Name of the Condition

• Spinal Enthesopathy, Thoracolumbar Region
• ICD Code: M46.05

Summary

Spinal enthesopathy in the thoracolumbar region refers to inflammation or degeneration of the entheses, where ligaments or tendons attach to the spine in the thoracic and lumbar areas. This condition can cause pain and stiffness in the mid to lower back.

Causes

• Repetitive stress or overuse of the spine.
• Autoimmune disorders such as ankylosing spondylitis.
• Traumatic injury to the thoracolumbar spine.

Risk Factors

• Age, especially middle-aged and older adults.
• Genetic predisposition to autoimmune disorders.
• Occupations or activities involving repetitive spinal movements.

Symptoms

• Persistent pain in the thoracolumbar area.
• Stiffness and reduced mobility in the back.
• Swelling or tenderness at the site of entheseal involvement.

Diagnosis

• Physical examination focusing on tenderness in the thoracolumbar region.
• Imaging techniques such as X-rays or MRI to detect changes in the spine.
• Blood tests to rule out inflammatory or autoimmune conditions.

Treatment Options

• Nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce pain and inflammation.
• Physical therapy to improve flexibility and strength.
• Corticosteroid injections for severe cases.
• Surgery in rare instances where conservative treatments fail.

Prognosis and Follow-Up

• Most patients experience improvement with appropriate management.
• Regular follow-up appointments are crucial to monitor symptoms and adjust treatment plans as needed.

Complications

• Chronic pain or disability without proper treatment.
• Increased risk of spinal abnormalities or deformities.

Lifestyle & Prevention

• Engaging in low-impact exercises such as swimming or walking to maintain spine health.
• Practicing good posture during activities.
• Avoiding repetitive, strenuous activities that put stress on the back.

When to Seek Professional Help

• Persistent back pain that does not improve with over-the-counter pain relievers.
• Significant loss of mobility or function in the back.
• Symptoms of an autoimmune disorder, including unexplained fatigue or joint pain.

Additional Resources

• Arthritis Foundation: arthritis.org
• American Academy of Orthopaedic Surgeons: orthoinfo.aaos.org

Tips for Medical Coders

• Ensure the code M46.05 specifically refers to the thoracolumbar region, distinguishing it from other spinal regions.
• Double-check patient records for mention of spinal inflammation and anatomical location to avoid errors in coding.