Spinal enthesopathy, occipito-atlanto-axial region
ICD-10 M46.01 is a billable code used to indicate a diagnosis of spinal enthesopathy, occipito-atlanto-axial region.
Spinal enthesopathy in the occipito-atlanto-axial region refers to a condition characterized by inflammation and degeneration at the sites where tendons and ligaments attach to the vertebrae in the upper cervical spine. This condition can be associated with various inflammatory spine diseases, including ankylosing spondylitis, which is a type of spondyloarthritis that primarily affects the spine and the sacroiliac joints. Patients may present with neck pain, stiffness, and reduced range of motion, particularly in the morning or after periods of inactivity. The condition can lead to significant discomfort and may contribute to spinal stenosis, where the spinal canal narrows, potentially compressing the spinal cord and nerves. Diagnosis typically involves clinical evaluation, imaging studies such as MRI or CT scans, and sometimes laboratory tests to rule out other inflammatory conditions. Treatment may include physical therapy, anti-inflammatory medications, and in some cases, surgical intervention if conservative measures fail.
Detailed history of symptoms, physical examination findings, imaging results, and response to treatment.
Patients presenting with chronic neck pain, stiffness, and a history of inflammatory arthritis.
Ensure that the documentation clearly indicates the relationship between enthesopathy and any underlying inflammatory conditions.
Comprehensive assessment of spinal alignment, range of motion, and any neurological deficits.
Patients with severe neck pain and potential neurological symptoms due to spinal stenosis.
Document any surgical interventions or referrals for further evaluation.
Used when injecting corticosteroids into the cervical spine region for symptomatic relief.
Document the indication for the procedure, the specific joint or region treated, and the patient's response.
Rheumatologists and orthopedic surgeons should ensure clear documentation of the diagnosis and treatment plan.
Spinal enthesopathy in this region is often associated with inflammatory conditions such as ankylosing spondylitis, which leads to inflammation at the sites where ligaments and tendons attach to the vertebrae.
