M54.16 Radiculopathy, lumbar region

ICD10CM code

#### Name of the Condition
- Radiculopathy, lumbar region
- Commonly referred to as sciatica or lumbar radiculopathy.

#### Summary
Radiculopathy in the lumbar region, often known as sciatica, is a condition where a nerve root in the lower back is compressed, leading to pain, numbness, or weakness extending down the leg. This condition is typically associated with a herniated disc or spinal degeneration.

#### Causes
- Herniated disc: A protruding disc that presses on a nerve root.
- Degenerative disc disease: Age-related breakdown of spinal discs.
- Spinal stenosis: Narrowing of the spinal canal.
- Injury or trauma to the back.

#### Risk Factors
- Age: Risk increases with aging due to degenerative changes.
- Obesity: Excess weight adds stress to the spine.
- Sedentary lifestyle: Lack of physical activity can weaken back muscles.
- Occupation: Jobs requiring heavy lifting or twisting.

#### Symptoms
- Sharp or burning pain radiating from the lower back to one leg.
- Numbness or tingling sensation in the leg and foot.
- Muscle weakness in the leg or foot.
- Difficulties in controlling the leg movements.

#### Diagnosis
- Physical examination focusing on the spine, legs, and reflexes.
- MRI or CT scan to visualize nerve root compression.
- Nerve conduction studies or EMG for nerve function assessment.

#### Treatment Options
- Medications: Pain relievers, anti-inflammatory drugs, or muscle relaxants to reduce symptoms.
- Physical therapy: Exercises to strengthen the back and improve flexibility.
- Corticosteroid injections: Reduce inflammation and pain around the nerve root.
- Surgery: In severe cases, procedures like discectomy or laminectomy may be considered.

#### Prognosis and Follow-Up
- With early treatment, many recover fully or experience significant pain reduction.
- Chronic cases may require long-term management strategies.
- Regular follow-up to monitor symptoms and adjust treatment as necessary.

#### Complications
- Chronic pain if left untreated.
- Permanent nerve damage leading to loss of sensation or movement.
- Decreased quality of life due to persistent pain and discomfort.

#### Lifestyle & Prevention
- Maintain a healthy weight to reduce stress on the spine.
- Engage in regular exercise to strengthen core muscles.
- Practice proper lifting techniques to avoid injury.
- Adopt ergonomic workplace setups to minimize strain on the back.

#### When to Seek Professional Help
- Severe, sudden pain in the low back or leg.
- Numbness or weakness in the leg.
- Loss of bowel or bladder control (may indicate a medical emergency).

#### Additional Resources
- American Academy of Orthopaedic Surgeons (AAOS): [aaos.org](https://www.aaos.org)
- National Institute of Neurological Disorders and Stroke (NINDS): [ninds.nih.gov](https://www.ninds.nih.gov)
- Spine-health: [spine-health.com](https://www.spine-health.com)

#### Tips for Medical Coders
- Ensure accurate documentation of the specific location of radiculopathy.
- Verify that the diagnosis specifically states "lumbar region" for using M54.16.
- Be mindful of differentiating between radiculopathy and other pain conditions like myopathy or neuropathy.

Medical Policies and Guidelines for Radiculopathy, lumbar region

Related policies from health plans

Similar Codes