Infection of intervertebral disc (pyogenic), sacral and sacrococcygeal region
ICD-10 M46.38 is a billable code used to indicate a diagnosis of infection of intervertebral disc (pyogenic), sacral and sacrococcygeal region.
M46.38 refers to a pyogenic infection of the intervertebral disc located in the sacral and sacrococcygeal region. This condition is characterized by the presence of bacteria that invade the disc space, leading to inflammation, pain, and potential neurological deficits. The infection can arise from hematogenous spread, direct extension from adjacent structures, or post-surgical complications. Clinically, patients may present with localized pain, fever, and neurological symptoms depending on the extent of the infection and any resultant spinal cord compression. Diagnosis typically involves imaging studies such as MRI, which can reveal disc space narrowing, edema, and abscess formation. Treatment often requires a combination of antibiotics and surgical intervention to debride infected tissue and relieve pressure on neural structures. The condition can be associated with other spondylopathies, including ankylosing spondylitis and spinal stenosis, which may complicate the clinical picture and management.
Detailed operative reports, imaging studies, and post-operative notes.
Surgical intervention for disc infection, management of abscesses.
Ensure clear documentation of the surgical approach and any complications.
Comprehensive patient history, laboratory results, and treatment plans.
Management of pyogenic infections, antibiotic therapy adjustments.
Document the rationale for antibiotic choice and duration of therapy.
Used in cases where surgical intervention is needed for disc infection.
Operative report detailing the procedure and indication.
Orthopedic surgeons must document the extent of the procedure and any complications.
Common causes include hematogenous spread from distant infections, direct extension from adjacent infections, and post-surgical complications. Conditions such as diabetes and immunosuppression can increase the risk.
