Whether you're adding spine surgery to an existing facility or building a new center from scratch, here's a rundown of the equipment you need to consider. Many companies produce a wide range of equipment, so you have a lot of options. The actual equipment you'll need depends on your surgeons' preferences and your facility's case mix, but some devices are standard for any facility that offers minimally invasive spinal procedures. Here's a review:

• Surgical tables. You want a table that will allow for easy fluoroscopic C-arm access, and a radiolucent Wilson frame is useful. Alternatively, you can position patients on a Jackson table, which allows easy C-arm positioning for kyphoplasty and vertebroplasty cases, especially when you're using two C-arms to visualize both the anteroposterior and lateral planes. You'll need lead gowns and shields when performing fluoroscopic-based procedures and the OR may need to be lead-shielded depending on your local building regulations.
• Retractor arm. Look for a device that's easy to set up, has a stable attachment and is designed for easy repositioning of the retractor during the case.
• Instrument sets. This is one of the more subjective purchasing decisions you'll face, as surgeons will have their own ideas about good design and the features that make one set better than another. Sets that are designed in a bayoneted fashion so that they don't obstruct the surgeon's view when he's looking down the tubular retractor are helpful. Micropituitary rongeurs (both the straight and upward-angled pituitaries) are also very helpful and can be used with micro up-and down-going currettes when working within the confines of the tubular retractor.
• Drill. Your surgeons need a long, tapered drill to work through the tubular retractor while visualizing the surgical field. In most cases, an electric drill works better than an air-driven drill because it runs more smoothly and barely moves when powered. A vendor will often supply drills for little or no cost as long as the same vendor supplies and charges for the bits used during each case.
• Retractor systems. You want a system that's versatile and easy to use, usually one with a diameter between 22mm and 26mm. During the procedure, surgeons insert an initial K-wire under fluoroscopic guidance to the area of interest and use tubular muscle retractors to approach the spine for the placement of the tubular retractor. Many different tubular retractors are on the market and many of these can easily expand to give surgeons room to operate.
• Visualization equipment. You can get operative visualization with either a microscope or an endoscope. The microscope has the benefit of surgeon familiarity, ease of use, three-dimensional visualization and versatility. Ideally, get a system with a small, easy-to-manipulate operative head and platform.
• Radiographic equipment. You'll need a fluoroscopic unit for visualization during most minimally invasive spine cases.

In addition to this equipment, you may also want to incorporate electrophysiological monitoring into your procedures for an extra level of safety. These systems allow for monitoring of nerves during percutaneous procedures. Companies offer this service or you can opt for an easy-to-use EMG nerve monitoring system that a surgeon can operate and interpret on his own. Electrophysiological monitoring helps identify the secondary changes that occur at the physiological level which would necessitate immediate adjustments to prevent permanent nerve damage to the patient.

Building the backbone
The first step in outfitting your facility for spine is to consider the rules and regulations of your state for such a project as well as the real expectations of your surgeons and ownership group. Collab-orate with the facility's designers and the construction company when building operating rooms, clinic areas and office space. This is as important as the design input from the surgeons and helps to improve patient flow throughout the facility. In addition, this input can lead to the creation of more efficient clinical space (adding a computer with large screens to view patients' films, for example).

Plan for capital budget expenditures, loan acquisitions and investment decisions. Select and coordinate the capital equipment you want to purchase and check to ensure that the proper equipment is ordered. Profitable facilities are founded on sound management strategies. Consult a specialist if you have questions about decision-making or marketing issues. Remember one of the most important aspects of developing new business: Invest only in the equipment that you plan to use and that will make your center profitable. Closely supervise and manage your spine program during the launch phase. Making corrections once a service line is established will likely result in capital losses.

Also consider establishing a well-integrated interventional pain program to augment your spine services. This can provide a profitable source of revenue to help cover overhead costs. Spine rehabilitation and physical therapy services are other potential sources of revenue. These services allow for an integrated approach to spine care, as physiatrists know how to treat the surgeons' patients to improve outcomes, and make spine care a team effort.

Select the right physicians, office staff and administrative support. The physician can help select individuals with whom he can work effectively. Working with your surgeons to staff the ORs with trained and skilled personnel will go a long way toward keeping your facility free of conflict.

Information technology plays a critical role in making recordkeeping, billing and scheduling efficient. The right system should have the capacity for collecting patient data and outcomes-based medical information. It should also have the potential to show patient outcomes and cost savings that you can use as leverage when negotiating with payors. Other features to look for in an IT system include a database for tracking patient satisfaction scores and an ability to integrate with your facility's Web site, intranet and ethernet.

Centered on excellence
Your spine surgeons play a key role in surgical equipment acquisition, operating room and facility design planning and imaging center integration, but it takes more than one person to run a successful center. You need input from many different disciplines in the creation of a high-performing team. Don't be afraid to ask for help. In the early going, you may want to hire business and legal specialists who can make it easier for you to meet the sometimes overwhelming administrative and legal requirements associated with running a new center.