Spondylolysis, occipito-atlanto-axial region
ICD-10 M43.01 is a billable code used to indicate a diagnosis of spondylolysis, occipito-atlanto-axial region.
Spondylolysis in the occipito-atlanto-axial region refers to a defect or fracture in the bony arch of the vertebrae located at the junction of the skull and the first two cervical vertebrae (the atlas and axis). This condition can lead to instability in the cervical spine, resulting in pain, neurological deficits, or other complications. Spondylolysis may be caused by congenital factors, trauma, or repetitive stress. Patients often present with neck pain, limited range of motion, and may experience headaches or neurological symptoms if the spinal cord or nerve roots are affected. Diagnosis typically involves imaging studies such as X-rays, CT scans, or MRIs to visualize the defect and assess any associated spinal deformities. Treatment options may include conservative management with physical therapy and pain management, or surgical intervention in cases of significant instability or neurological compromise. Understanding the implications of spondylolysis in this region is crucial for effective management and coding.
Detailed surgical notes, imaging results, and pre-operative assessments are essential.
Patients presenting with neck pain and instability, requiring surgical intervention.
Ensure that all surgical findings and post-operative care are documented to support coding.
Comprehensive neurological evaluations and imaging interpretations are necessary.
Patients with neurological deficits due to spinal instability.
Document any neurological assessments thoroughly to justify the diagnosis.
Used in cases where surgical intervention is necessary due to instability from spondylolysis.
Surgical notes must detail the procedure, indications, and any complications.
Orthopedic surgeons must ensure that all relevant pre-operative and post-operative documentation is complete.
Spondylolysis can be caused by congenital factors, trauma, or repetitive stress, particularly in individuals engaged in activities that place significant strain on the cervical spine.
