M48.061 Spinal stenosis, lumbar region without neurogenic claudication

ICD10CM code

#### Name of the Condition
- Spinal Stenosis, Lumbar Region Without Neurogenic Claudication

#### Summary
- Spinal stenosis in the lumbar region is a condition where the spinal canal narrows in the lower back, though in this case, it does not cause neurogenic claudication, a particular type of leg pain.

#### Causes
- This condition is often caused by age-related changes in the spine such as arthritis, disc degeneration, or thickening of ligaments. It may also be related to congenital spinal stenosis.

#### Risk Factors
- Age is a primary risk factor, with most cases occurring in individuals over 50. Other risk factors include hereditary structural deformities of the spine, a history of spine injuries, or occupations with repetitive stress on the spine.

#### Symptoms
- While neurogenic claudication is not present, individuals may experience lower back pain, stiffness, or a tingling sensation in the lower limbs.

#### Diagnosis
- Diagnosis typically involves a combination of a physical exam, a review of symptoms, and imaging studies such as MRI or CT scans to assess the narrowing of the spinal canal.

#### Treatment Options
- Treatments may include physical therapy to strengthen back muscles and improve flexibility, pain relief medications, and in some cases, surgical interventions to relieve pressure on the spinal cord or nerves. 

#### Prognosis and Follow-Up
- With proper management, symptoms can be effectively controlled, but regular follow-ups are necessary to monitor the spine’s condition, especially if it progresses.

#### Complications
- If the condition progresses, it can lead to significant pain, mobility issues, or even nerve damage, affecting quality of life.

#### Lifestyle & Prevention
- Engaging in regular exercise, maintaining a healthy weight, and practicing good posture can help manage symptoms and reduce further stress on the spine.

#### When to Seek Professional Help
- Seek medical attention if you experience severe back pain, weakness or numbness in your legs, or loss of bowel or bladder control, as these could indicate worsening of the condition.

#### Additional Resources
- For more information, refer to resources from the American Academy of Orthopaedic Surgeons and the North American Spine Society, or seek support from organizations like the Spine Health Foundation.

#### Tips for Medical Coders
- Ensure accurate documentation by verifying that neurogenic claudication is not present, which differentiates this specific code.
- Double-check imaging reports and clinical notes to confirm that the stenosis pertains specifically to the lumbar region.

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