Name of the Condition

• Radiculopathy, sacral and sacrococcygeal region
• Also known as sacral nerve root disorder

Summary

Radiculopathy refers to a condition where a nerve in the spine is compressed or irritated, causing pain, numbness, or weakness. In the case of sacral and sacrococcygeal radiculopathy, this discomfort is localized around the lower back, buttocks, and legs, as these areas are served by the sacral nerves.

Causes

• Herniated disc pressing on the nerve roots in the sacral area
• Degenerative disc disease
• Spinal stenosis (narrowing of the spinal canal)
• Trauma or injury to the spine
• Tumors or cysts affecting the spinal nerves

Risk Factors

• Aging
• Repetitive heavy lifting or bending movements
• Obesity, which increases pressure on the lower back
• Sedentary lifestyle
• Previous back injuries

Symptoms

• Lower back pain radiating to buttocks and legs
• Numbness or tingling in the lower extremities
• Muscle weakness in the legs
• Loss of reflexes in the legs
• Difficulty in controlling bowel or bladder (in severe cases)

Diagnosis

• Physical examination focusing on neurological symptoms
• Imaging tests such as MRI or CT scans to visualize disc and nerve root
• Electromyography (EMG) to assess nerve and muscle function

Treatment Options

• Medications: Pain relievers, anti-inflammatory drugs, or muscle relaxants to ease pain and discomfort
• Physical Therapy: Exercises to improve flexibility, strength, and posture
• Epidural Steroid Injections: Reducing inflammation around the nerve roots
• Surgery: In severe cases, procedures like discectomy or laminectomy to relieve pressure on the nerves

Prognosis and Follow-Up

• With appropriate treatment, many patients experience significant improvement.
• Chronic cases might require ongoing management.
• Regular follow-ups can help monitor symptoms and prevent complications.

Complications

• Chronic pain if the condition is not treated
• Permanent nerve damage leading to persistent weakness or sensory loss
• Cauda equina syndrome (serious condition requiring emergency treatment)

Lifestyle & Prevention

• Maintain a healthy weight to reduce spinal pressure
• Engage in regular physical activity to strengthen back muscles
• Practice good posture while sitting and standing
• Use proper techniques when lifting heavy objects

When to Seek Professional Help

• Sudden worsening of symptoms or severe pain
• Loss of bowel or bladder control
• Progressive weakness or numbness in the legs

Additional Resources

• American Academy of Orthopaedic Surgeons (AAOS)
• National Institute of Neurological Disorders and Stroke (NINDS)

Tips for Medical Coders

• Ensure specificity by confirming the involved region is sacral or sacrococcygeal.
• Document any additional symptoms or underlying conditions for accurate coding.
• Avoid common errors such as misclassifying the anatomical location or cause of radiculopathy.