Spinal enthesopathy, sacral and sacrococcygeal region
ICD-10 M46.08 is a billable code used to indicate a diagnosis of spinal enthesopathy, sacral and sacrococcygeal region.
Spinal enthesopathy refers to a condition characterized by inflammation and degeneration at the sites where tendons and ligaments attach to the bone, particularly in the sacral and sacrococcygeal regions. This condition is often 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 pain, stiffness, and reduced mobility, particularly in the lower back. The enthesopathy can lead to significant discomfort and functional impairment, as the inflammation can affect the surrounding soft tissues and contribute to spinal stenosis, where the spinal canal narrows and compresses the spinal cord and nerves. Diagnosis typically involves clinical evaluation, imaging studies such as MRI or X-rays, and sometimes laboratory tests to rule out other conditions. Treatment may include anti-inflammatory medications, physical therapy, and in some cases, surgical intervention if conservative measures fail. Understanding the underlying inflammatory processes is crucial for effective management and coding of this condition.
Detailed history of symptoms, physical examination findings, imaging results, and treatment plans.
Patients presenting with chronic low back pain, stiffness, and a family history of inflammatory arthritis.
Ensure that all inflammatory markers and imaging studies are documented to support the diagnosis.
Comprehensive assessment of spinal alignment, mobility, and any surgical interventions performed.
Patients with severe spinal stenosis requiring surgical evaluation or intervention.
Document any surgical findings and post-operative outcomes to justify coding.
Used when injecting corticosteroids for enthesopathy-related pain.
Document the joint/bursa involved, the substance injected, and the rationale for the procedure.
Rheumatologists should ensure that the injection site is clearly documented.
Spinal enthesopathy is primarily caused by inflammatory conditions such as ankylosing spondylitis, which leads to inflammation at the sites where tendons and ligaments attach to the bone.
