Issue link: http://viewer.e-digitaledition.com/i/100670
C AS e Stu dy THE PATIENT WAS a 70-year-old male who presented with left-sided low back pain radiating to the left gluteals and lateral thigh. His pain was exacerbated by standing longer than 7 minutes, and he could not walk more than 50 yards. An MRI of the lumbar spine was significant for lower lumbar facet arthrosis as well as L4/5 ligamentum hypertrophy, broad-based disc bulge, and mild to moderate canal stenosis. The patient���s analgesic medications included gabapentin and oxycodone 5mg, 4 pills per day, which made him slightly somnolent. He underwent two sets of three interlaminar epidural steroid injections, about a year apart. He experienced good but little pain relief from the second set. The patient also underwent left L5 and S1 nerve root injections, as well as left lumbar facet medial branch injections, without pain relief. He subsequently underwent a MILD (minimally invasive lumbar decompression) procedure at the L4/5 IMAGES COURTESY OF DR. ENGLOK YAP PHOTO COURTESY OF CLEVELAND CLINIC pain relief from the first set of injections level bilaterally, under awake sedation. At one-week follow-up, the patient reported an 80 percent reduction in pain and was able to reduce his oxycodone use to one pill per day. His functional activity has improved as a result of the procedure and his reduced opioid usage. use to patients with postherpetic neuralgia, complex regional pain syndrome (CRPS), patients with chronic abdominal and pelvic pain, and occasionally some patients with headache pain, as well,��� says Dr. Yap. Minimally Invasive Lumbar Decompression (MILD) Spinal stenosis is a source of chronic pain in the low back and legs. Causes include a combination of disc degeneration, thickened ligament flavum or arthritic facet joints. Until recently, long-term pain management included complex fusion of the lumbar spine or surgery to decompress the nerve roots. ���MILD is an innovative procedure,��� explains Dr. Yap. The image-guided Minimally invasive lumbar decompression (MILD) is an innovative procedure performed through a single halfinch portal in which the stenotic spinal canal is opened by resecting a small portion of the ligamentum flavum. The patient remains awake during the one-hour outpatient procedure which requires only local anesthetic. procedure is performed through a single half-inch portal in which the stenotic spinal canal is opened by resecting a small portion of the ligamentum flavum. The patient remains awake during the one-hour procedure which requires only local anesthetic. More than 100 patients are enrolled in the MILD procedure study at Cleveland Clinic, where a multi-center study showing long-term efficacy and safety was conducted (Pain Pract. 2012:12:184-193). A paper on more detailed functional outcomes is currently being prepared. ���What we���d like to offer to referring physicians is something different, particularly the expertise we have with interventional procedures, and in doing so work with them to reduce their patients��� chronic pain and use of opioid medications,��� says Dr. Yap. Cleveland Clinic pain management specialists treat more than 10,000 patients each year at Cleveland Clinic���s main campus and more than 20 Northeast Ohio locations. Dr. Yap sees patients at Hillcrest Hospital���s Medical Building, Beachwood Family Health Center and South Pointe Hospital. For more information, visit clevelandclinic.org/ painmanagement. To refer a patient, call (216) 444-PAIN (7246). ��� JANUARY- FEBRUARY 2013 ��� MDNEWS.COM ��� MD News Cleveland/Akron/Canton | 29