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Review
. 2022 May 5:15:1325-1354.
doi: 10.2147/JPR.S355285. eCollection 2022.

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

Timothy R Deer  1 , Jay S Grider  2 , Jason E Pope  3 , Tim J Lamer  4 , Sayed E Wahezi  5 , Jonathan M Hagedorn  6 , Steven Falowski  7 , Reda Tolba  8 , Jay M Shah  9 , Natalie Strand  10 , Alex Escobar  11 , Mark Malinowski  12 , Anjum Bux  13 , Navdeep Jassal  14 , Jennifer Hah  15 , Jacqueline Weisbein  16 , Nestor D Tomycz  17 , Jessica Jameson  18 , Erika A Petersen  19 , Dawood Sayed  20
Affiliations
Review

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

Timothy R Deer et al. J Pain Res. .

Abstract

Introduction: Lumbar spinal stenosis (LSS) is a common spinal disease of aging with a growing patient population, paralleling population growth. Minimally invasive treatments are evolving, and the use of these techniques needs guidance to provide the optimal patient safety and efficacy outcomes.

Methods: The American Society of Pain and Neuroscience (ASPN) identified an educational need for guidance on the prudent use of the innovative minimally invasive surgical therapies for the treatment of symptomatic LSS. The executive board nominated experts spanning anesthesiology, physiatry, orthopedic surgery, and neurosurgery based on expertise, publications, research, diversity and field of practice. Evidence was reviewed, graded using the United States Preventive Services Task Force (USPSTF) criteria for evidence and recommendation strength and grade, and expert opinion was added to make consensus points for best practice.

Results: The world literature in English was searched using Medline, EMBASE, Cochrane CENTRAL, BioMed Central, Web of Science, Google Scholar, PubMed, Current Contents Connect, Scopus, and meeting abstracts to identify and compile the evidence (per section) for LSS-related pain. Search words were selected based upon the section represented. Identified peer-reviewed literature was critiqued using USPSTF criteria and consensus points are presented.

Discussion: The algorithm for patient selection in the management of symptomatic spinal stenosis is evolving. Careful consideration of patient selection and anatomic architecture variance is critical for improved outcomes and patient safety.

Conclusion: ASPN created a guidance for best practice for minimally invasive surgical treatment of symptomatic spinal stenosis.

Keywords: epidural steroid injections; interspinous spacers; intrathecal drug delivery; neurostimulation; open decompression; percutaneous image-guided lumbar decompression.

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Conflict of interest statement

Dr Timothy R Deer reports personal fees, Consultant, Stock Options, Research from Vertos, personal fees, Consultant – Stock Options from Spinal Simplicity, during the conduct of the study; personal fees, Consultant, Research from Abbott, personal fees from Flowonix, personal fees, Consultant, Stock Options from SpineThera, personal fees, Consultant, Stock Options, Research from Saluda, Research from Mainstay, personal fees, Consultant, Research from Nalu, personal fees, Consultant, Stock Options from Cornerloc, personal fees, Consultant, Common Stock from Ethos, personal fees, Consultant, Stock Options, Research from SPR Therapeutic, personal fees from SI Bone, personal fees from Nevro, personal fees from Medtronic, personal fees, Consultant, Research from Boston Scientific, personal fees, Consultant, Stock Options, Research from PainTeq, personal fees from Tissue Tech, Research from Avanos, outside the submitted work. In addition, Dr Timothy R Deer has a patent Abbott pending to Abbott & Tim Deer. Dr Jason E Pope reports Consultant, Research, Advisory Board from Abbott, Consultant, Research, Advisory Board from Saluda, Consultant from Medtronic, Research from Boston Scientific, Consultant, Advisory Board from Biotronik, Consultant, Advisory Board, Stock Options from Vertos, Consultant, Equity from Spark, Consultant, Advisory Board, Research, Equity from Thermaquil, Consultant, Equity, Advisory Board from SPR Therapeutics, Advisory Board, Equity, Research from Painteq, Research, Advisory Board, Equity from Aurora Spine, Research, Consultant from Ethos, Research from AIS, Research, Consultant from Flowonix, Owner from Celeri Health, Owner from Neural Integrative Solutions, Owner from Pacific Research Institute, Consultant, Research from Mainstay, Consultant from WISE, Research from Muse, outside the submitted work. Dr Jonathan M Hagedorn reports personal fees from Boston Scientific, personal fees from Abbott, personal fees from Medtronic, personal fees from Nevro, personal fees from Saluda, outside the submitted work. Dr Steven Falowski reports grants, personal fees from Abbott, grants, personal fees from CornerLoc, grants, personal fees from Medtronic, Equity, Research from PainTeq, grants, personal fees from Aurora, personal fees from Vertos, grants, personal fees from Saluda, personal fees from SurgenTec, outside the submitted work. Dr Reda Tolba reports Consultant to Medtronic and Abbott. Dr Alex Escobar reports personal fees from Boston Scientific Vertiflex, personal fees from Vertos Medical, outside the submitted work. Dr Mark Malinowski reports personal fees, Consulting from Nalu Medical LLC, personal fees, Consulting from SI Bone, Inc., outside the submitted work. Dr Anjum Bux reports personal fees from Vertos, personal fees from Flowonix, personal fees from Boston Scientific, personal fees from AIS Healthcare, personal fees from Cornerloc, outside the submitted work. Dr Jennifer Hah reports Consultant from Nalu Medical, Consultant from SPR Therapeutics, grants from NIH NIDA, outside the submitted work. Dr Jacqueline Weisbein reports Research from Medtronic, Research and Professional Consulting Fees from Abbott, Consulting Fees, Advisory Board from Vertos, Consulting Fees from SI Bone, Advisory Board, Consulting Fees from Biotronik, Research & Consulting from Saluda, outside the submitted work. Dr Nestor D Tomycz reports Abbott consultant; SI-bone consultant. Dr Jessica Jameson reports personal fees from Abbott, personal fees from Nevro, personal fees from Saluda, personal fees from Control Rad, personal fees from Boston Scientific, personal fees from Vertos, personal fees from SI Bone, during the conduct of the study; personal fees from Abbott, personal fees from Nevro, personal fees from Saluda, personal fees from Boston Scientific, personal fees from Vertos, personal fees from SI Bone, personal fees from Control Rad, outside the submitted work. Dr Erika A Petersen reports she has received research support from Medtronic, Neuros Medical, Nevro Corp, ReNeuron, SPR, and Saluda, as well as personal fees from Abbott Neuromodulation, Medtronic Neuromodulation, Neuros Medical, Nevro, Saluda, Biotronik, and Vertos. She holds stock options from SynerFuse and neuro42. Dr Dawood Sayed reports personal fees, options from Vertos, grants from Boston Scientific, personal fees from Surgentec, options from Painteq, outside the submitted work. The authors report no other conflicts of interest in this work.

Figures

Figure 1
Figure 1
MIST 2.0 treatment algorithm. * Data would suggest up to three epidural injections within 6 weeks of initiation of treatment. **Although there are limited data on treatment of more than three spinal levels with minimally invasive spinal stenosis treatments, it is generally considered appropriate to seek a formal surgical consultation before proceeding. Special comment: Randomized controlled trial data suggest that the architecture of spinal stenosis (central, lateral recess, foraminal) was successfully treated with percutaneous direct and indirect decompressive strategies. Therefore, the distinction of stenosis architecture was removed from the MIST 1.0 original algorithm.
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