The MOTION Study: A Randomized Controlled Trial with Objective Real-World Outcomes for Lumbar Spinal Stenosis Patients Treated with the mild® Procedure: One-Year Results

Three-year results of the MOTION randomized controlled trial for treatment of lumbar spinal stenosis using the percutaneous mild® Procedure

Objective

The MOTION prospective, multicenter randomized controlled trial compares the outcomes of percutaneous image-guided lumbar decompression in combination with conventional medical management (CMM) to the use of CMM alone for the treatment of lumbar spinal stenosis with neurogenic claudication secondary to hypertrophic ligamentum flavum. The study includes extended follow-up for patients in both the treatment group and for those who crossed over from the control group to the treatment group.

Methods

The treatment group received the mild® Procedure (Vertos Medical, Aliso Viejo, CA, USA) in combination with nonsurgical CMM, while the active control group received CMM alone. There were no restrictions for either group regarding access to real-world CMM therapies. Patients reported outcomes using the Oswestry Disability Index (ODI), Zurich Claudication Questionnaire (ZCQ), and Numeric Pain Rating Scale (NPRS). Objective outcomes were measured using a validated Walking Tolerance Test (WTT), the incidence of subsequent lumbar spine interventions, and the occurrence of adverse events.

Results

Forty-eight patients initially receiving mild + CMM consented to extended follow-up and were available for 3-year follow-up. All outcomes for this group were significantly improved over baseline (p-values ranging from <0.0001 to 0.0001). At 3-year, ODI, NPRS back and leg, ZCQ symptom severity, and physical function improved by 16.9, 3.0, 4.3, 0.8, and 0.6, respectively. Walking tolerance test demonstrated 274 % improvement from baseline, and only 4 (5.6 %) patients had received surgical intervention. No device- or procedure-related adverse events were reported.

Conclusions

MOTION 3-year follow-up results continue to demonstrate the safety and durability of the mild Procedure combined with CMM for early interventional treatment of symptomatic LSS. The absence of device or procedure-related adverse events further underscores the robust safety profile of the mild Procedure. Significant and substantial improvements in all the outcomes were observed from baseline to follow-up for patients treated with the mild Procedure. These results support the mild Procedure as an effective approach for early intervention in LSS treatment.

An Algorithmic Overview of Advanced Pain Therapies: A Narrative Review

PURPOSE OF REVIEW

Quickly referenceable, streamlined, algorithmic approaches for advanced pain management are lacking for patients, trainees, non-pain specialists, and interventional specialists. This manuscript aims to address this gap by proposing a comprehensive, evidence-based algorithm for managing neuropathic, nociceptive, and cancer-associated pain. Such an algorithm is crucial for pain medicine education, offering a structured approach for patient care refractory to conservative management.

RECENT FINDINGS

A comprehensive literary review with PubMed and regulatory documents from the United States Food and Drug Administration were searched for a variety of interventions. Pain syndromes were categorized into nociceptive and neuropathic pain, and an algorithm was constructed. Serving as an educational tool for patients, trainees, and non-pain specialists, and as an accessible reference for pain specialists, this algorithm bridges knowledge gaps, promotes interdisciplinary collaboration, and streamlines the learning curve for new practitioners. The strength of this algorithm lies in integrating extensive clinical data, emphasizing the latest clinical evidence, and providing a structured decision-making pathway.

A Time Study Analysis of Fluoride Varnish Application in Pediatric Well Visits to Address Health Disparities among Children

Dental decay is the most common chronic disease in children. Fluoride varnish (FV) is a preventive oral health service with proven effectiveness at reducing dental caries in dental and primary care settings. The objective of this study was to determine how long it takes to apply FV treatments during primary care well visits to address one of the most common barriers as reported by pediatricians - lack of time. FV treatment videos were collected at six clinics in Georgia with rigorous time studies conducted on each video to determine the Standard Time for the FV treatment process as well as the FV Application Component of the process and reasons for delays. Median Standard Times varied by clinic, ranging from 67.7 seconds to 166.9 seconds with an overall median of 109.7 seconds. This results in per FV application labor costs of approximately $2.38 for pediatricians, $1.16 for registered nurses, and $0.53 for medical assistants. Findings from this study support the inclusion of FV applications as a common practice during primary care well visits.

Percutaneous image-guided lumbar decompression and outpatient laminectomy for the treatment of lumbar spinal stenosis: a 2-year Medicare claims benchmark study

Background

This prospective longitudinal study compares outcomes for Medicare beneficiaries receiving outpatient percutaneous image-guided lumbar decompression (PILD) using the mild® procedure to patients undergoing outpatient laminectomy. All patients were diagnosed with lumbar spinal stenosis (LSS) with neurogenic claudication (NC).

Methods

All medical claims for 100 % of Medicare beneficiaries were reviewed, with study subjects identified using Centers for Medicare and Medicaid Research Identifiable Files. Baseline data were extracted individually to allow for longitudinal analysis through two-year follow-up. The index procedure was defined as the first mild or outpatient laminectomy during the enrollment period. The rate of subsequent surgical procedures and incidence of harms were used as study outcomes.

Results

Cohorts included 2197 mild and 7416 laminectomy patients. mild patients were significantly older (76.7 years versus 73.4 years, respectively; p < 0.0001), and 57.4 % of mild were female, compared to 43.3 % of laminectomy (p < 0.0001). mild patients presented with significantly more baseline comorbidities compared to laminectomy patients (mean of 5.7 versus 4.8, respectively; p < 0.0001). Subsequent surgical procedure rate of 9.0 % for mild was significantly higher than 5.5 % for laminectomy (p < 0.0001). mild experienced harms at a significantly lower rate than laminectomy (1.9 % versus 5.8 %, respectively; p < 0.0001). The composite rate of subsequent surgical procedures and harms was similar between groups at 10.8 % for mild and 11.0 % for laminectomy.

Conclusions

mild can be considered a viable option for treatment of LSS with NC as evidenced by real-world data in this study. At two-years, mild patients experienced fewer harms and underwent more subsequent surgical procedures than laminectomy patients. The higher rate of subsequent surgical procedures for mild may be attributable to its position earlier in the LSS treatment algorithm. The overall rate of harms and subsequent surgical procedures was similar between groups, suggesting that mild should be considered as a treatment option, particularly for older patients with multiple comorbidities.

The MOTION study: Two-year results of a real-world randomized controlled trial of the mild® procedure for treatment of lumbar spinal stenosis

OBJECTIVE

The MOTION study is designed to measure the impact of percutaneous image-guided lumbar decompression as a first-line therapy on patients otherwise receiving real-world conventional medical management for lumbar spinal stenosis with neurogenic claudication secondary to hypertrophic ligamentum flavum. This prospective, multicenter randomized controlled trial uses objective and patient-reported outcome measures to compare the combination of the mild® percutaneous treatment and nonsurgical conventional medical management (CMM) to CMM-Alone.

METHODS

Test group patients received the mild procedure after study enrollment. Test and control groups were allowed conventional conservative therapies and low-risk interventional therapies as recommended by their physicians. Subjective outcomes included the Oswestry Disability Index, Numeric Pain Rating Scale, and Zurich Claudication Questionnaire. Objective outcomes included a validated Walking Tolerance Test, the rate of subsequent lumbar spine interventions, and safety data.

RESULTS

Two-year follow-up included 64 mild + CMM and 67 CMM-Alone patients. All outcome measures showed significant improvement from baseline for mild + CMM, whereas the majority of CMM-Alone patients had elected to receive mild treatment or other lumbar spine interventions by 2 years, precluding valid 2-year between-group comparisons. Neither group reported any device- or procedure-related adverse events.

CONCLUSIONS

The durability of mild + CMM for this patient population was demonstrated for all efficacy outcomes through 2 years. Improvements in walking time from baseline to 2 years for patients treated with mild + CMM were significant and substantial. The lack of reported device or procedure-related adverse events reinforces the strong safety profile of the mild procedure. These results provide support for early interventional treatment of symptomatic LSS with the mild procedure.

Lumbar Spinal Stenosis and Minimally Invasive Lumbar Decompression: A Narrative Review

Background

Lumbar spinal stenosis (LSS) is a common pain condition that causes lumbar back pain, radiating leg pain, and possible functional impairment. MILD is an emerging minimally invasive treatment for LSS. It is an image-guided percutaneous procedure designed to debulk hypertrophied ligamentum flavum. However, the exact short- and long-term efficacy, safety profile, indication criteria, and certain procedure details reported in medical literature vary.

Objective

This narrative review was to elucidate efficacy, safety profile, certain procedure details, advantages, and limitations of MILD.

Study Design

This is a narrative review.

Setting

All included articles are clinic trials including analytic studies and descriptive studies.

Methods

PubMed, Cochrane Library, and Scopus were searched. Only clinical trials of MILD procedure were included. Information of indications, contraindications, VAS scores, ODI scores, effective rate, efficacy durations, and certain procedure details was focused on.

Results

According to the literature, for the MILD procedure, the VAS score could be reduced from a pre-treatment level of 6.3-9.6 to a post-treatment level of 2.3-5.8. The ODI score could be reduced from a pre-treatment level of 38.8-55.3 to a post-treatment level of 27.4-39.8. The effective rate of the MILD procedure was reported to be 57.1%-88%. A 2-year postoperative stability of efficacy was also supported. One RCT study testified superior efficacy of MILD over epidural steroid injection.

Limitations

There is few high-quality literature in the review. Moreover, the long-term efficacy of MILD cannot be revealed according to the current literature.

Conclusion

Based on the reviewed literature, MILD is an effective and safe procedure. MILD can reduce pain intensity and improve functional status significantly. Therefore, it is a preferable option for LSS patients who failed conservative treatments, but not for those who require immediate invasive decompression surgery.

Percutaneous image-guided lumbar decompression and interspinous spacers for the treatment of lumbar spinal stenosis: A 2-year Medicare Claims Benchmark Study

OBJECTIVE

This prospective longitudinal study compares outcomes between Medicare beneficiaries receiving percutaneous image-guided lumbar decompression (PILD) using the mild® procedure and a control group of patients receiving interspinous spacers for the treatment of lumbar spinal stenosis (LSS) with neurogenic claudication (NC).

METHODS

Patients diagnosed with LSS with NC and treated with either the mild procedure or a spacer were identified in the Medicare claims database. The incidence of harms, the rate of subsequent interventions, and the overall combined rate of harms and subsequent interventions during 2-year follow-up after the index procedure were compared between the two groups and assessed for statistical significance with p = 0.05.

RESULTS

The study included 2229 patients in the mild group and 3401 patients who were implanted with interspinous spacers. The rate of harms for those treated with the mild procedure was less than half that of patients implanted with a spacer (5.6% vs. 12.1%, respectively; p < 0.0001) during 2-year follow-up. The rate of subsequent interventions was not significantly different between the two groups (24.9% and 26.1% for the mild and spacer groups, respectively; p = 0.7679). The total rate of harms and subsequent interventions for mild was found to be noninferior to spacers (p < 0.0001).

CONCLUSIONS

This comprehensive study of real-world Medicare claims data demonstrated a significantly lower rate of harms for the mild procedure compared to interspinous spacers for patients diagnosed with LSS with NC, and a similar rate of subsequent interventions during 2-year follow-up.