You need deep pockets and a strong fortitude to add spine, which ranks as one of the most expensive surgical service lines to equip and perform. "As a warning and as general advice, don't be shocked by the sticker price of getting started. It's going to be high," says Nathan Nitzky, BS, RN, CNOR, perioperative nursing care coordinator for neuro and spine surgery at Scottsdale (Ariz.) Healthcare's Osborn campus. "You have to be prepared to spend a lot of upfront money to get it going."

Yes, you'll spend a lot to get it going and a "staggering" amount for warranties and preventive maintenance on your equipment to keep it going, says Karen Reiter, RN, CNOR, RNFA, chief operating officer at Diagnostic and Interventional Surgical Center in Marina del Rey, Calif.

Is leasing an option? Sometimes. Richard Kaul, MD, of New Jersey Spine and Rehabilitation in Pompton Lakes, N.J., schedules 6 to 8 laser disc decompression patients on the same day of the week. He contracts with a company that provides the laser for a flat $350 charge, considerably less than the $3,500 a month it would cost to lease the laser. "Besides," adds Dr. Kaul, "they occupy a lot of space. Where are we going to put it when we're not using it?

High stakes, high dollar
It's almost easy to justify the exorbitant costs of the capital equipment ($350,000 on the low end for an OR table and table positioners, C-arm and microscope), instruments ($200,000 instrument trays, $88,000 electric high-speed drills) and supplies ($1,400 pedicle screws) you'll need when you consider the high stakes and the high-profit potential of minimally invasive spine surgery, says Mr. Nitzky.

"A millimeter of error can have devastating consequences," says Mr. Nitzky. "If you're off even a millimeter or 2, you risk damaging a nerve root or compromising the function of a limb permanently. It's high stakes, so it's high dollar, but that's only if it's done right. Don't skimp. Spine is serious business, not something to be taken lightly. You need to have the right equipment, and good equipment."

Take tables, for example. To allow for easy C-arm access and patient maneuverability, you'll need a radiolucent spine table with a sliding top so you can turn the patient head to foot as well as move the patient out away from the pedestal base. A standard table, in which the pedestal is under the patient's spine, won't let you position a C-arm or give you room for foot pedals for the drill and bipolar cautery, says Mr. Nitzky.

In addition to an appropriate table, you'll also need appropriate positioning equipment such as a Wilson Frame, or a specialty table such as a Jackson Table or Andrews Table, he adds. The compact Allen Spine system, which attaches to the OR table, is another option. The Wilson Frame is about $5,000; the specialty tables are significantly higher: $25,000 to $100,000, depending on whether you buy new or used and how they're outfitted. The Jackson, which is more for fusions, costs more than the Andrews, which is more for decompression without fusion. The Wilson, the most versatile, just sits on the regular table.

You'll have to have imaging capability, preferably a C-arm. A new C-arm will cost about $130,000, says Mr. Nitzky, while a used one will run you about $90,000. A 9-inch image intensifier will do so you can concentrate the beam into the smaller area of the spine, says Mr. Nitzky.

A new state-of-the-art scope — bright lights, computer-controlled, infrared and image guidance, auto-balancing — will cost about $200,000. An older, lower-end model with very good optics will run you $50,000 to $75,000. Face-to-face oculars for the assistant across the table are a necessity.

You can get much of what you'll need from resellers and secondhand suppliers. "They provide these things very competitively," says Dr. Kaul, who bought a used microscope for about $80,000. Ms. Reiter bought used C-arms for the second of her 2 spine centers. "If you can get something secondhand," she says, "it will halve the cost."

Enlist help from surgeons and their scrub techs
Besides equipment, a major portion of the per-case costs in spine are the permanent implants. Here, says Dr. Kaul, you have less control over cost, which makes it all the more important to shop around for the best prices. "Reach out to those in the spine community," he says.

Surgeons are integral to the implant cost-containment process, according to an abstract presented at the 2008 North American Spine Society's annual meeting. You should also enlist the help of your surgeons to become active participants in cost containment, asking them to negotiate with vendors to reduce the cost of the implants. Only one-fourth (26%) of 35 spine surgeons surveyed said that they'd help negotiate implant prices for their hospitals in the past, but nearly two-thirds (64%) stated that they'd be interested if provided with more incentive to do so. Only about one-fifth (22%) of respondents felt that helping the hospital negotiate down implant prices would impair their relationship with industry.

When buying instrument sets, ask spine surgeons' scrub techs to help you put an instrument list together, says Ms. Reiter. "This would be quite a challenge for an administrator," she says. "A scrub tech knows the instruments and knows the contacts at each company to trial."