Learn about spinal abscess diagnosis, including clinical documentation, ICD-10 codes (M46.20, M46.21, M46.22, G06.0), medical coding guidelines, and healthcare best practices for epidural abscess, intradural abscess, and spinal cord abscess. This resource provides information for physicians, clinicians, and healthcare professionals on accurate diagnosis, treatment, and documentation of spinal abscesses. Find details on symptoms, differential diagnosis, and coding for spinal infections and inflammatory conditions.
Also known as
Intraspinal abscess
Abscess located within the spinal cord.
Pyogenic spondylitis
Infection of the vertebrae, often leading to abscess.
Encephalitis, myelitis, and encephalomyelitis
Inflammation of the brain and/or spinal cord, sometimes with abscess.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the spinal abscess epidural?
Yes
With meningitis?
No
Is it intradural?
When to use each related code
| Description |
|---|
| Spinal Abscess |
| Epidural Abscess |
| Discitis |
Q: What are the most reliable diagnostic imaging modalities for differentiating spinal epidural abscess from other spinal pathologies mimicking its clinical presentation?
A: Differentiating a spinal epidural abscess (SEA) from other spinal pathologies like discitis or vertebral osteomyelitis can be challenging due to overlapping symptoms. MRI with gadolinium contrast is considered the gold standard for diagnosing SEA, offering superior visualization of soft tissues and allowing for assessment of the extent of the abscess, cord compression, and inflammatory changes. While CT myelography can be helpful if MRI is contraindicated, it is less sensitive for detecting early SEA. Plain radiographs may show vertebral destruction or disc space narrowing in later stages but are not sensitive enough for early diagnosis. Explore how combining MRI findings with clinical presentation and laboratory markers like elevated inflammatory markers can improve diagnostic accuracy. Consider implementing standardized imaging protocols in your practice to ensure prompt and accurate SEA diagnosis.
Q: When should I suspect spinal epidural abscess in a patient presenting with back pain and fever, and what is the crucial next step in management?
A: Back pain accompanied by fever should raise suspicion for a spinal epidural abscess (SEA), especially when coupled with neurological deficits (e.g., weakness, sensory changes, bowel/bladder dysfunction) or a history of intravenous drug use, recent spinal surgery, or immunosuppression. Early diagnosis is critical for preventing irreversible neurological damage. The crucial next step after initial clinical assessment is urgent MRI of the entire spine with gadolinium contrast to confirm the diagnosis and delineate the extent of the abscess. If SEA is confirmed or strongly suspected, prompt neurosurgical consultation is warranted for evaluation of surgical drainage or decompression. Learn more about the role of early antibiotic therapy in managing SEA alongside surgical intervention.
Patient presents with complaints consistent with spinal abscess, including back pain, fever, neurological deficits, and possible constitutional symptoms such as chills, night sweats, and weight loss. Onset and duration of symptoms were documented. Physical examination revealed localized tenderness to palpation over the affected spinal level, potentially with paravertebral muscle spasm, limited range of motion, and sensory or motor disturbances. Differential diagnoses considered include epidural abscess, discitis, vertebral osteomyelitis, pyogenic spondylitis, spinal cord compression, and other infectious or inflammatory conditions. Laboratory tests including complete blood count (CBC) with differential, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and blood cultures were ordered. Advanced imaging studies, including MRI of the spine with and without contrast, were performed to evaluate for the presence of an abscess, assess the extent of involvement, and rule out other pathologies. Preliminary findings suggest a possible spinal epidural abscess at the [specify level] level. Patient was admitted for further evaluation and management. Treatment plan includes intravenous antibiotics targeting the most likely pathogens, pain management with analgesics, and neurosurgical consultation for possible surgical intervention including drainage or decompression if indicated. Patient's neurological status is being closely monitored. Prognosis and potential complications, such as permanent neurological deficits, sepsis, and spinal instability, were discussed with the patient. ICD-10 code G06.0 (spinal abscess) is pending confirmation of diagnosis. CPT codes for procedures performed, such as imaging and laboratory tests, will be documented separately.