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Abstract

Coccydynia refers to a pathological condition in which pain occurs in the coccyx or its immediate vicinity. The pain is usually provoked by sitting or rising from sitting. Most cases are associated with abnormal mobility of the coccyx, which may trigger a chronic inflammatory process leading to degeneration of this structure. The exact incidence of coccydynia has not been reported; however, factors associated with increased risk of developing coccydynia include obesity and female gender. Several non operative interventions are currently used for the management of coccydynia including Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), hot baths, ring-shaped cushions, intrarectal massage and manipulation (manual therapy), steroid injection, dextrose prolotherapy, ganglion impar blocks, pulsed Radio Frequency Thermocoagulation (RFT) and psychotherapy. Several studies have reported good or excellent results after coccygectomy especially in patients who are refractory to conservative treatment.
Citation: Sarmast AH, Kirmani AR and Bhat AR. Coccydynia: A Story Retold. Austin J Surg. 2016; 3(3): 1091.
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Austin Journal of Surgery
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Abstract
Coccydynia refers to a pathological condition in which pain occurs in the
coccyx or its immediate vicinity. The pain is usually provoked by sitting or rising
from sitting. Most cases are associated with abnormal mobility of the coccyx,
which may trigger a chronic inammatory process leading to degeneration of this
structure. The exact incidence of coccydynia has not been reported; however,
factors associated with increased risk of developing coccydynia include obesity
and female gender. Several non operative interventions are currently used
for the management of coccydynia including Non-Steroidal Anti-Inammatory
Drugs (NSAIDs), hot baths, ring-shaped cushions, intrarectal massage and
manipulation (manual therapy), steroid injection, dextrose prolotherapy,
ganglion impar blocks, pulsed Radio Frequency Thermocoagulation (RFT)
and psychotherapy. Several studies have reported good or excellent results
after coccygectomy especially in patients who are refractory to conservative
treatment.
Keywords: Coccydynia; Coccygectomy; Sacrococcygeal joint
Introduction
e word ‘coccyx’ has its ancestry from the Greek word used the
beak of the cuckoo bird due to remarkable resemblance in appearance
when viewed from the side [1-3].
Any pain that occurs in the coccyx or its immediate vicinity is
termed as coccydynia, inherently referring to varied pathological
condition which gives rise to it [4]. e pain symptoms may be
particularly acute when external force acts directly on the tailbone;
this typically occurs during every-day activities such as sitting. Along
with the bilateral ischial tuberosities, the coccyx bears the brunt of
body weight during sitting. Notably, when a seated individual leans
back, the weight load is borne almost entirely by the coccyx, and gives
rise to classic pain syndrome when a person leans backwards [5].
Surgical treatment for coccydynia has been viewed with caution
historically [4] as it has been associated with high complication rates
and variable eectiveness. Better outcomes with coccygectomy have
been reported more recently [6].
e term coccydynia was coined by Simpson in 1859 [7]. e pain
is usually provoked by sitting or rising from sitting position as was
described by Maigne et al. [8]. ey found a high diagnostic value
of this symptom in predicting instability. Most cases are associated
with abnormal mobility of the coccyx, which may trigger a chronic
inammatory process leading to degeneration of this structure [9].
Postacchini and Massobrio described four types of conguration
of the coccyx and designated them type I through type IV. In type I,
the coccyx is curved slightly forward with its apex directed downward
and caudally. In type II, the forward curvature is more marked and
the apex extends straightforward. In type III, the coccyx most sharply
angles forward (Figure 1). Finally in type IV, the coccyx is subluxated
at the sacrococcygeal or intercoccygeal joint. e coccygeal
conguration also appears to inuence prevalence and causative
lesion. Types II, III, and IV are more prone to become painful than
Special Article - Brain Tumor Surgery
Coccydynia: A Story Retold
Sarmast AH*, Kirmani AR and Bhat AR
Department of Neurosurgery, Sher I Kashmir Institute of
Medical Sciences, India
*Corresponding author: Arif Hussain Sarmast,
Department of Neurosurgery, Sher I Kashmir Institute of
Medical Sciences, Dalipora Kawadara Srinagar Kashmir,
India
Received: May 06, 2016; Accepted: October 20, 2016;
Published: October 26, 2016
those with type I [10]. Anterior subluxation is a rare lesion and tends
to occur in type III and type IV patterns. Posterior subluxation is
more common in the straighter type I conguration [11].
Maigne et al. [11] also described four types of coccyges: rigid (with
or without a spicule), normal mobility, hypermobile and dislocating.
Incidence & Etiology
e exact incidence of coccydynia has not been reported; however,
factors associated with increased risk of developing coccydynia
include obesity and female gender. Women are 5 times more likely
to develop coccydynia than men. Adolescents and adults are more
likely to present with coccydynia than children. Anecdotally, rapid
weight loss canal so be a risk factor because of the loss of mechanical
cushioning. e most common etiology of coccydynia is external or
internal trauma. External trauma usually occurs due to a backwards
fall, leading to a bruised, dislocated, or broken coccyx. e location of
the coccyx makes it particularly susceptible to internal injury during
childbirth, especially during a dicult or instrumented delivery.
Figure 1: Coccyx Lat conguration.
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Minor trauma canal so occur from repetitive or prolonged sitting on
hard, narrow, or uncomfortable surfaces [11-13].
However, a study conducted by Maigne et al. has suggested that
only a traumatic event occurring within 1 month of onset is signicant
in increasing the risk of instability and subsequent coccydynia
[11,14]. ey demonstrated that the proportion of patients who
develop instability following a traumatic event before 1 month of
onset is nearly equal to the proportions that develop instability
without a history of trauma (55 and 53%, respectively). By contrast,
the instability rate was found to be 77.1% when the traumatic event
was less than a month previously [11].
In addition, the coccygeal lesion pattern observed in obese,
normal-weight, and thin coccydynia patients markedly diers. Obese
patients have mainly posterior subluxation, normal-weight patients
have mainly hyper mobility or radio graphically normal coccyges, and
thin patients have mainly anterior subluxation and spicules [11,15].
ese ndings suggest the following explanation. e coccyx of a
leaner patient normally rotates during sitting so that the coccyx is in
an optimal position to absorb the forces that are generated during this
activity. As the BMI increases, the degree of pelvic rotation with sitting
is reduced and the angle of incidence is increased. Consequently, the
coccyx in obese patients is more susceptible to sudden elevations in
intrapelvic pressure that occur with a fall and repeated sitting down.
is increased exposure to pressure places the coccyx at an increased
risk of posterior subluxation, which as mentioned previously is the
typical post-traumatic lesion. Normal and below-normal weight
patients are more likely to develop coccydynia consequent to lesion
patterns other than posterior subluxation as their coccyges rotate in
a more optimal fashion to lessen forces from falls and sitting [11,15].
Nontraumatic coccydynia can result from a number of causes,
including degenerative joint or disc disease, hyper mobility or
hypo mobility of the sacrococcygeal joint, infectious etiology, and
variants of coccygeal morphology. Coccydynia can also be radicular
or referred pain, although this type of pain usually is not associated
with the hallmark coccygeal tenderness on physical examination.
Less commonly, neoplasms have been associated with coccydynia.
Coccydynia can also be associated with nonorganic causes, such as
somatization disorder and other psychological disorders. Idiopathic
coccydynia has been described in the absence of any obvious
pathologic changes involving the coccyx, although this is considered
a diagnosis of exclusion; in these patients the pain may actually result
from spasticity or other abnormalities aecting the musculature of
the pelvic oor [16].
Presentation
e classic presentation of coccydynia is localized pain over the
coccyx. Patients present complaining of ‘‘tailbone pain’’. e pain will
usually be worse with prolonged sitting, leaning back while seated,
prolonged standing, and rising from a seated position. Pain may also
be present with sexual intercourse or defecation. History may be
signicant for a recent trauma with an acute onset of pain, or the onset
of pain may have been insidious with no clear inciting factor. Physical
examination will reveal tenderness over the coccyx, non tender
coccygeal pain rules out coccydynia & should guide the examiner
to look for disc disorder etc Local clinical examination should rule
out pilonidal sinus & rarely perianal abscess. Rectal examination
allows the coccyx to be grasped between the forengers and thumb.
Manipulation will elicit pain and may reveal hyper mobility or hypo
mobility of the sacro coccygeal joint [11]. Coccydynia is also qualied
as acute or chronic. Chronic coccydynia is dened as lasting > 2
months [17].
Differential diagnosis
e dierential diagnosis of coccydynia coccydynia is large and
includes lumbar spondylosis or disc herniation, proctalgia fugax,
levator ani syndrome, Alcock canal syndrome, descending perineal
syndrome, piriformis syndrome, anogenital syndrome, perianal
abscess or tula, and rectal tumors or teratomas [18]. Tarlov cyst
has been reported as a rare cause of coccydynia [19]. Care must be
taken to exclude patients with oending local pathological conditions
or atypical symptoms from consideration for coccygectomy.
Primary coccydynia is distinguished from referred coccydynia (so-
called pseudococcygodynia) [20] by inltrating the periosteum
at the tender point with 10 ml of 0.25% bupivacaine and 40 mg of
methylprednisolone acetate, which will elicit temporary symptomatic
relief in primary coccydynia. Although the injection provides relief of
coccydynia, the results are typically quite temporary, rendering this
more useful as a diagnostic tool than as a feasible long term solution.
Nevertheless, repeated periosteal injections may be considered a
treatment option in selected cases. ose with pseudococcygodynia
should not experience relief of pain with the injection, and these
patients must not be considered for coccygectomy.
Diagnosis; imaging studies
Dynamic radiographs: Single position radiographs seldom
demonstrate any denitive morphologic dierences between normal
individuals and patients with coccydynia; hence these views are not
diagnostic [10]. Dynamic radiographs obtained in both the sitting
and standing positions may be more useful than static X-rays because
they allow for measurement of the sagittal rotation of the pelvis
and the coccygeal angle of incidence. A comparison of sitting and
standing lms will yield radiographic abnormalities in up to 70% of
symptomatic coccydynia cases [21]. Dynamic radiographs are usually
taken to assess the hyper mobility of the sacrococcygeal region. e
rst radiograph is taken when the patient is standing for at least 10
min in order to get the coccyx in a neutral position. en the patient
is asked to sit with a straight back and thighs horizontal. Patient
is asked to bend backwards until pain is reproduced and a second
radiograph is taken at this point. A post subluxation occurs when
the coccyx is pushed backwards when sitting and comes back to its
normal place when standing up. A coccyx normally pivots between 5
and 25 degrees when the patient sits and returns to its original angle
once the subject stands. In contrast, individuals with coccydynia
frequently exhibit coccygeal displacement, immobility (<5º motion)
or hyper mobility (described as exion of >25º of motion) on lateral
radiographs [14,22].
Computed Tomography (CT) /Magnetic Resonance
Imaging (MRI)
Advanced imaging modalities may be also be utilized to establish
a diagnosis of coccydynia, although these techniques may not be as
accurate as dynamic radiographs. Lumbosacral MRI with contrast is
recommended in all patients to dene normal and abnormal bony
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anatomy and to rule out less common causes of coccydynia, such
as abscess or tumors. CT is superior to MRI in dening normal and
abnormal bony anatomy. CT should be ordered in cases of acute
pelvic trauma, and as an adjunct to MRI in evaluating neoplastic
disease. Magnetic Resonance Imaging (MRI) and technetium Tc-99m
bone scans may demonstrate inammation of the sacrococcygeal
area indicative of coccygeal hyper mobility. Provocative testing of
the coccyx, such as pressing on the region with a blunted needle to
elicit pain, and pain relief with the injection of local anesthetic under
uoroscopic guidance may also be useful in diagnosis as well [14,23].
Non operative management
Several non operative interventions are currently used for
the management of coccydynia including Non-Steroidal Anti-
Inammatory Drugs (NSAIDs), hot baths, ring-shaped cushions,
intrarectal massage and manipulation (manual therapy) steroid
injection, dextrose prolotherapy, ganglion impar blocks, pulsed
Radio Frequency ermo coagulation (RFT), corticosteroid and
methylene blue injections, intradiscal injections, intradiscal electro
thermal therapy and psychotherapy [16,24-32].
One possible mechanism for persistent coccydynia is excessive
activity or sensitivity of the ganglion impar, thus creating
sympathetically maintained coccyx pain [30]. Injection therapies
utilized in the management of coccydynia involve the following
possible mechanisms of pain relief: anti-inammatory eects [31],
formation of scar tissue [27], and inhibition of the ganglion impar
[17]. Local injection of an anesthetic can eectively block the
ganglion impar and thereby relieve coccyx pain. In a published report
by Foye and colleagues, nerve blocks using local anesthetics with a
fast onset (e.g., lidocaine) were shown to provide substantial relief
even by the time a patient sat up on the procedure table [29]. Aer
the local anesthetic block wears o, some of the coccyx pain may
start to return, but generally it returns at a much lower severity than
existed prior to the injection. Physical medicine and rehabilitation
coccydynia physicians and researchers at New Jersey Medical School
refer to this new plateau of severity as “resetting the thermostat”.
Published reports document that some patients with coccydynia
receive complete and permanent relief via a single ganglion impar
block [29].
ermo coagulation of the ganglion impar using Radiofrequency
Ablation (RFA) has been reported [31,33,34]. Ablation can also be
accomplished chemically (e.g., by carefully injecting neurotoxic agents
such as phenol and/or ethyl alcohol directly onto the targeted nerve
tissues). ese coccygeal ablation injections have been in clinical use
for multiple decades and thus are no longer considered experimental
[1]. Ablation is typically reserved for patients whose pain has failed
to be adequately relieved via oral analgesic medications, cushions,
coccyx steroid injections, and coccygeal sympathetic nerve blocks
(ganglion impar).
Maigne et al. [24] reported intra rectal manipulation had only
mild eectiveness in the treatment of chronic coccydynia and tended
to be more successful in patients with post-traumatic etiology, a stable
coccyx, and shorter duration of symptoms. Khatri et al. [25] reported
that intra rectal manipulation was eective for treating idiopathic
coccydynia. However, in their methods they did not adequately
control for the use of analgesics, which threatens the validity of
their conclusion. Two investigators performed manipulation in the
sagittal plane [24,26] while one chose to manipulate the coccyx in the
coronal plane [25]. Two studies included massage to the levatorani
as part of the manual therapy provided [24,26], however, the role of
the levatorani muscle in coccydynia is an area for further research.
In only one study was intra rectal manipulation performed by a
physiotherapist [27].
For patients who do not respond to these forms of intervention,
coccygectomy is oen recommended. Willems P et al. [35] however
in their study consistently showed a lack of consensus among spine
surgeons in surgical decision making. Despite high levels of training
and continuous medical education, patient selection for fusion
surgery in the treatment of chronic low back pain does not have a
uniform evidence base in clinical practice.
Operative management-Coccygectomy
Several studies have reported good or excellent results aer
coccygectomy [3,10,36-47].
Surgical Technique
Preoperative preparation
Before being listed for coccygectomy, each patient must have
failed medical therapy and nonsurgical treatment. is includes
the failure of Manipulation Under Anesthetic (MUA) and at least 2
attempts at local anesthetic and steroid inltration [48].
Usually a low-residue diet is started 5 days prior to surgery and
a eet enema is given 24 hrs before or on the day of the surgery.
Some surgeons start low residue diet just 1 day before surgery. An
increased risk of wound infection aer coccygectomy has been
reported; therefore, preoperative antibiotics are given aer induction
of anesthesia. Anecdotally, this is due to the anatomical region where
the surgery is performed.
Position
Patient is put in prone position on bolsters, or on a Wilsons frame
and the operation table is exed at the patient’s waist. Both buttocks
are separated by a hard tape to expose the area properly. e coccygeal
region and anus are prepared with iodine or chlorhexidine. e skin is
inltrated with lidocaine and epinephrine. Lateral uoroscopic images
are used to locate the sacro coccygeal junction. Most surgeons prefer
median longitudinal incision starting above the sacro coccygeal joint
and extending down to the coccyx. Care should be taken not to extend
the incision near perianal skin. e incision is deepened through the
fascia and gluteus muscles until the bone is felt. With blunt dissection,
the tip of the coccyx is located. e sacro coccygeal disc is removed
or osteotomized in the case of a synchondrosis. e coccygeal vessels
on each side are ligated or cauterized. e anococcygeal ligament
is incised and the tip of the coccyx is elevated. e coccygeus and
ileococcygeus muscles are dissected through muscle attachments and
incised carefully, protecting the rectum. All segments and layers of
the coccyx including the periosteum are excised.
Some surgeons prefer to create a subperiosteal plane on both sides
of tip by sharp dissection and leave the ligamentous and muscular
attachments along with periosteum behind. coccyx is separated from
the surrounding tissues in a subperiosteal plane using monopolar
electro cautery, elevating the coccyx posterior, and proceeding with an
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en bloc resection in a rostra to caudal direction according the method
of Key [49]. Dissection from a proximal to distal direction limits the
risk of rectal injury, especially in the case of an anteverted coccyx. En
bloc resection prevents treatment failures secondary to incomplete
resection. e results of a recent study show that periosteum
preservation and closure result in low risk of postoperative infection.
Care is taken in excising the coccyx as it lies close to the rectum.
Gardener described a technique in mobilizing the rectum and dense
fascia deep to sacro coccygeal joint with advantages of protecting the
rectum, less risk of infection, and more rapid healing [42]. Aer the
coccyx is removed the distal prominent end of the sacrum is beveled.
A complete resection may be ascertained by examining the resected
specimen and by checking a lateral C-arm oroscopic radiograph
to ensure complete resection compared with preoperative imaging.
e dead space is obliterated by drawing the cut ends of aponeurotic
tissues in the midline, and applying two to four mattress stitches with
absorbable sutures. e subcutaneous and skin is closed in layers.
Usually a small drain is placed if the dead space is le and a small
dressing is applied [42,48].
Nevertheless, wound infection is the most important
complication of this procedure. Apart from total coccygectomy, a
partial resection of the coccyx has also been described for the surgical
treatment of coccydynia. Postacchini reported no dierence in the
outcome for partial resection compared to that of complete coccygeal
resection [10]. However, other authors have demonstrated superior
postoperative outcomes with complete coccygectomy in comparison
to partial coccygectomy [40]. In our series, only a complete resection
was performed.
Complications
Coccygectomy may seem to be a technically facile procedure.
However, myriad complications have been documented in the
extant literature. In a review of 24 studies involving 671 patients,
an overall 11% complication rate has been reported. Complication
rates in studies varied from 0% [49] to 50% [50]. e most common
complications cited were: wound infections (8.34%), and wound
healing problems with dehiscence. Delayed healing (0.9%) and wound
hematomas (0.3%) were also reported [6]. Wound infections were in
the majority of cases supercial. Serious complications, such as severe
infections or injuries of the intestinal tract, rectal prolapsed etc have
also been described; however, these were extremely rare [6]. In myriad
studies, perioperative antibiotic prophylaxis was administered. e
local skin ora, proximity to the anus, and hygiene dilties due to
the anatomical location of the operative site increases the risk of
contamination. e most common causative agents of postoperative
wound infection were gram-negative rods [31]. Several studies have
shown that a ve-day course of postoperative antibiotics (second-
generation cephalosporins) can eectively reduce the infection rate
[22,41,46,50].
Doursounian L et al. [51] in their study of 136 coccygectomy
patients proposed the use of a topical skin adhesive on the
postoperative wound as a signicant contributor in preventing post
operative infections.
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Citation: Sarmast AH, Kirmani AR and Bhat AR. Coccydynia: A Story Retold. Austin J Surg. 2016; 3(3): 1091.
Austin J Surg - Volume 3 Issue 3 - 2016
ISSN : 2381-9030 | www.austinpublishinggroup.com
Sarmast et al. © All rights are reserved
... are trauma (50% of cases), 6 extensive weight loss, extensive weight gain, degenerative joint disease, pelvic floor muscle spasm, herniated lumbar disk, pilonidal cyst, fistula, perianal abscess, and neoplasm. 4,7 In our review of literature, we found no reported incidence rate of coccydynia. 4,7 Patients who are obese are predisposed to coccydynia because excess weight adds more pressure and force on the coccyx during periods of sitting and standing. ...
... 4,7 In our review of literature, we found no reported incidence rate of coccydynia. 4,7 Patients who are obese are predisposed to coccydynia because excess weight adds more pressure and force on the coccyx during periods of sitting and standing. 4,7 Paradoxically, extensive weight loss causes a loss of adipose tissue and fibrous cushioning around the coccyx and thus exposes the coccyx to more mechanical force, which leads to coccydynia. 4 The literature 4,7 shows coccydynia to be 5 times more likely in women than in men, primarily due to mechanical changes to the muscles of the pelvic diaphragm that attach to the coccyx during childbirth. ...
... 4,7 Patients who are obese are predisposed to coccydynia because excess weight adds more pressure and force on the coccyx during periods of sitting and standing. 4,7 Paradoxically, extensive weight loss causes a loss of adipose tissue and fibrous cushioning around the coccyx and thus exposes the coccyx to more mechanical force, which leads to coccydynia. 4 The literature 4,7 shows coccydynia to be 5 times more likely in women than in men, primarily due to mechanical changes to the muscles of the pelvic diaphragm that attach to the coccyx during childbirth. ...
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Article
A 21-year-old man with atypical coccydynia that radiated bilaterally to his thigh and lower back came for treatment 10 years after coccyx trauma. Pertinent review of systems showed unintentional weight loss of 20 lb over the past 1 to 3 years, a body mass index of 14.94, significant depression, and poor concentration. In addition to treating his pain, we addressed the weight loss and depression that he was experiencing by advising a balanced diet, discovering the origins of what the patient believed caused his depression, and using osteopathic manipulative treatment. The patient was treated with osteopathic manipulative treatment to alleviate somatic dysfunctions diagnosed in the head, cervical, thoracic, lumbar, and sacral regions. At follow-up visits, the patient described a reduction in his pain symptoms from an initial 5 out of 10 to 3 out of 10 on his third visit. This case report outlines the importance of using a holistic approach when treating patients and advocates for using osteopathic manipulative treatment as a viable treatment option for patients with coccydynia.
... Coccygectomy performed for patients with chronic coccydynia has met with considerable success, with success rate as high as 90%. 1 However, the procedure is associated with infection rate as high as 30% with the standard midline incision approach. [2][3][4][5][6][7] The prolonged nature of disease, uncertain treatment protocols and high rate of wound complications associated with the surgery can lead to a poor quality of life. ...
... Coccydynia is usually associated with direct trauma, repetitive microtrauma, postnatal period, spasm of pelvic floor muscles, local tumors, degenerative disc disease, post-weight loss/bariatric surgery or could be idiopathic in nature. 3,6,[11][12][13][14] It is most commonly seen in females and is associated with obesity. 11 The classical presentation of coccydynia is localized pain over the coccyx. ...
... Pain worsens with prolonged sitting, leaning back while seated, prolonged standing, and rising from a seated position. 6,11,14,15 The condition appears to be emerging as a major problem in the current millennium with an increasing population base that sits in front of computers for extended periods. Many patients also experience pain with sexual intercourse or defecation. ...
Full-text available
Article
Study design: Technical note. Objectives: Coccygectomy for chronic coccydynia has a high rate of successful clinical outcome. However, the procedure is associated with increased incidence of wound dehiscence and surgical site infection. The main objective was to evaluate the clinical outcomes of coccygectomy using the Z plasty technique of wound closure. Methods: Patients with chronic coccydynia refractory to conservative treatment underwent coccygectomy followed by Z plasty technique of wound closure between January 2013 and February 2018. Primary outcome measure was evaluation of the wound healing in the postoperative period and at follow-up; secondary outcome measure included visual analogue scale (VAS) score for coccygeal pain. Results: Ten patients (male:female 6:4) fulfilled the inclusion criteria. The mean age of patients was 40.78 years (range 19-55 years). The mean follow-up was 1.75 years (range 6 months to 5 years). All wounds healed well with no incidence of wound dehiscence or surgical site infections. The mean VAS improved from 7.33 ± 0.5 to 2.11 ± 1.2 (P < .05). Nine patients reported excellent outcomes and 1 patient reported poor outcome with regards to relief from coccydynia. Conclusion: Z plasty technique of wound closure is recommended as procedure of choice to avoid wound healing problems and surgical site infections associated with coccygectomy. Coccygectomy remains a successful treatment modality for chronic coccydynia.
... 19 Mixed local anesthetic and steroid injection around the coccyx, in either joints or ligaments, has diagnostic and therapeutic usefulness in identifying the cause of pain and the possible benefit from coccygectomy if all conservative approaches fail. 7,[23][24][25] Nevertheless, because coccygectomy is associated with a high complication rate and failure to relieve pain, it is not recommended. The alternative is application of polymethylmethacrylate cement, termed coccygeoplasty, to fix and fuse the sacrococcygeal joint. ...
... Although a local anasthetic with fast onset (e.g., Lidocaine) provides temporary relief, pain usually returns although at less severity than that experienced prior to injection, "resetting the thermostat" to a new, lower plateau of severity. 25 Despite having only mild effectiveness, as reported in randomized controlled trials by Maigne et al., 32 manipulation tends to be more successful with post-trauma cases, as seen in Case 2. The combination of local corticosteroid injection and manual manipulation provides a better success rate compared to either injection or manipulation alone. 31,33 Manipulation is thought to provide mechanical or neurophysiological effects that modulate pain through the stimulation of articular receptors type I and II. ...
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Article
Purpose The purpose of this study was to find out the effectiveness of coccygeal manipulation in the management of coccydynia. Design Randomized control trial where the subjects were randomly allocated to control & experimental groups. Setting Physiotherapy outpatient department of KLES Hospital, Belgaum, Karnataka state, India - 590010. Participants Subjects with idiopathic coccydynia. Interventions Phonophoresis, TENS & coccygeal manipulation. Main Outcome Measures Intensity of pain on visual analogue scale & pain free sitting time. Methods Control group subjects were treated with phonophoresis, use of coccygeal pillow and TENS only. Experimental group subjects were treated with coccygeal manipulation in addition to above protocol of the treatment. Results Subjects treated with coccygeal manipulation had statistically and clinically better out come in terms of pain relief and pain free sitting time at the end of tenth treatment session. Conclusions Idiopathic coccydynia is somewhat common in obese individuals as it determines the way a subject sits. Coccygeal manipulation could be of help and can be used as an addition to the conventional physiotherapy treatment.
Full-text available
Article
Objectives To assess the use of prognostic patient factors and predictive tests in clinical decision making for spinal fusion in patients with chronic low back pain. Design and setting Nationwide survey among spine surgeons in the Netherlands. Participants Surgeon members of the Dutch Spine Society were questioned on their surgical treatment strategy for chronic low back pain. Primary and secondary outcome measures The surgeons' opinion on the use of prognostic patient factors and predictive tests for patient selection were addressed on Likert scales, and the degree of uniformity was assessed. In addition, the influence of surgeon-specific factors, such as clinical experience and training, on decision making was determined. Results The comments from 62 surgeons (70% response rate) were analysed. Forty-four surgeons (71%) had extensive clinical experience. There was a statistically significant lack of uniformity of opinion in seven of the 11 items on prognostic factors and eight of the 11 items on predictive tests, respectively. Imaging was valued much higher than predictive tests, psychological screening or patient preferences (all p<0.01). Apart from the use of discography and long multisegment fusions, differences in training or clinical experience did not appear to be of significant influence on treatment strategy. Conclusions The present survey showed a lack of consensus among spine surgeons on the appreciation and use of predictive tests. Prognostic patient factors were not consistently incorporated in their treatment strategy either. Clinical decision making for spinal fusion to treat chronic low back pain does not have a uniform evidence base in practice. Future research should focus on identifying subgroups of patients for whom spinal fusion is an effective treatment, as only a reliable prediction of surgical outcome, combined with the implementation of individual patient factors, may enable the instalment of consensus guidelines for surgical decision making in patients with chronic low back pain.
Article
Coccygectomy is a controversial operation. Some authors have reported good results, but others advise against the procedure. The criteria for selection are ill-defined. We describe a study to validate an objective criterion for patient selection, namely radiological instability of the coccyx as judged by intermittent subluxation or hypermobility seen on lateral dynamic radiographs when sitting. We enrolled prospectively 37 patients with chronic pain because of coccygeal instability unrelieved by conservative treatment who were not involved in litigation. The operation was performed by the same surgeon. Patients were followed up for a minimum of two years after coccygectomy, with independent assessment at two years. There were 23 excellent, 11 good and three poor results. The mean time to definitive improvement was four to eight months. Coccygectomy gave good results in this group of patients.
Article
An understanding of the anatomy of the coccyx and its joints is helpful in evaluating its disorders. Injury and disease of the coccyx are subject to accurate diagnosis, as are any other bone and joint disorders. Lesions of the coccyx are comparable with those of other parts of the skeletal system. Traumatic osteoarthritis and sprain are the most common disorders of the coccygeal joints. True psychoneurosis related to the coccyx is rare. Pain in the coccyx can be relieved usually by removal of the weight from this area in sitting, aided by physical therapy. Persistent pain in the coccyx may be relieved by coccygectomy, but the operation should be chosen carefully and performed well.
Article
When conservative therapies such as pain medication or exercise therapy fail, invasive treatment may be indicated for patients with lumbosacral spinal pain. The Dutch Society of Anesthesiologists, in collaboration with the Dutch Orthopedic Association and the Dutch Neurosurgical Society, has taken the initiative to develop the guideline "Spinal low back pain," which describes the evidence regarding diagnostics and invasive treatment of the most common spinal low back pain syndromes, that is, facet joint pain, sacroiliac joint pain, coccygodynia, pain originating from the intervertebral disk, and failed back surgery syndrome. The aim of the guideline is to determine which invasive treatment intervention is preferred for each included pain syndrome when conservative treatment has failed. Diagnostic studies were evaluated using the EBRO criteria, and studies on therapies were evaluated with the Grading of Recommendations Assessment, Development and Evaluation system. For the evaluation of invasive treatment options, the guideline committee decided that the outcome measures of pain, function, and quality of life were most important. The definition, epidemiology, pathophysiological mechanism, diagnostics, and recommendations for invasive therapy for each of the spinal back pain syndromes are reported. The guideline committee concluded that the categorization of low back pain into merely specific or nonspecific gives insufficient insight into the low back pain problem and does not adequately reflect which therapy is effective for the underlying disorder of a pain syndrome. Based on the guideline "Spinal low back pain," facet joint pain, pain of the sacroiliac joint, and disk pain will be part of a planned nationwide cost-effectiveness study. © 2015 World Institute of Pain.
Article
The ganglion impar, a single structure usually found at the anterior aspect of the sacrococcygeal joint, is the lowest ganglion of the paravertebral sympathetic chain. Its blockade is indicated in visceral pain syndromes and/or sympathetic pain syndromes of the perineal region. Several approaches to this block have been described, mainly through the anococcygeal or sacrococcygeal ligaments. We propose a modified approach to thermocoagulation of the ganglion impar, using a two-needle technique, the first one, placed through the sacrococcygeal ligament, the transsacrococcygeal needle, and the second one through a coccygeal disc, the transdiscal needle. The thermocoagulation technique that we employ uses a conventional radiofrequency application of 80°C for 80 seconds through each needle.In this prospective study, 13 patients with chronic perineal, noncancer-related pain were followed for a maximum of 6 months. All of these patients underwent diagnostic ganglion impar block with local anesthetic prior to inducing neurodestruction with conventional radiofrequency application, as a positive result to the diagnostic local anesthetic block was a requisite for radiofrequency neurodestruction. We measured pain using a visual analog scale (VAS) before and after treatment. Statistical significance was assessed using the Mann–Whitney U-test and Wilcoxon range summation test. Initially the VAS was equal to or greater than 7. After therapy the VAS decreased by an average of 50% in the whole group. There were no adverse events.Our result show that this proposed modified approach to the block and use of radiofrequency for the ganglion impar is useful for the treatment of perineal noncancer-related pain.
Article
Imaging of the painful coccyx currently relies on standard and dynamic radiography. There are no literature data on MRI of the coccyx. This examination could provide information on the cause of pain. 172 patients with severe chronic coccydynia underwent MRI and dynamic radiography of the coccyx. Disc abnormalities (seen in 70 patients) were related to either the presence of intradiscal liquid effusion (17/70), or abnormality of the endplates similar to Modic 1 changes (38/70), or uncertain abnormalities (15/70). Abnormalities of the tip of the coccyx (seen in 41 patients) were located in the surrounding soft tissues: venous dilatations (18/41), soft tissue inflammation (13/41) and ambiguous images (9/41). Vertebral bone oedema was observed in five cases and a benign tumour was observed once. The type of imaging feature depend broadly on the mobility of the coccyx: the 105 cases with a mobile coccyx mainly presented abnormal features mainly in a disc (63 cases vs. 4 cases for the tip), whereas the 67 patients with a rigid coccyx mainly showed abnormal features at the tip (37 cases vs. 7 for the joints, p < 0.001). We recommend MRI of the painful coccyx when dynamic radiography fails to reveal clearly a pathological lesion (i.e., normal or slightly increased mobility of the coccyx or a rigid coccyx lacking a spicule).
Article
Objective: This study examines the potential usefulness of a novel thermal imaging technique in the assessment of local physiologic responses before and after conservative therapies for coccygodynia. Methods: Patients with coccygodynia were selected on the basis of detailed history taking, clinical examination, and dynamic series radiography. They underwent therapeutic modalities consisting of 6 to 8 sessions of manual medicine treatments (massage of the levators followed by Maigne's manipulative technique) and external physiotherapy (short-wave diathermy) 3 times a week for 8 weeks. We performed the assessments with numeric pain rating scale (NPRS) and infrared thermography (IRT) before treatment and at 12 weeks. Results: A total of 53 patients (6 males and 47 females) ranging from 18 to 71 years of age and clinically diagnosed with coccygodynia received the full course of therapy and assessments. There were significant differences in both NPRS and surface temperature obtained by IRT in the 12-week follow-up (P < .05). The correlation between NPRS improvement and temperature decrement was significantly high (r = 0.67, P < .01). Conclusions: The study shows that IRT can objectively show the decrement of surface temperatures correlating with changes in subjective pain intensity after treatment of coccygodynia. With the advantages of being painless, noninvasive, and easy to repeat, IRT appears to be useful as a quantifiable tool for monitoring the dynamics of the disease activity in coccygodynia.
Article
Little is known about coccydynia in adolescents. The aim of this study was to explore causes, clinical and imaging features and response to treatment of chronic coccydynia in adolescents. This was a cohort study. The study included patients followed up at a specialized consultation in a university hospital. A series of 53 adolescent patients with chronic coccydynia were followed for 1-4 years. Investigations included dynamic X-ray films, with a magnetic resonance imaging scan of the coccyx in 26/53. Treatment was by coccygeal steroid injection or non-steroidal anti-inflammatory drugs (NSAIDs). Amitriptyline or coccygectomy were used as second-line treatment. Outcomes were assessed at a consultation two months after the treatment, then between one to four years later, by telephone interview, questionnaires and by a visual analogue scale (VAS). Fifty-one adult patients with coccydynia formed the control group. In 20 cases (37.7%) the coccydynia was subsequent to trauma. Obesity was not a risk factor. Abnormal mobility was rarer and spicules more frequent compared to adult patients (P<0.001); 11/27 MRI scans showed a hypersignal within the disc or adjacent bone and 6/27 a hypersignal surrounding the tip of the coccyx (bursitis). Initial treatment was a coccygeal steroid injection for 41 patients and NSAIDs for 12. Ten were given amitriptyline and 3 a coccygectomy. At final assessment, there was no pain or almost no pain in 32/53 (60.4%), moderate pain and functional impairment in 12/53 (22.6%) and severe pain and functional impairment in 9/53 (17%). Coccydynia in adolescents differs from coccydynia in adults. A MRI scan is helpful and should be obligatory for diagnosis. Prognosis is relatively good. Our results should help clinicians manage this rare and debilitating condition.