Clinical Documentation Improvement Series #4, Documenting Myelopathies and Radiculopathies
When there are spine related disorders, specially the ones related to degenerative spondylosis, it is very important to establish if myelopathies or radiculopathies are present. A myelopathy is present if there is compression of the spinal cord. It can show as pain, difficulty walking or loss of bladder or bowel control. The nature of the symptom depends on the affected level in the spine. A radiculopathy is caused by the compression of a nerve root. Its main symptoms are pain, numbness, weakness and tingling. Documenting these conditions is essential to describe and specify correctly the nature of the spinal disorder.
Marco A. Ramos MD, CCDS
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