If you're adding or expanding interventional pain management services, choosing the right C-arm is one of the most important decisions you'll have to make. At $125,000 to $135,000, these machines are a huge up-front expense and the largest capital equipment outlay associated with pain management. Good fluoroscopy is also vital to ensuring positive outcomes, patient safety and efficient case flow. Here's what you need to consider when shopping for a C-arm.

The fundamentals
A C-arm that you're going to use primarily for interventional pain management doesn't need to have as many bells and whistles as a unit that's going to be used for, say, cardiac or orthopedic services. Your needs in a pain C-arm are relatively basic, but no less important.

• Image quality. First and foremost, you've got to have good image resolution. Your physicians are trying to access tiny nerve pathways, and in many cases they're dealing with patients who've undergone surgery and may have some hardware on the spine, which can impede visualization. The C-arm should be able to deliver crisp, clear images to help physicians navigate these difficult areas. An effective pain C-arm must also provide digital subtraction angiography, a computer-assisted fluor-oscopy technique that subtracts bone and soft tissue and lets clinicians clearly view contrast-filled blood vessels. This capability helps your pain docs detect intravascular injection, which can lead to potential complications ranging from mild to severe symptoms.
• Power. Ideally, you want a generator that lets you take multiple X-ray pictures without having to stop for a long cool-down period. When we were shopping around for a new C-arm, we looked at one system that, after about 3 minutes' worth of fluor-oscopy, used up most of the heat units available and had to stop for a cool-down period of a couple minutes. That might be acceptable for a smaller practice, but at our fast-paced facility, where we do about 40 cases a day, the less downtime required by our C-arms, the better. If you're in a high-volume facility, look for a C-arm with a big enough generator to accommodate the available heat units that are consumed when taking frequent images.
• Size and mobility. When the physician is placing needles along the nerve pathway, you want to make sure the fluoroscopy equipment has enough clearance so that it's not interfering with the doctor's hand or field of view. Consider the size of the C-arm opening (a bigger "C" is better) and its flexibility. It should be easy to manipulate the unit to get a better view, so you don't have to worry about moving and repositioning the patient. If you're going to be sharing the C-arm among several specialties, consider how easy it is to move the machine from one room to another. At my facility, we're fortunate to have 1 C-arm for each of our 4 ORs, plus a 5th for backup, but depending on the size and caseload of your facility, you may not have the luxury of keeping each unit confined to its own room.
• Pulse mode. Reduced radiation exposure and increased patient safety are key goals. Our C-arms can be set on live mode, which delivers X-rays continuously, or pulse mode, a safer alternative to a steady, continuous dose of radiation. Pulse mode doesn't change the amount of energy delivered, but rather how it is delivered. For example, it breaks up a 1-second dose into shorter quick pulses. This lets the patient absorb less radiation while still yielding quality images. Once considered a high-end feature, pulsed fluoroscopy is now a standard feature in many C-arms.

Data portability
With just about every aspect of healthcare record-keeping going digital these days, the portability of fluoroscopic data is an added feature that's becoming increasingly mainstream in the C-arm market. Manufacturers are integrating information-sharing technology into their C-arm units that lets you instantly import radiological images into your electronic medical records, picture archiving, communications system and other types of information management systems. You can then share the images with your own docs, send them to referring physicians, import them into EMRs, print hard copies for patients and save and archive the data for future reference. Many pain management cases involve litigation (car accidents, workers' compensation), so the easier it is to compile and archive images taken by your C-arms, the easier it is to share that information with referring physicians and attorneys upon request.

Of course, C-arm systems that include these high-tech, information-sharing features come with a higher price tag than your basic models. When we looked into the possibility of adding these features to our models several years ago, it would have amounted to a $10,000-per-machine upgrade. We ended up using a workaround instead: We use third-party software applications that retrieve the images from our machines, and we manually import the data into our information management systems. It's essentially the same technology, but requires some extra time and manpower on our part.

Purchase options
Cost is a major factor to consider when you're in the market for a new C-arm. We chose to lease our C-arms rather than purchase them. Leasing helps you keep your monthly costs low while giving you greater leeway to upgrade as technology improves. Similar to an automobile lease, leasing options will vary depending upon the terms you desire. We lease our C-arms for 60 months. At the end of the lease, we can trade in the equipment to upgrade to newer technology or refinance with the opportunity to purchase the C-arms. Some manufacturers let you purchase the equipment coming off lease at a significant cost savings compared to new equipment.

You may also consider purchasing a package that includes both the C-arm and the surgical table. If you're going to be using the table primarily for pain cases, make sure you can rotate it, raise and lower it and tilt it from side to side. While it's often more expensive, having a table that tilts is money well spent. In pain management, the more you have to move the patient, the longer the case takes.

As with any piece of technology, routine maintenance and service are additional operational costs associated with pain C-arms. Many manufacturers offer a service plan that will augment a new product warranty or cover a used, older piece of equipment. A manufacturer's service plan can help to levelize maintenance and repair costs if they're factored into the selling price or lease agreement. You should also inquire about service call response times. An inoperable C-arm leads to cancelled cases and lost revenue. We're fortunate to have a backup machine on site, but you may not be so lucky. Some manufacturers will provide a dedicated response time for on-site service with the purchase of a service plan. Work with your rep to include a response time in the terms of the agreement.

Make time for trials
Due to the size and expense of the equipment, setting up a demonstration and trial at your facility may require a considerable amount of lead time and preparation. You may be able to forego an on-site C-arm trial. Often you can work with company reps to observe a demonstration at a neighboring facility before deciding whether to bring the equipment into your own facility. C-arm trials may last for a few days to a week, with vendors coming in to teach frontline staff how to use the equipment and explain the benefits. Be sure to listen to the feedback from your physicians and techs after the trial, as they're the ones who are going to be using this equipment once you've made your purchase.