Syringomyelia and syringobulbia

This code identifies a chronic neurological condition characterized by the formation of a fluid-filled cyst (syrinx) within the spinal cord (syringomyelia) or brainstem (syringobulbia). This cyst expands over time, compressing and damaging surrounding nerve tissue, leading to a variety of neurological deficits.

Assign this code when documentation clearly indicates a diagnosis of syringomyelia or syringobulbia, regardless of the underlying cause. This includes cases secondary to Chiari malformation, trauma, tumors, or idiopathic origins. Supporting documentation should detail neurological symptoms and imaging findings (e.g., MRI) confirming the presence and location of the syrinx.

• Do not use this code for simple spinal cord cysts without evidence of syrinx formation and associated neurological compromise.
• Always code any underlying or associated conditions, such as Chiari malformation (Q07.0), in addition to this code.
• Ensure documentation specifies whether the syrinx is in the spinal cord or brainstem, as this impacts the specificity of the diagnosis.