Radiculopathy, occipito-atlanto-axial region
ICD-10 M54.11 is a billable code used to indicate a diagnosis of radiculopathy, occipito-atlanto-axial region.
Radiculopathy in the occipito-atlanto-axial region refers to the condition where nerve roots in the cervical spine, particularly at the junction of the occipital bone and the first two cervical vertebrae (atlas and axis), become compressed or irritated. This condition can lead to symptoms such as neck pain, headaches, and neurological deficits that may radiate into the upper extremities. The pathophysiology often involves degenerative changes, herniated discs, or trauma that affects the cervical spine. Patients may present with varying degrees of pain and sensory or motor deficits, which can significantly impact their quality of life. Diagnosis typically involves a thorough clinical examination, imaging studies such as MRI or CT scans, and nerve conduction studies to assess the extent of nerve involvement. Treatment options range from conservative management, including physical therapy, medications, and lifestyle modifications, to surgical interventions like decompression or fusion, depending on the severity and persistence of symptoms.
Detailed neurological examination findings, imaging results, and treatment plans.
Patients presenting with neck pain and radiating symptoms, post-traumatic radiculopathy.
Ensure clear documentation of neurological deficits and correlation with imaging studies.
Surgical notes, pre-operative assessments, and post-operative follow-up documentation.
Patients requiring surgical intervention for cervical radiculopathy.
Document the rationale for surgical intervention and any pre-existing conditions.
Used when surgical intervention is required for decompression of nerve roots.
Surgical notes detailing the procedure and indications.
Orthopedic surgeons must document the rationale for surgery.
Common symptoms include neck pain, headaches, and neurological deficits such as numbness or weakness in the arms.
