Sacral spina bifida without hydrocephalus
ICD-10 Q05.8 is a billable code used to indicate a diagnosis of sacral spina bifida without hydrocephalus.
Sacral spina bifida is a type of neural tube defect characterized by the incomplete closure of the bony encasement of the spinal cord in the sacral region. This condition occurs during embryonic development and can lead to various neurological deficits, depending on the severity and location of the defect. Unlike other forms of spina bifida, sacral spina bifida typically does not involve hydrocephalus, which is the accumulation of cerebrospinal fluid in the brain. Patients may present with symptoms such as weakness or paralysis of the lower limbs, bowel and bladder dysfunction, and orthopedic issues. Diagnosis is usually made through prenatal ultrasound or postnatal imaging studies. Management may involve surgical intervention to close the defect and multidisciplinary care to address associated complications. Early intervention is crucial for optimizing functional outcomes and quality of life for affected individuals.
Detailed neurological assessments, developmental milestones, and treatment plans must be documented to support the diagnosis.
Pediatric patients presenting with lower limb weakness, bowel and bladder issues, and orthopedic complications.
Consideration of the child's age and developmental stage is crucial for accurate coding and management.
Genetic counseling notes, family history, and any chromosomal analysis results should be included.
Cases where spina bifida is part of a syndrome or associated with chromosomal abnormalities.
Understanding the genetic basis of congenital malformations can aid in accurate coding and family counseling.
Used during surgical intervention for closure of the defect.
Operative reports detailing the procedure and any complications.
Pediatric surgeons should provide detailed documentation of the surgical approach and outcomes.
Sacral spina bifida specifically refers to defects located in the sacral region of the spine, which may present with different symptoms and complications compared to lumbar or thoracic spina bifida. It is important to document the specific type to ensure accurate coding and management.
