Clinical: mild Patient Identification

Question 1

What percentage of people over the age of 60 have LSS¹?

Answer 1

~20%

¹ Kalichman L, Cole R, Kim DH, et al. Spinal stenosis prevalence and association with symptoms: The Framingham Study. Spine J. 2009;9(7):545-550. doi:10.1016/j.spinee.2009.03.005.

Question 2

Approximately how many US patients are in active treatment for lumbar spinal stenosis (LSS)¹?

Answer 2

2 million

¹ Health Market Science report for Vertos Medical, 2013.

Question 3

What are the two different pathophysiological causes of lumbar spinal stenosis (LSS) pain?

Answer 3

1. Radicular pain
2. Neurogenic claudication (NC)

Question 4

What causes radicular pain?

Answer 4

Inflammation of the nerve root

Question 5

What causes neurogenic claudication (NC)?

Answer 5

Ischemia of the nerve root, due to thecal sac compression

Question 6

What is the differential diagnosis (DDx) for neurogenic claudication (NC)?

Answer 6

Ischemia related to thecal sac compression →

Decompression required →

Treat patient with mild →

Patient receives long-term relief of NC symptoms

Question 7

What is the differential diagnosis (DDx) for radicular pain?

Answer 7

Nerve root inflammation →

Anti-inflammatory required →

Treat patient with ESI, blocks, etc. →

Patient receives temporary relief of radicular pain symptoms, repeat treatments likely needed

Question 8

What is vascular claudication?

Answer 8

Lower extremity arterial blockage, resulting in poor circulation

Question 9

Patient has the following symptoms:

• Pain when walking upright, relieved by forward flexion
• Pain when standing upright, relieved by forward flexion
• Worse pain when walking downhill than uphill

What is most likely causing their lumbar spinal stenosis (LSS)? Neurogenic claudication or radicular pain or vascular claudication?

Answer 9

Neurogenic claudication (NC)

NC symptoms are typically relieved by forward flexion, slowed gait, leaning onto objects (e.g., over a shopping cart), and limiting distance of ambulation

Question 10

Patient has the following symptoms:

• Pain when walking upright, forward flexion has no effect
• Pain when standing upright, forward flexion has no effect
• Pain when seated

What is most likely causing their lumbar spinal stenosis (LSS)? Neurogenic claudication or radicular pain or vascular claudication?

Answer 10

Radicular pain

Question 11

Patient has the following symptoms:

• Pain when walking upright, relieved by stopping
• Pain when active, relieved by stopping
• Pain when seated or riding bike in flexed position, relieved by stopping
• Diminished peripheral pulse

What is most likely causing their lumbar spinal stenosis (LSS)? Neurogenic claudication or radicular pain or vascular claudication?

Answer 11

Vascular claudication

Question 12

Who are typical lumbar spinal stenosis (LSS) patients?

Answer 12

• Seniors, over age of 60
• Adults with degenerative conditions

Question 13

Lumbar spinal stenosis (LSS) patients typically have symptoms of:

Answer 13

• Pain, numbness, heaviness or tingling in back, legs or buttocks when standing or walking
• Limited mobility and spend time sitting to avoid pain

Question 14

Lumbar spinal stenosis (LSS) patients typically get relief when:

Answer 14

• Walking in flexed/stooped posture to open canal for temporary relief of symptoms
• Using canes/walking aids
• Sleeping in fetal position

Question 15

Other therapies that lumbar spinal stenosis (LSS) patients commonly try are:

Answer 15

• Over the counter meds
• Opioids
• Physical therapy
• Epidural steroid injections (ESIs)

Question 16

If neurogenic claudication (NC) symptoms are present…

Answer 16

“Look for the ligament”

Question 17

Hypertrophic ligamentum flavum (HLF) contributes up to what percent of spinal canal narrowing¹?

Answer 17

85%

¹ Hansson T, Suzuki N, Hebelka H, Gaulitz A. The narrowing of the lumbar spinal canal during loaded MRI: the effects of the disc and ligamentum flavum. Eur Spine J. 2009;18(5):679-686. doi:10.1007/s00586-009-0919-7.

Question 18

What is the starting point for HLF thickness when considering the mild Procedure?

Answer 18

2.5mm

Question 19

The mild Procedure removes a major root cause of lumbar spinal stenosis (LSS) to improve back and leg pain and…

Answer 19

“Leaves nothing behind”

Question 20

Besides central canal stenosis, what other comorbidities may mild Patients have?

Answer 20

“Even in patients with comorbidities”

• Disc bulges
• Facet hypertrophy
• Lateral recess narrowing/stenosis
• Foraminal narrowing/stenosis