Osteomyelitis of vertebra, occipito-atlanto-axial region
ICD-10 M46.21 is a billable code used to indicate a diagnosis of osteomyelitis of vertebra, occipito-atlanto-axial region.
Osteomyelitis of the vertebra in the occipito-atlanto-axial region refers to an infection of the bone in the upper cervical spine, specifically affecting the occipital bone and the first two cervical vertebrae (atlas and axis). This condition can arise from hematogenous spread, direct extension from adjacent infections, or post-surgical complications. Symptoms may include localized pain, fever, neurological deficits, and signs of systemic infection. Diagnosis typically involves imaging studies such as MRI or CT scans, which can reveal bone edema, abscess formation, or other changes indicative of osteomyelitis. Treatment often requires a combination of antibiotics and, in some cases, surgical intervention to drain abscesses or debride necrotic tissue. The condition can lead to serious complications, including spinal instability and neurological impairment, making early diagnosis and management crucial.
Detailed operative notes, imaging results, and post-operative care plans.
Surgical intervention for abscess drainage or debridement in cases of osteomyelitis.
Ensure clear documentation of the surgical approach and any complications encountered.
Comprehensive history of infection, laboratory results, and treatment response.
Management of osteomyelitis with antibiotic therapy and monitoring for complications.
Document the rationale for antibiotic selection and duration of therapy.
Used when joint aspiration is performed due to suspected infection.
Document the reason for aspiration and findings.
Orthopedic surgeons should note the joint involved and any complications.
Common causes include hematogenous spread from distant infections, direct extension from adjacent soft tissue infections, and post-surgical complications.
