Cauda equina spinal cord injury without evidence of spinal bone injury

This code signifies damage to the cauda equina nerve roots, resulting in neurological deficits, but without any associated fracture or dislocation of the vertebral column. It represents a soft tissue injury to the nerve bundle below the conus medullaris. The injury typically manifests as lower extremity weakness, sensory loss, and bowel/bladder dysfunction.

Apply this code when documentation clearly indicates cauda equina syndrome or injury, and imaging (e.g., X-ray, CT) confirms the absence of a spinal bone injury. This code is appropriate for traumatic or non-traumatic causes where the primary pathology is nerve root compression or damage without bony involvement. Supporting documentation includes neurological exam findings, imaging reports, and physician notes detailing the injury mechanism and neurological deficits.

• Ensure documentation explicitly states "without evidence of spinal bone injury" or similar.
• Differentiate from spinal cord injuries with bony involvement (e.g., fractures, dislocations).
• Consider an additional code for the underlying cause of the cauda equina injury (e.g., disc herniation, tumor) if applicable.