It’s normal to experience aches and pains in our back, particularly as we get older. Roughly 75 to 85% of adults in the U.S. experience back pain sometime in their lifetime.

Our back pain may be a simple sign of an aging spine. Or sometimes, it may indicate we have a disease or injury. A visit to our doctor can help sort through what is normal from what may be a problem.

One common back pain progression begins with age-related degeneration of the spine. Spondylosis is a broad term that encompasses different types of spine degeneration.

“Over time, spondylosis in the lower back can cause lumbar spinal stenosis,” says Farzad Karkvandeian, DO. Dr. Karkvandeian is a doctor at the Philadelphia region’s Main Line Spine medical practice.

He continued, “The mild procedure can relieve lumbar spinal stenosis back pain for some patients who don’t respond to traditional conservative treatments.”

What Is Spondylosis?

Spondylosis results from normal “wear and tear” degeneration of soft structures and bones in our spine. It can appear in any part of the spine. However, it is most commonly observed in the neck (cervical) and lower back (lumbar) regions.

“Osteoarthritis of the spine” is an alternative name for spondylosis.

Patients with this degenerative condition may or may not experience symptoms. Most people don’t experience significant pain or other issues related to these arthritic changes, Dr. Karkvandeian noted. Spondylosis frequently evades detection until a patient undergoes an imaging scan triggered by a different condition.

“Nevertheless, some individuals experience a decline that ultimately results in discogenic pain,” he added. “This can limit a patient’s range of motion. In the lower back, it also indicates a patient may have lumber spinal stenosis.”

Research indicates that spondylosis affects approximately 90% of individuals aged 60 and above. Lumbar spinal stenosis is present in about 20% of this same population in the United States.

What Is Lumbar Spinal Stenosis?

Lumbar spinal stenosis (LSS) usually occurs from an injury or changes in the spine as we age. It can cause the spinal canal in the lower part of the back to narrow.

This narrowing can create pressure on nerves running through the hollow space in the center of the spine’s vertebrae. The pressure may lead to a set of lumbar spinal stenosis symptoms called pseudoclaudication, also called neurogenic claudication.

“When lumbar spinal stenosis occurs, it typically impacts the lower L3 to L5 levels of the spine,” Dr. Karkvandeian noted. “When patients have lumbar spinal stenosis, their legs will often feel heavy. Some describe it as if they were walking in cement.”

Other early symptoms may include cramping or discomfort in the leg(s) after a long walk. Those with the condition may also feel leg numbness or achiness after prolonged standing. In the later stages, pseudoclaudication may progress into even more severe leg pain that worsens when walking.

Illustration of lower spine S1 and L5 to L1 and spinal canal
Illustration of the lower portion of the spine from S1, L5 to L1, and illustration of the spinal canal.

Back Pain Relief with the mild Spine Procedure

According to Dr. Karkvandeian, one of the major causes of lumbar spinal stenosis is the presence of excess ligament tissue. This usually develops on the spine with spondylosis.

Over time, the strong ligament cords that help hold the spine’s bones together can become thick and stiff. As this happens, these thick ligaments can push into the spinal canal.

Spondylosis and lumbar spinal stenosis are not one in the same and shouldn’t be confused for each other. But Dr. Karkvandeian emphasized that it would be uncommon to find thickened ligaments and LSS without the presense of spondylosis.

“The mild procedure provides us with a minimally invasive way to remove that excess ligament tissue,” Dr. Karkvandeian says. “By doing that, we can restore space in the spinal canal. This relieves pressure on spinal nerves and the associated low back pain.”

Mild stands for minimally invasive lumbar decompression.

The mild back surgery procedure typically takes less than an hour. It is performed with specialized instruments through a single, tiny incision that measures less than the diameter of a baby aspirin (5.1 mm). mild® is normally completed in an outpatient surgery center using local anesthetic and light sedation.

“It’s important to remove the excess ligament tissue from both sides of the spinal segment during the procedure,” Dr. Karkvandeian emphasized. “There are no half-measures that are adequate when you want to maximize the long-term outcome for a patient.”

mild Procedure Durability

“Every patient is different, and the outcomes have varied,” says Dr. Karkvandeian. “We have witnessed individuals transition from experiencing extreme pain levels of 10 out of 10 to complete pain relief. When the procedure works well, it is an extremely gratifying experience for our patients and medical team.”

“Like with all procedures of this kind,” Dr. Karkvandeian added with caution, “it doesn’t work for everyone.” “However, a study of the five-year follow-up of Cleveland Clinic mild procedures shows encouraging results.”

Seventy-five individuals received mild® treatment at the Cleveland Clinic between 2010 and 2015. Of that group, only 9 needed additional lumbar surgical decompression during a 5-year follow-up afterwards¹.

“We will continue to learn more from clinical studies that will follow this one,” Dr. Karkvandeian said. “But for now, Cleveland Clinic’s experience provides an objective record of long-term success with mild. Our own direct experience with mild procedure outcomes with our patients remains positive.”


  1. Mekhail N, Costandi S, Nageeb G, Ekladios C, Saied O. The durability of minimally invasive lumbar decompression procedure in patients with symptomatic lumbar spinal stenosis: Long-term follow-up. Pain Pract. 2021 Nov; 21(8): 826-835 [PubMed]
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WASHINGTON, D.C. – Dr. Farzad Karkvandeian of Main Line Spine presented a talk on the PILD procedure at the Spine Intervention Society’s 2021 Annual Meeting. PILD, or Percutaneous Image-guided Lumbar Decompression, is a minimally-invasive treatment for Lumbar Spinal Stenosis.

During his briefing, Dr. Karkvandeian noted that while there are a few different ways that doctors can decompress the spine to reduce pain, PILD is one of the newest methods available. During this procedure, using a fluoroscope or x-ray for indirect guidance, a surgeon focuses on the ligamentum flavum, a series of bands of elastic tissue that runs from the lamina. After a small incision is made, an instrument called a tissue sculptor is used to remove a very small portion of the ligamentum flavum to reduce pain.

Dr. Karkvandeian also discussed how MILD® – a specialized device and system for performing the PILD procedure – has established a safe track record in multiple clinical studies.

Dr. Farzad Kardvandeian speaking at the Spine Intervention Society's 2021 annual meeting
Dr. Farzad Karkvandeian speaks at the Spine Intervention Society’s Annual Meeting

About the Spine Intervention Society (SIS)

The Spine Intervention Society (SIS) is an international physician organization dedicated to the development and promotion of the highest standards for the practice of interventional pain procedures. The Society’s annual 2021 meeting was attended by almost 400 physicians who specialize in the spine intervention field.

About Main Line Spine

Main Line Spine is a Physical Medicine and Rehabilitation practice in King of Prussia, PA which is uniquely focused on providing patients with the least invasive, most effective, and latest groundbreaking medical advances in the field. Main Line Spine’s expertise covers musculoskeletal, spine, and sports conditions and problems – as well as pain management.

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Jeffery Rowe, MD, is a physical medicine and rehabilitation physician, also known as a physiatrist, with a subspecialty in pain medicine. He practices at Main Line Spine and specializes in minimally invasive interventional spine surgeries.

In this Q&A, Dr. Rowe shares how he helps patients with new technologies and advanced treatment options to relieve chronic pain of the spine, including the low back and neck.

You practice a unique subspecialty. Could you tell us more about it?

When you have chronic pain, there are two ends of the spectrum where you can seek treatment.

At one end of the spectrum are physiatrists who utilize non-surgical and minimally invasive approaches and procedures to treat your pain. These approaches might range from exercise to physical therapy, medication management, and injections such as epidural steroid injectionsfacet blocks, and SI joint injections. Anesthesiologists who have had a spine fellowship also traditionally use these approaches.

At the other end of the spectrum are orthopedic and neurologic surgeons. They focus on much more major surgical procedures to address spine pain issues. These procedures include lumbar and cervical fusions and decompressive laminectomies to relieve pressure on the spinal nerve roots.

Many new treatments fall in the gap between these two extremes. These are minimally invasive surgical procedures to relieve pain, appropriate when conservative treatment options haven’t provided long-term benefits. These procedures offer patients options that are far less severe surgically than those where orthopedists and neurosurgeons traditionally focus.

My surgical subspecialty is providing patients with pain relief options in this treatment gap.

What kind of treatments and procedures are we talking about in this gap?

One area in this gap includes neuromodulation devices that work by interrupting pain signals before they reach your brain. These include traditional Spinal Cord Stimulators (SCS)Dorsal Root Ganglion (DRG) stimulators, and Peripheral Nerve Stimulators (PNS).

Neuromodulation technologies have improved by leaps and bounds over the past five years, and they now incorporate improved batteries and Bluetooth technologies for programming.

Another minimally invasive treatment option is an interspinous spacer device, which can provide relief from lumbar spinal stenosis. This procedure can be an alternative to surgical decompression, such as a laminectomy.

I began to adopt these procedures four years ago when they officially became commercially available. Given that I was one of the early adopters of this treatment option, I now regularly teach other physicians and surgeons on the proper usage of this decompressive technology.

I also perform a minimally invasive SI joint fusion procedure. This procedure is often appropriate when SI joint injections fail to provide long term improvement.

In the past, SI joint fusion surgery involved a lateral approach with significant muscle disruption, requiring a lengthy recovery period. Now we use a posterior approach with a small incision to provide SI joint stabilization and fusion. This new alternative causes minimal tissue disruption and has a very short recovery period.

Beyond those, there are several other procedures that I’m currently using to provide additional minimally invasive treatment options, as well as others emerging on the horizon.

How did you end up with this specialty focus?

I have a surgical background from the start of my medical career. I completed two years of general surgery and then worked at a burn surgery center for eight years. These experiences provided me with an extensive foundation in handling complex surgical conditions.

I also completed a physical medicine and rehabilitation residency at the University of Pennsylvania Hospital and a spine fellowship. From that point, I began specializing in providing patients with access to technologies and treatments in the gap that weren’t previously available.

The sum of this training and experience enables me to consider, with a surgical perspective, how best to use these advanced procedures.

Dr. Jeffery Rowe teaching the spinal cord stimulation procedure.

What kind of patients do you see? When is it appropriate for a patient to consult with you?

I see a broad range of patients. Some have only recently experienced an onset of pain, and others have been suffering from pain for years.

I pride myself in offering patients treatments when they have been told they exhausted all available pain treatment options. These previous failed attempts may have included epidural steroid injections, facet blocks, SI joint injections, rhizotomies, and radiofrequency nerve ablations.

For example, let’s say a patient has multi-level degenerative disc disease and they’ve had multiple injections but still have ongoing symptoms. The injections may have worked well, but the effectiveness wore off over time.

This hypothetical patient is now at a point where they need a longer-term solution with a more permanent treatment option. Neurostimulation or an interspinous spacer device may be an appropriate option for them.

My initial consultation is extensive as I tease through the issues each patient has been dealing with. I need to hear their full backstory, including how long they have been managing their condition and what they’ve done previously to attempt to alleviate their pain. I also review their diagnostic studies, including any MRIs or CT scans.

This thorough evaluation allows the patient and me to review the treatment options which are best suited for their condition. It also enables me to recommend a long-term treatment plan using one or more of the new technologies that sit in the gap.

Nationally, neuromodulation therapies don’t always work effectively for some patients. Why is it that you seem to get successful results with your patients?

Our ongoing successes build from a variety of factors. Patient selection is key to having a successful outcome. I take great care where I place the leads and reinforce that with strict testing protocols to make sure I’ve optimized lead placement correctly. I also use an advanced lead anchoring technique, so the leads don’t move out of position.

I additionally attribute my success to performing hundreds of neuromodulation trials and implants each year for patients across the country and teaching these procedures nationally.

What is your life like outside of the Main Line Spine medical practice?

It is very important to me that I balance my medical practice with my family life. When you work as hard as I do, it’s crucial to have a great family support system.

My family includes my wife, two daughters, a Savannah cat, and a Belgian Malinois dog. We enjoy outdoor activities including hiking and riding dirt bikes. For me, at the end of the day, it doesn’t get better than that.

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KING OF PRUSSIA, PA – Dr. Jeffery Rowe of Main Line Spine recently completed the first Minuteman® G3 procedure in Pennsylvania. The Minuteman® G3 was developed by Spinal Simplicity LLC as an innovative, minimally invasive, simple solution to treat complex spinal disorders.

Dr. Jeffrey Rowe, MD (center) stands between two colleagues after completing the first Spinal Simplicity G3 procedure in Pennsylvania.
Dr. Jeffrey Rowe, MD (center) stands between two colleagues after completing the first Spinal Simplicity G3 procedure in Pennsylvania.

The device is intended for the temporary fixation of the thoracic, lumbar and sacral spine while awaiting bony fusion to occur. It is designed for attachment to the posterior non-cervical spine at the spinous processes through its bilateral locking plates. It is intended for use with bone graft material placed within the device.

The Minuteman® G3 is indicated to treat patients with Degenerative Disc Disease, Lumbar Spinal Stenosis, and Spondylolisthesis. Generally, patients who could be eligible for Minuteman have not found lasting relief with conservative therapies like Physical Therapy, Epidural Steroid Injections, Medial Branch Blocks, and Radio Frequency Ablations.

Dr. Rowe views the Minuteman as one of the options he now considers to treat his patients’ back and leg pain.

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