SDS, anesthesiologists tackle pain management
New Procedures
SDS, anesthesiologists tackle pain management
Spinal endoscopy, blocks use fluoroscopy
The growing complexity of pain management procedures is creating opportunities for same-day surgery programs, as SDS managers form links with specialized anesthesiologists to treat a new population of patients.
While some pain patients simply can visit their doctor’s office or a clinic for steroid injections, others need more sophisticated epidural treatments that require continuous radiologic guidance. And a new procedure, spinal endos copy, involves threading a tiny fiber optic camera into the epidural space so the anesthesiolo gist can see the irritated nerve and inject medication at its root.
Spinal endoscopy must be performed in a sterile environment, such as an OR. That requirement has led to a natural bond between pain management anesthesiologists and same-day surgery facilities, says Robert J. Masone, MD, director of the Fair field Pain Management Center in Lancaster, OH. Masone also is the anesthesia director for River View Surgery Center in Lancaster, which opened a year ago and recently began offering pain management procedures.
"This marriage is kind of new," says Masone. "There’s a tendency for doctors to have freestanding pain clinics. They will probably try to locate near surgery centers to utilize their resources."
The new procedures offer a new source of case volume at reasonable reimbursement levels, says Patricia Moore, RN, CNOR, director of River View Surgery Center. In fact, workers’ compensation boards often favor pain management for workers injured on the job, she says. "They see pain management as an opportunity to get the work force back where they need to be in a shorter period of time with less complications or recurrences."
When Moore first began offering pain management at a different surgery center in the 1980s, CPT codes didn’t even exist for the procedures. She had to fight for reimbursement and sometimes lost money. That situation has completely turned around now, as pain management grows in acceptance and desirability, she says.
"Pain management offers new procedures for old problems," she says. "In the past, if you had sciatica, then you would be pretty much treated medically with bed rest and oral medications. Now that [researchers] have validated the potential positive outcomes and patients are actually doing better being on a pain management program, payers see the benefit of those and added the procedures to the reimbursement list."
1,200 patients a year
Surgery centers often offer the same injections and nerve blocks performed in clinics or office settings. For example, Bethesda North Ambulatory Surgery Center in Cincinnati, which is hospital-based, began offering blocks about four years ago and now sees 1,200 pain management patients a year. Bethesda North converted space in its recovery area for pain management, says clinical nurse manager Carolyn Lekien, RN, CNOR.
Pain management procedures occur in the OR at River View Surgery Center because of a need for fluoroscopy or the new spinal endoscopy equipment. "One nurse is assigned to the procedure primarily for patient support and positioning," says Moore. Patients wait for about 15 min utes in the recovery area for observation before discharge. Because a patient may need three injections, she keeps a single revolving chart to record each visit.
If patients don’t get relief from the injections, they may be candidates for spinal endoscopy, says Masone. The procedure is used to diagnose and treat chronic low back pain and radiculopathy, or pain that radiates to the legs.
Myelotec of Roswell, GA, received approval from the Food and Drug Administration for use of the endoscopic equipment for diagnostic purposes in 1996 and approval as a drug delivery system in 1998.
"We actually use a fiberoptic camera and go up the spinal canal from the caudal area, and we can look at each nerve root," says Masone. "You can inject medicine on the nerve root. This is especially helpful for people who have a normal MRI but still have back pain."
The spinal endoscope, which is barely a millimeter in diameter, costs $3,000 and lasts for about 35 procedures. Physicians also need to use an access kit ($60 per case) and video-guided catheter ($375 per case). A conversion unit ($1,350) is available for facilities that already have a video system, or you can purchase a video system from Myelotec (about $18,000; see sources, above). The facility fee varies widely by payer and region of the country, with a non-Medicare reimbursement ranging roughly from $900 to $3,000 per case.
Patients are mildly sedated during the hour-long procedure, and they help direct the anesthesiologist to the nerve that is causing their chronic pain.
A non-scientific study of 72 patients who were surveyed before the procedure and six months later showed a reduction in the severity of overall pain and an increase in physical functioning. Yale University researchers have published articles related to the spinal endoscopic technique1,2 and are analyzing other outcomes data. About 6,000 procedures have been performed nationwide.
Resolving — or significantly improving — a patient’s chronic pain ultimately can lead to lower health care costs, says Masone. Pain patients often end up in the emergency department seeking treatment, and they use hundreds of dollars worth of medicines in an effort to control the pain, he says.
"You present that [potential savings] to managed care companies, and they’ll weigh the risks and the benefits," he says.
References
1. Saberski LR, Kitahata LM. Review of the clinical basis and protocol for epidural endoscopy. Conn Med 1996; 60: 71-73.
2. Saberski LR, Kitahata LM. Direct visualization of the lumbosacral epidural space through the sacral hiatus. Anesth Analg 1995; 80:839-840.
Sources
For more information on spinal endoscopy, contact:
• Charles Eichenberg, RN, PhD, Director of Medical Affairs, Myelotec, 4000 Northfield Way, Suite 900, Roswell, GA 30076. Telephone: (800) 574-1633. Fax: (770) 664-4363.
For information on training in spinal endoscopy, contact:
• Janice Gore, Office of Postgraduate and Continuing Medical Education, Yale University School of Medicine, New Haven, CT 06520-8052. Telephone: (203) 785-4578. Fax: (203) 785-3083.
For more on pain management programs in same-day surgery facilities, contact:
• Patricia R. Moore, Director, River View Surgery Center, 2401 N. Columbus St., Lancaster, OH 43130. Telephone: (740) 681-2700. Fax: (740) 681-2750.
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