Transcription:
Minimally Invasive Lumbar Decompression (MILD)

Prakash Chandran (Host): Minimally invasive lumbar decompression or MILD for short is a relatively new procedure for treating patients with lumbar spinal stenosis. Those with this condition usually have difficulty walking or standing and might be interested in how the MILD procedure can help them when more conservative treatments don't work. We're going to talk about it today with Dr. Stephen Erosa, a dual board-certified interventional spine physician at St. John's Riverside Hospital.

This is Riverside Radio HealthCast, the podcast from St. John's Riverside Hospital. My name is Prakash Chandran. And so Dr. Erosa, really great to have you here today. Thank you so much for your time. I wanted to get started by asking about the condition lumbar spinal stenosis. Could you tell us a little bit more about what that is?

Stephen Erosa, DO (Guest): Absolutely. So lumbar spinal stenosis is a narrowing of the center of the spinal canal. That's what stenosis means, is narrowing. And as we age, as part of the degenerative process or the aging or the process of developing arthritis, the canal can become narrowed for a couple of different causes. Sometimes the joints of the back become arthritic and grow into the canal. Sometimes discs herniate or bulge out causing the canal to be narrowed. And sometimes ligaments within the canal can become thickened over time and become larger, making the space where the nerves pass through the middle tighter. And that can cause pain, can cause something we call neurogenic claudication. What that means is that the nerves are being squeezed and blood flow is not passing through to those nerves as effectively as it once was. And that can cause pain that travels down the back, to the legs. It can affect how long we can stand before we start feeling pain. It can affect how long we're able to walk, the distance we're able to walk before we start to feel pain. And many times, patients, you may have seen family members that are walking kind of flexed forward, hunched over as we age, that is part of the body's mechanism to decrease some of those symptoms. When we flex our back forward, we open up the canal. When we stand upright, we make the canal smaller. And so as a protective mechanism, the aging person, the aging spine tends to like to bend forward. And so that's what spinal stenosis is. And those are the pain problems and functional problems that it can cause.

Prakash Chandran (Host): Yeah, that was an excellent explanation. And I didn't realize that stenosis meant the narrowing. You know, is this why when people sit down, they are more relieved because it causes that opening when they're in a seated position?

Stephen Erosa, DO (Guest): Absolutely. That's exactly why the symptoms from spinal stenosis and neurogenic claudication are alleviated with sitting, because you're flexing the spine and opening the space as well as bending forward when you're walking, like with a cane, a walker, or like many patients will find that have this condition, that they have less pain and are able to walk longer distances if they're using a shopping cart or a walker, it's actually called the shopping cart sign, that when you stand upright, you have pain. And when you lean forward, it gets better. And that's an exam finding or a sign that you may have lumbar spinal stenosis with neurogenic claudication or nerve compression.

Prakash Chandran (Host): Now, before we move on to treatments, I just wanted to understand broadly, you said it was degenerative. Is this just like something that most people can expect? Is it people that are playing like high-impact sports that this affects more? Can you talk a little bit about the demographic of people that actually get lumbar spinal stenosis?

Stephen Erosa, DO (Guest): Yeah, so lumbar spinal stenosis means a narrowing of the spine and the particular type we're discussing is the degenerative lumbar spinal stenosis with the claudication symptoms. There are patients out there that are younger that can have traumatic accidents that causes stenosis. There are patients that are born with smaller canals that cause congenital stenosis. But specifically, what we're talking about is the aging population, the demographic 65 and older, sometimes a little bit younger that have arthritic changes of the spine that are just natural causes of wear and tear over time that can have this particular type of spinal stenosis that we're going to discuss MILD treatment about.

Prakash Chandran (Host): Yeah. So let's get into that. What exactly are the traditional treatments for lumbar spinal stenosis?

Stephen Erosa, DO (Guest): So traditionally, we start with conservative measures such as physical therapy. So physical therapies can help with the muscular and arthritic components to the pain, can help with postural training and provide strategies for being able to ambulate longer distances and function a little bit better. When physical therapies are not working, we move on and talk about medication management or pharmacotherapies. And when we talk about medications, we are talking about our analgesics like Tylenol, we're talking about anti-inflammatories like ibuprofen, and then some of our nerve pain medications like gabapentin or Lyrica. Those can help calm down some of those symptoms that you feel in your legs when you're standing for long periods of time. And some patients respond well to those, but they also have a lot of side effects such as dizziness and drowsiness. And so when you're already having difficulty ambulating and walking, sometimes these added effects of dizziness and drowsiness are not helpful and actually can impede your overall functioning, as well as medications, such as opioids, which have been traditionally used which is a hot topic of conversation in the country right now, because of the overuse of opioids, and the negative side effects that they have when used long-term. Especially if we have a condition like lumbar spinal stenosis that is a long-term problem, these things can have negative effects.

As far as next steps after pharmacotherapy, we have interventional treatments, injection therapies, where we would inject some steroids around the nerves in the form of an epidural steroid injection. So epidural steroid injections have been used for decades to help with spinal stenosis. And typically, after medicines and physical therapy, this was the only thing we had left before someone would need to move on to having surgery. And a lot of times, patients are more interested in conservative, minimally invasive options prior to undergoing a laminectomy, which is a surgery that removes the bone and opens the canal, and then further surgeries, such as laminectomies with fusions, where we have to stabilize the spine from a surgical standpoint. And so those are the options that we had, injections like epidurals. And then if those do not work, which you can only have about three in one year safely, then we move on to surgery. And this is where the MILD actually fits in, in between injections and larger surgeries.

Prakash Chandran (Host): Got it. So let's get into this MILD procedure. Talk a little bit about what it is and who the right candidate is for it.

Stephen Erosa, DO (Guest): So the MILD procedure or minimally invasive lumbar decompression, which actually works out great with an acronym being MILD, is actually a very simple procedure. What we are doing with MILD is we are focusing on one particular part of the spinal stenosis, meaning the ligamentum flavum. So I said earlier that the ligament can become thick. There is a ligament in the spine, which is a stabilizer that's inside of the spine, that as we age and there's arthritic changes occurring to this ligament, it will get thicker. And as it gets thicker, it encroaches on the canal, making it narrow.

Now, patients that have on MRI imaging ligamentum flavum with a thickness of 2.5 millimeters or more, which most people have much larger ligaments. I've seen 7 millimeters and larger in that space. Those patients are the candidates that can benefit from the MILD procedure. So what we're looking at if somebody with spinal stenosis and neurogenic claudication, the symptoms of the leg pain when standing that are alleviated with flexing the trunk or sitting, and on an MRI, they have a thickened ligamentum flavum causing their stenosis; patients that have had an epidural and it did not help, or it only lasted for a few weeks when we really should be seeing months of relief; patients who have failed those epidurals and they're no longer working are candidates for this procedure.

Now, what we do is through a small what we call a stab incision, a small poke in the skin, the size of the baby aspirin, we slide a little trocar and shave a little bit of the bone and shave a little bit of that ligament to open up the space. Everything is done through this small incision. It is a same-day procedure and patients go home and back to normal activity 24 hours after the procedure. It can open up the space and allow for that blood flow to restore to those nerves and decrease those symptoms of leg pain when ambulating or standing for long periods of time.

Prakash Chandran (Host): I mean, that sounds incredible. Just the fact that you're able to make this incision the size of an aspirin or a baby aspirin, and then go home, you know, less than 24 hours later. I think I understand, but talk to us about what makes the MILD procedure unique and different from traditional surgical treatments.

Stephen Erosa, DO (Guest): So what makes the MILD treatment unique is that not only the patients leave the same day. They don't stay. There's no hospital stay. There are no stitches during this procedure. We close that little poke with a little bit of glue or Dermabond and the patients are back to normal activity in 24 hours. A traditional spinal surgery, which patients may need, is something called a laminectomy where they actually, instead of shaving a little bit of that bone, you are removing a larger portion of the bone to open up space in the canal. And depending on your spine, it may require or necessitate a fusion procedure where if there's some instability, you then have to stabilize with other hardware or implants.

Now, this procedure does not leave any implants behind. It does not affect the overall stability of your spine. So your spine, as long as it's stable before the procedure, will be stable after the procedure, and you will be able to go back to your normal activities. The MILD procedure can continue to provide relief months after the procedure is done. So once it is complete, patients see more functional gain as time progresses over a six-month period with therapy and exercise. Patients that have benefited from this can get about and stand about seven times longer than they did in the previous clinical trials and walk 16 times farther. So the procedure is very good at improving functional outcomes as well as decreasing pain by at least 50%. It gets even better with some of the results. What they found at a five-year data study, so patients that had after five years of having the MILD procedure, 88% of the patients that had this had sustained benefit and only a small percentage of patients went on to needing further surgery. So the procedure is minimally invasive and durable without needing to have extensive surgical time, hospital stay or having implantable devices. So it really is the best next step when conservative measures have not helped and injections have stopped helping prior to moving on to a neurosurgical or an orthopedic surgical procedure, because let's say we do do this and it doesn't help because in small percentage of patients, it may not help, you are perfectly able and capable to have any and all surgical options. It does not close any doors for you. It only provides you another option to help alleviate your pain and improve your function.

Prakash Chandran (Host): Yeah, I mean, it is such a cool time that we are living in and it really sounds like a no-brainer next step when other conservative measures don't work. Do I have the right read on that?

Stephen Erosa, DO (Guest): Yeah, that's exactly it. It's a very safe procedure and I'm glad you brought that up, because the safety profile on this procedure was found to be the same as an epidural steroid injection. So when people think about surgery on their back or they think about procedure, they go, "Am I going to be paralyzed? Am I going to have an injury to my spine when you do this?" And this procedure, the way it has been created, the safety protocols that are in place, all of the procedural field is outside of the spine, not inside the spine where all of your sensitive nerves and neural tissue is. We are simply shaving and opening up a space in the same area that we placed our injection. And so the safety profile has been studied extensively over the past 15 years and been demonstrated to be just as safe as an epidural steroid injection.

Prakash Chandran (Host): I love it. Well, Dr. Erosa, this has been a hugely informative conversation. Is there anything else that you'd like to share with our audience today before we close?

Stephen Erosa, DO (Guest): No, I think that's it. I think I would just like to say that, like you said, we are living in exciting times. There are a lot of options for patients. And I just want to let them know that we're here to help. We're here to offer them the best state-of-the-art treatments and get them the best outcomes possible. That's what we're trying to do here at St. John's.

Prakash Chandran (Host): Well, we truly appreciate you. Thank you so much, Dr. Erosa.

Stephen Erosa, DO (Guest): Thank you.

Prakash Chandran (Host): That was Dr. Stephen Erosa, a dual board-certified interventional spine physician at St. John's Riverside Hospital. Thanks for checking out this episode of Riverside Radio HealthCast.

For more information on providers, you can visit St John's med group.com or call 9 1 4 2 0 7 0 0 0 4. To make an appointment with Dr. Arosa.

If you found this podcast to be helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you. Once again, this has been Riverside Radio HealthCast, the podcast from St. John's Riverside Hospital. My name is Prakash Chandran. Thanks so much, and we'll talk next time.