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Biopsy, soft tissue of back or flank; deep

CPT4 code

Name of the Procedure:

Biopsy, soft tissue of back or flank; deep

Summary

A deep soft tissue biopsy of the back or flank is a procedure where a sample of tissue is taken from the deeper layers of the muscle or other soft tissues in the back or side. This sample is then analyzed under a microscope to diagnose or rule out conditions such as infections, inflammatory diseases, or cancers.

Purpose

The primary purpose of a deep soft tissue biopsy is to identify the presence of abnormalities or disease in the soft tissue. It helps in diagnosing infections, inflammatory conditions, or malignancies (cancers), and to guide the appropriate treatment plan.

Indications

  • Persistent, unexplained lumps or masses in the back or flank area
  • Symptoms of soft tissue infections or inflammations
  • Unexplained pain or other changes in the back or flank site
  • Need to clarify a diagnosis when imaging studies are inconclusive

Preparation

  • Patients may be asked to fast for a certain period before the procedure.
  • Medication adjustments may be necessary, especially if the patient is on blood thinners.
  • Pre-procedure assessments might include blood tests and imaging studies (like MRI or CT scans) to locate the precise area for biopsy.

Procedure Description

  1. The patient is positioned comfortably, often lying face down or on their side.
  2. The area for the biopsy is cleaned and sterilized.
  3. Local anesthesia is administered to numb the biopsy site; sedation or general anesthesia may be used in some cases.
  4. A small incision is made, and a special biopsy needle is inserted to reach the deeper tissues.
  5. A sample of the soft tissue is removed using the needle.
  6. The incision is closed with sutures or sterile strips and covered with a dressing.

Duration

The procedure typically takes about 30 to 60 minutes, depending on the complexity.

Setting

A deep soft tissue biopsy is usually performed in a hospital, outpatient clinic, or surgical center.

Personnel

  • Surgeon or interventional radiologist
  • Nurse or medical assistant
  • Anesthesiologist or nurse anesthetist (if sedation or general anesthesia is used)

Risks and Complications

  • Pain or discomfort at the biopsy site
  • Bleeding or hematoma formation
  • Infection
  • Damage to surrounding tissues or structures
  • Allergic reaction to anesthesia

Benefits

  • Accurate diagnosis of the underlying condition
  • Facilitates the formulation of an appropriate treatment plan
  • Minimally invasive with a relatively quick recovery period

Recovery

  • Patients can usually go home the same day.
  • Keep the biopsy site clean and dry.
  • Mild discomfort and pain can be managed with over-the-counter pain medication.
  • Follow-up appointments to check on the biopsy site and discuss results.
  • Avoid strenuous activities for a few days post-procedure.

Alternatives

  • Imaging studies alone (MRI, CT scans) though less definitive
  • Fine needle aspiration (FNA) which is less invasive but may not provide as comprehensive a sample
  • Surgical biopsy for more extensive tissue sampling, though more invasive

Patient Experience

  • Mild pain or pressure during the procedure if local anesthesia is used
  • Post-procedure soreness at the biopsy site
  • Possible brief anxiety or discomfort about needle insertion
  • Sedation or general anesthesia, if used, will help alleviate discomfort but may require longer recovery time.

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