Discitis, unspecified, occipito-atlanto-axial region
ICD-10 M46.41 is a billable code used to indicate a diagnosis of discitis, unspecified, occipito-atlanto-axial region.
Discitis is an inflammatory condition affecting the intervertebral discs, characterized by infection or inflammation that can lead to severe pain and neurological deficits. In the occipito-atlanto-axial region, which includes the junction between the skull and the first two cervical vertebrae, discitis can result from various etiologies, including bacterial infections, autoimmune disorders, or post-surgical complications. Symptoms often include neck pain, stiffness, and potential neurological symptoms due to spinal cord compression. Diagnosis typically involves imaging studies such as MRI or CT scans, alongside laboratory tests to identify infectious agents. Treatment may include antibiotics, anti-inflammatory medications, and in severe cases, surgical intervention to relieve pressure on the spinal cord or stabilize the spine. The unspecified nature of this code indicates that the specific cause of the discitis has not been determined, which can complicate treatment and management.
Detailed clinical notes on patient history, physical examination findings, imaging results, and treatment plans.
Patients presenting with neck pain, stiffness, and neurological symptoms following trauma or infection.
Orthopedic specialists must ensure that all relevant imaging studies are documented to support the diagnosis of discitis.
Comprehensive lab results, including cultures and sensitivity tests, along with clinical notes on the patient's response to treatment.
Patients with suspected infectious discitis presenting with fever, localized pain, and systemic symptoms.
Infectious disease specialists should document the specific pathogens identified to justify the use of this code.
Used to evaluate suspected discitis in the occipito-atlanto-axial region.
Radiology report must be included in the patient's medical record.
Orthopedic and neurosurgical specialists should ensure imaging is clearly linked to the diagnosis.
Common causes of discitis include bacterial infections, autoimmune disorders, and post-surgical complications. In some cases, the cause may remain unspecified despite thorough investigation.
