If you're pondering purchasing a C-arm for pain management procedures, you already know that the choice is not easy. Many considerations - including cost, technical options and surgeon preferences - can cloud the decision. I perform an average of 60 pain management procedures a week, and this article outlines what I have learned about what's important in a pain management C-arm.

Shore up your commitment
With many new, full-body C-arms starting at more than $100,000 for the base model - and considering other expenses like radiology tech wages, storage costs and maintenance fees - price justification is always the top concern. It is essential to ensure adequate procedure volume, as any pain management practice needs a critical patient load to justify this expense. In my experience, a pain service must perform at least 40 procedures a week to make it possible to break even after investing in a $128,000 C-arm (see "Break-Even Scenario").

Unfortunately, even when you have a confident estimate of volume, projecting revenue is still more of an art than a science. Insurers continue to change the reimbursement rules for pain management services, and we have no way of knowing what may come our way tomorrow. For example, Medicare recently stopped reimbursing surgery centers for facet injections, while effectively doubling the reimbursement rate for these injections done in the office. Before taking the C-arm plunge, it's wise to make sure your entire staff is dedicated to finding ethical yet creative solutions to these challenges so you can optimize reimbursement and keep the pain service viable.

Break-even Scenario This hypothetical situation illustrates why a pain management service needs to treat a minimum of 40 patients a week to break even. The example assumes a five-year lease based on a C-arm price of $128,000 and an annual service cost of $20,000, for a total monthly lease cost of $2,500. Proponents of leasing cite several reasons for choosing this option: It can help you evaluate your true need for the C-arm without necessitating an outright purchase, and leasing can give you the flexibility to "trade-up" should technological advances arise. ? ?Annual lease expense: $27,500 ? ?Year-one down payment: $2,500 ? ?Annual overhead: $10,000 ? ?Annual salary/benefits: $45,000 ? ?Total yearly expense: $85,000 ? ?Average global facility fee per patient: $175 ? ?Less physician's reading fee ($75) ? ?Supplies ($15) ? ?Bad collections debt ($9) ? ?Gross revenue per exam: $76 ? ?Yearly break-even volume: 1,118 ? ?* Daily break-even volume: 4.4 ? ?** Nonpayment factor: 100 percent ? ?Daily break-even factor: 8 * Assumes 252 operational days/year ** Assume that insurance carriers won't reimburse 50 percent of pain procedures and account for this in the financial projection.

Keep the unit in one place
Once you decide to make a purchase, determine how you will set up the equipment. In my experience, units that get moved around a lot need more maintenance than units that stay put. Moving C-arms inevitably increases the chance of breakdown. Resolution, for example, can be affected when the machine hits too many doors and walls. If at all possible, I recommend reserving a room for your pain management service so you can keep the C-arm - whether mobile or stationary - in one place as much as possible.

Get a big "C"
In pain management, a good rule of thumb is to look for a unit with a large C. Researchers have drawn a link between obesity and chronic pain, and a relatively high proportion of my patients who seek treatment are obese. Smaller units cannot accommodate these patients, so the deeper the C (immersion space) and the greater the distance between the imaging surface and tube (free space), the better.

Don't skimp on image quality
The ability to clearly visualize pathology is absolutely essential to pain management physicians, and a good clear image also tends to reduce fluoro time and radiation exposure. Because the image you see on the monitor results from an interplay of numerous and complex technical factors - like the computer program, the TV camera and the efficiency of the image intensifier - the only way to adequately evaluate it is to demo the unit. Many others and I recommend doing so using your own staff and without the company representative holding your hand, because how you use the equipment in the OR will affect your results. Nevertheless, while you're shopping around for a demo unit, it can help to evaluate several "baseline" indicators of image quality:

• Power. Pain practitioners need lots of power, or anode current, simply to reach target areas like the lateral lumbar spine, which tend to be deep in the body and enveloped by dense tissues. When patients are obese, you need even more power to visualize target tissues. Fortunately, units with large C's are more powerful than their smaller counterparts.
• Monitor resolution and focal spot size. These two indicators will influence the quality of the image, and this is important for several reasons. First, pain practitioners often need an excellent image simply to diagnose the cause of pain, because the pathology can be very subtle. For example, the success of a discogram (an increasingly common diagnostic procedure) depends on the practitioner's ability to perceive even small abnormalities in the intervertebral discs based on the behavior of a liquid contrast agent injected into the disc(s). Even the shape and distribution of dye that extrudes through a discal tear is key to accurate diagnosis. Second, excellent visualization is paramount during injection treatments, because success hinges on accurate needle placement. Essentially, you can gauge monitor resolution based on pixels - the greater the number of pixels, the clearer the picture on the screen. And when it comes to focal spot size, the smaller the better.

To aid visualization, many pain management physicians also require two large screens so they can easily view two separate images simultaneously.

Maximize "C-ROM"
During pain management procedures, the range of motion (ROM) of the C in both the arc of the C (AP-to-lateral plane) and the patient's cephalic-to-caudal plane is important. The greater the C-ROM, the better the chance the surgeon will be able to angle the C to visualize difficult-to-see areas, such as facet joints, without rolling or bolstering the patient. Moving the patient with a needle partially inserted is difficult and risks needle dislocation.

In "C-arm talk," any degree of rotation within the AP-to-lateral plane beyond 90 degrees is known as "overscan." The degree of overscan is an important feature for pain management physicians; the more overscan the better.

Emphasize user-friendliness
Given their dependence on fluoroscopy, pain management practitioners know that the experience and knowledge of the radiation technician is critical. It serves to reason, however, that the more user-friendly the unit, the better off you'll be, especially when a new or replacement tech joins the pain management team. Look for a unit that does not require special training and, during the demo, be sure the unit is intuitive. If your staffers find themselves doing an in-depth read of the manual before using the C-arm, reconsider the purchase. In addition, the unit should have auto-adjusting features as well as manual exposure settings.

Secure your tomorrows
With pain management, cash flow stops the minute the fluoro shuts down, so it's a good idea to ensure that either a sufficient loaner unit will be immediately available or you secure a high-level service contract that guarantees you'll be operational again right away. Independent maintenance firms may not be capable of working on a C-arm that is out of warranty, and this is especially pertinent if you buy a refurbished unit. Also, look for a company that has a technical support hotline with coverage when you need it.

A good warranty is also invaluable. A "good" warranty will cover parts (including glassware) and labor for at least a year and will be a full, rather than a prorated, plan. Be sure to check the details, as some warranties cover certain parts for only six months. In addition, you may be able to negotiate an extended two-year warranty as part of the deal.

Off to a good start Certainly, there are other buying considerations that, while not specific to pain management, are nevertheless essential when buying any new C-arm - like radiation output and exposure; digital image storage with the ability to sort by physician, patient or procedure; an on-board printer for sending hard copies of images with insurance reports; and future 'upgradeability.' When it comes to minimizing radiation exposure, for example, pulsed frequency is a key feature, as is foot pedal control. All in all, however, these tips should give you a good start in your quest to finding the right C-arm for your pain management service.