Subluxation and dislocation of C4/C5 cervical vertebrae
ICD-10 S13.15 is a billable code used to indicate a diagnosis of subluxation and dislocation of c4/c5 cervical vertebrae.
Subluxation and dislocation of the C4/C5 cervical vertebrae refers to a condition where the cervical vertebrae at the fourth and fifth levels are misaligned or displaced. This injury can occur due to trauma, such as a fall, motor vehicle accident, or sports injury, leading to potential spinal cord compression and neurological deficits. The mechanism of injury often involves hyperflexion or hyperextension of the neck, which can disrupt the normal alignment of the vertebrae. Clinically, patients may present with neck pain, limited range of motion, and neurological symptoms such as numbness, tingling, or weakness in the upper extremities. Diagnosis typically involves imaging studies, including X-rays, CT scans, or MRI, to assess the degree of dislocation and any associated soft tissue injuries. Management may include conservative treatment such as immobilization and physical therapy, or surgical intervention if there is significant instability or neurological compromise. Complications can include chronic pain, persistent neurological deficits, or the development of cervical myelopathy if not appropriately managed.
Documentation must include a detailed account of the mechanism of injury, initial assessment findings, and any imaging performed.
Trauma patients presenting after a fall or motor vehicle accident with neck pain and neurological symptoms.
Ensure that all neurological assessments are documented, including any changes in motor or sensory function.
Operative reports must detail the surgical approach, findings, and any corrective measures taken.
Patients requiring surgical intervention for stabilization of the cervical spine after dislocation.
Document any pre-existing conditions that may affect surgical outcomes, such as osteoporosis or previous spinal surgeries.
Performed to relieve spinal cord compression due to dislocation.
Operative report must detail the procedure and any findings.
Ensure that the surgical approach and any complications are documented.
Subluxation refers to a partial dislocation where the joint surfaces are misaligned but still in contact, while dislocation indicates a complete separation of the joint surfaces.
