In simple words: This code refers to a baby born with an unspecified type of spina bifida, a birth defect where the spinal cord doesn't close completely, along with hydrocephalus, a condition where there's too much fluid in the brain.

Unspecified spina bifida with hydrocephalus. Spina bifida is a birth defect that occurs when the spine and spinal cord don't form properly. It falls under the broader category of neural tube defects. Hydrocephalus is a condition characterized by an excessive buildup of fluid in the brain, which can cause increased pressure inside the skull and lead to various complications.

Example 1: A newborn is diagnosed with spina bifida and hydrocephalus during prenatal ultrasound. After birth, the infant undergoes surgery to close the spinal defect and a shunt placement to manage the hydrocephalus., An infant presents with an abnormally large head and signs of developmental delay. Imaging studies reveal an open spinal defect and hydrocephalus, leading to a diagnosis of spina bifida with hydrocephalus., A child with previously undiagnosed spina bifida occulta experiences progressive neurological symptoms, and subsequent imaging reveals hydrocephalus as a complicating factor.

Documentation should include detailed imaging findings (e.g., MRI, CT scan) confirming the presence of spina bifida and hydrocephalus. Clinical notes should describe the level and extent of the spinal defect, the presence of any neurological deficits, and the child's developmental milestones. Surgical reports should document any procedures performed, such as closure of the spinal defect or shunt placement.