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Bob Underwood, MD (Host): By providing targeted decompression with nominal disruption to surrounding tissues, minimally invasive lumbar decompression can effectively alleviate symptoms and improve the quality of life for individuals suffering from spinal stenosis and neurogenic claudication. This is Expert Insights with the Carle Foundation Hospital.

I'm your host, Dr. Bob Underwood, and today we are excited to talk about minimally invasive lumbar decompression or the MILD procedure with Carle Pain Management Specialist, Dr. Francesco Vetri. Dr. Vetri, Welcome to Expert Insight. Thanks for being on today.

Francesco Vetri, MD: Oh, it is my pleasure. Thank you for having me.

Host: Yeah, absolutely. So, let's start just with the discussion about what is your primary focus as a pain management specialist?

Francesco Vetri, MD: Well, that's a good question. I do like the fact that I can help patients to return to their activity levels, activity or pleasurable activities, before started having chronic pain. Or the pain in the case of patients who have chronic conditions that are kind of hard to address or completely cure, then, you know, to have the possibility to restore some of the function that is lost or the abilities that kind of been put aside because of the pain.

Host: And I think that that's incredibly important and, you know, pain management is often an overlooked part of the entire continuum of healthcare. And, getting people back to their baseline or, or what they see as their personal goals around pain management, I think is incredibly important. So do you have any new treatments, that you're offering to your patients in the pain management space?

Francesco Vetri, MD: I do actually have several things that I have learned over the years that not necessarily, you know, done by all pain physicians. I'm very strongly interested in neuromodulation, both for like a spinal cord stimulator, for instance, as well as, peripheral nerve stimulation for, you know, more kind of specific nerve pain and peripheral nerve branches. So those are the things that I really believe in because they can help a lot of patients that otherwise would be really, limited by their pains.

Not necessarily new, but, there's something that oftentimes is overlooked, unfortunately, by the medical community, like vertebral compression fractures which can be treated with kyphoplasties. That is, something that, you know, as pain physicians, both myself and my colleague, Dr. Avni Gupta, who works at Methodist at the Atrium, so that, you know, we're very versed in this type of you know, treatments so that we can help patients who otherwise would, you know, find themselves to kind of be bedridden or even, add into the burden of, and to the family and then you know, even increasing the risk of the complications because of just immobilization, for instance.

Host: Yeah, I know as an emergency physician, I've referred many patients with compression fractures for kyphoplasty. I think that's a huge benefit to have that as an option. And talk about a little, for the neuromodulation or nerve stimulator. I think that that's something that a lot of people don't really understand kind of the concept and how it works.

Francesco Vetri, MD: Yes, and I actually do even basic research in the neuromodulation area. I have several publications and I started, you know, research with a group who kind of brought one of the main advances actually in the field of neuromodulation, which is what's called DTM.

You know, in the company, the platform is Medtronic. So the spinal cord stimulation in general, okay, is a very powerful technique. It exploits a current, an electrical current, at the level of the spinal cord to interfere with the painful sensation, and typically coming in from the lower extremities or from the back, so if lower back and leg pain, or you can also use it in the cervical spine for neck and arm pain or upper extremity pain.

 So the idea is that, you know, there's a variety of reasons why, it's a very complex matter, but just to kind of, you know, simplify; it interferes with the painful sensation coming from these areas at the level of the spinal cord. One of the problems with the chronic pain is that it changes the way the spinal cord sends the inputs to the brain.

So oftentimes, even in the absence of any specific issue at the periphery, maybe there was an injury, there was a, you know, let's say complex pain regional syndrome. That there was a you know, remote injury, like an ankle fracture or there was minor trauma.

And then even after the tissue injury has resolved or is improved, then the pain still is present and it typically spreads. So there's a, you know, that's one of the typical indication for spinal cord stimulation because basically you act at the level where the problem, so to speak, is being created.

So it's a, it's a, it's a transmission, it's an abnormal transmission of painful signals from the spinal cord to the brain. So it reverts the kind of shortcuts, if you will, that keep sending pain signals to the brain when it is not, so to speak, necessary for the normal, you know, physiology.

Host: Yeah, and I think that it's a fascinating application of technology that we have today that hasn't always been there. So, next let's talk about kind of what I talked about in the introduction is the MILD procedure, which is minimally invasive lumbar decompression. How does that work to alleviate symptoms of spinal stenosis and neurogenic claudication?

Francesco Vetri, MD: Yes, the way it works, it's relatively simple. Okay, so you can have a spinal stenosis, which is a narrowing of the spinal canal that it compresses on the nerves or the spinal cord, and it's related to the redundancy or the hypertrophy sometimes described by the radiologists of the ligamentum flavum, which is a thick ligament that you know, it has a function to stabilize the spine.

It's one of the three ligaments that stabilizes the spine. But oftentimes with arthritis and, you know, with the disc degeneration, which tends to decrease the space in between the vertebrae, it will buckle and that will push basically eventually toward the spinal canal, contributing or being the main contributor, actually, oftentimes to the spinal stenosis.

So the procedure, which is relatively simple, but it will kind of, you know, eliminate this redundant ligament. It will literally scoop out some of it to create more space in the spinal canal and therefore decompressing the, the nerves and the nerve compression.

Host: So, Dr. Vetri, what's some of the research that really backs up the MILD procedure's being effective?

Francesco Vetri, MD: Riht There are actually several studies on the safety and efficacy of this procedure. The classical studies, the most cited one is the MIDAS study, MIDAS ENCORE. There's a level one evidence for both the safety and the efficacy of this procedure, even five years out. So there's a pretty good longevity of the studies.

Eighty eight percent of these patients actually were able to avoid a surgery in the five years of following the initial procedure. And so that means like they had long lasting relief, which is not very common for studies to be, you know, following up the patient that far out. In the typical, effect is study was the increase in the standing time, which was seven times longer, in the walking distance, which was even 16 times farther.

The patient could you know, walk for a longer time. So because one of the problem with the spinal stenosis is that it's the limitations in those basic activities like, you know, patients say, I cannot walk to the mailbox without having pain, without having to stop, or I cannot prepare a meal without having to sit down because my back and my legs hurt.

So those are the things that, we can help. These are patients that are not surgical candidates, you know, this is not like a, you know, a steal or a competition with the surgeons because their patients are not candidates for MILD they're candidates for surgery and that's what it is.

But there's a lot of patients that are not candidates for surgery or they do not want to have surgery that can definitely benefit from this procedure.

Host: Yeah. No, those are phenomenal outcomes, especially how long lasting they are.

So, what's the minimally invasive part of the procedure?

Francesco Vetri, MD: Right? So, you know, spinal decompression can, you know, typically is performed by a surgeon. Okay? So I'm not a surgeon. I always tell the patients I'm not a surgeon, okay, but this is what I can do for you. So it is minimally invasive because it involves like an incision that is about a quarter of an inch. So it's a very small incision. There is a cannula or choker, basically it is a for the non medical audience.

Host: Right.

Francesco Vetri, MD: It's imagine it's like a big needle I tell the patients. And through that big needle, I will introduce two different tools that are able to scrape off some of the bone to create basically access to the ligament.

And then, the second tool, which allows to actually chip off or take out some of that excess ligament. So there is one small incision and you can decompress up to three levels on both sides, basically angulating and, you know, passing the instrument an direct it to different segment of the spine so that you can obtain like a, you know, pretty decent decompression at multiple levels, which if done by the surgeon will require a significant downtime and, you know, longer procedure, longer time for surgery and recovery. One of the advantages that I see in this procedure is that there's basically no downtime. So you can go back to your normal activities the day of.

Host: Wow.

Francesco Vetri, MD: Usually there is a, you know, some discomfort in the back, but honestly, nothing that like some ibuprofen cannot take care of. You know, I do not routinely prescribe opioids after the procedure because it's just not necessary.

Host: Yeah, and that's one of the great things about it is the relatively rapid return to normal behavior after a minimally invasive procedure as opposed to a major surgical intervention.

Francesco Vetri, MD: Correct.

Host: Yeah, no, it's phenomenal. So, what kind of updates is there around pain research? What's on the horizon for folks?

Francesco Vetri, MD: There's a few things, you know, going back to the neuromodulation, there's been a lot of emphasis lately to treat with neuromodulation a, a painful diabetic neuropathy. There's been a lot of studies from company, it's called Nevro or HFX is the therapy that is delivered.

But, you know, it basically, uh, it took like 200 patients and they follow them like, you know, with a spinal cord stimulator to treat the pain in bilateral extremities related to diabetic neuropathy and they did very, very well. So this is something that, you know, kind of is I find a little bit difficult sometimes to address with podiatrist or, you know, other specialists who are, you know, dealing with diabetic patients.

You know, oftentimes their medications can either have a lot of side effects or not being effective at all. So that is definitely something to consider for this patient population, that's kind of refractory to more conventional therapies.

Host: Yeah, that's really exciting stuff. Anything else that you'd like to share before we close out today?

Francesco Vetri, MD: I mean, we do offer a variety of treatments, literally from the head to tail. Let's not forget migraines, which is one of the main problems in the general population. We'd be happy to assist with those as well, you know, and there's definitely the breadth of treatments that we can offer, it's sometimes unanticipated, so don't be, don't be afraid to refer patients to us and we'll, we'll try our best to help them out.

Host: No, it's a phenomenal service to be able to offer to the patients, that's for sure. So, for more information and to get connected with one of our providers, please visit carle.org. That's C-A-R-L-E.O-R-G. And if you found this podcast helpful, please share it on your social channels. And for a listing of Carle providers and to view Carle sponsored educational activities, head on over to our website at carleconnect. com. And that wraps up this episode of Expert Insights with the Carle Foundation Hospital. I'm your host, Dr. Bob Underwood.