M46.38
Infection of intervertebral disc (pyogenic), sacral and sacrococcygeal region
Clinical Classification Guidelines
Medical Intelligence & Overview
An infection of the intervertebral disc in the sacral and sacrococcygeal region, identified as M46.38 in the ICD-10 coding system, is a serious condition caused by bacteria or other infectious agents. Also known as pyogenic discitis, this condition involves inflammation and infection of the disc space situated between the vertebrae. While it's relatively rare, it requires prompt medical attention to prevent complications. The infection can cause significant pain, affect mobility, and in severe cases, lead to structural damage around the spinal area.
Causes & Symptoms
Clinical Causes: Bacterial infections, most commonly involving Staphylococcus aureus Spread from adjacent infected tissues or nearby bloodstream (hematogenous spread) Complications from spinal surgeries or invasive procedures Open wounds near the sacral or coccygeal region Pre-existing infections elsewhere in the body that disseminate to the spine Immunocompromised conditions that weaken the body's defense mechanisms
Key Symptoms: Localized pain in the lower back, sacral, or coccygeal region that worsens with movement Fever and chills, indicating systemic infection Tenderness in the affected area upon palpation Restricted movement or stiffness in the lower back Unexplained weight loss in some cases Neurological symptoms such as numbness or weakness if the infection affects nerve structures General malaise and fatigue
Diagnostic & Treatment
Diagnosis Path: Diagnosis involves a combination of clinical evaluation, imaging tests, and laboratory studies. Physicians typically consider the following:
Treatment Protocols: Managing pyogenic infection of the intervertebral disc typically involves a multidisciplinary approach:
Clinical Advice & FAQs
Billing Guidance
Is M46.38 a billable ICD-10 code?
Yes, M46.38 is a specific, billable code that can be used to indicate a diagnosis for reimbursement purposes.
Documentation
How do I report M46.38?
Clinical documentation must specify the nature of Infection of intervertebral disc (pyogenic), sacral and sacrococcygeal region and any associated comorbidities for accurate reporting.
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