Blind Procedure Research Articles

Accuracy of ultrasound-guided and non-US-guided botulinum toxin injection into cadaver salivary glands

Recent investigations have reported the increased efficacy and safety of BTX injection under US guidance, there have not been any studies comparing the injection accuracy between blind and US-guided approaches. This study was designed to evaluate the injection accuracy of blind and US-guided botulinum injections into the parotid and submandibular glands of fresh cadavers. Two rehabilitation physician injected dye into three sites in the salivary glands (two sites in the parotid gland, and one site in the submandibular gland) on one side of each cadaver (one was injected on the right side, while the other was injected on the left side), using either a non-US-guided injection procedure based on superficial landmarks or a US-guided procedure. Orange dye was used for the US-guided procedure, and green dye was used for the blind procedure. Two physicians uninvolved with the injection procedures and who were blinded to the method of injection dissected the cadavers to identify whether the dye was accurately injected into each target site. The accuracies of the blind and US-guided injections into the parotid gland were 79.17% and 95.83%, respectively. In the submandibular gland, the accuracies of the blind and US-guided injections were 50.00% and 91.67%, respectively. The difference in accuracy between the two procedures was statistically significant only in the submandibular gland ( P = 0.025). There were no significant differences in the accuracy of US-guided and non-US-guided injections between the two physicians for the two sites in the parotid gland ( P = 0.278 and P = 0.146, respectively). US-guided BTX injection into the submandibular gland offers significantly greater accuracy over blind injection. For the treatment of drooling by injecting BTX into the submandibular gland, clinicians should consider using US guidance for improved accuracy.

CONFIDENHTTM SYSTEM SAFETY AND PERFORMANCE OF DIAGNOSTIC ELECTRICAL MAPPING OF RENAL NERVES FOR RENAL SYMPATHETIC DENERVATION PROCEDURE

Objective: Renal denervation procedures remains a so-called blind procedure. The objective of the present study is to assess the safety and feasibility of renal nerve stimulation using the ConfidenHTTM mapping system.Design and method: The Confiden(HT) study is a prospective first-in-man multicenter study designed to assess the safety and feasibility of renal nerve mapping using the ConfidenHT™ system in 20 hypertensive patients with an indication for coronary angiography or with a planned renal sympathetic denervation. The ConfidenHT™ System consists of two main parts, a catheter and a console. The Console delivers electrical energy to the catheter using a multi-channel stimulator, and a real time intra-arterial Blood Pressure (BP) monitor, which records, analyzes and displays the stimulation outcome (BP and/or HR changes) during stimulation. The ConfidenHT™ catheter is a non-occluding flexible catheter with expendable multi electrode design, compatible with an 8Fr guiding catheter and 0.014’ guide wire, for a wide range of renal artery diameters. The technology could help to improve RDN procedures by providing: (1)better patient selection of RDN responders and non-responders, and (2)intra-procedural guidance and feedback to optimize technical success rates. The primary performance endpoint was the change in blood pressure during stimulation. 20 patients (58 ± 11.5 years old, 156 ± 23 office systolic BP, 9/11 male/female respectively, and GFR of 78 ± 13 mL/min/1.73 m2) have been included. Most of procedures were performed under local anesthesia with mild conscious sedation. Results: The system appeared safe in all 20 cases with no peri-procedural adverse events. Post stimulation there were no signs of angiographically visible spasms/thrombus or dissection in any of the treated arteries. A varying response to electrical stimulation was found among patients with a clear location dependent response along the artery (Hot and Cold spots). The increase in systolic BP and MAP ranged from 0 to 30 mmHg and 0 to 18 mmHg respectively. Conclusions: Results suggest that renal nerve mapping using the ConfidenHTTM system technology is feasible and safe and offers promising diagnostic electrical renal nerve mapping opportunities in hypertensive patients which could help in optimizing the result of renal sympathetic denervation.

Madness and Text: The Psychiatric Paper as a Business and as a Means of Censorship

The journals are basically the only channel through the scientists can make the result of their research know to their colleagues. Scientific journals select the information they publish and guarantee its quality by means of a double blind procedure of censorship by peers. If on the one hand this procedure seems logical as a method for including a study within a consolidated scientific field it is also true that it can function as a mechanism for censorship. If, furthermore, a scientific field such as pharmacology is intimately linked to the business interest of large companies then the companies and journals not only became providers of guidance, but also censors who conceal part of the truth and obstruct scientific advance to defend the economic interest of their patents.

Minimum effective betamethasone dosage on the neurological phenotype in patients with ataxia‐telangiectasia: a multicenter observer‐blind study

Ataxia-telangiectasia (A-T) is a rare neurodegenerative disease, due to A-T mutated (ATM) gene mutations, which typically presents with signs of progressive neurological dysfunction, cerebellar ataxia and uncoordinated movements. A-T severely affects patients' quality of life. Successful treatment options are still not available. The aim of this multicenter study, performed with a blind evaluation procedure, was to define the minimal effective dosage of oral betamethasone, thus preventing the occurrence of side effects. Nine A-T patients were enrolled to receive betamethasone at increasing dosages of 0.001, 0.005 and 0.01 mg/kg/day. Neurological assessment and the evaluation of quality of life were performed through the Scale for the Assessment and Rating of Ataxia and the Italian version of the Childhood Health Assessment Questionnaire (CHAQ) at each time-point. The drug safety profile was evaluated. Patients were categorized as responders, partial responders and non-responders. Four of nine patients had a benefit at a dose of 0.005 mg/kg/day of oral betamethasone. Using the higher dosage, only one additional patient had a positive response. Conversely, a daily dose of 0.001 mg/kg was ineffective. A correlation between the serum adrenocorticotropic hormone levels and the clinical response was observed. Five of 30 CHAQ items improved in four patients. These data suggest that a short-term betamethasone oral treatment, at a daily dosage of 0.005 mg/kg, is effective in some patients. Pre-existing risk factors for side effects should be taken into account before therapy.

CRT-600.15 Safety and Performance Of Diagnostic Electrical Mapping of Renal Nerves in Hypertensive Patients and/or Potential Candidates for a Renal Sympathetic Denervation (RDN) Procedure

As the exact location of renal nerves cannot be visualized, renal sympathetic denervation (RDN) remains a so-called blind procedure. The aim to the present study is to assess the safety and feasibility of renal nerve stimulation using the ConfidenHTTM mapping system. The technology could help to

Comparison of the ultrasonography-guided technique and conventional anatomical landmark technique for localization of epidural space during epidural block

Background and aims Anatomical landmarks-based level confirmation and loss of resistance-based space confirmation is a standard method for epidural block but is a blind procedure. Recently, the use of ultrasonography (USG) guidance during central neuraxial blocks to preview the anatomy before needle puncture has started. We carried out a study to find whether USG-guided technique is superior than landmark guided for epidural space localization. Patients and methods This randomized prospective, open-label study included 76 patients aged 40 to 65 years, American Society of Anesthesiologist physical status I–III undergoing infraumbilical surgeries, divided in two groups. In group 1, anatomical landmark-guided technique and in group 2, preprocedural USG scan was used for puncture site determination. We evaluated the time taken to insert an epidural needle; number of attempts, number of times the cortexes of bone touched by needle, ultrasound visibility score, distance between skin to ligamentum flavum, correlation between actual needle depth and ultrasound-measured depth. Results Mean time taken for insertion of epidural needle in group 1 was 72.21±45 s and in group 2 was 54.82±40.87 s (P=0.027). Epidural space was located in the first attempt in 71.15% individuals of group 1 and 92.1% individuals of group 2. The Pearson’s correlation coefficient between the USG-measured distance between skin to ligamentum flavum and the actual depth of needle mark was significant. Conclusion The USG-guided epidural space localization reduces time to insert epidural needle and number of attempts for localization of epidural space. There is a strong correlation between the USG-measured depth and the actual needle depth.

Role of point-of-care ultrasound to prevent dilatation of false passage in a critically ill patient with urethral stricture

Urethral strictures are fairly common in elderly males getting admitted to the intensive care unit. Urethral catheterization is mostly done as a blind procedure and often leads to urethral trauma and, sometimes, false channelization in a patient who is many a time sedated, intubated, and is unable to tell about extreme of pain occurring which could warn the handler. Fluoroscopy is utilized in difficult situations to aid insertion, but this is not always an option for patients in intensive care units. The scope of ultrasonography is expanding in the practice of critical care. We used point-of-care ultrasound to confirm the position of guidewire before dilatation, in order to prevent dilatation of false passage.

Arytenoid release procedure plus exo-endolaryngeal suture lateralization with precise suture placement

Purpose: Bilateral vocal fold immobility (BVFI) presents a challenging endeavor to surgeons and a suture lateralization (SL) procedure under endoscopy has been proposed to treat BVFI. The goal of this study is to introduce an adaptable method to calibrate an appropriate entrance on the thyroid lamina for the stitch canal to precisely reach an appropriate endolaryngeal site for the suture loop placement and minimize the endolaryngeal soft-tissue (ELT) damage. Materials and Methods: From 2007–2015, a total of 38 patients with BVFI due to various causes had undergone 40 exo-endolaryngeal SL (exoeSL) procedures in our hospital. The former 20 patients had undergone so-called blind suture loop placement procedures. The latter 18 patients had been treated with a refined suture placement technique. Results: The suture placement in former 20 patients had undergone one to three episodes of needle entrances into the ELT with average of 1.7 episodes each patient and caused one paraglottic hematoma. The latter 18 of the 38 patients had obtained one episode of ELT damage each patient and produced no vascular events. Conclusions: The topographic relationship of the pyriform recess on the thyroid lamina can serve as a consistent and surgically useful landmark for avoiding the paraglottic dead space infection from the stitching canal during the SL procedure. With this suture placement refinement, the exoeSL procedure can really obtain a relatively appropriate endolaryngeal site to place the suture loop and decrease the ELT damage.

Novel Role of Amniocentesis-Prenatal Utility

Amniocentesis is an outpatient procedure with an aim to obtain the amniotic fluid for various purposes most commonly for prenatal chromosomal diagnosis and infection screen, lung maturity and Rh incompatibility. It has been under constant evolution since 1959 by Experts. Procedure advanced from blind procedure to ultrasound guided. I have used it diligently in various obstetrics cases which saved time and helped in compiling to a planned care. If used it will definitely help obstetricians achieve very motive safe mother and child. Objective: It’s a compliment to the clinician in a critical situation with the addition to other modalities including Ultrasound.

Fish scale identification: From individual to species-specific shape variability

Background. Species identification from recovered fish scales, e.g., from the sediment or stomach contents, has proven to be problematic for clupeid species. To ensure reliable species discrimination within Clupeidae, we attempted to reveal inter- and intra-specific, as well as, the intra-individual variability of scale shape in two sympatric clupeid species the European pilchard, Sardina pilchardus (Walbaum, 1792) and the round sardinella, Sardinella aurita Valenciennes, 1847. Our aim was to test, whether the landmark-based geometric morphometric method is reliable for species identification from mixed samples. Materials and methods. The specimens of European pilchard and round sardinella were collected between May and October 2014 from the Gulf of Ambracia, Greece. The scale samples were taken from ten body areas (marked by letters A–J) of 487 specimens in total. A multiple-step analysis was conducted on randomly selected blind samples. The differences between body areas were assessed with canonical variate analysis (CVA) and discriminant function analysis (DFA) to compute generalized Mahalanobis distances (D) and discriminant functions (T2), respectively. Results. The CVA based on the total scale samples showed that in sardinella, all body areas differed significantly from each other (D = 2.54 ± 0.79, P < 0.001) except for one (area I vs. J: D = 22.36, P = 0.085). In pilchard, two body area pairs represented non-significant group pairs (area D vs. G: D = 1.03, P = 0.12; and area F vs. G: D = 1.21, P = 0.06), whereas all other areas were significantly different (D = 2.43 ± 0.88, P = 0.003). At the last step of the blind sampling procedure, all scales were correctly classified by species with an average discrimination rate as high as 96.3%. Conclusion. In contrast to scale identification based merely on morphology, the geometric morphometric method is capable of detecting differences in scale shape from mixed samples that are unattainable with the former approach. Therefore, a more reliable and effective species identification can be accomplished from recovered scales, especially when discriminating species within the same family or genus.

Effect of Artificial Respiratory Muscle Training in Patients with Chronic Obstructive Pulmonary Disease

Chronic obstructive lung disease (COPD) is a chronic lung pathology that leads to respiratory muscle weakness and decreased function capacity. Patients need to have pulmonary rehabilitation to increase respiratory muscle strength. The aim of the study was to assess the effect of artificial respiratory muscle training (ARMT) on respiratory muscle function and exercise performance in chronic obstructive pulmonary disease (COPD). Thirty patients in the mild to moderate COPD stage were randomly classified into an ARMT (n = 10), a control group (n = 10), and a standard respiratory muscle training group (SRMT; n = 10) by following the blind procedure. The control group received no training. The training groups, however, were trained at home for 30 min per day, every day, for 6 weeks. The measurement analyses included spirometry, an inspiratory muscle strength examination, and an exercise performance test. Exercise performance was evaluated by a 6 min walk test (SWT). The results showed that the maximal inspiratory pressure (PImax) and the maximal expiratory pressure (PEmax) were observed to have significantly increased in both the ARMT group and the SRMT group compared with the control group (p < 0.05). Moreover, the ARMT group was found to have significantly increased the 6 min walking distance in comparison with the control group. However, the ARMT group and the SRMT group did not differ significantly in those parameters. We conclude that it would be possible for the ARMT group among COPD patients to have improved respiratory muscle strength and increased capacity to walk.

Haptic forces and gamification on epidural anesthesia skill gain

Epidural anesthesia is a blind medical procedure, where the needle insertion is a critical step. Its correct placement and location is related to the tactile perception and the loss of resistance (LOR) of tissues inside the epidural lumbar region, in order to avoid the puncture of the dura-mater membrane. Skill development and maintenance occurs through continuous practice. The main objective of this work is the development of a virtual simulator to enhance the training on the epidural anesthesia, in order to reduce the high failure rate currently reported on these medical procedures. This simulator integrates the development of the following 3 new models: (1) a force-displacement model to cover the progression of resistance forces generated by tissues along the needle insertion, based on real experiment data; (2) a force-needle model, to calculate the axial forces produced by needle deflection upon insertion, based on experiment data; and (3) a tissue model to design the thickness for each tissue on the simulator, from patient height, weight and age, based on average body measurements. The developed models added more realism when compared to previous works. The force-displacement model considers stiffness, friction and cutting forces for each tissue on epidural region, and includes a representation of needle insertion stages before and after the puncture in the behavior of each tissue. Other force models did not consider force modifiers for needle deflection before. The simulator environment implements the integration of a haptic device to control the needle movement, manipulated by the user. These devices enable to reproduce the resistance generated by the developed models providing physical feedback to user movements, to emulate sensations and reactions from the bypassed tissues (skin, fat, spinal ligaments, epidural space and dura-mater), as if those actions were executed in a real patient. The haptic device used presents six degrees of freedom (DOF), allowing translations and rotations on three axes (x, y, and z). The simulator interface was improved by incorporation of points and achievements as gamification elements to enhance the user interaction. These elements may contribute for maintenance of the trainee activity along the procedure practices, and to motivate and stimulate the student learning and skill improvement. No work have employed gamification elements on the interface of epidural simulators before.

Elucidation of Binding Site and Chiral Specificity of Oxidovanadium Drugs with Lysozyme through Theoretical Calculations.

This study presents an implementation of the protein-ligand docking program GOLD and a generalizable method to predict the binding site and orientation of potential vanadium drugs. Particularly, theoretical methods were applied to the study of the interaction of two VIVO complexes with antidiabetic activity, [VIVO(pic)2(H2O)] and [VIVO(ma)2(H2O)], where pic is picolinate and ma is maltolate, with lysozyme (Lyz) for which electron paramagnetic resonance spectroscopy suggests the binding of the moieties VO(pic)2 and VO(ma)2 through a carboxylate group of an amino acid residue (Asp or Glu). The work is divided in three parts: (1) the generation of a new series of parameters in GOLD program for vanadium compounds and the validation of the method on five X-ray structures of VIVO and VV species bound to proteins; (2) the prediction of the binding site and enantiomeric preference of [VO(pic)2(H2O)] to lysozyme, for which the X-ray diffraction analysis displays the interaction of a unique isomer (i.e., OC-6-23-Δ) through Asp52 residue, and the subsequent refinement of the results with quantum mechanics/molecular mechanics methods; (3) the application of the same approach to the interaction of [VO(ma)2(H2O)] with lysozyme. The results show that convenient implementation of protein-ligand docking programs allows for satisfactorily reproducing X-ray structures of metal complexes that interact with only one coordination site with proteins and predicting with blind procedures relevant low-energy binding modes. The results also demonstrate that the combination of docking methods with spectroscopic data could represent a new tool to predict (metal complex)-protein interactions and have a general applicability in this field, including for paramagnetic species.

Significance of Adenosine Deaminase in Diagnosing Tuberculous Pleural Effusion in Nepalgunj Medical College Teaching Hospital Kohalpur

Background: Tuberculosis (TB) is a major public health problem in developing countries including Nepal. One of the common presentations of TB is pleural effusion. The diagnosis of tubercular pleural effusion can be difficult because of the low rate of detecting tubercular bacilli by direct stain and culture of pleural fluid for acid-fast bacilli (AFB). Pleural biopsy can be useful but is invasive and requires experts. In this context, pleural fluid Adenosine Deaminase (ADA) level has been proposed as easy, cheap and highly sensitive test for diagnosis of TB pleural effusion.Objectives: The present study was undertaken to define the role of pleural fluid ADA value in accurate diagnosis of Tubercular pleural effusion.Methods: A Prospective analysis of 68 patients admitted in Nepalgunj Medical College teaching Hospital was done from January 2014 to December 2015 with pleural effusion. Pleural fluid ADA level was evaluated in all patients, and significance of pleural fluid ADA level in TB pleural effusion was studied.Results: Age of patients were between 20 to 80 years, with the minimum being 20 years and maximum being 79 years. In this study 85% of cases had pleural effusion due to tuberculosis. Out of the 68 patients with pleural effusion, 58(85%) were finally diagnosed to be due to tuberculosis, 2 were diagnosed to be due to malignancy, 4 due to pneumonia leading to parapneumonic effusion, 1 due to congestive heart failure and 3 due to nephrotic syndrome.Conclusion: It is difficult to diagnose TB pleural effusion by other conventional methods, as it has also been shown in our study also. Previous literatures have also mentioned AFB detection rate to be low from pleural fluid sample. Determination of ADA is a cheap and easy test which we now consider in the early routine evaluation of patients with pleural effusions, particularly if diagnosis of tuberculosis is suspected and in places where prevalence of the disease is still high as is in our country. The other method considered for diagnosing TB pleural effusion is pleural biopsy which is invasive blind procedure and requires high expertise as well. JNGMC Vol. 14 No. 1 July 2016

Endoscopic Decompression of a Gouty Tophus at the Hand Dorsum

Medical treatment including lifestyle and dietary modifications and drug therapy remains the mainstay of treatment for gouty arthritis of the hand and wrist. Without proper and timely treatment, tophi develop approximately 10 years after the onset of the disease. Open surgery for tophaceous gout is associated with a relatively high rate of complications particularly related to the surgical wound and overlying skin necrosis. Intralesional shaving of the tophi through small incisions has been reported and has the advantage of fewer wound complications. However, this is a blind procedure, and the underlying tendons and neurovascular bundles are at risk. The purpose of this Technical Note is to report an endoscopic approach to debulking a gouty tophus at the hand dorsum. This allows the minimally invasive debulking procedure to be performed under endoscopic visualization and reduces the risk of injury to the tendon and neurovascular structures.

Language, procedures, and the non-perceptual origin of number word meanings.

Perceptual representations of objects and approximate magnitudes are often invoked as building blocks that children combine to acquire the positive integers. Systems of numerical perception are either assumed to contain the logical foundations of arithmetic innately, or to supply the basis for their induction. I propose an alternative to this framework, and argue that the integers are not learned from perceptual systems, but arise to explain perception. Using cross-linguistic and developmental data, I show that small (~1-4) and large (~5+) numbers arise both historically and in individual children via distinct mechanisms, constituting independent learning problems, neither of which begins with perceptual building blocks. Children first learn small numbers using the same logic that supports other linguistic number marking (e.g. singular/plural). Years later, they infer the logic of counting from the relations between large number words and their roles in blind counting procedures, only incidentally associating number words with approximate magnitudes.

Aspiration in injections: should we continue or abandon the practice?

Aspiration during any kind of injection is meant to ensure that the needle tip is at the desired location during this blind procedure. While aspiration appears to be a simple procedure, it has generated a lot of controversy concerning the perceived benefits and indications. Advocates and opponents of aspiration both make logically sound claims. However, due to scarcity of available data, there is no evidence that this procedure is truly beneficial or unwarranted. Keeping in view the huge number of injections given worldwide, it is important that we draw attention to key questions regarding aspiration that, up till now, remain unanswered. In this review, we have attempted to gather and present literature on aspiration both from published and non-published sources in order to provide not only an exhaustive review of the subject, but also a starting point for further studies on more specific areas requiring clarification. A literature review was conducted using the US National Institute of Health’s PubMed service (including Medline), Google Scholar and Scopus. Guidelines provided by the World Health Organization, Safe Injection Global Network, International Council of Nursing, Center for Disease Control, US Federal Drug Agency, UK National Health Services, British Medical Association, Europe Nursing and Midwifery Council, Public Health Agency Canada, Pakistan Medical Association and International Organization of Standardization recommendations 7886 parts 1-4 for sterile hypodermics were reviewed for relevant information. In addition, curricula of several medical/nursing schools from India, Nigeria and Pakistan, the US pharmacopeia Data from the WHO Program for International Drug Monitoring network in regard to adverse events as a result of not aspirating prior to injection delivery were reviewed. Curricula of selected major medical/nursing schools in India, Nigeria and Pakistan, national therapeutic formularies, product inserts of most commonly used drugs and other possible sources of information regarding aspiration and injections were consulted as well.

Optimal dual fusion frames for probabilistic erasures

For any fixed fusion frame, its optimal dual fusion frames for reconstruction is studied in case of erasures of subspaces. It is considered that a probability distribution of erasure of subspaces is given and that a blind reconstruction procedure is used, where the erased data are set to zero. It is proved that there are always optimal duals. Sufficient conditions for the canonical dual fusion frame being either the unique optimal dual, a non-unique optimal dual, or a non optimal dual, are obtained. The reconstruction error is analyzed, using the optimal duals in the probability model considered here and using the optimal duals in a non-probability model.

Aspiration in injections: should we continue or abandon the practice?

Aspiration during any kind of injection is meant to ensure that the needle tip is at the desired location during this blind procedure. While aspiration appears to be a simple procedure, it has generated a lot of controversy concerning the perceived benefits and indications. Advocates and opponents of aspiration both make logically sound claims. However, due to scarcity of available data, there is no evidence that this procedure is truly beneficial or unwarranted. Keeping in view the huge number of injections given worldwide, it is important that we draw attention to key questions regarding aspiration that, up till now, remain unanswered. In this review, we have attempted to gather and present literature on aspiration both from published and non-published sources in order to provide not only an exhaustive review of the subject, but also a starting point for further studies on more specific areas requiring clarification. A literature review was conducted using the US National Institute of Health’s PubMed service (including Medline), Google Scholar and Scopus. Guidelines provided by the World Health Organization, Safe Injection Global Network, International Council of Nursing, Center for Disease Control, US Federal Drug Agency, UK National Health Services, British Medical Association, Europe Nursing and Midwifery Council, Public Health Agency Canada, Pakistan Medical Association and International Organization of Standardization recommendations 7886 parts 1-4 for sterile hypodermics were reviewed for relevant information. In addition, curricula of several medical/-nursing schools from India, Nigeria and Pakistan, the US pharmacopeia Data from the WHO Program for International Drug Monitoring network in regard to adverse events as a result of not aspirating prior to injection delivery were reviewed. Curricula of selected major medical/nursing schools in India, Nigeria and Pakistan, national therapeutic formularies, product inserts of most commonly used drugs and other possible sources of information regarding aspiration and injections were consulted as well.

Economic Outcomes of the Addition of Fluoroscopic Guidance to the Lumbar Puncture Procedure: A Call for Standardized Training

Objectives: 1. To evaluate the socio-economic impact of the addition of fluoroscopic guidance to the lumbar puncture procedure through our institutional series from 2010 to 2013. 2. To investigate the increased cost and socio-economic impact associated with fluoroscopic guidance, which at our institution is used after failure of blind procedure. 3. To describe the utility of standardized training to decrease the number of failed bedside lumbar Patients and methods: A retrospective analysis of 211 lumbar punctures from LSU Health Sciences in Shreveport, LA was analyzed under the current neuroendovascular faculty (2010-2013) via use of billing data. Results were restricted to lumbar punctures performed for diagnostic (CPT 62270) or therapeutic codes (62272) with the addition of fluoroscopic guided placement of needle (77003). Neurosurgical resident lumbar punctures are not billed for by the department and therefore are not accounted for in analysis. Results: 88 lumbar punctures performed were diagnostic and 123 were billed as therapeutic. 93 cases were done with addition of fluoroscopic guidance either directly from neurosurgical resident blind procedure failure or consulting service blind procedure failure. 70 patients were free care with no charge. The department billed $80,469 and collected $13,004 for the actual lumbar puncture procedure (62270 and 62272). The average additional billing cost for fluoroscopic guidance was $356. However, of the additional $41,649 billed only $2014 was collected. For the additional use of fluoroscopy, the mode for Medicaid re-imbursement was $19 and for Medicare was $41. This does not take into account the additional use of radiology technologists, procedural nursing, and recovery nursing. Conclusion: This study is limited by information available for retrospective review. Fluoroscopic guided lumbar punctures utilize skills and procedural time of the neuro-interventionalist. Focused standardized training of residents, which has been proven to improve lumbar puncture success outcomes, would reduce the use of these valuable resources.