Fatigue fracture of vertebra, occipito-atlanto-axial region
ICD-10 M48.41 is a billable code used to indicate a diagnosis of fatigue fracture of vertebra, occipito-atlanto-axial region.
A fatigue fracture of the vertebra in the occipito-atlanto-axial region typically occurs due to repetitive stress or overuse, leading to microtrauma that exceeds the body's ability to repair itself. This condition is particularly relevant in patients with underlying spondylopathies, such as ankylosing spondylitis, where inflammation and structural changes in the spine can predispose individuals to fractures. The occipito-atlanto-axial region includes the base of the skull and the first two cervical vertebrae, which are critical for head movement and stability. Symptoms may include neck pain, reduced range of motion, and neurological deficits if spinal cord compression occurs. Diagnosis often involves imaging studies such as X-rays, MRI, or CT scans to assess the extent of the fracture and any associated spinal stenosis or inflammatory changes. Management may include conservative treatment with rest, physical therapy, and pain management, or surgical intervention in severe cases. Accurate coding is essential for proper reimbursement and to reflect the complexity of the patient's condition.
Detailed imaging reports, surgical notes if applicable, and comprehensive patient history.
Patients presenting with neck pain and a history of inflammatory spine disease.
Ensure clear documentation of fracture type and any surgical interventions performed.
Thorough documentation of inflammatory markers, patient history of spondylitis, and treatment plans.
Patients with chronic back pain and a diagnosis of ankylosing spondylitis.
Document the relationship between inflammatory conditions and fracture risk.
Used in cases of vertebral compression fractures.
Pre-operative imaging and post-operative follow-up notes.
Orthopedic surgeons must document the indication for the procedure clearly.
Fatigue fractures in this region are primarily caused by repetitive stress and overuse, particularly in patients with underlying conditions like ankylosing spondylitis that affect spinal integrity.
