Radiculopathy, occipito-atlanto-axial region

This code signifies nerve root compression or irritation originating from the upper cervical spine, specifically involving the occiput, atlas (C1), and axis (C2) vertebral levels. Patients typically present with pain, numbness, tingling, or weakness radiating into the head, face, or upper neck, corresponding to the distribution of the affected nerve root.

Apply this code when documentation clearly indicates radicular symptoms (e.g., dermatomal pain, paresthesia, motor weakness) attributed to nerve impingement in the C1-C2 region. This diagnosis is often supported by physical examination findings, neurological deficits, and imaging studies (e.g., MRI) demonstrating nerve root compression or inflammation at these specific levels.

• Ensure documentation specifies the occipito-atlanto-axial region; otherwise, a more general cervical radiculopathy code may be appropriate.
• Distinguish from cervicogenic headache, which is pain referred from the cervical spine but without true radicular symptoms.
• Consider sequencing this code after any underlying cause of the radiculopathy, such as cervical disc disorder or spondylosis, if documented.