Many providers are moving beyond epidural steroid injections (ESIs) for patients with chronic low back pain associated with lumbar spinal stenosis (LSS).

Instead of simply masking the pain caused by an enlarged ligament with epidural injections, which may only provide temporary pain relief, providers now opt for more innovative and durable spinal stenosis treatment options such as the mild® Procedure.

A Hispanic woman in her 60s, with the quote "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," nd I said, "No, I'm finished with them." - mild® patient.

Managing LSS with ESIs

An epidural steroid injection, which is a medication that is injected into the epidural space in the lower spine to reduce swelling and offer pain relief, may be offered to patients with chronic low back pain from conditions such as lumbar spinal stenosis.

Recent data indicates that repeat epidural injections for patients who experience only short-term improvement may not be in the patient’s best interest in the long term. Alternative treatments, such as minimally invasive lumbar decompression, or the mild® Procedure, may be a better option for some patients.

Durability of Relief, Column 1: Epidural Steroid Injections - To achieve effectiveness over 2 to 3 years, 5 or more injections per year may be required. Column 2: mild Procedure - mild helped 88% of patients avoid back surgery for at least 5 years while providing lasting relief.

What is LSS?

Lumbar spinal stenosis, also called LSS, contributes to chronic low back pain and is prevalent in approximately 20 percent of patients over the age of 60.  LSS is often caused by an enlarged ligament in the back, which compresses the space around 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. A common visual cue is often referred to as the “shopping cart syndrome,” where the act of leaning over, often over a shopping cart, cane, or walker, helps to temporarily alleviate pressure felt in the lower back pain.

Two spinal vertebrae next to each other. Left shows a healthy spine. The right shows an aging spine with LSS (lumbar spinal stenosis). It includes a disc bulge, a thickened ligament, and bone overgrowth.

In addition to epidural steroid injections, some common conservative treatment options for LSS can include the mild® Procedure, medication, and/or physical therapy, with more invasive options including procedures such as spacer implants, spinal stenosis surgery, or other open surgery.

How exactly does an ESI work?

Epidural steroid injections are typically offered to LSS patients when more conservative treatment options, such as exercise and physical therapy, have failed to provide relief.

Steroid medication is injected directly into the epidural space, which may relieve pain by reducing inflammation around the spinal cord and nerves. The effects typically last for less than 6 months, after which additional injections may need to be administered.

How effective are ESIs for LSS?

Data shows that epidural steroid injections can effectively relieve pain for LSS patients—but the effects are not lasting, and pain may return, typically in months. ESIs treat the symptoms but do not address the root cause of pain associated with LSS.

The Dark Side of ESIs—The Downsides, Side Effects, and Risks

While ESIs are an effective form of early treatment for some patients, they may not provide reliable, lasting relief for all low back pain.

As mentioned in the Best Practices for Minimally Invasive Lumbar Spinal Stenosis Treatment 2.0 (MIST), certain payer guidelines, including Centers for Medicare and Medicaid Services (CMS), now stipulate that patients should have obtained a minimum of 3 months of pain relief with eventual recurrence of pain before it is reasonable to proceed with additional injection therapy.

This means that for patients exhibiting shorter-term relief of less than 3 months after receiving an ESI, clinicians should consider alternative treatment options.

ESI treatment may require repeat injections over time

Steroid medication reduces inflammation, which can temporarily relieve pain. However, epidural steroid injections only treat the symptoms of LSS—not the root causes of pain and inflammation. The effects of epidural steroid injections typically last less than 6 months, and patients often require an average of 2–3 injections per year to sustain long-term relief from low back pain associated with LSS.

A white man in his 60s contemplating the dark side of epidural steroid injections, with the quote "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." - mild patient.

Repeat ESIs can have negative impacts on patient health

There are many patients for whom repeat epidural steroid injections may offer more risks than benefits. For instance, steroid medications have been linked to bone loss, or osteoporosis. ESIs may also introduce risks for patients with certain comorbidities such as diabetes, cardiovascular conditions, active infections, bleeding disorders, or those taking anticoagulant medications.

As an alternative, epidural injections without the use of steroids may be considered, as well as more advanced decompressive therapies such as the mild® Procedure.

ESI Exhaustion

In addition to the health concerns associated with repeat steroid injections, the mental and emotional effects experienced by many LSS patients can also reveal the dark side of repeat epidural steroid injection treatments.

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.

A woman of color, in her 60's with the quote, "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.'" - mild patient.

ESI Exhaustion Sign #1: Feelings of Hopelessness

When patients experience short-term relief for a condition as challenging as LSS, they can easily become frustrated and lose hope. LSS patients often experience debilitating pain and loss of mobility that can have a devastating impact on their outlook and optimism for the future. Losing additional time and energy to repeated appointments, procedures, and recovery times can also be detrimental to their quality of life, and some patients may start to feel hopeless if injections remain ineffective or lose their efficacy soon after receiving them.

ESI Exhaustion Sign #2: Decreased Durability of Relief

One of the more common questions patients have about a steroid injection is, “How long will the results last?” Unfortunately, with epidural steroid injections, efficacy can vary by patient, and it can be difficult to predict the degree of relief or durability of effect for the individual. While studies have shown symptom relief for up to 6 months in some lumbar spinal stenosis patients, other studies have demonstrated the limited effectiveness of epidural steroid injections.

ESI Exhaustion Sign #3: Solution Shopping

If patients are dissatisfied with their results and feel they have run out of options in your practice, they may search for another solution. By offering alternative treatments such as the mild® Procedure as an early intervention, you can retain the patients in your practice and increase productivity, while continuing to develop closer relationships and increase your reach within your community.

 

Avoiding repeat ESIs

Given the significant advances in minimally invasive spine technology, current research confirms that repeat epidural steroid injections should be reserved only for patients who experience significant and lasting relief after the injections, and/or those who are not candidates for higher-level interventions or surgical decompression.

For patients experiencing relief that lasts fewer than 3 months, clinicians may wish to consider more durable treatment options.

Move past injections and make the MOVE2mild®

While they may offer temporary relief, epidural steroid injections do not “cure” LSS. Without addressing the enlarged ligament, which contributes up to 85% of spinal canal narrowing , relief may only be experienced on a short-term or temporary basis.

Minimally invasive lumbar decompression may be the next step for long-lasting relief from LSS and to reduce pressure in the canal. By decreasing the amount of space taken up by the enlarged ligament, patients can experience decreased pressure on the spinal nerves, which may lead to decreased pain.

Performing multiple epidural steroid injections only delays patients from receiving treatment with more lasting results, such as minimally invasive lumbar decompression—the mild® Procedure.

Turning to mild® as the first line of therapy addresses the root cause of LSS by removing excess ligament tissue around the spine, proven to provide a 5-year durability of results.

The Evidence is Extensive. The Consensus is Clear. Level 1 data and real-world outcomes support mild as the gold standard of care for LSS. 5-year durability. >35 peer-reviewed publications. 16 clinical studies. Level 1 data: 2 multicenter RCT studies.

MOVE2mild® after the first ESI fails

The mild® Procedure is a short, outpatient procedure that can be performed using only local anesthetic and light sedation. The procedure is performed through a single incision in the low back smaller than the size of a baby aspirin, or the diameter of a drinking straw (5.1mm).

By removing excess ligament tissue that has built up around the spine, mild® restores space in the spinal canal. This reduces pressure on the nerves in the low back, addressing a major root cause of LSS, which can help reduce pain.

  • The mild® Procedure does not leave an implant behind, and patients typically resume normal activity in 24 hours with no restrictions
  • mild® does not require stitches, staples, or complex bandaging
    • Typically, patients leave the outpatient procedure facility with just a Band-Aid covering their incision and visit their doctor a few days post-procedure for a quick wound check to ensure healing is progressing normally
  • The safety profile of mild® is similar to epidural steroid injections, but with lasting results
  • mild® has been shown to provide lasting relief, with 88% of patients avoiding open back surgery for at least 5 years

The next step may be mild. Image outline of a woman in her 60s walking.

The mild® Difference

When Epidural Steroid Injections (ESIs) Don’t Provide Lasting Relief, mild® can improve patient outcomes across a variety of measures:

Walking/Standing

In a study performed at the Cleveland Clinic 1 year after the mild® Procedure, patients were able to:

  • increase their standing time from 8 minutes to 56 minutes with less pain.
  • increase their average walking distance from 246 feet (comparable to walking to the mailbox) to 3,956 feet (comparable to walking around the mall).

An illustration showing Increased mobility over time following the Mild® Procedure. Patient functionality continues to improve as time progresses. Stand 7x longer: Baseline at 8 minutes versus Month 12 at 56 minutes. Walk 16x farther: Baseline at 246 feet (example, walking to the mailbox) versus Month 12 at 3,956 feet (example, walking around the mall).

Pain Relief & Mobility

mild® demonstrated excellent long-term durability with significant improvements in both pain and mobility over 2 years. Clinical data from the MiDAS ENCORE 2-Year Study finds mild® provided patients with lasting pain relief and increased mobility.

Long-Term Durability

A 5-year study performed at the Cleveland Clinic demonstrated that mild® helped 88% of patients avoid back surgery for at least 5 years while providing lasting relief.  Use our Find a mild® Doctor tool to connect with an interventional pain management specialist in your local area to find out if mild® is right for you.

To learn more about mild® and how it can help people suffering from LSS get on the path to lasting relief, explore mildprocedure.com.

Could Knowing Your “Back Story” Help You Rewrite Your Future?

Vertos Medical is proud to have joined forces with the American Society of Pain & Neuroscience (ASPN) and the National Association of Memoir Writers (NAMW) to develop the Know Your Back Story campaign, a national public health awareness campaign that seeks to help patients suffering from chronic low back pain (CLBP) learn more about their “back stories.” The campaign encourages providers to educate their patients on lumbar spinal stenosis (LSS) and provide awareness around the enlarged ligament that may be causing their pain.

Vertos Medical is committed to empowering healthcare providers and patients with minimally invasive treatments for LSS, and the Know Your Back Story campaign plays a significant role in fulfilling our core mission: to help patients suffering from chronic back pain reclaim their quality of life using the simplest, safest, most durable, and earliest treatment available.

The Prevalence of Chronic Low Back Pain

As part of the Know Your Back Story campaign, we partnered with The Harris Poll to conduct a landmark survey on CLBP in the United States. Results from the “Mobility Matters: Chronic Low Back Pain in America” survey indicate that CLBP affects more people than arthritis, diabetes, or heart disease, but over one-third of CLBP patients have never been told by a provider what the exact cause of their pain is.

Image Woman's bare back. Text More than 72.3 million US adults (28% of the population) reported having CLBP. 59 million US adults reported at least 1 symptom of LSS. However, 78% of adults with CLBP do NOT know that an enlarged ligament may be the cause. Image 10 silhouettes, 8 of which are shaded blue and 2 are grey.

The Need for Increased Patient Education

“Mobility Matters: Landmark Survey on Chronic Low Back Pain in America” also revealed misconceptions about CLBP and the need for education about the associated impacts on mobility and quality of life, and where to go to for diagnoses and information about available treatment options.

Text, More than half of chronic low back pain ("CLBP") patients say their chronic pain has a major or moderate negative impact on their overall quality of life. Image, circle chart, 53% highlighted, 47% not highlighted.

Finding the Right Doctor

The average chronic low back pain sufferer has seen at least 3 different healthcare professionals (HCPs) seeking treatment for their pain and has made 4 visits to an HCP within the last year.

For the most accurate diagnoses and treatment recommendations that may lead to lasting relief, patients should seek out doctors who specialize in spine health, such as pain specialists, physical medicine, and rehabilitation (PM&R) physicians, interventional pain physicians, or physiatrists.

Text, healthcare professionals ("HCPs") seen for chronic low back pain ("CLBP"). Graphic 4 circle charts. Chart 1: Label - Spine Health Specialists, 31%. Chart 2: Label - Chiropractors, 30%. Chart 3: Label - Physical Therapists, 30%. Chart 4: Label - Primary Care Physicians, 49%.

By meeting with doctors who specialize in spine health, patients may be able to gain new insights into the root cause of their pain.

LSS: The Often-Overlooked Cause of CLBP

Lumbar spinal stenosis (LSS) is a condition, prevalent in approximately 20% of patients over the age of 60, in which the lower spinal canal narrows and compresses the nerves in the lower back. Up to 85% of spinal canal narrowing is caused by an enlarged ligament.

This pressure around the spinal cord can cause pain, numbness, heaviness, or tingling in the low back, legs, and buttocks, but the vast majority of CLBP patients have never heard of this potential diagnosis.

The Know Your Back Story campaign’s objective is to spread awareness around LSS and get more patients on the path to lasting relief. By collecting intensive data, developing tools for patient education, and sharing insights with both patients and providers about the effects of LSS and its potential treatment options, the Know Your Back Story campaign has served as a significant step in bringing more visibility to this condition.

Get To Know Your Back Story

Getting screened for LSS and CLBP can open the door to learning more about treatment options available, such as the mild® Procedure.

Woman's back. Text, Before mild, After mild. First image spine is impacted by the thickened ligament. Second image, spine is normal and not under pressure.

 

Introducing the First-Of-Its-Kind Mobility Index

One of the key accomplishments of the Know Your Back Story campaign is the development of the first-ever Mobility Index, a breakthrough resource for demonstrating the differences in mobility and quality of life between patients with CLBP and their peers without CLBP.

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.

Results from the “Mobility Matters: Landmark Survey on Chronic Low Back Pain in America” conducted by The Harris Poll show that with age, CLBP patients experience significantly greater challenges performing physical tasks and making it through the day without pain or limited mobility than others within their age group without low back pain.

For instance, nearly 3 in 4 individuals in their 50s who do not suffer from CLBP are able to easily stand for half an hour or longer. In contrast, the number of CLBP patients in the same age range who are able to do the same is just over 3 in 10.

When it comes to other activities such as walking, dancing, or using the stairs, the Mobility Index can be a great tool for educating patients. By reviewing the differences in mobility between similar individuals with and without CLBP, patients can understand more about what chronic pain is keeping them from—and their options for finding lasting relief.

Bringing the Know Your Back Story Campaign to the Public

On the quest to educate, engage, and increase awareness within communities, the Know Your Back Story campaign took the #LookForTheLigament Education and Experiential Mobile Unit on tour down the East Coast, stopping in New York City, NY; Philadelphia, PA; Washington, D.C.; and Sarasota, West Palm Beach, and Miami, FL.

The mission of this tour was to encourage people suffering from CLBP to get screened for LSS and an enlarged ligament by a spine health doctor, and to provide both patients and HCPs with an in-depth look at the causes and effects of LSS through interactive experiences and demonstrations, including:

  • Visualization stations that explored why LSS symptoms occur, tips on how to identify symptoms, how an enlarged ligament impacts spine health, and the potential for the mild® Procedure as a treatment option.
  • An immersive 3D journey down the spinal canal to the lumbar region that explored the enlarged ligament, spine degeneration, and how mild® works.
  • The Interactive Ligament Kiosk, which featured Mobility and the Enlarged Ligament, an animated educational program that demonstrated the inherent spinal compression associated with the diagnosis of LSS and its effect on pain, posture, and mobility; a Look for the Ligament interactive opportunity for people to view and compare MRI images of how a healthy ligament should look against imaging of an enlarged ligament; and a How Do Doctors Describe LSS? module filled with a colorful list of analogies and explanations doctors often use to describe the condition to their patients.
  • Interactive Motion Memoir iPads, featuring our writing program developed with award-winning author, certified therapist, and founder of the National Association of Memoir Writers (NAMW), Dr. Linda Joy Meyers, who provided tips and encouragement to help patients trace their own history of low back and leg pain to visualize the next chapter of their potentially pain-free life.

Watch the Video to See More Highlights From the #LookForTheLigament Tour:

Getting Involved as a Healthcare Provider

By staying aware of the impacts of LSS and CLBP on patients’ mobility and potential treatment options, healthcare providers can help more patients in their communities get on the path to lasting relief. By working alongside others in their practice or by creating referral networks with primary care, physical therapy providers, and other local providers, HCPs in Interventional Pain Management (IPM) or spine health specialties can play a more effective role in identifying patients suffering with LSS or CLBP and connect them to providers that are able to offer more durable treatment options.

Physicians and Advanced Practice Providers (APPs) can also play a more proactive role in identifying LSS by staying aware of common patient misconceptions about back pain. By utilizing the tools and resources developed as part of the Know Your Back Story campaign, you can keep your patients as educated as possible about the potential causes of their chronic pain, as well as the treatment options that may finally provide them with relief.

Hear From Patients

How Patients Can Find Relief

For patients looking to learn more about the source of their pain and their options for relief, finding a local spine health doctor is a crucial first step. By using the MD Finder tool, patients can find doctors in their area who may be able to provide the answers they’ve been seeking.

A spine health specialist can help walk patients through their options for treatment, from more conservative therapies such as medication or physical therapy to longer lasting, minimally invasive treatments such as the mild® Procedure.

How mild® Makes a Difference

The mild® Procedure, or minimally invasive lumbar decompression, may be pursued as a first-line therapy for LSS.

A minimally invasive procedure that is considered the gold standard of care in LSS treatment, mild® addresses a major root cause of LSS by debulking the enlarged ligament to restore space in the spinal canal and reduce compression of the nerves. With a safety profile equivalent to an epidural steroid injection (ESI), mild® has helped 88% of patients avoid back surgery for at least 5 years while providing lasting relief,—a durable, lower-risk treatment option to spacer implants or open surgery.

With mild, patients can do more: Stand 7x longer and Walk 16x farther. Patients increased average standing time from 8 minutes to 56 minutes with less pain. Patients increased average walking distance from 246 feet to 3,956 feet with less pain.

For patients considering mild®, the Move More Questionnaire is a great resource for identifying current limitations and tracking their reduced pain and improved mobility after the procedure.

By becoming familiar with the Know Your Back Story campaign and exploring the insights and resources developed to spread awareness about LSS, both patients and providers can help spread the word about this under-diagnosed cause of CLBP.

Vertos Medical is committed to helping patients experiencing chronic pain reclaim their quality of life with a short, minimally invasive early treatment option with the mild® Procedure, both through the Know Your Back Story campaign and in everything we do.

Learn more about Mild Get on the path to lasting relief: Find a spine health doctor in your area

 

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.

Image showing older man holding lower back as a result of pain. Text overlay states: "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 chronic low back pain (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.

Image of an older woman with a nurse. Text overlay reads: "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 chronic lower back pain 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 chronic lower back pain (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

Sign up to stay informed and receive the latest updates!

Sign Up Now

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.

icon of ringing bell

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?

icon of a speech bubble

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

icon of a bell ringing

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.

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.

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

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

In a prior CME webinar hosted by the American Society of Pain & Neuroscience (ASPN), 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 discussed how physicians and APPs can match more patients with the right treatments sooner by working together.

Visit ASPN’s website

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:

Piggy bank icon

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

icon of a clock with exclamation point

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

icon of an exam chart

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.
Image of an icon of a wall calendar with text that states:

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 discussing epidural steroid injection fatigue

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 - swinging a golf club following successful Mild treatment

“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
Infographic 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.

© 2024 Vertos Medical, Inc. All Rights Reserved.