Objective Real-World Outcomes of Patients Suffering from Painful Neurogenic Claudication Treated with the mild® Procedure: Interim 6-Month Report of a Randomized Controlled Trial

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.

Pacific Spine and Pain Society (PSPS) Evidence Review of Surgical Treatments for Lumbar Degenerative Spinal Disease: A Narrative Review

INTRODUCTION

Interventional treatment options for the lumbar degenerative spine have undergone a significant amount of innovation over the last decade. As new technologies emerge, along with the surgical specialty expansion, there is no manuscript that utilizes a review of surgical treatments with evidence rankings from multiple specialties, namely, the interventional pain and spine communities. Through the Pacific Spine and Pain Society (PSPS), the purpose of this manuscript is to provide a balanced evidence review of available surgical treatments.

METHODS

The PSPS Research Committee created a working group that performed a comprehensive literature search on available surgical technologies for the treatment of the degenerative spine, utilizing the ranking assessment based on USPSTF (United States Preventative Services Taskforce) and NASS (North American Spine Society) criteria.

RESULTS

The surgical treatments were separated based on disease process, including treatments for degenerative disc disease, spondylolisthesis, and spinal stenosis.

CONCLUSIONS

There is emerging and significant evidence to support multiple approaches to treat the symptomatic lumbar degenerative spine. As new technologies become available, training, education, credentialing, and peer review are essential for optimizing patient safety and successful outcomes.

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.

Best Practices for Minimally Invasive Lumbar Spinal Stenosis Treatment 2.0 (MIST): Consensus Guidance from the American Society of Pain and Neuroscience (ASPN)

Introduction

Methods

Results

Discussion

Conclusion

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

OBJECTIVE

The purpose of this study is to provide Level-1 objective, real-world outcome data for patients with lumbar spinal stenosis suffering from neurogenic claudication secondary to hypertrophic ligamentum flavum.

DESIGN

The MOTION Study is a prospective, multicenter, randomized controlled trial comparing the mild® Procedure (minimally invasive lumbar decompression; Vertos Medical, Aliso Viejo, CA, USA) as a first-line therapy in combination with nonsurgical conventional medical management (CMM) vs CMM alone as the active control.

METHODS

Patients in the test group received the mild Procedure at baseline. Both the mild+CMM group and the control group were allowed unrestricted access to conventional real-world therapies. Patient-reported outcomes included the Oswestry Disability Index, the Zurich Claudication Questionnaire, and the Numeric Pain Rating Scale. A validated Walking Tolerance Test, the incidence of subsequent lumbar spine interventions, and the occurrence of adverse events were used to measure objective outcomes.

RESULTS

Sixty-nine patients in each group were analyzed at 1-year follow-up. No device- or procedure-related adverse events were reported in either group. Results from all primary and secondary outcome measures showed statistical significance in favor of mild+CMM.

CONCLUSIONS

One-year results of this Level-1 study demonstrated superiority of mild+CMM over CMM alone for patients with lumbar spinal stenosis who were suffering from neurogenic claudication secondary to hypertrophic ligamentum flavum. Use of the validated Walking Tolerance Test to objectively measure increased ability to walk without severe symptoms provided evidence of statistically significantly better outcomes for mild+CMM than for CMM alone. With no reported device or procedure-related adverse events, the long-standing safety profile of the mild Procedure was reaffirmed. mild is a safe, durable, minimally invasive procedure that has been shown to be effective as an early interventional therapy for patients suffering from symptomatic lumbar spinal stenosis.