Spinal stenosis, occipito-atlanto-axial region
ICD-10 M48.01 is a billable code used to indicate a diagnosis of spinal stenosis, occipito-atlanto-axial region.
Spinal stenosis in the occipito-atlanto-axial region refers to the narrowing of the spinal canal at the junction of the occipital bone and the first two cervical vertebrae (atlas and axis). This condition can lead to compression of the spinal cord and nerve roots, resulting in neurological deficits. Symptoms may include neck pain, stiffness, headaches, and in severe cases, myelopathy characterized by weakness, numbness, or coordination issues in the upper and lower extremities. The condition can arise from various etiologies, including degenerative changes, congenital anomalies, trauma, or inflammatory diseases such as ankylosing spondylitis. Accurate diagnosis often involves imaging studies like MRI or CT scans to assess the degree of stenosis and its impact on surrounding structures. Treatment options may range from conservative management, such as physical therapy and pain management, to surgical interventions aimed at decompressing the spinal canal.
Detailed surgical notes, imaging results, and pre-operative assessments.
Surgical intervention for severe stenosis causing myelopathy.
Ensure clear documentation of neurological assessments and surgical indications.
Comprehensive neurological evaluations, imaging interpretations, and treatment plans.
Management of patients with neurological deficits due to spinal stenosis.
Document all neurological findings and correlate them with imaging results.
Performed for decompression of spinal stenosis.
Operative report detailing the procedure and indications.
Orthopedic or neurosurgical documentation must clearly outline the need for surgery.
Common symptoms include neck pain, stiffness, headaches, and neurological deficits such as weakness or numbness in the arms and legs.
