Cervical spina bifida with hydrocephalus

This code signifies a congenital neural tube defect where the cervical vertebrae fail to close completely, resulting in an open spinal canal in the neck region, co-occurring with hydrocephalus. This condition involves the protrusion of spinal cord tissue or meninges through the vertebral defect, leading to neurological deficits and increased intracranial pressure due to cerebrospinal fluid accumulation.

Use this code when documentation clearly indicates a diagnosis of spina bifida specifically located in the cervical spine, along with a confirmed diagnosis of hydrocephalus. This is typically identified at birth or early infancy through imaging studies like ultrasound, MRI, or CT scans, and clinical assessment of neurological function and head circumference.

• Always ensure the documentation specifies the cervical region for the spina bifida component.
• Verify that hydrocephalus is explicitly documented as co-occurring with the spina bifida, not as a separate, unrelated condition.
• Consider additional codes for any associated neurological deficits, such as paralysis or sensory loss, and for the specific type of hydrocephalus if known.