IN ACTION The features and the future possibilities of 3D mean better visualization and more precise hardware placement.

I have to admit, when we had vendors come in and demonstrate the capabilities of 3D C-arms before we bought our unit about 2 years ago, I was a bit overwhelmed by the cool factor. The 3D spin and the quality of the image wowed the radiologic technologists and surgeons in our facility.

Our hospital needed a new C-arm, and many of our state grants rely on our advancing with technology. So we decided to have a look at 3D C-arms (and all the features that came with them). With a price tag typically running between $200,000 to $300,000 (depending on the configuration that's right for your facility), yes, it's expensive. But we love the features and the future possibilities.

Everyday use
When you buy a 3D C-arm, you don't lose regular fluoroscopic imaging capabilities. Rather, it's a module that you activate separately, when you need it. So in our facility, the C-arm itself gets used every day for spine procedures. For those, it's the usual 2 views — AP and lateral.

Three-dimensional imaging is ideal for orthopedic and spine surgery, neurosurgery, bone trauma procedures, and oral and maxillofacial surgery. We use it for spine. Right now, about 3 times a week, the surgeons will request use of the 3D module for a lumbar, cervical or thoracic fusion that they feel would benefit from a 3D scan that allows better visualization of the vertebral body placement.

Set up is per the usual — nothing out of the ordinary. Then you turn on the 3D module and, with a few buttons pushed, you're ready to run the fluoroscopy in pulse mode, which gets you up to 25 frames per second. You'll see incredibly rich, detailed images of the spinal anatomy on 2 screens as the 3D spin is carried out via mechanized function. One screen shows the frame-by-frame video of the complete rotation. The other screen has 4 quadrants where the physician can manipulate the axial, sagittal, lateral and dorsal planes, and view the scan from all angles.

This lets surgeons better determine where to place screws for the fusion procedures. If, at the end of the procedure, the surgeon wants to double-check screw placement, we'll do another scan, and he can adjust as needed from there.

In addition to the superior quality of the 3D reconstruction and easy set-up, I also have to praise the compactness of the design. The footprint of 3D C-arms can be less than 1 square meter, so they're not eating up OR space, and they're easy to move (an important feature for your radiologic technologists).

Key considerations
Certainly, the vendor demos pumped up the technology but, overall, I wouldn't say they were over the top. Now that the 3D C-arm is in place and in use, there are 3 — I wouldn't call them drawbacks — but key considerations.

• Expansion. We don't do the 3D spins as often as we thought we would when we first got it, and physicians were bickering over who got to use the shiny new toy for their procedures. As it turns out, for the most part, they feel comfortable with their surgical techniques and "feeling out" hardware placements. But they do like the backup of reassurance when it's needed, in more complex anatomy or during a difficult procedure.

In the future, I think we'll get expanded use out of the 3D C-arm when it's used in collaboration with a navigation system, which we're shopping for now. Having a computer-aided surgery system in place will let us do the initial 3D spin, render the images, and then let the surgeon work in real time, watching his progress on the flat-panel monitor. He'll be able to see where the instruments are, how far the screws are going into the bones and the pedicle placement. We won't have to X-ray again; everything will come from the navigation system.

• Radiation exposure. The scan takes under a minute with the 3D C-arm but, if anything, it's longer than with 2D imaging. So you're probably exposing the patient to more radiation, but it's not even close to a harmful dose. These systems come with targeted dosing control, to minimize the radiation dose used, which protects patients and staff alike. So the low increase in radiation (and in time under anesthetic) is outweighed by the benefits in data acquisition, generating individual multiplanar reconstructions, hardware placement and surgeon peace of mind.

• Trial and training. At our facility, the majority of our existing C-arms were from the same company. The 3D C-arm was from a new company and, well, you know how people are with change. It took a few months for everyone to get completely comfortable with the different interface, and there was some grumbling. But it was a lot like switching from Windows to Mac — it's pretty straightforward, some things are just in different places. It helps, though, to let the OR radiologic techs test the units during demo, and to train to reinforce after purchase. I found it helpful that the software on the 3D unit we got sort of guides you through each step, not letting you move forward until you're done.

FROM ALL ANGLES Four quadrants detail the anatomy from every view the surgeon might need.

Final take
After having seen the process unfold — and finding that, as a daily end-user, I'm happy with the results — I'd say there are 3 keys to buying the 3D C-arm that's right for you.

• Research the capabilities (Is this something your surgeons need?) and get demos from the various vendors. Although it's ultimately all the same technology, the systems will inevitably present slight differences in user-interface that may influence the decision to purchase.

• Have the people who will be the end-users try it out to see if they find the interface intuitive and user-friendly.

• Think about whether to go the distance with the upgrade. To me, the 3D technology is impressive on its own, but much more beneficial as an assisting piece to a navigation system. That's the next step we're taking; I just wish we'd made the leap all at once.