Pain management can be a lucrative line. Its short cases can fit easily into a day's schedule. It's in high demand by an aging yet still active patient population seeking post-surgical comfort and relief from chronic pain. And, best of all, you may already have the necessary basics on site. Read on for insights into equipping your center to handle pain procedures.

First and foremost, you'll need a C-arm. There's no way of getting around it: If you intend to host pain management procedures, mobile fluoroscopic imaging equipment is a must-have. And you'll want it to be a large, standard OR C-arm, as the mini C-arms designed for scanning patients' extremities don't deliver a sufficient quality of image for pain management purposes.

A C-arm will represent a significant capital investment. A new unit may cost $100,000. If you'd rather avoid the expense of a new C-arm, explore the used market. When obtained through a reputable dealer, a refurbished model will work just as well at a $60,000 to $70,000 price point. Just be sure to inquire about the terms and length of the service warranty backing it up. Yet another option is leasing the C-arm on a per-month or per-procedure basis, which gives you the opportunity to equip your pain management providers with a new, state-of-the-art C-arm without the hefty up-front expenditure.

That is, of course, if your facility doesn't own a C-arm. If you're a multispecialty center that hosts orthopedic, sports medicine, urology or podiatry cases, the odds are good that you already have one. Adding pain management to your case mix spreads the cost of the equipment over an additional service line. Since pain management is a natural extension of specialties that deal in chronic pain — the cervical and lower back pain dealt with in orthopedics and neurosurgery, the foot and leg pain of podiatry, the pelvic and prosthetic pain of urology and gynecology — your existing services may provide an ideal avenue of referrals for your new one.

Added aspects
The latest C-arm models offer a lot of technological bells and whistles. One recent development is digital subtraction, an imaging feature through which certain aspects of the anatomy (such as bones) can be removed from the image in order to highlight other aspects (such as blood vessels). While that's certainly impressive technology, all you'll really need is a basic C-arm that produces a decent fluoroscopic image of the skeletal structure and, following the injection of contrast dye, the nerves you'll be treating.

Starting a pain service line doesn't actually require the latest and greatest equipment. For example, while intraoperative imaging has driven the trend toward flat-panel monitors, an older cathode-ray-tube monitor is sufficient to serve the needs of pain management. It may occupy a larger footprint in your procedure room, but as long as it's compatible with your imaging equipment it'll do the job, especially for facilities still building their case volume. You can always upgrade later when the added service begins paying off.

One added feature you may want to look for in a C-arm, though, is pedal-controlled operation. Pedals will make pain management visualization much more convenient for your providers by letting them capture images at the exact moment they want them, without having to direct a radiology tech to snap the picture and wait for them to do so.

Setting the table
In addition to the C-arm, an imaging table is an essential component of pain management procedures. The table should be built on a carbon-fiber or otherwise radiolucent framework in order to enable fluoroscopy without the image interference that a metal structure would cause.

An imaging table will cost about $40,000 if your facility isn't already equipped with one. In my own experience, I've never seen a used one for sale. Perhaps the market for refurbished imaging tables is still new, or not many of the fluoroscopy-ready tables that have been purchased over the past decade have been traded in on the used market yet.

In terms of table features, articulation is key. Your surgeons will want to raise and lower the patient to the ideal ergonomic height for the procedure. The ability to tilt the patient into the Trendelenburg position can also prove helpful in the event that a patient suffers a spell of low blood pressure or lightheadedness mid-procedure.

Every imaging table will have handheld controls but, as with the C-arm, pedal controls are a nice add-on. This lets the practitioner raise, lower or tilt the table independently and to just the right level, without the need for directing staff. Weight capacity is also an important consideration here: You'll want the table to be able to support and lift each patient, so take the average body size of your patient population into account when testing out your options.

Tools of the trade
It's likely that the majority of the pain management procedures you'll be hosting will be simple, selective nerve block injections, so beyond the C-arm and imaging table, the only other necessities (besides, of course, the crash cart of rescue drugs and equipment you'll have on hand no matter what cases you're hosting) are the drugs, syringes and supplies used in each case.

The contents of an injection tray are largely subject to a practitioner's likes and dislikes, and the requirements of a particular case. But several medical device and pharmaceutical manufacturers market pre-packaged, sterile supply kits that bring "one-stop shopping" to pain management. At about $10 each, depending on the amount purchased, I've found these to be a cost-effective option for surgical facilities with substantial pain procedure volumes.

The trays, available in many configurations, contain a variety of preps, needles and syringes in one place, for use anywhere. Your staff simply pulls the tray along with the necessary drugs, pops it open, and everything they need for the procedure is ready to go. Some manufacturers even let facilities customize their orders, at cost. At our facility, we've gone with a pre-fabricated kit, but one we've found to have the smallest packaging, to reduce waste.

As I've noted, injections make up the majority of most facilities' pain management case volumes. In the event, however, that your practitioners want to treat pain that doesn't respond to traditional, medication-based methods with such advanced procedures as radiofrequency ablation or spine stimulator implants, advanced equipment will be necessary.

For a facility that's just starting up a pain program and that doesn't expect immediate day-in, day-out use of a radiofrequency generator, the units can be rented for the days they're needed as an alternative to a purchase or long-term lease. Depending on the terms of the lease and your reimbursement, you could easily break even or profit by occasionally renting an RF unit for a day's cases.

Spine stimulator implants, on the other hand, are essentially free, since you're buying them just for the day of surgery. The medical device manufacturer supplies them to you with its invoice, after which you place them and charge the patient or insurer.

Room to operate
Surgical facilities that host a high volume of orthopedic procedures may have a dedicated fluoroscopy suite. If this isn't the case at your facility, you don't by any means need to dedicate space to pain management in order to host the specialty.

You don't need a large room. Since the majority of pain procedures are simple injections, you don't always need a sterile room. You don't need specialized lighting. And as long as you keep your clinical staff and other employees at least 4 feet from the source of the fluoroscopic equipment's radiation, you don't need a lead-lined room.

Whatever space you can fit an imaging table and C-arm into will work for pain management, whether it be an OR or a GI?suite. It may be difficult to fit a C-arm into a pre-op or PACU bay, but there's no other reason why you couldn't perform pain procedures in them. Some of my patients have remarked that they appreciated the fact that their treatment took place in a procedure room as opposed to a bright and chilly OR, as it made it seem like less of a big deal.

Basic pain management injection cases are short, about 15 minutes apiece. The pain is diagnosed and located, then the drugs are administered. You can schedule blocks of cases in whichever rooms, and at whichever times, are available on your schedule.

Staffing situations
Perhaps the biggest impact that pain management — or, for that matter, any specialty that involves fluoroscopic imaging — will have on the staffing of your facility is that it may require you to hire a certified radiology technician. Be sure to consult your individual state's laws on the subject to see if you'll need to budget another salary when you budget for a C-arm. Most if not all require the presence of a licensed technician whenever X-ray machinery is operated (although this is not the case in the District of Columbia, where I practice).

Consulting state law will also determine whether the pain management practitioner or a member of the clinical staff is eligible to fill this role through the completion of a course on radiation safety. If not, the certified technician can help to educate staff on radiation safety, including the operation of fluoroscopic equipment, when the extent of imaging requires lead aprons and the quelling of unreasonable fears involving radiation.

Most pain procedures are very short and efficient. You'll interview the patient, take his blood pressure and administer the injection or injections. The cases are as fast-moving as collecting blood samples. For that reason, your provider will want a nurse or assistant who is malleable, who can work fast and who is resourceful.

Positioning patients for pain management isn't terribly complex. In fact, I can't think of a time when the patient is not in the prone position. But when they're escorted into the procedure room, before laying them on their stomachs, place a roll-shaped positioning device or a rolled-up towel on the table. The positioner, of varying size depending on the patient's anatomy, should be placed underneath their navel, reaching across from hip to hip. The purpose? In the prone position, the spine exhibits a downward curve. A positioner placed beneath the patient's body will curve the spine upward, even opening its joints, allowing the practitioner and his injection syringes greater access.

Pain management prospects
The baby boom generation has created a widening population of patients facing such musculoskeletal issues as osteoarthritis, lumbar canal stenosis and degenerative disc disease. Unlike their elders, they'd rather not simply suffer through them, especially if treatments are available to help them maintain an active, mobile and pain-free life. With several prescription drug options now off the market or under tight federal scrutiny, outpatient pain management services show the potential for high demand.