Central cord syndrome at C4, sequela

This code signifies the long-term effects or complications arising from central cord syndrome specifically affecting the C4 level of the cervical spinal cord. Central cord syndrome is characterized by disproportionately greater motor impairment in the upper extremities than in the lower extremities, bladder dysfunction, and variable sensory loss, typically resulting from hyperextension injuries. The "sequela" designation indicates that this code is used for residual conditions after the acute phase of the injury has passed.

Use this code when documenting the chronic neurological deficits or ongoing symptoms directly attributable to a past central cord injury at the C4 level. This applies to patients presenting with persistent weakness, sensory changes, or spasticity in the upper limbs, or bladder issues, that are a direct consequence of the original C4 central cord injury. Documentation should clearly state the C4 level involvement and the chronic nature of the condition.

• Always assign this code as a secondary diagnosis, following the code for the specific residual condition (e.g., hemiplegia, spasticity).
• Ensure documentation specifies "C4 level" and indicates the condition is a "sequela" or "chronic" effect of the injury.
• Distinguish from acute central cord syndrome (S14.124A, D) which would be used for the initial injury or subsequent encounter for active treatment.