstract poster below to learn more about the results.

Infographic: Patients with Foraminal Narrowing Benefit from mild Treatment

Expand

Watch Dr. Denis Patterson present his abstract from the Pacific Spine & Pain Society (PSPS) 2021 Annual Conference where he reviews the data and shares why LSS patients with a narrowed foramen can benefit from mild®.

Are you ready to put your lumbar spinal stenosis patients on the path to long-term relief? Contact Vertos Medical and discover why leading interventionalists offer mild® in their practice.

Denis G. Patterson, MD (00:00)

Hey, this is Dr. Denis Patterson. I’m a physical medicine rehabilitation physician who specializes in interventional pain management. I am located in the greater Reno, Tahoe area. I’m the owner of Nevada Advanced Pain Specialists. I’ve been seeing and treating patients in the greater Reno, Tahoe area now for about 15 years, and I have to say that one of the best treatment options that I’ve had come around within the past decade has been the mild® Procedure.

Prior to this procedure, as an interventional pain physician, we’re more trying to cover up pain or, alleviate pain, but we never really could treat the underlying pathophysiology. And so it was nice that we finally got a tool in our bag of tricks to help patients that we could actually treat their underlying pathophysiology. So, a patient with wear and tear over the years, not only are they going to get a swollen disc, swollen facet joints, but the ligamentum flavum can also encroach and push into the spinal canal. And that’s what the mild® Procedure does, it allows us to have access to get between the lamina, dig out this ligamentum flavum, create a couple more millimeters of space, and in essence, probably decrease the pressure at that level in their spine and help alleviate their neurogenic claudication symptoms.

Being an advocate for this procedure, I talked to multiple physicians around the country, and one of the interesting comments that I’ve heard over the years is that, “Hey, I can give this or I can treat patients with this, but they can only have central canal stenosis.” And so to me, these physicians are looking for what I would call is a unicorn. A unicorn is a patient who has central canal stenosis only due to the ligament being hypertrophied and that’s simply not the case. When you really look back at the literature and the 2-year study that they did, the MiDAS study, what we see is only 5% of the patients in that study only had central canal stenosis. 95% of those patients had multifactorial stenosis and so that means they can have neuroforaminal stenosis, lateral recess stenosis, and central canal stenosis. And what we saw in the MiDAS study is all those patients benefited.

(02:17) But even though we have that data, over the years of training physicians in the mild® Procedure, I continue to hear, “Well they have neuroforaminal stenosis, they don’t have just central canal stenosis so, I think I’m going to pick a competitive product to treat these patients instead of the mild® Procedure.” So, from the MiDAS data that I had talked about earlier, we’d seen that patients with multifactorial stenosis benefited from the mild® Procedure. Myself, Dr. Pryzbylkowski, and Dr. Khemlani wanted to retrospectively look at patients who we had treated with the mild® Procedure and see if we could validate the results of [what] the MiDAS study had shown. And so we retrospectively reviewed 91 patients from our 3 clinics, and this went back to January of 2020. And what we found is that 32 of the patients that we had treated out of the 91 had no neuroforaminal narrowing. Meaning, they had central canal stenosis, which included ligamentum flavum hypertrophy, but they also could have had multifactorial pathology, including disc bulges and facet hypertrophy. And then the other 59 patients out of the 91, besides having multifactorial pathology, also had neuroforaminal narrowing. And then what we ended up doing is retrospectively looking at our results of these patients, who benefited from the mild® Procedure in these groups; did both groups, 1 group, or neither group benefit? And we looked at our results at one and three months after having the procedure done. And if you look under our results, we look at [how] both groups got significant pain reduction and response rates, what we see is that the foraminal narrowing group did better.

86% of these patients had a positive response rate, while only 75% of the patients that had no neuroforaminal narrowing had a pain reduction. So, when you first look at this, you think, “Oh God, this has got to be statistically significant that the foraminal narrowing group benefited more than the no foraminal narrowing group from the mild® Procedure.” But, when you really look at the “P” value, there is no statistical significance between the 2 groups. And so the conclusion that we came to, is that patients with lumbar stenosis, with neurogenic claudication, whether they have central canal stenosis only, or they have multifactorial stenosis only, both groups can benefit from having the mild® Procedure done. And so, all physicians should know that they should not exclude patients with multifactorial stenosis from having this procedure be considered.

At the American Society of Pain and Neuroscience (ASPN) 2021 meeting in Miami, several abstracts highlighted recent data that supports use of the mild® Procedure as a first line therapy. Additionally, a panel of prominent Interventional Pain Physicians convened to discuss their experiences and clinical pearls for implementing the mild® Procedure in their practices. The consensus? The abstract authors and panelists repeatedly confirmed the rationale, supporting evidence, and benefits of moving to mild® as a first line therapy for lumbar spinal stenosis (LSS).

What’s driving the MOVE2mild® among leading clinicians?

According to information presented at ASPN, mild® is continuing to be validated as an ideal procedure for LSS patients with neurogenic claudication for several key reasons:

  1. A broad base of treatable patients in pain practices and the community
  2. Refined techniques that enhance procedure efficiency
  3. Positive patient and practice impact

MOVE2mild® by recognizing LSS patient candidates in your practice

4 speakers on the panel, Drs. Navdeep Jassal, Mark Coleman, Lindsay Shroyer, and David Dickerson, each spoke to the broad patient base that is appropriate for the mild® Procedure.

Dr. Navdeep Jassal: Look for the ligament

“For percutaneous image-guided lumbar decompression, any patient with 2.5 millimeters of ligamentum flavum hypertrophy, whether they have central stenosis or lateral stenosis, is a candidate and may achieve pain relief and functional improvement…that’s where I start. The indications are very clear.”

Dr. Mark Coleman: Treat multilevel stenosis with the Streamlined Technique

“The fact that they have multilevel disease would lead you towards doing a mild®. A lot of folks were afraid of mild® because of excess radiation, but we can now do these procedures in a fraction of the time that it took in the past. Being able to treat multiple levels of stenosis opens mild® as an option for many more patients.”

Dr. Lindsay Shroyer: No limits around scoliosis

“For these procedures, positioning is everything. If you start the procedure with the patient well-positioned, you should be able to access the level you are targeting. Even if you are taking some of the ligament on the opposite side, that can produce good outcomes for the patient. So, for scoliotic curve, there’s not really a maximum or a minimum.”

Dr. David Dickerson: Focus on patients with comorbidities

“This is an elderly patient population. A lot of patients have comorbidities or may be on blood thinners that make them poor candidates for surgery. Why not start with mild®? The excellent safety profile of mild® makes it an excellent option and a procedure I offer to so many of my patients that have lumbar spinal stenosis.”

MOVE2mild® with refined techniques to enhance procedure efficiency

Clinical approaches that support delivery of the mild® Procedure faster, with less radiation, were a significant focus of the discussions at ASPN. Several leading physicians participated in a clinical study presented by Dr. Dawood Sayed that evaluated the safety and efficacy of the Streamlined Technique compared to the Standard Technique for the Percutaneous Image-Guided Lumbar Decompression (PILD) Procedure.

Image showing spinal decompression performed with a single midline incision
Image showing spinal decompression performed with a single midline incision

Their results demonstrated:

  • No significant differences in VAS scores between the 2 techniques
  • No complications with either technique

In a separate study, Dr. Navdeep Jassal and APP Christine Christensen, MSN, APRN similarly concluded that the Streamlined Technique is a more minimally invasive procedural approach for mild® and is comparable in safety to the Standard Approach, with no increased risk of serious postoperative complications to the patient. Based on this finding, they suggested mild® should be considered the first-line intervention for patients with lumbar spinal stenosis (at least 2.5 mm of hypertrophic ligamentum flavum) and neurogenic claudication after the first epidural steroid injection (ESI) fails.

Finally, Drs. Jason Pope, Timothy Deer, and Steven Falowski submitted a poster investigating the safety of using osteal landmarks instead of an epidurogram to establish a visual safety barrier prior to decompression with mild®. Based on zero complications reported across all 147 patients participating in the study, they assert that an epidurogram is not necessary for safe decompression with the mild® Procedure. Contralateral oblique view of the epidural line provides a clear view of the lamina and osteal landmarks, enabling identification of the targeted location for decompression.

X-Rays of a spine suffering from lumbar spinal stenosis
X-Rays of a spine suffering from lumbar spinal stenosis

MOVE2mild® together to drive positive patient and practice impact

Across the panel, numerous speakers highlighted the particular benefits of mild® to patients and urged early integration of mild® in the treatment algorithm.

Dr. Lindsay Shroyer: Happy patients tell their friends

mild® has completely changed the way I practice. I implement it early in my algorithm and my patients are really happy. They don’t want surgery, or may have comorbidities that mean they are not a candidate, and they are so excited about their results with mild®. They’ll go out and tell their friends and neighbors, and then we have more patients coming in asking for mild®.”

Dr. Peter Pryzbylkowski: Give patients a better quality of life

“When you start doing mild®, the word will spread like wildfire. I’ve done multiple family members who saw the results their loved ones achieved. I tell people, ‘why keep doing epidural steroid injection after epidural steroid injection?’ We know mild® has excellent safety. With mild®, we can give patients good, durable benefits that let them stand, walk, and enjoy a better quality of life.”

Dr. Jessica Jameson: Works well in multi-discipline practices

“For pain physicians in practices that include a lot of surgeons, start by picking patients who are not good surgical candidates. There are so many patients that may not be ideal for surgery or don’t want surgery that you can help. When you start there, the surgeons in your practice will see the outcomes you’re able to achieve and you can expand from there. This helps smooth the practice dynamics.”

Is your practice ready to MOVE2mild®?

For clinicians considering integrating mild® in their practice armamentarium, or practices already performing the mild® Procedure for failed serial ESI patients or patients who are not candidates for surgery, the data is clear: performing mild® early in the treatment algorithm can offer your LSS patients lasting functional improvements with a safety profile equivalent to ESIs.,

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