Thinking of adding spine? With minimally invasive spine surgeries increasingly moving to the outpatient setting, this potentially lucrative specialty can be a great compliment to your caseload, particularly if you're already doing orthopedics at your facility. The initial capital outlay for spine is fairly significant, but if you make wise purchasing decisions and take the time to develop efficient procedures to keep these cases running smoothly, spine can be a real profit-booster at a time when reimbursements for some of the more high-volume outpatient specialties are declining.

Equipment needs
If you already perform orthopedic surgery and pain management at your facility, adding a few basic outpatient spine procedures to your case mix — such as microdiscectomy, microdecompression and posterior cervical foraminotomy — is the best way to start out with this specialty. Here's what you'll need:

• A regular OR table plus a Wilson frame for lumbar spine surgery. The frame, which sits on the table to help hold the patient in position for basic spinal procedures, costs about $6,000. You can purchase safety straps and gel pads for positioning and securing the patient on the table from the same vendor at an additional cost to the frame.
• Microscope. The important thing is to purchase a scope your surgeons are comfortable with; chances are they already have a preference based on what they use at the hospital. However, this equipment doesn't come cheap; a brand new, high-end spinal microscope will cost you about $250,000. If you're just starting out, you may want to consider purchasing an older, reconditioned neurological scope for around $80,000 to $100,000. While it's not ideal, if you have an ophthalmology scope another option is to purchase accessories to adapt the scope for spinal procedures at around $15,000 to $25,000.
• Surgeon headlight. Some spine surgeons prefer to use a headlight and loops to open and close the case; ours use the microscope from beginning to end.
• A full-sized C-arm with enough power to image the spine is essential, as your surgeons will need fluoroscopy to verify the correct surgical level and accurate placement of hardware. If you're already doing pain management or orthopedic cases, you probably already have a C-arm large and powerful enough to accommodate spine surgery.
• High-speed drill with enough torque and minimal chattering. Many spine centers are switching from pneumatic drills to electric drills for better performance. The number of drills you decide to purchase will depend on your caseload. If you expect to schedule back-to-back spine cases, you're going to need 2 drills, since the handle and cord have to be sterilized between patients. We have 4 drills for our 2 spine ORs, which lets us do 4 cases simultaneously without stopping in between. Depending on your anticipated volume, you may be able to strike a deal with the drill manufacturer where you get the drills for free and only pay for the disposables.
• Cautery and bipolar units. For fine-detailed spinal work, your surgeons may prefer to use an independent bipolar electrosurgery unit rather than a combined cautery/bipolar unit.
• Instrument trays. As with the drill, you'll want 2 sets of spine instruments per OR if you plan to do back-to-back spine procedures. You'll also need both cervical and lumbar retractors. Make sure you have a sterilizer big enough to handle these fairly large trays, and also ensure it's compatible with the instruments your surgeons will be using for spinal procedures. If you're already doing orthopedic procedures, your sterilizer is probably large enough to accommodate your spine trays, but like any time you add a new procedure, check with the manufacturer of the instruments to ensure you have the proper equipment to sterilize them.
• Allen frame. This device, priced around $35,000, can be adapted to your standard OR table to better position patients for more complex fusion cases.

Smart buying tips
With such a large investment at stake, you're going to need to assemble an expert team to work together and make the hard decisions, such as whether to purchase or lease, buy new or refurbished, start small or go big. Bring your financial team together with your physicians and OR manager to determine the best way to maximize your capital dollars. For example, if your surgeons insist on getting the latest, top-of-the-line microscope model, see if you can get their buy-in for a refurbished C-arm. Start investigating your equipment options and making decisions at least 3 to 6 months before you plan to open your spine services. Ultimately, your goal should be to satisfy your surgeons' preferences (so they'll be motivated to bring their spine cases to your center) without breaking the bank.

If you're not already contracting with a group purchasing organization, I strongly recommend you do so before adding spine. Your GPO can help get you significant discounts on big-ticket items like the Wilson frame, C-arm and microscope. We purchased almost all of our equipment through our GPO, and it made a massive difference in the cost. Another way to cut down on start-up costs is to purchase some capital equipment refurbished, or see if you can work with one of the major manufacturers to set up a creative financial arrangement. When we first opened, we got one of our vendors to purchase a majority of the equipment and lease it back to us at a monthly rate, which helped diffuse what would have been a substantial initial capital outlay.

While you have plenty of options for reducing your costs, one area where I would advise you not to cut corners is service. The warranties on your scopes, C-arms, drills and sterilizers are a significant addition to your overall costs, and you'll need to take them into account when budgeting for spine. Resist the urge to cut back on your service, repair and maintenance agreements. I've got everything covered with some kind of warranty, which can be very expensive, but I believe the investment pays for itself eventually. When a piece of equipment goes down, it's nice to know that the company is going to respond quickly and bring us a replacement while it's being fixed, thereby saving us from having to cancel cases.

Build a great team
While it's important to focus on outfitting your spine OR with quality, reliable equipment, don't overlook the people who'll be manning that equipment. Your spine team should consist of a scrub tech with experience in spine surgery, highly skilled OR nurses, experienced surgeons and anesthesia providers who can communicate effectively with the surgeons to address the specificities of outpatient spine.

If you're recruiting new surgeons to your facility to do spine, they're going to want assurances that the nursing and anesthesia staff are experienced and know what they're doing. For example, you don't want an anesthesiologist who's going to overly sedate the patient, making it difficult to wake the patient up and mobilize him early enough to be discharged the same day. Be sure to assemble your team well in advance of opening your spinal suite and have them train together, give input on equipment purchasing decisions and help design the setup of the room for optimal efficiency.

Effective patient management is a big component of a successful outpatient spine program. If done right, it's what will set your facility apart from the hospital in the eyes of both the surgeons and the patients. Your nurses should be well-trained to educate patients and their families early and comprehensively about what to expect when going in for an outpatient spine procedure. Create learning tools such as informative brochures to distribute to patients before surgery, and take the time to follow up with them post-operatively to ensure they're being properly cared for after they leave your facility. Patient satisfaction is all about managing expectations: The earlier you begin educating them about post-op pain management and mobility, the fewer complaints they're likely to have after their surgery. And the happier your patients are, the happier your surgeons will be, too.