Not all herniated disk patients are eligible for minimally invasive spinal surgery. The ideal candidate has:
- No severe spinal stenosis (build-up of bone in the spinal cavity).
- Well-maintained disc height, preferably with 30 percent or less disc collapse.
If such conservative treatments as bed rest, analgesics and physical therapy fail to relieve the problem, I do tests such as discography, MRI and CAT scans. If these tests confirm that the problem is a herniated disc and the patient meets the aforementioned criteria, he is a good candidate for outpatient surgery such as nucleoplasty.
Assuming you can get preauthorized by your payers, the average facility fees for spinal surgeries - insurance payment plus collection of facility and professional fees - are about $1,800 to $2,500 (the physician reimbursement is about $700 to $1,200 per case), depending on your location and whether your facility is an ASC or a hospital. Reimbursement can be a tricky proposition, both with Medicare and third party payers (see "A Primer on Minimally Invasive Disc Surgery"). Here in Pennsylvania, some payers simply will not cover the case cart costs in an ASC, which is why I do all my cases in the hospital. Keep in mind, however, that there is no medical reason why minimally invasive disc surgery cannot be performed with equal efficacy in a freestanding ambulatory surgery center.
If you want to make a case with your payers to reimburse for spinal procedures, you can draw on the significant volume of clinical data proving the efficacy of outpatient disc surgery, which strongly suggests that these procedures can prevent the need for more expensive open procedures. Open disc surgery can cost up to $30,000 in OR costs and hospital admission fees. Open disc surgery results in epidural scarring and also requires a much lengthier recovery period than minimally invasive spinal surgery, where the patient can be ambulatory the same day and post-op pain is minimal.
Capital equipment and case supply needs
Facilities that do arthroscopy and similar orthopedic procedures are in the best position to add minimally invasive disc decompression surgery. Neurological surgery centers are also good candidates. These facilities will already have most or all of the key pieces of equipment.
In large part because I've performed 85 Perc-D nucleoplasty cases in the last two years, let's use this ablation technique as an example to show the types of capital equipment you'll need. (see "A Primer on Minimally Invasive Disc Surgery"). To perform nucleoplasty, you need the following pieces of capital equipment:
- a C-arm,
- an OR table on which the patient can be laid prone while AP and lateral projections are taken, and
- a generator manufactured by ArthroCare.
If you already do other types of orthopedic surgery, especially arthroscopic surgery, chances are that you will already have the generator in the OR. ArthroCare typically provides the generator free of charge when you contract with the company to purchase the disposable wands and probes that are needed for each related case. Similarly, another popular procedure, IDET, also requires a generator from its manufacturer, Oratec. If the generators are not available as free loaners, they cost about $12,000 to $15,000. Other types of procedures, such as LED, may require a YAG laser.
You'll need a new $900 disposable ArthroCare Perc-D nucleoplasty wand (the Spine Wand) to do each case. You also need discogram needles with removable hubs, which cost about $10 each. The Spine Wand can be used for multiple disc levels in the same patient; however, it cannot be resterilized and reused. I generally need two discogram needles per case cart.
Finally, you need a 18-gauge needle loaded with local anesthetic. The anesthesiologist provides light sedation; the patient is awake and responsive through the procedure.
Plan OR staffing
To perform disc decompression procedures, you'll need a fluoroscopy tech and a nursing staff familiar with these cases. Most minimally invasive disc surgeries are quick procedures, ranging from about 20 minutes to an hour, and the most time-consuming part of the procedure is the set-up. Let's run through what your staff will have to be able to do to set up and effectively assist the surgeon in a typical nucleoplasty procedure.
The surgical team places the patient in a prone position on the OR table and secures the patient. This is especially important because the patient will be conscious during the procedure, and maintaining precise positioning is crucial. Before we proceed, we take lateral projections to verify the disc levels in the patient's back. Finally, we prep and drape the patient and I administer a local anesthetic. Your anesthesia provider should be skilled in providing IV sedation. General anesthesia is required for open disc surgery, but not for the outpatient cases.
The surgeon then must insert and position the needles for doing the procedure. A large measure of the success of the surgery depends on precise placement of the needle through which the wand passes. The surgeon relies upon fluoroscopic guidance to place the needle centrally within the nucleus of the disc, so it is important to have a skilled C-arm tech assist the surgeon.
Remember, time is money in the OR. These surgeries can be done very quickly but only if the entire team is well rehearsed and if they do the procedures the same way each time.