Purpose: The audience will (1) learn the pathoanatomic basis and patient selection for PILD; (3) see the stepwise fluoroscopic technique for safe and effective execution of the procedure; and (3) appraise the safety data and methods to integrate PILD into practice.
Methods/Materials: The presentation is based on a comprehensive literature review of, and personal experiences with, the PILD procedure.
Results: Patients with neurogenic claudication often face limited options between repeated injections and invasive surgery. PILD uses a percutaneous, image-guided approach to debulk hypertrophied ligamentum flavum, alleviating central canal narrowing. Since FDA approval in 2006, evidence has supported its safety and efficacy.
PILD is performed under fluoroscopy with dedicated instruments. Steps include (1) level identification with contralateral oblique imaging, (2) spinal access, (3) bone debridement and ligamentum flavum sculpting, and (4) confirmation of decompression. Contraindications include prior laminectomy at the target level and active spinal infection.
Safety is well established. In the multicenter MiDAS ENCORE RCT (n=300), adverse events occurred in 1.4% of PILD patients vs 2.2% with epidural injection. The MOTION RCT confirmed durable improvements in standing time and walking distance with no major complications. A 2025 meta-analysis (12 studies, n=500) showed an overall adverse event rate of 8.2%, with no neurologic deficits or dural tears, compared with ~9% rates for each after surgery. Rare case reports describe CSF leak, hematoma, or nerve root injury, typically early in operator experience.
Conclusions: PILD is an evidence-based, minimally invasive option for select patients with lumbar spinal stenosis and neurogenic claudication. It is safe, reproducible, and transferable to interventional radiologists familiar with vertebral augmentation. Outcomes are durable, with significant reductions in pain and disability; and marked gains in walking and standing tolerance. Success is best assessed with patient-reported outcomes rather than imaging. With the forthcoming CPT Category I code, PILD is positioned for broader integration into IR practice, bridging the gap between injections and open surgery.
