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Needle insertion(s) without injection(s); 1 or 2 muscle(s)

CPT4 code

Name of the Procedure:

Needle insertion(s) without injection(s); 1 or 2 muscle(s)

Summary

Needle insertion without injection involves placing thin needles into one or two muscles without delivering any substances. Often used for diagnostic or therapeutic purposes, it is a minimally invasive procedure.

Purpose

This procedure is used to address conditions like muscle tension, pain, or hyperactivity. It helps in diagnosing underlying muscle disorders, relieving muscle tension, or interrupting pain signals.

Indications

  • Muscle pain or tenderness
  • Muscle stiffness or spasms
  • Hyperactivity of muscles (e.g., spasticity)
  • Diagnostic purposes for conditions like myofascial pain syndrome

Preparation

  • Patients might be asked to wear loose-fitting clothing.
  • No fasting generally required.
  • Patients should inform their doctor of any medications they are taking.
  • Diagnostic tests such as muscle ultrasound may be conducted beforehand.

Procedure Description

  1. The patient is positioned comfortably to expose the targeted muscle(s).
  2. The skin over the muscle is cleaned with an antiseptic solution.
  3. A thin, sterile needle is gently inserted into the muscle.
  4. The needle may be moved slightly to obtain the desired response or data.
  5. No substances are injected during this procedure.
  6. The needle is then removed, and the site is checked for any immediate reactions.

Tools and Equipment:

  • Thin, sterile needles
  • Antiseptic solution
  • Clean gauze or bandage

Anesthesia or Sedation:

  • Usually, no anesthesia is required due to minimal discomfort.

Duration

The procedure typically takes around 10-15 minutes.

Setting

  • Outpatient clinic
  • Hospital setting

Personnel

  • Physician or specialist (e.g., neurologist, physiatrist)
  • Nurse or medical assistant for support

Risks and Complications

  • Mild discomfort or pain at the insertion site
  • Minor bleeding or bruising
  • Rare risk of infection
  • Rare risk of nerve damage

Benefits

  • Relief of muscle pain or tension
  • Improved muscle function or reduced spasticity
  • Diagnostic clarity for muscle-related conditions Benefits are often realized shortly after the procedure.

Recovery

  • Minimal recovery time is required.
  • Patients can usually resume normal activities immediately.
  • If discomfort persists, over-the-counter pain relievers may be used.

Alternatives

  • Physical therapy
  • Medication (e.g., muscle relaxants)
  • Other minimally invasive procedures like trigger point injections
  • Each alternative has its pros and cons depending on the specific condition being treated.

Patient Experience

During the procedure, patients may experience a mild, brief discomfort when the needle is inserted. Post-procedure, there might be slight soreness at the site. Pain management typically involves simple measures and most patients report minimal discomfort.

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