Understanding Cervical Myelopathy (CSM), also known as Cervical Spondylotic Myelopathy or Cervical Spinal Cord Compression, requires accurate clinical documentation and medical coding. This resource provides information on diagnosing and documenting Spinal Cord Compression in the cervical spine, including key symptoms, diagnostic criteria, and relevant ICD-10 and CPT codes for healthcare professionals. Learn about best practices for documenting Cervical Myelopathy in medical records to ensure proper patient care and accurate billing.
Also known as
Other spondylosis with myelopathy
Cervical spondylosis causing spinal cord compression.
Cervical disc disorders
Includes herniated discs that can cause myelopathy.
Other and unspecified disorders of spinal cord
Use for myelopathy when other codes are not applicable.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is myelopathy due to cervical disc displacement/herniation?
Yes
With myelopathy?
No
Is myelopathy due to cervical spondylosis?
When to use each related code
| Description |
|---|
| Neck pain with spinal cord dysfunction. |
| Neck pain from wear and tear, may involve cord. |
| Narrowing of the spinal canal in the neck. |
Code C alone lacks specificity for Cervical Myelopathy. Requires additional codes to reflect etiology (e.g., spondylosis).
Vague documentation may lead to inaccurate code assignment. Needs clear clinical evidence supporting Cervical Myelopathy diagnosis.
Missing or incorrect laterality coding can impact reimbursement and quality metrics if applicable.
Q: What are the most sensitive and specific physical exam findings for diagnosing cervical myelopathy in a patient presenting with neck pain and upper extremity radiculopathy?
A: While there isn't a single pathognomonic physical exam finding for cervical myelopathy, certain signs are highly suggestive and should raise suspicion, especially in the context of neck pain and upper extremity radiculopathy. Hyperreflexia, particularly in the lower extremities, is a classic finding. The presence of Hoffman's sign (flexion and adduction of the thumb and index finger upon flicking the fingernail of the middle finger) and the inverted supinator sign (finger flexion instead of elbow extension or supination with brisk tapping of the brachioradialis tendon) are also indicative of upper motor neuron involvement. Gait disturbances, including a spastic gait, wide-based gait, or difficulty with tandem walking, are crucial to assess. Sensory deficits, such as a decrease in proprioception and vibratory sense in the lower extremities, are common. Explore how combining these findings with advanced imaging, like MRI, can increase diagnostic accuracy. Consider implementing a standardized neurological exam in your practice for consistent assessment of suspected cervical myelopathy cases.
Q: How can I differentiate cervical myelopathy from other conditions mimicking its presentation, such as carpal tunnel syndrome, multiple sclerosis, and amyotrophic lateral sclerosis (ALS), in a primary care setting?
A: Differentiating cervical myelopathy from conditions like carpal tunnel syndrome, multiple sclerosis, and ALS requires careful history taking and targeted neurological examination. While all can present with upper extremity weakness or sensory changes, key distinctions exist. Carpal tunnel syndrome typically involves sensory disturbances in the median nerve distribution, sparing the thenar eminence, unlike the more diffuse pattern often seen in myelopathy. Multiple sclerosis can present with diverse neurological symptoms, including optic neuritis, bowel/bladder dysfunction, and cognitive changes, usually with a relapsing-remitting course, unlike the gradual progression of myelopathy. ALS typically presents with lower motor neuron signs like fasciculations and muscle atrophy, which are less prominent in cervical myelopathy's upper motor neuron picture. Learn more about the specific patterns of sensory and motor deficits associated with each condition to aid in differential diagnosis. Consider implementing a detailed neurological exam including assessment of reflexes, gait, and upper and lower motor neuron signs to refine your diagnostic approach. If diagnostic uncertainty remains, prompt referral to a specialist is crucial.
Patient presents with complaints consistent with cervical myelopathy, also known as cervical spondylotic myelopathy and cervical spinal cord compression. Symptoms include progressive neck pain, upper extremity numbness and tingling, gait disturbances characterized by a spastic gait, and varying degrees of hand dexterity impairment. Physical examination revealed hyperreflexia in the upper and lower extremities, positive Hoffmann's sign, and positive Babinski reflex. The patient reports difficulty with fine motor skills such as buttoning shirts and writing. Differential diagnoses considered include multiple sclerosis, amyotrophic lateral sclerosis (ALS), and peripheral neuropathy. Magnetic resonance imaging (MRI) of the cervical spine was ordered to evaluate for spinal cord compression and rule out other etiologies. Preliminary MRI findings suggest cervical spondylosis with evidence of cord compression at the C5-C6 level. Treatment plan includes referral to neurosurgery for consultation regarding surgical decompression options. Conservative management options, such as physical therapy and pain management, will also be discussed. ICD-10 code M47.12, Cervical spondylotic myelopathy without myelopathy, is provisionally assigned pending further diagnostic confirmation and neurosurgical evaluation. Patient education provided regarding cervical myelopathy symptoms, prognosis, and treatment options. Follow-up appointment scheduled in two weeks to discuss neurosurgical recommendations and further management.