A couple of months ago, I did a spine operation on the kind of large patient we see increasingly frequently these days. Only, this patient was even more extreme. He was a young man who tipped the scales at 470 pounds. In the old days — say, a decade ago — I wouldn't have bothered to bring a C-arm into the OR. Why waste everyone's time when you know there's no chance you'll be able to see the patient's spine?

Times have changed. Welcome to the new world of C-arms, where recent advancements in technology are nothing short of remarkable. Among other things, newer C-arms are powered in such a way that you can shoot X-rays through some of the largest human beings on the planet, and still get the vivid pictures you need. By making surgery dramatically safer and more efficient, as well as affording several other advantages, they've become, in my opinion, vital investments for clinicians who are committed to providing the best care possible.

Seeing is believing

I recently went through an evaluation process and helped guide the purchase of a new state-of-the-art C-arm fluoroscopy unit for my hospital's outpatient surgery center. The advantages and innovations with the new machines are many, but they start with the visuals. Simply put, they put the "see" in C-arms.

Those of us who've been practicing for more than a few years remember working with grainy pictures on monitors that were at best equivalent to standard TV monitors. The ability to see what you really needed was very limited. And if you happened to have a heavier patient, you really couldn't see anything because the machine didn't have enough juice to get the X-rays through the patient.

Most newer units not only have fairly large 4K monitors (about 20 inches) that display beautiful, vivid visuals, no matter how large the patient is, they also let you connect the output from the C-arm to the monitor of your choice. In other words, if you have a 40- or 50-inch ultra-high-def monitor on your wall or boom, you can get an even bigger and bolder view of the anatomy you're working with.

No seconds needed

And if that view isn't good enough, you can make it even bigger — a lot bigger, if necessary. With older models, you could magnify an image to maybe twice its actual size. Now, with some of the new C-arm technologies, you can magnify images up to 10 times. That means you can actually see extremely small and subtle findings that you never would have been able to see before.

That's huge. As spine surgeons, if we're dealing with a fracture, and there are bone fragments that we need to be able to manipulate, we used to have to depend on pre-operative images because we could never see them intraoperatively. That meant you had to assume (and hope) you moved them the way you wanted them to move. If you didn't, you'd find out after surgery, which meant your patient was now facing a second operation.

The new C-arms let you see things in real time that you can't see with the naked eye, so if things don't move the way they're supposed to, you can take the needed corrective action right then and there, and prevent the need for a second procedure.

Smaller footprint, greater efficiency

But bigger pictures don't mean bigger machines. Because the imaging systems are digital, the machines are significantly smaller than they used to be. That smaller footprint helps ease the cramped space in the typical OR. It also means the machines are much easier to move in and out of the room and around the patient than ever before.

The mobility is one more aspect of an improved level of efficiency that lets you move patients through surgical procedures faster, but with the same degree of safety. You realize a benefit by being able to do more procedures in a given period of time.

The technology can also open up venues that let you expand the types of services you can provide. When I was training, in the 1990s, patients who'd had surgical spine fusions would be in the hospital for 5 to 7 days post-operatively. Now, I routinely do the same operation in an outpatient facility, and the patient goes home 2 hours later. Of course, there are anesthesia-related improvements, ad-vanced recovery techniques and other advances that let us do much more complicated operations than we've ever done in the past as outpatient procedures, but the modern C-arm technology also plays a critical part.

The amount of radiation used is also less with the newer models, so everybody in the room gets exposed to less radiation with the newer machines.

The new C-arms also crank things up a notch when it comes to data storage and retrieval. Some of the older machines stored images, but it was a hassle if you needed to get the images out of storage. If you were offsite, you had to drive back to the facility and have somebody bring the picture up on the device, so you could look at it again.

The new machines all have USB output ports, so I carry an encrypted USB drive with me, and can plug it directly into the C-arm and download my patients' images onto my personal drive. That way I can take the images and upload them into my practice's PACS system. If there's a problem or a question, you can look at the images right away, because you have them with you.

Of course, there's a hefty price tag. The basic models with modern digital imaging start in the neighborhood of $130,000 to $150,000, and the price goes up as you add software and other technologies. For example, if you upgrade to a dual-monitor system, you can run the price up to a quarter million or more.

Do you need a dual-monitor system? Nice but not necessary, I say. If I want to compare a pre-fusion image to an intraoperative post-fusion image, to see whether I've made the alignment change I was attempting to make, being able look at those pre- and post- images right next to each other saves time and makes life easier. Some systems also come with software packages that let you reconstruct multiple images into 3-dimensional pictures. OSM