Basic pain management procedures are in demand, profitable and comparatively easy to perform, making them popular additions to many surgical facilities' offerings. If your facility is willing to take a step further, however, advanced methods for treating chronic pain are perhaps the specialty's best kept secret, even though the technology's been around for years. They're not 15-minute, inspect-and-inject procedures, but these services - radiofrequency nerve ablation, discography, percutaneous discectomy and spinal cord stimulator implantation - can provide relief for patients as well as volume for your pain physicians.

1. Radiofrequency nerve ablation
The steroid injections of basic pain management work wonders, but they also tend to be short-lived. If patients respond well, but temporarily, to injections, it's not really practical or ethical to keep them returning again and again. Procedurally, the next logical step is to consider the relatively new technology of radiofrequency nerve ablation.

In radiofrequency therapy, instead of injecting medications, you insert a probe with a sensitive, needle-pointed tip into the patient to direct radio waves at a specifically targeted location. The waves deliver a heat of 90'C in order to destroy the nerves that have been identified as the pain-generating site.

It's true that radiofrequency nerve ablation is also a temporary treatment since, as with hair, nerves grow back. But its effects are longer-lasting. Enabling patients to live with reduced pain or entirely without pain for six to 12 months is more effective than making them come back week after week for the comparatively short-term results of injections.

Traditional RF ablation does have its risks. It's possible that the heat can destroy nerves so severely that it results in neuropathy. A newer version of RF exercises caution on that front. Pulsed radiofrequency nerve ablation delivers only intermittent doses of radio waves at a lower temperature - 42'C instead of 90'C - to "warm" the nerves instead of "blasting" them. The pulsed method destroys the nerve enough to shut down the pain signal, but not so much that it risks causing lasting damage for patients to suffer through.

RF treatment is a fairly general, all-purpose pain management procedure. It's ideal for lumbar facets, cervical facets and sacroiliac joints. If we can define a peripheral nerve causing problems, we can address it with heat: it's up to the physician's imagination. Even podiatrists might be interested in its use in treating Morton's neuroma.

This therapy doesn't necessarily require pain management specialization. Any physician who's trained to use the equipment can administer it. The patient should be under light IV sedation so as to be capable of meaningful verbal contact with the physician. Test a patient's nerves before enacting the ablation to avoid doing damage to a patient's motor nerves, which you'll want to be very cautious around.

While basic pain management injections require only a C-arm, a fluoroscopy table, a tray of supplies and medications, advanced procedures like this one will require add-ons in terms of equipment, though not extensively so. A radiofrequency ablation machine may cost you from $35,000 to $40,000 and a set of disposable probes about $30 per patient.

2. Discography
Beyond radiofrequency nerve ablation, two slightly more invasive pain management efforts involve intervertebral discs. While the first, discography, is strictly diagnostic in nature, the other, percutaneous discectomy, attempts to quell a patient's pain.

In the pain management field, we've been performing discographies for 20 years. Using a syringe connected to a meter measuring pounds per square-inch, a physician injects dye into a patient's spinal discs. This not only indicates which disc - or discs, in cases of multiple degenerative disc disorder - has ruptured, but also how much pressure causes the pain to occur.

Discography won't make a patient feel better the way that RF ablation will. But as a diagnostic test it's invaluable since it shows where the pain is originating from and offers a pretty accurate suggestion as to where we might operate to resolve the pain. In terms of equipment, discography requires a single-use PSI meter, which lists at about $150 to $200 each.

Another newer, more interactive method of discography, known as functional anesthetic discography, straddles the line between diagnostic and curative, if only temporarily.

Instead of a dye-injecting needle, you insert a catheter or cannula tube into a patient's disc, or even multiple catheters or tubes into multiple disc levels. You inject a local anesthetic agent into one level suspected of causing the pain. If you've accurately targeted the source of pain, the functioning patient will report that it has gone away when, for example, he bends over to tie his shoes. The procedure has identified where to operate. You should be able to obtain the supplies needed for functional anesthetic discography for less than $50.

Once you've located the disc that's causing the pain - through traditional discography's measurements, functional anesthetic discography's direct applications or a simple history and physical - percutaneous discectomy can help to relieve the pain.

3. Percutaneous discectomy
The solution to a bulging or ruptured disc is to decompress it, to shrink its volume by taking some of the disc material away. Percutaneous discectomy employs a specific hand tool that drills in and draws the material out, in similar fashion to a screw or an auger, while an external pump device suctions away the material. Newer innovations use a laser to coagulate the material instead of drilling it out. The chief benefit of this treatment is that it potentially saves the patient from having to undergo laminectomy surgery, which will require a back incision, the stripping of muscles from the spine and the breaking of lamina in order for surgeons to insert their tools. In contrast, percutaneous discectomy leaves no scar and does not disrupt a patient's bones or musculature. Plus, if a patient ends up requiring a laminectomy later in life, the discectomy procedure does nothing that would block a surgeon's ability to perform the more extensive surgery. The price range for the hand tool and suction device required for percutaneous discectomy is about $10,000 to $20,000; the kit of disposable supplies needed costs $100 to $200.

4. Spinal cord stimulator
For patients who've undergone laminectomies but have found them unsuccessful in relieving their pain; or for older patients, perhaps suffering from spinal stenosis, who may not be ideal candidates for the risks of such surgery and its strenuous recovery, the next level in the continuum of pain management care is the implantation of a spinal cord stimulator.

This procedure, still a minimally invasive surgery, takes pain management out of the procedure room and into the OR, and from local to general anesthesia. It doesn't change a patient's anatomy, but it can greatly change how they feel.

The implantable spinal stimulator, kind of like a pacemaker for pain, involves wire leads and electrodes placed into the anatomy of the lower back. They generate electrical impulses that create a buzzing or tingling sensation at the nerve to drown out its pain signals and prevent them from reaching the brain. You either feel the buzz or the pain and if it's successful I'm told that, over time, patients don't even feel the buzzing or tingling anymore. This technology has been around for three decades, but we're just beginning to use it to its best advantage.

This procedure is performed in two steps. First, we want to make sure that implanting a spinal stimulator will provide effective therapy. During a 15- or 20-minute procedure under local or MAC anesthesia in the OR, we insert an electric stimulator lead through a catheter into the epidural space. The lead is connected to a small, self-contained, external computer and battery. Once discharged, the patient keeps that setup for a week to see whether and how much the treatment affects their normal daily life. This functionality lets us truly measure the level of success we can expect to achieve with the second step, the permanent implant. I've seen resulting improvements of 50 percent to 90 percent. I've had patients tell me that they've regained significant levels of mobility and activity, that they've slept better, that they've reduced their dependence on pain drugs. Incidentally, this trial period offers demonstrable reasons for implantation that you can take to the patients' insurance companies.

When the patient returns to the OR, we remove the catheter and bury the stimulator device beneath the skin of the patient's flank. It's about the size of a Post-it note and perhaps 0.75 inches thick. Its electrical antenna wirelessly charges through proximity to a plug-in charger in the patient's home. The patient recovers from the surgery in about two to four days. Compare that to the months of recovery patients endure after spinal fusion.

While this technology is largely used to combat lower back pain, I've also seen it used for neck cases, and in truth, the possibilities for treating severe, chronic, neuropathic pain with this method seem unlimited. The trial surgery's component kit costs about $1,495, while the permanent stimulator implant costs about $16,000 plus about $2,950 for each electric lead used. This is admittedly a heavy expense, especially if a patient is paying out of pocket, but compare it over the long run with more surgeries and a continued regimen of pain prescriptions.

A step beyond
At a half-hour to an hour per case, these procedures take longer than basic four-to-an-hour injections, but if volume follows the demand, they'll be well worth it.