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Biopsy, soft tissue of shoulder area; deep

CPT4 code

Name of the Procedure:

Biopsy, soft tissue of shoulder area; deep

Summary

A deep soft tissue biopsy of the shoulder area involves the removal of a small sample of tissue from the muscle, fat, or other deep structures in the shoulder. This sample is then analyzed in a lab to help diagnose various conditions.

Purpose

This procedure is performed to diagnose abnormalities in the soft tissues of the shoulder. It can help identify infections, cancers, inflammatory conditions, or other pathologies affecting the deep soft tissue structures. The goal is to obtain a precise diagnosis to guide appropriate treatment.

Indications

  • Persistent or unexplained shoulder pain or swelling
  • A mass or lump in the shoulder area
  • Unexplained weight loss or systemic symptoms
  • Suspected malignancy or infection in the shoulder

Preparation

  • Patients may need to fast for several hours before the procedure.
  • Certain medications, such as blood thinners, may need to be adjusted.
  • Pre-procedure imaging studies, like MRI or CT scans, may be required to locate the biopsy site.

Procedure Description

  1. The patient is positioned to allow optimal access to the shoulder area.
  2. The skin over the biopsy site is cleaned and sterilized.
  3. Local anesthesia is administered to numb the area.
  4. A small incision is made, and a needle or surgical instrument is used to extract a tissue sample from deep within the shoulder.
  5. The tissue sample is sent to a lab for analysis, and the incision is closed with stitches or adhesive strips.

Duration

The procedure typically takes about 30 to 60 minutes.

Setting

This biopsy is usually performed in a hospital, outpatient clinic, or surgical center.

Personnel

  • Surgeons or specialized physicians (e.g., orthopedic or general surgeons)
  • Nurses
  • Anesthesiologists or nurse anesthetists (if sedation is used)

Risks and Complications

  • Infection at the biopsy site
  • Bleeding or hematoma formation
  • Pain or discomfort in the biopsy area
  • Rarely, damage to surrounding structures such as nerves or blood vessels

Benefits

  • Accurate diagnosis of shoulder abnormalities
  • Helps in planning appropriate treatment
  • Minimal recovery time due to the typically minimally invasive nature of the procedure

Recovery

  • Post-procedure care involves keeping the biopsy site clean and dry.
  • Mild pain or swelling can be managed with over-the-counter pain medications.
  • Most patients can return to normal activities within a few days.
  • Follow-up appointments may be needed to discuss biopsy results and next steps.

Alternatives

  • Imaging studies only (e.g., MRI, CT) without biopsy, though less definitive for diagnosis
  • Fine-needle aspiration (less invasive but may not provide as comprehensive a sample)
  • Watchful waiting with periodic monitoring, if initial concern is low

Patient Experience

  • Patients may feel some pressure or discomfort during the biopsy despite local anesthesia.
  • Mild soreness at the biopsy site for a few days post-procedure.
  • Pain management includes prescribed or over-the-counter pain relief.
  • Most individuals return home the same day and can resume normal activities shortly after.

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