Spinal enthesopathy, lumbar region
ICD-10 M46.06 is a billable code used to indicate a diagnosis of spinal enthesopathy, lumbar region.
Spinal enthesopathy refers to a condition characterized by inflammation at the sites where tendons and ligaments attach to the bone, particularly in the lumbar region of the 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 chronic lower back pain, stiffness, and reduced mobility, particularly after periods of inactivity. The enthesopathy can lead to changes in the spinal structure, including calcification and ossification of the spinal ligaments, contributing to spinal stenosis and further complications. Diagnosis typically involves clinical evaluation, imaging studies such as MRI or X-rays, and sometimes laboratory tests to rule out other conditions. Treatment may include anti-inflammatory medications, physical therapy, and in some cases, surgical intervention to relieve symptoms and improve function.
Detailed history of symptoms, physical examination findings, and imaging results.
Patients presenting with chronic back pain and stiffness, particularly in younger adults.
Documentation must clearly indicate the inflammatory nature of the condition and any associated systemic symptoms.
Surgical notes, pre-operative assessments, and post-operative follow-ups.
Patients requiring surgical intervention for spinal stenosis or severe enthesopathy.
Ensure that the surgical necessity is well-documented, including conservative treatment attempts.
Used when a patient with lumbar enthesopathy receives a corticosteroid injection.
Document the indication for the injection, the joint involved, and the patient's response.
Rheumatologists may frequently perform this procedure for symptom management.
Spinal enthesopathy is primarily caused by inflammatory conditions such as ankylosing spondylitis, which leads to chronic inflammation at the entheses, resulting in pain and structural changes in the spine.
