2025 ICD-10-CM code Q76.0
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Congenital malformations - Congenital malformations of spine and bony thorax Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99) Feed
Spina bifida occulta is a congenital condition characterized by the incomplete closure of the vertebral arches, without protrusion of the spinal cord or meninges.
Medical necessity for further evaluation or intervention for spina bifida occulta depends on the presence of symptoms, associated anomalies, and the presence of tethered cord syndrome.Asymptomatic cases usually require no intervention beyond regular monitoring.Symptomatic cases may require surgical intervention to correct the defect or address complications.
Diagnosis and management of spina bifida occulta may involve neurological examination, imaging studies (X-ray, MRI), and monitoring for any associated symptoms or complications.Referral to a neurosurgeon or orthopedist may be necessary depending on the severity and presence of symptoms.
- Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99)
- Q76 Congenital malformations of spine and bony thorax
In simple words: Spina bifida occulta is a birth defect where the bones of the spine don't completely close, but the spinal cord and its covering remain inside the body.Most people with this condition don't experience any symptoms.
Spina bifida occulta is a type of spina bifida in which the posterior vertebral arches fail to fuse completely, leaving a defect in the spine.However, unlike other types of spina bifida (such as meningocele and myelomeningocele), the spinal cord and meninges do not protrude through the opening.This condition is often asymptomatic and may be discovered incidentally on imaging studies.It's typically located in the lumbosacral region.
Example 1: A 20-year-old patient presents for a routine physical examination.An incidental finding of spina bifida occulta is noted on X-ray imaging of the lumbar spine.The patient is asymptomatic and requires no further treatment., A 35-year-old pregnant woman undergoes an ultrasound examination, revealing spina bifida occulta in the fetus.Genetic counseling and prenatal care are provided to address potential complications or associated anomalies., A 10-year-old child presents with lower back pain and reports intermittent numbness in the legs.Imaging reveals spina bifida occulta, and further investigation is conducted to rule out any neurological compromise or tethered cord syndrome.Referral to a neurosurgeon is made for further evaluation.
Detailed patient history, including symptoms (if any), family history of spina bifida or other congenital anomalies. Physical examination findings, including neurological examination. Imaging reports (X-ray, MRI, CT) if performed.Results of any additional tests performed to evaluate for tethered cord syndrome or other associated conditions.Physician's assessment and plan of care, outlining management and monitoring strategies.
** Spina bifida occulta is a relatively common condition that is often asymptomatic.The diagnosis is usually made incidentally on imaging studies.The prognosis is generally excellent for asymptomatic individuals.However, symptomatic cases may require further evaluation and intervention.
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