Building on our core strengths, our diagnostic imaging center launched a new revenue center around the treatment of osteoporosis.

Today’s imaging centers are faced with ongoing reimbursement cuts as well as the challenges of a down economy. That is why it is more important than ever for diagnostic imaging centers to differentiate themselves and seek out new revenue opportunities. At Indian River Radiology, located in Vero Beach, Fla, we took a proactive approach to building our business and positioning our organization for long-term growth. Our strategy was simple. We assessed our fundamental strengths—including a proven track record for successfully performing vertebroplasties and kyphoplasties—and identified a new niche service, which is a natural extension or outgrowth of our expertise.

The result was the development of a comprehensive primary care osteoporosis clinic. In a sense, you could say the skeleton of our new venture was already there; it was a matter of fleshing out additional beneficial services. At the clinic, patients who are seen for vertebral compression fractures (VCFs) are counseled concerning bisphosphonate therapy, evaluated for additional treatment as needed, and often seen for new secondary VCFs. Our clinic offers a much-needed service for patients and provides Indian River Radiology with an additional profit center. Here is the story of how our osteoporosis clinic came about.

Core Strengths and Services

Founded in 1992, Indian River Radiology has no hospital affiliation and is owned and operated by four board-certified radiologists who provide professional radiology services. With a total of 13 full-time employees, our group provides imaging exams consisting of CT scanning, fluoroscopy, DEXA scanning, plain films, ultrasound, and MRI—a Philips Panorama 1.0 Tesla Open MRI system. Soft tissue biopsies and minimally invasive interventional procedures are performed at the facility as well.

Our radiologists were also involved with the organization and construction of an ambulatory surgery center (ASC), which is located adjacent to our imaging center. The ASC opened in March 2002 and has two full operating suites. Vertebroplasties and/or kyphoplasties have been performed almost exclusively in the ASC since its opening. The ASC is equipped with a Siemens SIREMOBIL Compact L C-arm with a 23-inch image intensifier. It is staffed by a full-time board-certified anesthesiologist who provides deep sedation with midazolam and propofol for vertebroplasty and/or kyphoplasty patients. Postoperative recovery is done at the ASC. When postoperative imaging is needed on the day of vertebroplasty and/or kyphoplasty, the patient is wheeled approximately 200 feet from the ASC to Indian River Radiology.

As a neuroradiologist with a certificate of added qualification (CAQ) in neuroradiology, I perform all vertebroplasties and/or kyphoplasties referred to Indian River Radiology. Our group has made a concerted effort to provide subspecialty coverage to patients and referring physicians. In fact, since 2000, we have performed over 1,000 vertebroplasties and/or kyphoplasties ranging from T4 to L5 to include sacroplasties. Vertebroplasties and/or kyphoplasties are all performed using the Siemens C-arm with a 23″ image intensifier. Deep sedation is provided and monitored by our anesthesiologist.

H. Paul Hatten, Jr, MD, (left) of Indian River Radiology. The imaging center offers DEXA scanning (center) and Reclast infusion (right).

In addition to vertebroplasties and kyphoplasties, Indian River Radiology has an active pain clinic at our diagnostic imaging center where epidural steroid injections (ESI), SI joint injections, facet injections, bone biopsies, and other procedures are performed. A registered nurse (RN) employed by Indian River Radiology monitors all these procedures and provides assistance.

Our full-time RN with advanced cardiovascular life support (ACLS) certification has worked at Indian River Radiology for 10 years. The RN serves as coordinator for all interventional patients at both the ASC and the imaging center. She also coordinates the pain clinic and assists with all pain-related procedures in addition to her other nursing responsibilities. The RN is available to all of our patients by telephone. She coordinates necessary diagnostic appointments and procedures for potential vertebroplasty and/or kyphoplasty and pain treatment patients. Her role is essential in the organizing and follow-up of patients.

Our commitment to patient care includes rigorous follow-up. For example, I call all interventional spine patients the night of the procedure and our RN phones them the next day, keeping a log and monitoring their pain response. Vertebroplasty and/or kyphoplasty patients return to Indian River Radiology in approximately 7 to 10 days for a CT scan of treated VCFs. Then, I interview each patient. Included in the dictation of the CT scan are the patient’s results and their current level of pain. If further treatment is indicated, they are scheduled at that time for a follow-up evaluation and any additional procedures.

Launching a New Service

With our core services in place and a highly successful track record for patient care, we began to think about additional patient needs. Osteoporosis is on the rise. The National Osteoporosis Foundation anticipates 14 million cases of osteoporosis and over 47 million cases of low bone mass in the United States by the year 2020. We recognized a growing need and knew our group had the expertise to deliver additional clinical care.

In 2006, Indian River Radiology made a commitment to serve as a treatment resource for osteoporosis, particularly for our vertebroplasty and/or kyphoplasty patients. There is evidence that bisphosphonate therapy reduces the risk of secondary VCFs by approximately 50%.1 A number of bisphosphonates are commercially available and patients are questioned and encouraged to take these drugs.2 Patients are educated regarding the importance of vitamin D, calcium levels, and regular exercise. Our RN provides information on inexpensive calcium and vitamin D supplements and counsels the importance of a DEXA scan to monitor their osteoporosis. In February 2009, Indian River Radiology initiated an Infusion Center where zoledronic acid (Reclast®, Novartis Pharmaceuticals, East Hanover, NJ) is given as an annual infusion. Patients are referred by their attending physicians to the infusion center where appropriate prescreening of vitamin D, calcium, and creatinine levels is performed. The RN at Indian River Radiology recalls patients on an annual basis without the necessity of a new referral from their attending physician.

I have had the opportunity to use several bioinjectable materials for vertebroplasty. The most recent bioinjectable material was a biphasic ceramic bone substitute, Cerament™ (Bone Support AB, Lund, Sweden). Cerament is an FDA-approved bone filler, which has been used off-label in vertebroplasty protocols. It provides excellent pain relief and is unique because of its bone healing potential and because it appears to stimulate new bone growth.3 The future of bioinjectable materials is not only in providing relief of pain from vertebral compression fractures, but in producing new bone and strengthening the compressed vertebral body with a bioinjectable material, which will reduce secondary VCFs in adjacent vertebral bodies.

I have used multiple vertebroplasty kits sold by multiple vendors. My preference is larger gauge needles (10 gauge, 11 gauge), which provide better dispersion of bioinjectable materials during vertebroplasty. In general, 13 gauge needles are used in upper level vertebroplasties because of the smaller size of pedicles. Currently, all PMMA vertebroplasties are performed using the Stryker PCD Precision Cement Delivery system. Kyphoplasties are performed using DFine Inc’s RF Kyphoplasty StabiliT Vertebral Augmentation System.

Integrated Approach to Osteoporosis

In addition to pain control in vertebroplasties, our patients often return to Indian River Radiology for imaging to evaluate either new or preexisting conditions not related to their spine. Indian River Radiology provides full radiology services including CT abdomen, chest, and pelvis; ultrasound; DEXA; and other general radiology services.

An integrated approach to osteoporosis in patients with vertebral compression fractures has allowed Indian River Radiology to serve as a comprehensive “primary care” resource for patients with back pain. The ability to treat their pain, counsel them about treatment alternatives, and provide follow-up of new pain and new compression fractures has proven extremely helpful. While Indian River Radiology is a general and full service freestanding diagnostic imaging center, patients with back pain and vertebral compression fractures can be quickly seen and evaluated through the integrated approach at the center.

H. Paul Hatten, Jr, MD, is a neuroradiologist and principal of Indian River Radiology based in Vero Beach, Fla. Dr Hatten did his neuroradiologist fellowship at Massachusetts General Hospital, and his practice is primarily neuroradiology and interventional spine radiology.

  1. Trout AT, Kallmes DF. Does vertebroplasty cause incident vertebral fractures? A review of available data. AJNR Am J Neuroradiol. 2006;27:397-403.
  2. Kearns AE, Kallmes DF. Osteoporosis primer for vertebroplasty; expanding the focus beyond needles and cement. AJNR Am J Neuroradiol. 2008;29:1816-1822.
  3. Submitted for presentation, American Society of Neuroradiology (ASNR) meeting, Boston, May 15-20, 2010.