Stable burst fracture of first cervical vertebra
ICD-10 S12.01 is a billable code used to indicate a diagnosis of stable burst fracture of first cervical vertebra.
A stable burst fracture of the first cervical vertebra (C1), also known as the atlas, occurs when the vertebra sustains a fracture that does not compromise the spinal canal or lead to neurological deficits. This type of injury is typically caused by high-energy trauma, such as motor vehicle accidents, falls from significant heights, or sports-related injuries. The mechanism of injury often involves axial loading or hyperextension of the neck. Clinically, patients may present with neck pain, limited range of motion, and tenderness over the cervical spine. Diagnostic imaging, including X-rays and CT scans, is essential for confirming the diagnosis and assessing the extent of the fracture. Management usually involves conservative treatment with immobilization, pain management, and physical therapy, although surgical intervention may be necessary in cases of instability or associated injuries. Complications can include chronic pain, reduced mobility, and, in rare cases, neurological impairment if the fracture is mismanaged.
Documentation must include a thorough assessment of the patient's neurological status, mechanism of injury, and any imaging results.
Patients presenting with acute neck pain following trauma, requiring immediate evaluation and imaging.
Ensure that the documentation clearly states the stability of the fracture and any neurological findings.
Operative reports must detail the surgical approach, findings, and any fixation methods used.
Surgical intervention for unstable fractures or decompression of the spinal canal.
Accurate coding requires clear documentation of the surgical procedure and any complications encountered.
Used in cases where surgical intervention is required for stabilization.
Operative report must detail the procedure and any complications.
Ensure that the diagnosis supports the need for surgical intervention.
A stable burst fracture does not compromise the spinal canal or cause neurological deficits, while an unstable fracture may lead to spinal cord injury or require surgical intervention.
