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2025 ICD-10-CM code A18.01

Tuberculosis of the spine.

Use additional code to identify resistance to antimicrobial drugs (Z16.-). Do not code non-specific reactions to tests for tuberculosis without active disease (R76.1-).

Medical necessity for services related to A18.01 is established by the presence of signs and symptoms of spinal tuberculosis, along with confirmatory diagnostic tests. Treatment is medically necessary to prevent serious complications like spinal deformity, neurological damage, and further spread of infection.

Physicians should be aware of the insidious nature of spinal tuberculosis and maintain a high index of suspicion in patients with persistent back pain, especially those from endemic areas or with risk factors for TB.A thorough clinical evaluation, including imaging and biopsy if necessary, is crucial for diagnosis. Multidisciplinary management involving specialists such as orthopedic surgeons, infectious disease specialists, and neurologists may be necessary.

In simple words: Pott's disease is a serious infection of the spine caused by the same bacteria that cause tuberculosis in the lungs. The infection can weaken the bones of the spine, sometimes causing them to break and leading to a hunched back. It can also cause pain, nerve problems, and even paralysis.

Tuberculosis of the spine, also known as Pott's disease, is a form of extrapulmonary tuberculosis that affects the vertebrae.It typically begins in the lungs and spreads to the spine through the bloodstream, causing inflammation and the formation of abscesses. This can lead to vertebral collapse, kyphosis (curvature of the spine), and neurological complications.

Example 1: A 30-year-old immigrant with a history of pulmonary tuberculosis presents with progressive mid-back pain, low-grade fever, and weight loss. An MRI reveals destruction of the T10-T11 vertebrae and a paraspinal abscess, confirming spinal tuberculosis., A 65-year-old immunocompromised patient experiences severe neck pain, difficulty swallowing, and neurological deficits in the arms. Imaging reveals spinal tuberculosis in the cervical spine with significant cord compression, necessitating surgical intervention., A child from a developing country presents with a noticeable kyphotic deformity in the thoracic spine.Diagnostic studies and biopsy confirm spinal tuberculosis, and the child is started on anti-tubercular therapy.

Documentation for A18.01 should include evidence of Mycobacterium tuberculosis infection in the spine, such as imaging findings (X-ray, CT, MRI) showing vertebral destruction, disc involvement, or abscesses. Biopsy results confirming the presence of M. tuberculosis are also essential. Clinical findings like back pain, neurological deficits, and constitutional symptoms (fever, weight loss) should be documented. Details of treatment, including medications and surgical procedures, should also be recorded.

** Spinal tuberculosis is more common in individuals with weakened immune systems, such as those with HIV. Early diagnosis and treatment are crucial to preventing long-term complications.

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