Name of the Condition

• Fusion of Spine, Lumbar Region
• Medical Term: Lumbar Spinal Fusion

Summary

Lumbar spinal fusion refers to a surgical procedure that joins two or more vertebrae in the lower back. It aims to stabilize the spine and reduce pain by preventing movement between the fused vertebrae.

Causes

• Degenerative disc disease
• Spinal stenosis
• Spondylolisthesis
• Herniated discs that may require stabilization post-removal
• Congenital spinal deformities

Risk Factors

• Age: More common in older adults
• Previous spine surgeries or injuries
• High-impact activities causing continuous spinal stress
• Smoking, which can affect bone healing

Symptoms

• Chronic lower back pain
• Stiffness or decreased range of motion
• Radiating pain or numbness down the legs
• Muscle weakness in the lower extremities

Diagnosis

• Physical examination and clinical history
• Imaging tests such as X-rays, MRI, or CT scans
• Electromyography (EMG) to measure the electrical activity of nerves and muscles

Treatment Options

• Surgical: Lumbar spinal fusion surgery using bone grafts, screws, and rods to stabilize the spine
• Medication: Pain relievers and anti-inflammatory drugs to manage symptoms
• Physical Therapy: Post-surgery rehabilitation through exercises to restore movement and strength
• Alternative Therapies: Chiropractic care or acupuncture might be suggested for pain management

Prognosis and Follow-Up

• Variable outcomes depending on the underlying cause and patient's health
• Regular follow-up appointments to monitor recovery and identify any issues with fusion
• Long-term success often requires adhering to rehabilitation programs

Complications

• Infection at the surgical site
• Blood clots
• Nerve damage leading to neurological deficits
• Possibility of nonunion (failure of the bones to fuse)

Lifestyle & Prevention

• Maintain a healthy weight to reduce spine stress
• Engage in regular, low-impact exercises like swimming or walking
• Ensure proper ergonomic setup and posture when sitting or lifting
• Quit smoking to enhance bone health and healing

When to Seek Professional Help

• Persistent or severe back pain
• New or worsening symptoms like numbness or weakness
• Signs of infection (e.g., fever, increased redness, and swelling at the surgical site)

Additional Resources

• American Association of Neurological Surgeons: www.aans.org
• Spine-health: www.spine-health.com

Tips for Medical Coders

• Ensure precise documentation of the vertebrae involved in the fusion.
• Document the underlying condition prompting the need for fusion, as it can affect coding and billing.
• Be aware of surgery-specific codes that may accompany M43.26 in cases of spinal instrumentation.