Minimally invasive spinal surgery in lieu of traditional open surgery to relieve chronic back pain is ideal for outpatient facilities. These disc decompression cases are usually short procedures, with handpicked, low-risk patients, strong success ratios and fewer post-op complications than open surgery. And the demand for these procedures continues to surge. But how do you make disk decompression surgery profitable? I've been performing outpatient spinal surgery for 15 years. Here are some pointers based on my experiences.

Not all herniated disk patients are eligible for minimally invasive spinal surgery. The ideal candidate has:

• No severe spinal stenosis (build-up of bone in the spinal cavity).
• Well-maintained disc height, preferably with 30 percent or less disc collapse.

The Benefits of Minimally Invasive Spinal Surgery Growing clinical data proving efficacy Short procedures Low-risk cases with high success ratios Predictable and consistent case costs High-volume potential

If such conservative treatments as bed rest, analgesics and physical therapy fail to relieve the problem, I do tests such as discography, MRI and CAT scans. If these tests confirm that the problem is a herniated disc and the patient meets the aforementioned criteria, he is a good candidate for outpatient surgery such as nucleoplasty.

Assuming you can get preauthorized by your payers, the average facility fees for spinal surgeries - insurance payment plus collection of facility and professional fees - are about $1,800 to $2,500 (the physician reimbursement is about $700 to $1,200 per case), depending on your location and whether your facility is an ASC or a hospital. Reimbursement can be a tricky proposition, both with Medicare and third party payers (see "A Primer on Minimally Invasive Disc Surgery"). Here in Pennsylvania, some payers simply will not cover the case cart costs in an ASC, which is why I do all my cases in the hospital. Keep in mind, however, that there is no medical reason why minimally invasive disc surgery cannot be performed with equal efficacy in a freestanding ambulatory surgery center.

If you want to make a case with your payers to reimburse for spinal procedures, you can draw on the significant volume of clinical data proving the efficacy of outpatient disc surgery, which strongly suggests that these procedures can prevent the need for more expensive open procedures. Open disc surgery can cost up to $30,000 in OR costs and hospital admission fees. Open disc surgery results in epidural scarring and also requires a much lengthier recovery period than minimally invasive spinal surgery, where the patient can be ambulatory the same day and post-op pain is minimal.

A Primer on Minimally Invasive Disc Surgery Here's a quick crash course on three of the best known outpatient techniques for disc surgery. NUCLEOPLASTY: Nuclear ablation is one of the newest methods for performing outpatient disc surgery. Nucleoplasty is a type of nuclear ablation called coblation. The surgeon uses radio-frequency energy to remove tissue. Because the thermal energy is channeled with great precision, there is minimal thermal damage to collateral tissue. Pre-op testing. I do tests such as MRIs and CAT scans when indicated by a discogram. In a discogram, a needle is placed in the disc under local anesthesia and fluoroscopic guidance, and the corresponding pain level is recorded. Intraop procedures. With the patient under local sedation, I place the discography needle into the nucleus of the affected disc under C-arm guidance. I then insert the wand into the nucleus of the disc. As I move the wand forward, tissue ablates at the tip and then disintegrates. As I draw the wand back, the adjacent tissue is coagulated. I repeat this process several times. The nucleus should shrink about 15 percent during the procedure. Post-op. I have experienced excellent outcomes using this procedure: the success ratio in 85 cases has been 78 percent. Although the patient still needs a physical therapy program, he can return to work within a week. Typical outcomes are a 50 percent or greater reduction of disc-related pain within about eight weeks postop. Coding and Billing. Pre-authorization is crucial. Nucleoplasty is on Medicare's national list of covered procedures, but it was placed on the Local Noncoverage Decisions list on the basis that the procedure is still considered "experimental." This may affect your ability to get reimbursed. The CPT codes we use are 62287 for percutaneous discectomy and 76003 for fluoroscopic guidance. The AMA definition for 62287 is: "Aspiration or decompression procedure, percutaneous, of nucleus pulposus of intervertebral disk, any method, single or multiple levels, lumbar (manual or automated percutaneous diskectomy, percutaneous laser diskectomy, for example)." ArthroCare is applying to get coblation technology listed in the CPT code definition with the AMA. IDET (Intradiscal Electrothermal Annulplasty): IDET, an alternative option to nucleoplasty, uses a generator and a catheter (SpineCath) manufactured by Oratec. The procedure involves using thermal energy to heat the herniatic disc in the lumbar or lower thoracic spine, causing the collagen to shrink around the tear. IDET has been performed more than 25,000 times since 1999 in the U.S. Pre-op testing. The same as with nucleoplasty. Intraop procedures. With the patient under local sedation, the surgeon uses fluoroscopic guidance to place an introducer needle and the catheter. The surgeon heats the disc for 16.5 minutes. The catheter and needle are then removed and the patient goes to the PACU. Post-op. About two-thirds of patients attain at least 50 percent reduction in their pain by the 8th to 12th postop week, according to American Board of Interventional Pain Management data. Post-op pain generally occurs at a somewhat higher rate for IDET than nucleoplasty. Coding and Billing. The FDA approved IDET on the same basis as nucleoplasty. There is no specific CPT code for IDET, but it can be billed using a similar set of codes, pending pre-approval. SED (SelectiveEndoscopic Discectomy): I do not perform this procedure, but it is an option for treating both herniated discs (paracentral, far lateral, foraminal and central) and annular tears (primary, above the site of a previous fusion). In addition to treating discs as a primary surgical option, SED can be used for spinal diagnostics or as a second option if one of the aforementioned procedures fails to produce relief. This is an expensive and difficult procedure to perform. In addition to the cost of the Richard Wolf spinal endoscope, a Ho:Yag laser and an Ellman radiofrequency probe are often used with the procedure. The laser alone costs more than $100,000 (but can be loaned at about $200 per case). The cost of disposables needed for the procedure is about $1,000 per case. Pre-op testing and patient selection. Once conservative therapies fail and if standard pre-op tests indicate that the cause of the problem is a herniated disc, SED may be an option. Contraindications are spinal stenosis, spinal instability, anatomic inaccessibility, and prior open disc surgery at that level. Intraoperatively, SED can itself be used as a diagnostic tool to discover conditions such as annular scar tissue from microdiscectomy and foraminal herniations. Intraop procedures. With the patient awake under local anesthesia, the surgeon places a needle into the disc at a 45-degree angle and injects a combination of blue dye and iodine to visualize the herniated disk on an X-ray. The surgeon inserts into the disc a spinal endoscope manufactured by Richard Wolf, which guides the surgeon to mechanically dissect and remove the posterior quarter of the disc. The Ho:Yag laser is fired to further refine the opening in the disc and to shrink the collagen next to the tears. The radiofrequency probe is used along the annulus. The surgeon then decompresses the nerve root with a small forceps. Postop. Researchers say that 81 percent of SED patients experience good to excellent outcomes. The risks of complications are relatively low but significant. Nerve root damage is possible, as is epidural bleeding. Reimbursement. LED must be pre-approved on a case-by-case basis from your payers. Depending on what is done, it has been billed under CPT codes 29999 or more commonly, in the 63056 to 63030 range. Reimbursements are reported to range from a few thousand dollars on the low end to about $14,000 at the highest end. - Lewis Sharps, MD

Capital equipment and case supply needs
Facilities that do arthroscopy and similar orthopedic procedures are in the best position to add minimally invasive disc decompression surgery. Neurological surgery centers are also good candidates. These facilities will already have most or all of the key pieces of equipment.

In large part because I've performed 85 Perc-D nucleoplasty cases in the last two years, let's use this ablation technique as an example to show the types of capital equipment you'll need. (see "A Primer on Minimally Invasive Disc Surgery"). To perform nucleoplasty, you need the following pieces of capital equipment:

• a C-arm,
• an OR table on which the patient can be laid prone while AP and lateral projections are taken, and
• a generator manufactured by ArthroCare.

If you already do other types of orthopedic surgery, especially arthroscopic surgery, chances are that you will already have the generator in the OR. ArthroCare typically provides the generator free of charge when you contract with the company to purchase the disposable wands and probes that are needed for each related case. Similarly, another popular procedure, IDET, also requires a generator from its manufacturer, Oratec. If the generators are not available as free loaners, they cost about $12,000 to $15,000. Other types of procedures, such as LED, may require a YAG laser.

You'll need a new $900 disposable ArthroCare Perc-D nucleoplasty wand (the Spine Wand) to do each case. You also need discogram needles with removable hubs, which cost about $10 each. The Spine Wand can be used for multiple disc levels in the same patient; however, it cannot be resterilized and reused. I generally need two discogram needles per case cart.

Finally, you need a 18-gauge needle loaded with local anesthetic. The anesthesiologist provides light sedation; the patient is awake and responsive through the procedure.

Plan OR staffing
To perform disc decompression procedures, you'll need a fluoroscopy tech and a nursing staff familiar with these cases. Most minimally invasive disc surgeries are quick procedures, ranging from about 20 minutes to an hour, and the most time-consuming part of the procedure is the set-up. Let's run through what your staff will have to be able to do to set up and effectively assist the surgeon in a typical nucleoplasty procedure.

The surgical team places the patient in a prone position on the OR table and secures the patient. This is especially important because the patient will be conscious during the procedure, and maintaining precise positioning is crucial. Before we proceed, we take lateral projections to verify the disc levels in the patient's back. Finally, we prep and drape the patient and I administer a local anesthetic. Your anesthesia provider should be skilled in providing IV sedation. General anesthesia is required for open disc surgery, but not for the outpatient cases.

The surgeon then must insert and position the needles for doing the procedure. A large measure of the success of the surgery depends on precise placement of the needle through which the wand passes. The surgeon relies upon fluoroscopic guidance to place the needle centrally within the nucleus of the disc, so it is important to have a skilled C-arm tech assist the surgeon.

Remember, time is money in the OR. These surgeries can be done very quickly but only if the entire team is well rehearsed and if they do the procedures the same way each time.

Dr. Sharps ([email protected]) is the director of the Orthopaedic Surgery and Sports Medicine Center in Paoli, Pa.