Spinal enthesopathy, thoracic region
ICD-10 M46.04 is a billable code used to indicate a diagnosis of spinal enthesopathy, thoracic region.
Spinal enthesopathy refers to a condition characterized by inflammation and degeneration at the sites where tendons and ligaments attach to the vertebrae in the thoracic region of the spine. This condition can be associated with various inflammatory spine diseases, including ankylosing spondylitis, which is a type of spondyloarthritis that primarily affects the spine and the sacroiliac joints. Patients may present with chronic back pain, stiffness, and reduced spinal mobility. The thoracic region is particularly significant as it houses vital structures and can impact respiratory function if severely affected. Spinal enthesopathy can also be a component of broader inflammatory conditions, such as psoriatic arthritis or reactive arthritis, and may coexist with spinal stenosis, where narrowing of the spinal canal leads to nerve compression. Accurate diagnosis often requires imaging studies, such as MRI or CT scans, to visualize inflammation and structural changes in the thoracic spine. Treatment typically involves anti-inflammatory medications, physical therapy, and in some cases, surgical intervention if conservative measures fail.
Detailed history of symptoms, physical examination findings, and imaging results.
Patients presenting with chronic back pain, stiffness, and a family history of inflammatory diseases.
Documentation should clearly outline the inflammatory nature of the condition and any systemic involvement.
Surgical notes, imaging studies, and pre-operative assessments.
Patients requiring surgical intervention for spinal stenosis or severe enthesopathy.
Ensure that the surgical rationale is well-documented, linking it to the diagnosis of enthesopathy.
Used when injecting corticosteroids into the thoracic spine area.
Document the indication for the procedure and the specific site of injection.
Rheumatologists should ensure that the procedure is linked to the diagnosis of enthesopathy.
Spinal enthesopathy is an inflammatory condition affecting the sites where tendons and ligaments attach to the spine, particularly in the thoracic region, leading to pain and functional impairment.
