Find relief from spinal stenosis without open surgery.
The MILD procedure (minimally invasive lumbar decompression) is a same-day, fluoroscopy-guided treatment that removes small portions of bone and thickened ligamentum flavum to restore space in the spinal canal. It does not require general anesthesia, leaves no implants behind, and is FDA-cleared with multiple randomized controlled trials supporting its effectiveness.
MILD is for adults in Houston over 50 with lumbar spinal stenosis who experience leg pain, numbness, or cramping that worsens with walking or standing and improves when sitting, when central canal stenosis caused by ligamentum flavum hypertrophy is confirmed on MRI and conservative care has not provided adequate relief.
or call 346-217-1111 · Houston office
By the Pain Management Team at Performance Pain and Sports Medicine
Suzanne Manzi, MD · Matthias Wiederholz, MD · Jade Nemeth, PA-C
Updated May 2026
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Walking to the mailbox should not feel like a challenge. For adults in Houston with lumbar spinal stenosis, standing in line at the grocery store, walking through the Galleria, or strolling along Buffalo Bayou can cause leg pain, numbness, and cramping that only eases when sitting down. The MILD procedure (minimally invasive lumbar decompression) is a same-day treatment that restores space in the spinal canal without open surgery or implants.
A 2025 systematic review of 15 studies found high-quality evidence supporting its effectiveness for the right candidates (Orhurhu et al., Journal of Pain Research, 2025). At Performance Pain and Sports Medicine in Houston, Dr. Suzanne Manzi, MD and Dr. Matthias Wiederholz, MD evaluate each patient to determine whether MILD may be appropriate. The Houston office is located in the T-Mobile Tower on the Southwest Freeway, near the intersection of I-59 and the 610 West Loop.
What Is the MILD Procedure?
MILD stands for minimally invasive lumbar decompression. It is a percutaneous procedure performed through a small skin opening using fluoroscopic (real-time X-ray) guidance. A physician removes small portions of bone and thickened tissue called the ligamentum flavum to create more room in the spinal canal.
MILD does not require general anesthesia, and no implants are left behind. It is not open surgery, not a spinal fusion, and not a spinal cord stimulator. The procedure is FDA-cleared and supported by multiple randomized controlled trials (Orhurhu et al., Journal of Pain Research, 2025).
What Is Lumbar Spinal Stenosis?
Lumbar spinal stenosis (LSS) occurs when the spinal canal in the lower back narrows and compresses nearby nerves. A common cause is thickening of the ligamentum flavum, a tissue that lines the canal and enlarges with age. This narrowing often leads to neurogenic claudication, causing pain, numbness, or cramping in the legs during walking or standing.
Neurogenic claudication is most common in adults over 50, and symptoms typically improve when sitting or leaning forward (Costandi et al., Pain Practice, 2015). Conservative treatments such as physical therapy, medications, and injections may provide temporary relief but do not address the structural narrowing.
Who Is a Candidate for the MILD Procedure?
MILD is designed for patients with central canal stenosis caused by a thickened ligamentum flavum. A 2025 systematic review confirmed that proper patient selection based on imaging is key to treatment success (Zhang et al., Pain Physician, 2025). Candidates typically meet these criteria:
- Central canal stenosis confirmed on MRI
- Ligamentum flavum thickness of 2.5 mm or greater
- Neurogenic claudication symptoms not adequately controlled by conservative care
Research shows MILD can be effective in patients both under and over age 65, and a prior epidural steroid injection history does not appear to affect outcomes.
The MILD procedure is not appropriate for patients with primarily foraminal stenosis, spinal instability requiring fusion, or severe scoliosis. A thorough evaluation with MRI review and clinical assessment is the first step in determining whether MILD is right for you.
How the MILD Procedure Works
- Step 1: Evaluation. The physician reviews MRI imaging to confirm central canal stenosis with ligamentum flavum hypertrophy and completes a diagnostic assessment.
- Step 2: The Procedure. MILD is performed as an outpatient under local anesthesia with light sedation. Using fluoroscopic guidance, specialized tools remove tiny portions of bone and thickened ligamentum flavum through a small skin opening. The procedure typically takes less than one hour. The MOTION RCT confirmed this approach produces objectively measurable improvements in walking capacity (Deer et al., Pain Medicine, 2022).
- Step 3: Recovery. Most patients resume light activities within 24 hours. There are no implants to manage and no lengthy rehabilitation. A follow-up visit is scheduled to monitor progress.
Benefits of the MILD Procedure
Clinical trial data support several potential benefits for appropriate candidates.
- Superior to epidural steroid injections. The MiDAS ENCORE RCT (n=302) found MILD statistically superior on all primary and secondary outcomes at one year, with a 62.2 percent disability responder rate compared to 35.7 percent for ESI (Benyamin et al., Pain Physician, 2016).
- Objectively measured walking improvement. The MOTION trial (n=155) used actigraphy (a wearable sensor) to objectively measure walking capacity, showing significant improvement in pain and real-world walking function at one year (Deer et al., Pain Medicine, 2022).
- Long-term durability. MOTION trial follow-up shows sustained improvement through three years (Costandi et al., Interventional Pain Medicine, 2025). Cleveland Clinic data demonstrated sustained relief and reduced opioid use at five years (Mekhail et al., Pain Practice, 2021).
Additional benefits include:
- No general anesthesia required
- No implants left in the body
- Short recovery, with most patients returning to light activities within 24 hours
- Future treatment options remain open because nothing is permanently changed
- Can be performed alongside other interventional pain management approaches
Risks and Side Effects
MILD has a favorable safety profile across clinical trials. In the MiDAS ENCORE RCT, no device-related or procedure-related serious adverse events were reported, and safety was comparable to epidural steroid injections (Benyamin et al., Pain Physician, 2016). A separate complication analysis comparing minimally invasive approaches for spinal stenosis confirmed a low adverse event rate for the MILD procedure (Mekhail et al., Regional Anesthesia and Pain Medicine, 2024).
Potential risks may include:
- Temporary soreness at the procedure site
- Rare risk of infection
- Rare risk of bleeding
- Temporary increase in pain before improvement
Serious complications are uncommon. Patients should discuss individual risk factors with their physician before proceeding, including any blood-thinning medications, active infections, or imaging findings that may affect candidacy.
MILD Procedure vs. Other Treatments
- MILD vs. Epidural Steroid Injections. Epidural steroid injections can reduce inflammation and provide temporary relief. The MiDAS ENCORE trial showed MILD produced superior outcomes at one year, likely because it addresses the structural narrowing rather than inflammation alone. For many patients, an epidural is a reasonable first step; for those who respond only partially or briefly, MILD may be the next consideration.
- MILD vs. Open Laminectomy. Laminectomy is open surgery that removes a larger portion of bone to decompress the spinal canal. While a direct randomized comparison between the MILD procedure and open laminectomy is not yet available, Medicare claims data suggest MILD may offer comparable outcomes with a less invasive approach and shorter recovery (Staats et al., Interventional Pain Medicine, 2024). MILD is best suited for central canal stenosis, while laminectomy may be more appropriate for complex or multilevel cases.
- MILD vs. Spinal Cord Stimulation. Spinal cord stimulation modulates pain signals with electrical impulses rather than physically decompressing the canal. It is typically considered when other treatments have not provided adequate relief. Radiofrequency ablation uses targeted heat to disrupt pain signals from specific nerves and may be recommended for facet joint pain or other nerve-mediated spinal conditions.
Cost and Insurance
The MILD procedure is covered by Medicare and many commercial insurance plans when deemed medically necessary. Coverage typically requires documentation that conservative treatments (physical therapy, anti-inflammatory medication, epidural steroid injections) have not provided adequate relief, plus MRI confirmation of central canal stenosis with ligamentum flavum hypertrophy. Out-of-pocket costs depend on your specific plan, deductible status, and whether sedation is used.
Our Houston office accepts most major commercial insurance plans, Medicare, and Texas workers’ compensation, and routinely handles documentation for injuries sustained on Ship Channel terminals, in petrochemical plant turnarounds, on offshore platforms, and in Houston healthcare settings. The office team can verify your specific insurance coverage and discuss any out-of-pocket costs before your appointment. For coverage questions, call 346-217-1111.
MILD at Our Houston Office
Performance Pain and Sports Medicine performs the MILD procedure at the Houston office at 4126 Southwest Freeway, Suite 1700, Houston, TX 77027, in the T-Mobile Tower on the Southwest Freeway. The location sits inside the 610 Loop near the intersection of I-59 and 610 West, with covered garage parking and validation, making it convenient for patients from Uptown, the Galleria, River Oaks, West University, Bellaire, Memorial, the Energy Corridor, the Texas Medical Center, Greenway Plaza, Upper Kirby, Sugar Land, Missouri City, Pearland, Katy, and The Woodlands.
Dr. Suzanne Manzi, MD is quadruple board-certified in Physical Medicine and Rehabilitation, Pain Medicine, Electrodiagnostic Medicine, and Obesity Medicine. She completed her residency at Baylor College of Medicine and her fellowship in interventional spine and pain management at Michigan State University, and currently serves as off-site clinical faculty at UT Health Houston McGovern Medical School.
Dr. Matthias Wiederholz, MD is quadruple board-certified in Physical Medicine and Rehabilitation, Pain Medicine, Sports Medicine, and Anti-Aging, Regenerative and Functional Medicine. He founded Performance Pain and Sports Medicine in 2009 and brings extensive experience in image-guided spine procedures. Jade Nemeth, PA-C supports patients throughout evaluation, treatment, and follow-up care.
The Houston patient population reflects the city’s unique mix of high-load industrial work, world-class medical and research employment, and active suburban living. Adults over 50 with neurogenic claudication who can no longer walk through the Galleria, Memorial Park, or Buffalo Bayou greenways without sitting down, retirees from River Oaks and West University, healthcare professionals across the Texas Medical Center, oilfield and offshore workers, and Ship Channel and refinery staff all present with lumbar spinal stenosis symptoms that have not responded to conservative care. The office accepts most major commercial insurance, Medicare, and Texas workers’ compensation, and routinely handles referrals from Texas Medical Center providers, Houston Methodist, Memorial Hermann, HCA Houston, and primary care offices across Greater Houston.
What sets the Houston practice apart:
- Fellowship-trained interventional pain specialists performing every procedure
- Fluoroscopic guidance for every MILD procedure
- Comprehensive MRI review and diagnostic evaluation before recommending any intervention
- A complete spine pathway from epidural injections to MILD to spinal cord stimulation, all under one roof
- Most major insurance plans, Medicare, and Texas workers’ compensation accepted
To schedule an evaluation, call the Houston office at 346-217-1111 or contact us online. The MILD procedure is also available at the League City, Baytown, and Lawrenceville Performance Pain locations.
Performance Pain and Sports Medicine
Address: 4126 Southwest Freeway, Suite 1700, Houston, TX 77027
Landmark: T-Mobile Tower, Suite 1700
Major Cross Streets: I-59 (Southwest Freeway) at 610 (West Loop)
Parking: Covered garage with validation provided
Phone: 346-217-1111
Frequently Asked Questions
Is the MILD procedure available at the Houston office?
Yes. The MILD procedure is performed at the Houston office in the T-Mobile Tower on the Southwest Freeway, by Dr. Suzanne Manzi, MD and Dr. Matthias Wiederholz, MD. It is performed as an outpatient procedure under local anesthesia with light sedation, with most patients leaving the office within a few hours of the procedure.
What is the MILD procedure for spinal stenosis?
MILD stands for minimally invasive lumbar decompression. It is a same-day outpatient procedure that removes small portions of bone and thickened ligamentum flavum to create more space in the spinal canal. It treats central canal stenosis caused by ligamentum flavum hypertrophy and does not require general anesthesia or implants.
What happens if the MILD procedure fails?
Results vary from patient to patient, and some may not experience the level of relief they were hoping for. If symptoms persist, your physician may recommend further evaluation or alternative approaches such as spinal cord stimulation, repeat injection therapy, or surgical referral. Because MILD does not involve implants and does not bridge or fuse any vertebrae, patients retain their full range of future treatment options.
What are the side effects of the MILD procedure?
The most common side effect is temporary soreness at the procedure site. In the MiDAS ENCORE trial (n=302), no serious device-related or procedure-related adverse events were reported. Rare risks include infection and bleeding. Your physician will review your complete medical history and any blood-thinning medications before the procedure.
What are the pros and cons of the MILD procedure?
Pros include same-day outpatient treatment, no general anesthesia, no implants, short recovery, and clinical evidence showing sustained benefit for up to five years. Cons include that it only treats central canal stenosis caused by ligamentum flavum hypertrophy (not foraminal stenosis or spinal instability), results vary by patient, and a direct randomized comparison to open laminectomy is not yet available.
Can the MILD procedure be repeated?
Yes, MILD can be repeated if clinically appropriate. Because it does not involve implants, a second procedure may be considered if symptoms return. Five-year data suggest many patients maintain improvement without repeating the procedure (Mekhail et al., Pain Practice, 2021).
What is the success rate of the MILD procedure?
In the MiDAS ENCORE RCT, 62.2 percent of MILD patients met the threshold for clinically meaningful disability improvement at one year, compared to 35.7 percent for epidural steroid injections (Benyamin et al., Pain Physician, 2016). The MOTION trial confirmed these findings with objective walking measurements. Individual results vary by diagnosis and overall health.
How much does the MILD procedure cost?
MILD is covered by Medicare and many commercial insurance plans when deemed medically necessary. Out-of-pocket costs depend on the patient’s plan and deductible status. Contact the Houston office at 346-217-1111 to verify benefits before scheduling.
How long is recovery after the MILD procedure?
Most patients can return to light daily activities within 24 hours. There is no lengthy rehabilitation requirement. Heavy lifting should be avoided for a short period as directed by the physician, and a follow-up appointment is typically scheduled to monitor recovery.
Do you accept workers' compensation for oilfield, offshore, Ship Channel, or TMC healthcare injuries?
Yes. The Houston office accepts Texas workers’ compensation and routinely treats injured workers from oil and gas companies, offshore operators, longshore and Ship Channel terminal employers, petrochemical contractors, and Texas Medical Center healthcare systems. The office handles documentation and authorization directly with carriers.
Schedule Your MILD Procedure Consultation in Houston
If you are living with lower back or leg pain that worsens with walking and improves with sitting, the MILD procedure may help. The pain management team at Performance Pain and Sports Medicine can review your MRI and clinical history to determine whether you are a candidate. Contact the Houston office or call 346-217-1111 to schedule a consultation with Dr. Suzanne Manzi, MD or Dr. Matthias Wiederholz, MD.
MEDICAL DISCLAIMER
This article is for educational purposes only and does not replace professional medical advice, diagnosis, or treatment. The information presented reflects an interventional pain management perspective and is intended to support, not substitute, your relationship with a qualified healthcare provider. Individual results vary based on diagnosis, pain duration, overall health, and response to treatment. Some procedures may not be covered by insurance. Treatment outcomes depend on proper patient selection and accurate diagnosis. Always consult a board-certified physician before pursuing any pain management treatment.
Medically reviewed by Dr. Matthias Wiederholz, MD · Performance Pain and Sports Medicine · Last reviewed: May 2026
Medically reviewed by Matthias Wiederholz, MD
Board-Certified in Physical Medicine & Rehabilitation, Pain Medicine, Sports Medicine, and Anti-Aging, Regenerative and Functional Medicine
Last reviewed: May 2026
