Spinal stenosis, thoracolumbar region
ICD-10 M48.05 is a billable code used to indicate a diagnosis of spinal stenosis, thoracolumbar region.
Spinal stenosis in the thoracolumbar region refers to the narrowing of the spinal canal in the thoracic and lumbar areas of the spine, which can lead to compression of the spinal cord and nerve roots. This condition can result from various factors, including degenerative changes, congenital abnormalities, trauma, or inflammatory diseases such as ankylosing spondylitis. Patients may present with symptoms such as back pain, numbness, tingling, and weakness in the lower extremities, which can significantly impact their quality of life. Diagnosis typically involves imaging studies like MRI or CT scans to visualize the degree of stenosis and its effects on surrounding structures. Treatment options may range from conservative management, including physical therapy and pain management, to surgical interventions like laminectomy or spinal fusion, depending on the severity of symptoms and the underlying cause of the stenosis.
Detailed surgical notes, imaging results, and pre-operative assessments are essential.
Patients presenting with severe back pain and neurological deficits requiring surgical intervention.
Ensure that the surgical approach and rationale are clearly documented to support the coding of procedures.
Comprehensive history of inflammatory symptoms, laboratory results, and imaging studies.
Patients with ankylosing spondylitis presenting with spinal stenosis symptoms.
Document the relationship between inflammatory conditions and spinal stenosis to support accurate coding.
Used in cases of severe spinal stenosis requiring surgical intervention.
Operative reports detailing the procedure and indications for surgery.
Orthopedic surgeons must document the rationale for surgical intervention clearly.
Common symptoms include back pain, leg pain, numbness, tingling, and weakness in the lower extremities, often worsening with activity.
Diagnosis typically involves a thorough clinical evaluation followed by imaging studies such as MRI or CT scans to assess the degree of stenosis.
