Traumatic spondylopathy, occipito-atlanto-axial region
ICD-10 M48.31 is a billable code used to indicate a diagnosis of traumatic spondylopathy, occipito-atlanto-axial region.
Traumatic spondylopathy in the occipito-atlanto-axial region refers to a condition resulting from trauma that affects the vertebrae in the upper cervical spine, specifically the occiput, atlas (C1), and axis (C2). This condition can arise from various types of trauma, including falls, motor vehicle accidents, or sports injuries. The trauma may lead to structural changes, instability, or inflammation in the spinal region, which can result in pain, neurological deficits, and impaired mobility. Clinically, patients may present with neck pain, headaches, and in severe cases, neurological symptoms such as weakness or sensory changes due to spinal cord compression. Diagnosis typically involves imaging studies such as X-rays, CT scans, or MRIs to assess the extent of the injury and rule out other conditions such as ankylosing spondylitis or spinal stenosis. Treatment may include conservative management with physical therapy, pain management, or surgical intervention in cases of significant instability or neurological compromise.
Detailed trauma history, imaging results, and treatment plans.
Post-traumatic evaluations, surgical interventions for instability.
Ensure accurate representation of the injury mechanism and associated symptoms.
Neurological assessments, imaging interpretations, and symptomatology.
Evaluation of neurological deficits following trauma.
Document any neurological findings thoroughly to support coding.
Used when surgical intervention is required for decompression due to traumatic spondylopathy.
Operative reports detailing the procedure and indication for surgery.
Orthopedic surgeons must document the extent of trauma and rationale for surgical intervention.
M48.31 is primarily caused by traumatic events such as falls, accidents, or sports injuries that affect the occipito-atlanto-axial region.
M48.31 is specifically for traumatic spondylopathy, while other codes may refer to degenerative or inflammatory conditions. Documentation of trauma is key.
