Spinal stenosis, cervical region
ICD-10 M48.02 is a billable code used to indicate a diagnosis of spinal stenosis, cervical region.
Spinal stenosis in the cervical region refers to the narrowing of the spinal canal in the neck area, which can lead to compression of the spinal cord and nerve roots. This condition can result from various factors, including degenerative changes, trauma, or congenital abnormalities. Symptoms often include neck pain, numbness, tingling, and weakness in the arms or hands, as well as potential balance issues and coordination problems. The condition is commonly associated with spondylopathies, such as osteoarthritis and degenerative disc disease, which contribute to the narrowing of the spinal canal. Inflammatory spine conditions, including ankylosing spondylitis, can also lead to spinal stenosis due to inflammation and subsequent structural changes in the vertebrae. Diagnosis typically involves imaging studies like MRI or CT scans to assess the degree of stenosis and its impact on surrounding neural structures. Treatment options may range from conservative management, such as physical therapy and medications, to surgical interventions aimed at decompressing the spinal canal.
Detailed surgical notes, imaging results, and pre-operative assessments.
Surgical intervention for severe stenosis causing significant neurological deficits.
Ensure documentation reflects the surgical approach and any complications.
Comprehensive neurological evaluations and imaging studies.
Management of conservative treatment for symptomatic stenosis.
Document neurological assessments thoroughly to support diagnosis.
Performed for decompression of cervical spinal stenosis.
Operative report detailing the procedure and indication.
Orthopedic or neurosurgical documentation must clearly indicate the need for surgery.
Common symptoms include neck pain, numbness or tingling in the arms, weakness, and balance issues. Symptoms may vary based on the severity of the stenosis.
