Lateral mass fracture of first cervical vertebra
ICD-10 S12.04 is a billable code used to indicate a diagnosis of lateral mass fracture of first cervical vertebra.
A lateral mass fracture of the first cervical vertebra (C1) is a specific type of injury that occurs in the upper cervical spine, typically resulting from high-energy trauma such as motor vehicle accidents, falls, or sports injuries. This fracture involves the lateral masses of the atlas, which are critical for supporting the skull and facilitating head movement. Clinically, patients may present with neck pain, limited range of motion, and neurological deficits depending on the extent of the injury and any associated spinal cord involvement. Diagnosis is primarily through imaging studies, including X-rays and CT scans, which can reveal the fracture's location and severity. Management often involves immobilization, pain control, and in some cases, surgical intervention to stabilize the spine and prevent further neurological compromise. Complications can include chronic pain, instability, and potential neurological deficits if not managed appropriately. Accurate coding is essential for proper treatment reimbursement and tracking of injury patterns.
Thorough documentation of the patient's presentation, mechanism of injury, and initial assessment findings is crucial.
Patients presenting after a fall or motor vehicle accident with neck pain and neurological symptoms.
Ensure that all imaging results and neurological assessments are documented to support the diagnosis.
Detailed operative reports and post-operative notes are necessary to capture the surgical intervention and outcomes.
Surgical stabilization of the cervical spine following a lateral mass fracture.
Document the surgical approach, fixation methods, and any intraoperative findings that may affect coding.
Used in cases where surgical intervention is required for stabilization of the cervical spine.
Operative report detailing the procedure, indications, and post-operative care.
Ensure that the surgical approach and any complications are documented.
The primary mechanism of injury is typically high-energy trauma, such as from motor vehicle accidents, falls, or sports-related injuries, which can cause axial loading or rotational forces on the cervical spine.
