SWEET RELIEF Pain management reimbursements have dipped slightly in recent years, but it's still a moneymaking specialty.

If you're interested in adding quick and profitable procedures to your case mix, look no further than pain management, a high-volume specialty that's relatively easy to launch. Let's look at what you need to launch a successful pain program.

1. The latest treatments. Starting with the least invasive, here's the latest in pain procedures.

• Epidural steroid injections. Delivered in the lower back to treat lower back and neck pain, the injections are often used in conjunction with less-invasive modalities such as physical therapy. After injections, patients will hopefully experience pain relief with rest for a week or 2 as the steroids decrease tissue inflammation around the injection area.

• Dorsal medial branch block. If steroid injections fail to control a patient's pain, physicians can perform a dorsal medial branch block — which involves injecting a local anesthetic along the spinal nerve pathway — to determine if the patient would benefit from radiofrequency neurotomy. (If the local block relieves the pain, physicians presume neurotomy would provide longer-term relief.)

• Radiofrequency neurotomy. This is at the forefront of pain management advances. Physicians insert a hollow radiofrequency needle near the targeted nerve, then place a wired electrode through the needle to denature proteins in the nerve's coverings, which impedes electrical impulses that conduct down pain pathways. The technique targets a nerve's sensory branch, not its motor branch.

The procedure, which is especially beneficial to patients suffering from chronic discomfort, essentially stops impulses from moving across the pain pathway for 12 to 18 months, until new tissue begins to grow over the ablated portions of the nerve coverings. Patients may have to repeat the procedure in a year or two, perhaps sooner.

To add radiofrequency neurotomy, you'll need a radiofrequency generator, ranging in cost from $5,000 on the refurbished market to $25,000 for new, that creates the electrical energy needed to ablate the nerve coverings. The hollow-bore needles are single-use; the probes are sterilized between cases.

• Implants. If radiofrequency neurotomy is ineffective, perhaps because of advanced pathology or chronic pain that doesn't respond to other treatments, patients might be candidates for spinal cord stimulation or implantation of a pain medication pump. These last-ditch options are more invasive procedures performed in outpatient settings in 1 to 2 hours — physicians make pockets under the skin's surface to insert a battery (similar in size to a pacemaker) or a medication pump, then place the stimulator's electrodes or tunnel the pump's medication catheter along the spinal nerves.

2. Upgraded imaging. Mini C-arm displays have improved dramatically in recent years, giving physicians full HD images of injection sites. Fluoroscopic images are shades of gray, so the greater the definition of those shades, the better the overall images with which physicians have to work. Newer machines can also integrate electronic images into electronic medical records, transmit saved images to a facility's picture archiving system or send them to other clinicians through secured networks.

Pain management is a volume-driven specialty, which means C-arms will be started and stopped frequently throughout the day. Every time a physician activates the fluoroscopy, the C-arm's internal anode will heat up. Newer units "time out" as the C-arm cools, which helps reduce excessive wear and damage. To reduce fluoro exposure times, many C-arms now offer low-dose or pulse capabilities. C-arms range from $85,000 to $125,000, depending on accessories you buy with the base unit. If you're launching a pain program, consider a lease-to-purchase option to limit upfront capital expenses.

3. Versatile tables. A pain table must be radiolucent, allowing for fluoroscopic pulses to pass through its surface. Its base should be at one end, instead of at the center, in order to provide enough room for staff to maneuver the C-arm. A cutout where the patient's head rests is a welcome comfort design. Your physicians and staff will likely prefer tables that automatically move up and down, tilt left and right, and caudally and cranially, so patients don't have to be repositioned mid-procedure using wedge pillows. Radiolucent tables can cost as little as $4,000 and as much as $13,000, but typically run between $7,000 and $10,000.

4. Injection trays. Manufacturers offer stock epidural or pain injection trays, but your docs might want additional items included. To save money, buy the items requested by specific surgeons separately, such as particular syringes, needles or gloves. Instead of filling injection trays with unique items, include generic medical supplies such as drapes, sponges and medicine cups.