G83.4 Cauda equina syndrome

ICD10CM code

# Cauda Equina Syndrome (ICD: G83.4)

#### Name of the Condition
- **Cauda Equina Syndrome (CES)**
- Also known as *Cauda Equina Compression*.

#### Summary
Cauda Equina Syndrome is a rare but serious condition where a bundle of spinal nerve roots at the lower end of the spinal cord become compressed. This can lead to issues such as severe lower back pain, leg weakness, and bladder or bowel dysfunction.

#### Causes
- Herniated lumbar disc.
- Spinal stenosis.
- Tumors or infections affecting the spine.
- Traumatic injury to the lower back.
- Complications from spinal surgeries.

#### Risk Factors
- Severe or high-impact trauma to the spine.
- A history of spinal conditions like lumbar degenerative disc disease.
- Congenital spinal defects.
- Certain occupations involving repetitive heavy lifting.

#### Symptoms
- Severe lower back pain.
- Numbness or tingling in the "saddle" area (buttocks, inner thighs, and back of the legs).
- Muscle weakness in the legs.
- Loss of bladder or bowel control.
- Sexual dysfunction.

#### Diagnosis
- Physical examination to assess muscle strength, sensation, and reflexes.
- MRI or CT scan to identify the location and cause of nerve compression.
- Electromyography (EMG) to evaluate the function of muscles and nerve cells.

#### Treatment Options
- **Surgical Decompression**: Often urgent surgery to relieve pressure on the cauda equina nerves.
- **Medications**: Pain management, steroids to reduce inflammation.
- **Physical Therapy**: Post-surgery to restore function and strength.

#### Prognosis and Follow-Up
- Early treatment often results in better outcomes and functional recovery.
- Follow-up includes physical therapy and regular neurological assessments.
- Some residual symptoms might persist even after treatment.

#### Complications
- Permanent paralysis or loss of bowel/bladder control if untreated.
- Chronic pain or sexual dysfunction.
- Weakness or numbness in the lower limbs.

#### Lifestyle & Prevention
- Regular exercise to strengthen back muscles.
- Proper techniques for lifting heavy objects.
- Early treatment and management of lower back conditions.
- Routine monitoring for individuals with a history of spinal issues.

#### When to Seek Professional Help
- New or worsening severe back pain.
- Sudden onset of bladder or bowel dysfunction.
- Numbness in the saddle area.
- Difficulty walking or severe leg weakness.

#### Additional Resources
- [National Institute of Neurological Disorders and Stroke (NINDS)](https://www.ninds.nih.gov)
- [Spine Health - Cauda Equina Syndrome](https://www.spine-health.com)
- Support groups like the American Spinal Injury Association.

#### Tips for Medical Coders
- Ensure documentation specifies "Cauda Equina Syndrome" to use the correct ICD code G83.4.
- Double-check for associated underlying causes like herniated disc or trauma.
- Avoid misclassification with other lumbar or spinal disorders.

Medical Policies and Guidelines for Cauda equina syndrome

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