Infection of intervertebral disc (pyogenic), occipito-atlanto-axial region
ICD-10 M46.31 is a billable code used to indicate a diagnosis of infection of intervertebral disc (pyogenic), occipito-atlanto-axial region.
M46.31 refers to a pyogenic infection of the intervertebral disc located in the occipito-atlanto-axial region, which includes the first two cervical vertebrae (the atlas and axis) and the base of the skull. This condition is characterized by the presence of pus-forming bacteria that invade the disc space, leading to inflammation, pain, and potential neurological deficits. The infection can arise from hematogenous spread, direct extension from adjacent structures, or post-surgical complications. Clinically, patients may present with severe neck pain, fever, and neurological symptoms such as weakness or sensory changes due to spinal cord compression. Diagnosis typically involves imaging studies such as MRI, which can reveal disc space narrowing, edema, and abscess formation. Treatment often requires a combination of antibiotics and surgical intervention to decompress the affected area and remove infected tissue. Prompt recognition and management are crucial to prevent long-term complications, including chronic pain and disability.
Detailed operative reports, imaging studies, and clinical notes outlining the infection's progression and treatment plan.
Post-operative infections following spinal surgery, acute presentations of discitis in patients with prior spinal conditions.
Ensure that all surgical interventions and their indications are well-documented to support the coding of M46.31.
Comprehensive history and physical examination notes, laboratory results, and treatment plans detailing antibiotic therapy.
Management of pyogenic infections in immunocompromised patients or those with chronic conditions.
Documentation must clearly indicate the source of infection and any underlying conditions that may complicate treatment.
Performed to decompress the spinal cord due to infection-related abscess.
Operative report detailing the procedure and indication for surgery.
Orthopedic surgeons must document the extent of infection and any complications encountered.
Common causes include hematogenous spread from distant infections, direct extension from adjacent structures, and post-surgical infections. Risk factors include immunocompromised states, diabetes, and prior spinal surgery.
