Find comprehensive information on paraspinal abscess diagnosis, including clinical documentation, ICD-10 codes (M46.2), medical coding guidelines, and healthcare resources. Learn about symptoms, treatment options, and best practices for documenting paraspinal abscesses in medical records. This resource offers valuable insights for physicians, nurses, coders, and other healthcare professionals seeking information on paraspinal abscess management and accurate clinical documentation.
Also known as
Other infective spondylopathies
Includes infections of the spine like a paraspinal abscess.
Cutaneous abscess, furuncle and carbuncle of trunk
Abscesses on the trunk, potentially including back near the spine.
Postprocedural pain
Pain following a spinal procedure, possibly indicating an abscess as a complication.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the paraspinal abscess related to a spinal procedure?
Yes
Is it within the post-op period?
No
Is there tuberculosis involved?
When to use each related code
| Description |
|---|
| Paraspinal Abscess |
| Epidural Abscess |
| Vertebral Osteomyelitis |
Coding lacks laterality (right, left) or spinal level, impacting DRG assignment and reimbursement. CDI crucial for specificity.
Missing documentation of infectious agent (e.g., Staphylococcus) leads to coding gaps, hindering infection tracking and analysis.
Incisional vs. percutaneous drainage impacts code selection. Inadequate documentation creates audit risks and inaccurate procedural data.
Q: What are the key differentiating features in the clinical presentation and imaging findings of a paraspinal abscess versus a psoas abscess in a patient with back pain?
A: While both paraspinal and psoas abscesses can present with back pain, fever, and elevated inflammatory markers, there are key differentiating features. Paraspinal abscesses typically manifest with localized back pain and tenderness with or without palpable fluctuance adjacent to the spine. Imaging, particularly MRI, reveals a collection of fluid and/or inflammatory tissue located within the paraspinal muscles, separate from the psoas muscle. Psoas abscesses, on the other hand, may present with pain radiating to the hip or groin, often with accompanying hip flexion. Imaging shows the abscess within the psoas muscle compartment, potentially extending into the retroperitoneum. Distinguishing between these two entities is crucial for guiding appropriate management, including targeted drainage and antibiotic selection. Explore how different imaging modalities can be utilized for accurate diagnosis and differentiation. Consider implementing a standardized diagnostic protocol for patients presenting with back pain and suspected deep soft tissue infections.
Q: What is the recommended initial antibiotic therapy regimen for a suspected paraspinal abscess in an adult patient with no known drug allergies, including specific considerations for MRSA coverage?
A: Initial empiric antibiotic therapy for a suspected paraspinal abscess should cover both gram-positive and gram-negative organisms, including Staphylococcus aureus (with MRSA coverage) and Enterobacteriaceae. Vancomycin or linezolid are often considered for initial MRSA coverage, while a broad-spectrum beta-lactam antibiotic such as piperacillin-tazobactam or a carbapenem (meropenem or imipenem) can provide coverage for gram-negative bacteria. The specific regimen chosen should consider local resistance patterns and patient-specific factors, such as renal function. Culture and sensitivity data from the abscess fluid (obtained via aspiration or drainage) should guide subsequent antibiotic therapy, allowing for de-escalation to a more targeted regimen once the causative organism is identified. Learn more about the principles of antimicrobial stewardship and its role in optimizing antibiotic therapy for deep soft tissue infections.
Patient presents with complaints consistent with paraspinal abscess. Symptoms include localized back pain, tenderness to palpation of the paraspinal musculature, fever, chills, and possible neurological deficits depending on the abscess location and size. Differential diagnoses considered include epidural abscess, muscle strain, pyomyositis, vertebral osteomyelitis, discitis, and spinal tumor. Physical examination reveals erythema, swelling, and fluctuance in the affected paraspinal region. Neurological examination findings are documented, including motor strength, sensory function, and reflexes. Laboratory tests ordered include complete blood count with differential, erythrocyte sedimentation rate, C-reactive protein, and blood cultures. Imaging studies, such as MRI of the spine with and without contrast, or CT scan of the spine, are obtained to confirm the diagnosis of paraspinal abscess, delineate its extent, and assess for involvement of adjacent structures. Treatment plan includes intravenous antibiotics targeting the likely causative organisms, such as Staphylococcus aureus or other gram-positive and gram-negative bacteria, based on culture and sensitivity results. Surgical intervention, including incision and drainage or aspiration of the abscess, may be necessary depending on the size and location of the abscess and patient response to medical management. Patient education provided on the importance of medication adherence, wound care if applicable, and follow-up appointments to monitor treatment response and potential complications. ICD-10 code M46.2, Abscess of back, is assigned. Procedure codes for any interventions, such as drainage or aspiration, will be documented separately based on the specific procedure performed.