ArticleLiterature Review

Clinical anatomy of the coccyx: A systematic review

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Abstract

The coccyx has been relatively neglected in anatomical research which is surprising given the population prevalence of coccydynia and our inadequate understanding of its etiology. This systematic review analyzes available information on the clinical anatomy of the coccyx. A literature search using five electronic databases and standard anatomy reference texts was conducted yielding 61 primary and 7 secondary English-language sources. This was supplemented by a manual search of selected historical foreign language articles. The coccygeal vertebrae, associated joints, ligaments and muscles, coccygeal movements, nerves, and blood supply were analyzed in detail. Although the musculoskeletal aspects of the coccyx are reasonably well described, the precise anatomy of the coccygeal plexus and its distribution, the function of the coccygeal body, and the anatomy of the sacrococcygeal zygapophyseal joints are poorly documented. Further research into the anatomy of the coccyx may clarify the etiopathogenesis of coccydynia which remains uncertain in one-third of affected patients.

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... The coccyx is derived from the Greek word "kokkцs" because it resembles the inclined beak of a cuckoo. The coccyx is a triangular-shaped bone consisting of 3 to 5 fused vertebral segments at the terminal part of the vertebra [1]. It is a vital structure because it forms a leg of the tripod together with the two ischia and is an adhesion site for numerous pelvic muscles and in the pelvic region [2]. ...
... In 2012, Woon et al. [1] performed sacrococcygeal and intercoccygeal measurements in 112 adult CT scans. The SCA and ICA were 166 and 143 degrees, respectively. ...
... The presence of subluxation, bone spicule, fusion, and lateralization may differ between ethnic groups. In Woon's study in 2012, subluxation was rarely found in the New Zealand population, bone spicule rate was 23%, and 57% of patients had fusion [1]. In the studies of Marwan [11] and Shalaby [16], subluxation was found in 31.7%, ...
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Background/Aim: The coccyx has several variants which could sometimes be confused with fractures. Our study aimed to alert physicians about the types of coccyges that can be easily confused with coccyx fractures in daily practice. Methods: Mid-sagittal and mid-coronal computerized images of 75 patients were analyzed to determine the types of coccygeal fracture, the coccyx types, number of segments, joint fusion, coccygeal bony spicules, subluxation, sacrococcygeal angle (SCA), intercoccygeal angle (ICA), and lateral deviation of the coccyx. Results: The mean age of the patients was 43.5 (13.6) years. There were 33 (44%) males, and 42 (56%) females. While 57 (76%) patients were thought to have a coccygeal fracture, only 18 patients (24%) actually had them. There was a significant difference between the coccyx types mistaken for fractures and actual coccygeal fractures (P<0.001). Conclusion: It is essential to know the coccyx types and distinguish normal variants from fractures. If the difference between coccyx fractures and coccyx types is known and the patients are informed accordingly, both the loss of workforce decreases, and the necessary treatment can be started early.
... Rarely, it may be inclined backwards in the sagittal plane (4). Clinically, pathologies associated with the coccyx are seen in many tumors, fractures, dislocations, and infections (5)(6)(7)(8). In addition, coccygodynia, first described by Simpson in 1859, is an important pathology of this region, causing pain at the lower end of the spine that is severe when sitting, standing, and walking. ...
... In addition, coccygodynia, first described by Simpson in 1859, is an important pathology of this region, causing pain at the lower end of the spine that is severe when sitting, standing, and walking. Trauma, infection, tumor, disc degeneration, and birth are causative factors for coccygodynia (5)(6)(7)(9)(10)(11). Radiologic images taken in situ and in standing position and clinical findings are important for diagnosis. ...
... Using these shadow images, the obtuse section images are reconstructed, and a 3D model of the internal microstructure and density in the selected height range is created in the transition images. Internal morphologic parameters can be calculated by reconstruction (7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17). There are a few studies on the coccyx anatomy or morphometry and very few on micro CT. ...
Article
Aim: We investigated the coccyx anatomy accurately in detail by microcomputed tomography (micro CT) and computed tomography (CT) to contribute to the data related to the coccyx anatomy and the potential clinical contribution of these datas in the treatment of coccyx’s pathologies. Material and Methods: Twenty coccyges from embalmed cadavers were examined with a micro CT device. The inferior part of the sacrum and coccyx together with the surrounding soft tissue was removed safely. The tissue was scanned with a micro CT device, and all parameters were measured with micro CT image viewer programs. CT images of 29 patients without coccyx pathology were measured with OsiriX programs. Measured morphometric parameters with micro CT and CT were evaluated using statistical methods. Results: Generally, the morphometric parameters as mean values were larger in males than in females. Mean values for vertical length and coccyx width were higher for CT compared with micro CT images. Coccyx was more flat in the frontal plane in females. There were statistically significant differences between the micro CT and CT images regarding mean vertical length, width, lateral deviation angle, and sacrococcygeal angle and length of the vertebrae (p < 0.05). There were no statistically significant differences in number and width of the vertebrae (p > 0.05). Conclusion: We suggest that examining the normal coccyx morphology will help to better understand and treat the pathologic conditions of the coccyx. We believe our findings will contribute to the data related to the coccyx anatomy. Keywords: Coccyx - Anatomy - Microcomputed tomography – Computed tomography - Cadaver
... It is usually located in front of the sacral bone in a midline position under the sacro-coccygeal junction crossed by somatic fibers from the perineum, rectum, anus, distal uretra, vagina, penis and scrotum [11,12]. Anatomical studies showed variations in the localization of this ganglion between the sacro-coccygeal joint and coccyx end. ...
... Anatomical studies showed variations in the localization of this ganglion between the sacro-coccygeal joint and coccyx end. It is mostly located in front of the sacrococcygeal joint and coccygeal vertebra [11,12]. We describe a case report which supports the efficacy and safety of ganglion impar denervation in patients with cancer pain. ...
... This approach carries a higher risk of rectal perforation and requires a rectal exploration during needle insertion which can be very painful or even impossible in these patients. We prefer using the trans-sacrococcygeal approach, as described by Wenn in 1995 which carries lower risk of rectal perforation but can be difficult or impossible in case of a calcified sacro-coccygeal ligament [11]. Neurolytic techniques are described with the use of agents such as phenol or alcohol. ...
... Closely associated with the coccyx, the coccygeal plexus arises from the ventral primary rami of the S4, S5, and Co1 nerve roots along with contributions from the sacral sympathetic trunk [18]. The coccygeal plexus then goes on to give rise to nerves that innervate the sacrococcygeal joint, anococcygeal ligament, sacrotuberous ligament, and inconsistently, the coccygeus muscle [19]. Overactivity of these nerves may lead to increased tension or spasm of the muscles or tendons taking their origin off the coccyx. ...
... In addition to the coccygeal plexus nerves, the ganglion impar, located directly in front of the coccyx between the sacrococcygeal joint and the tip of the coccyx serves as the primary relay for the sympathetic efferents and nociceptive afferents from the perineum and terminal urogenital regions [19,22]. The ganglion impar is one of the primary targets for nerve blocks in patients with chronic coccydynia and in patients with chronic pain arising from rectal, anal, colon, bladder, and cervical cancers [23]. ...
... Given the many neural networks in the pelvis, the benefit obtained after coccygectomy may be less due to removal of the bone itself and more likely secondary to the disruption of the nerves surrounding the coccyx [19]. Neurolysis of the nerves responsible for painful pelvic muscle spasm is a potential mechanism of pain relief when considering the location of the coccygeal plexus and the ganglion impar in relation to the coccyx. ...
Article
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Objective Performing coccygectomy procedures on patients with psychiatric disorders and/or chronic low back pain have been previously thought of as contributing factors leading to inconsistent and often poor results. To determine if these two variables affect the post-operative pain relief obtained after coccygectomy, an analysis of the opioid requirements and pain descriptions before and after surgery was undertaken in each patient studied. Methods The hospital electronic medical records were searched, and only patients undergoing coccygectomy for chronic coccydynia were selected. A total of 8 patients were found. Each patient underwent a trial of conservative therapy prior to surgical evaluation. Results The average duration of symptoms prior to surgery was 41.3 months. In 7 out of 8 patients, at least one psychiatric disorder was present. In 6 out of 8 patients, chronic low back pain was present. Pain control with opioid-based medicines was required in 5 out of 8 patients prior to surgery. Of those, 4 were able to discontinue or reduce the amount of opioid-based medicines consumed after surgery. The average follow-up was 9 months. Discussion The results of this study indicate that patients with preexisting psychiatric disorders and/or chronic low back pain suffering from debilitating coccyx pain can obtain pain relief after coccygectomy as seen from a reduction in opioid requirements and pain burden. It should be noted that the obtained benefits from coccygectomy usually occur in a delayed fashion.
... Overall, finding information about sacral and coccygeal fusion in both anthropological and clinical data is difficult. In a literature review by Woon and Stringer (2012), provide conflicting conclusions about sacrococcygeal fusion. First, Woon and Stringer (2012) provide sources that, "suggest that sacrococcygeal fusion is more likely in older subjects but is not exclusively age related." ...
... In a literature review by Woon and Stringer (2012), provide conflicting conclusions about sacrococcygeal fusion. First, Woon and Stringer (2012) provide sources that, "suggest that sacrococcygeal fusion is more likely in older subjects but is not exclusively age related." ...
Poster
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Age and sex estimation are increasingly less accurate and precise as age increases due to degenerative changes on the skeleton. Tague (2011) uses sacrococcygeal fusion to estimate age, also to understand how sexual dimorphism affects sacrococcygeal fusion. Results provided by Tague (2011) and Passalacqua (2009) show conflicting conclusions on whether sacrococcygeal fusion is related to age. Both studies lack a large sample size for individuals over 80 years and have considerably less females than males. This research includes a preliminary examination of the methods Tague (2011) used to analyze sex and age correlation of sacrococcygeal elements. An analysis of the pelvic measurements, fusion rates between the sacrum and coccyx and the number of fused coccyx elements were conducted for this study. The individuals analyzed are from the Texas State Donated Skeletal Collection.
... It has been reported to be the source of pain in 2.7% of patients presenting to a hospital for back pain (1). Coccydynia was the cause of over 14 000 emergency department visits in the United States in 2014 (2), and over 1300 coccygectomies are performed in the United States each year (3). ...
... Additionally, the rectosacral ligament is seen anteriorly in the midline and is composed of the retrorectal fascia, which blends with the presacral fascia that attaches to the anterior sacrum and coccyx, blending with their periosteum (Fig 5). These fascial structures combined may be referred to as the Waldeyer fascia, or the presacral fascia alone may be considered the Waldeyer fascia (3,9). The parietal pelvic fascia that covers the piriformis, ischiococcygeus, and levator ani muscles blends medially with the presacral fascia (3) and could play a role in referred or traction-related coccyx pain. ...
Article
The coccygeal region has complex anatomy, much of which may contribute to or be the cause of coccyx region pain (coccydynia). This anatomy is well depicted at imaging, and management is often dictated by what structures are involved. Coccydynia is a common condition that is known to be difficult to evaluate and treat. However, imaging can aid in determining potential causes of pain to help guide management. Commonly, coccydynia (coccygodynia) occurs after trauma and appears with normal imaging features at static neutral radiography, but dynamic imaging with standing and seated lateral radiography may reveal pathologic coccygeal motion that is predictive of pain. In addition, several findings seen at cross-sectional imaging in patients with coccydynia can point to a source of pain that may be subtle and easily overlooked. Radiology can also offer a role in management of coccygeal region pain with image-guided pain management procedures such as ganglion impar block. In addition to mechanical coccyx pain, a host of other conditions involving the sacrococcygeal region may cause coccydynia, which are well depicted at imaging. These include neoplasm, infection, crystal deposition, and cystic formations such as pilonidal cyst. The authors review a variety of coccydynia causes, their respective imaging features, and common management strategies.©RSNA, 2020.
... All images contained in this poster are the result of a number of articles search. Figure 1 and 2 using illustrations or sketches to explain the movement of the coccyx and the anatomic signs of coccydynia, this technique is used for a better understanding of normal and abnormal movement direction of the coccyx (Woon, 2012;Fogel, 2004). Figure 3 and 4 using a real radiographic picture to explain the posterior subluxation and a farcture of coccyx, this technique is used for a better understanding about the coccyx abnormality during standing and sittting position (Maigne, 2012). ...
... Range of motion of the coccyx. The apex of the angle in the standing (bold line, B) and sitting (dotted line,C) positions is at the mid -sacrococcygeal joint(Woon, 2012). ...
... Abnormal coccygeal mobility associated with changes in posture may account for the pain in some cases (2). In others, pain may be generated by coccygeal intervertebral disc pathology (6), pericoccygeal soft tissue inflammation (6), sacrococcygeal cornual junction pathology (7), or coccygeal nerve entrapment (4,7). The condition is associated with severe pain that causes daily activities to be limited. ...
... Abnormal coccygeal mobility associated with changes in posture may account for the pain in some cases (2). In others, pain may be generated by coccygeal intervertebral disc pathology (6), pericoccygeal soft tissue inflammation (6), sacrococcygeal cornual junction pathology (7), or coccygeal nerve entrapment (4,7). The condition is associated with severe pain that causes daily activities to be limited. ...
Article
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Background: Several nonsurgical and surgical treatment modalities are available for patients with chronic coccydynia, with controversial results. Extracorporeal shock wave therapy (ECSWT) is effective in the treatment of many musculoskeletal disorders; however, it has not been tested for chronic coccydynia. Objectives: We performed the current study to determine the effects of ECSWT on pain in patients with chronic coccydynia. Patients and methods: This quasi-interventional clinical study included 10 patients with chronic coccydynia without acute fracture. All the patients received ECSWT with a radial probe delivering 3,000 shock waves of 2 bar per session at 21 Hz frequency directed to the coccyx. Each patient received four sessions of ECSWT at one-week intervals. The pain severity was recorded according to the visual analog scale (VAS) at one, two, three, and four weeks after initiation of therapy. The VAS score was also evaluated at one and six months after ending the therapy. Results: Most of the participants were women (90.0%), and the participants' mean age was 39.1 ± 9.1 (ranging from 28 to 52) years. The VAS score did not decrease significantly seven months after therapy when compared to baseline (3.3 ± 3.6 vs. 7.3 ± 2.1; P = 0.011). However, the VAS score at two months (2.6 ± 2.9 vs. 7.3 ± 2.1; P = 0.007) and at four weeks (3.2 ± 2.8 vs. 7.3 ± 2.1; P = 0.007) significantly decreased when compared to baseline. The decrease in VAS scores was not persistent after cessation of the therapy. Conclusions: ECSWT is an effective modality in relieving the pain intensity in patients with refractory chronic coccydynia for the early period after intervention.
... Coccydynia or coccygodynia, is an inflammatory condition presents with pain in sacrococcygeal area which may radiate to the buttocks and lower back. Etiology of coccydynia is known to be either local factors or idiopathic, and also it can be a referral pain from other regions [1] [2] [3]. ...
... Local factors including traumas (fractures, fracture-dislocation, sprain and child birth), congenital disorders (changes of normal curve or coccygeal configuration), tumors (the most common one is cordoma), degenerative conditions (arthrosis of sacrococcygeal joint), coccygeal intervertebral disc pathology [1] [2], pericoccygeal soft tissue inflammation [2], sacrococcygeal corneal junction pathology [3] and coccygeal nerve entrapment [4]. ...
... The pelvic splanchnic nerves (PSN) (green), which constitute the sacral part of the parasympathetic system, arise from the sacral nerve roots and supply the left colon, anorectum, uterus/vagina, prostate/seminal vesicles, and bladder. The vagus nerve is the source of parasympathetic supply to the remaining visceral organs and gonads [17,[30][31][32][33][34][35][36][37][38]. ...
... Sympathetic nerves in the lower limbs cause vasoconstriction and reduce perspiration on stimulation. Moreover, sacral sympathetic ganglia may give off direct postsynaptic fibers to the pelvic viscera [38]. ...
Article
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A prerequisite for nerve-sparing pelvic surgery is a thorough understanding of the topographic anatomy of the fine and intricate pelvic nerve networks, and their connections to the central nervous system. Insights into the functions of pelvic nerves will help to interpret disease symptoms correctly and improve treatment. In this article, we review the anatomy and physiology of autonomic pelvic nerves, including their topography and putative functions. The aim is to achieve a better understanding of the mechanisms of pelvic pain and functional disorders, as well as improve their diagnosis and treatment. The information will also serve as a basis for counseling patients with chronic illnesses. A profound understanding of pelvic neuroanatomy will permit complex surgery in the pelvis without relevant nerve injury.
... The sacrococcygeal articulation is a cartilaginous joint reinforced by numerous sacrococcygeal ligaments. At the sacrococcygeal border, sacralizations of the coccyx or coccygealizations, that is, detachment of the fifth sacral vertebra, have rarely been investigated (Lee et al., 2016;Tague, 2011;Woon et al., 2013;Woon & Stringer, 2012). Nevertheless, sacralizations of the first coccygeal vertebra are quite common, either by synostosis or calcification of the lateral sacrococcygeal or the interarticular ligaments (sometimes also called ligamentum intercornuale, Woon et al., 2013). ...
... An additional sixth lumbar vertebra could be completely sacralized, and concomitantly one sacral element would either be missing or morphologically coccygealized. Yet, the morphological variation of the coccyx, the sacrococcygeal border, and the post-sacral numeric variability have not yet been sufficiently explored to resolve this issue (Lee et al., 2016;Tague, 2011;Woon et al., 2013;Woon & Stringer, 2012). O'Connell (1951) and Andrew (1954) also described a similar morphological state as "occult sacralization," which corresponds to a sacrum with six elements that are cranially placed relative to the inlet of the pelvis. ...
Article
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Objectives Despite the high frequency of segmentation anomalies in the human sacrum, their evolutionary and clinical implications remain controversial. Specifically, inconsistencies involving the classification and counting methods obscure accurate assessment of lumbosacral transitional vertebrae. Therefore, we aim to establish more reliable morphological and morphometric methods for differentiating between sacralizations and lumbarizations in clinical and paleontological contexts. Materials and Methods Using clinical CT data from 145 individuals aged 14–47 years, vertebral counts and the spatial relationship between the sacrum and adjoining bony structures were assessed, while the morphological variation of the sacrum was assessed using geometric morphometrics based on varied landmark configurations. Results The prevalence of lumbosacral and sacrococcygeal segmentation anomalies was 40%. Lumbarizations and sacralizations were reliably distinguishable based on the spatial relationship between the iliac crest and the upward or downward trajectory of the linea terminalis on the sacrum. Different craniocaudal orientations of the alae relative to the corpus of the first sacral vertebra were also reflected in the geometric morphometric analyses. The fusion of the coccyx (32%) was frequently coupled with lumbarizations, suggesting that the six-element sacra more often incorporate the coccyx rather than the fifth lumbar vertebra. Conclusions Our approach allowed the consistent identification of segmentation anomalies even in isolated sacra. Additionally, our outcomes either suggest that homeotic border shifts often affect multiple spinal regions in a unidirectional way, or that sacrum length is highly conserved perhaps due to functional constraints. Our results elucidate the potential clinical, biomechanical, and evolutionary significance of lumbosacral transitional vertebrae.
... Saluja reported that the incidence of sacrococcygeal joint fusion in skeletal collections was higher among the elderly (Saluja, 1988), whereas Woon and Stringer (2014) reported that sacrococcygeal cornual fusion was not related to either sex or age. From a clinical perspective, the zygapophyseal joint between the sacral and coccygeal cornua, and the coccygeal plexus (with nerve entrapment) appear to have been ignored as potential sources of pain (Woon and Stringer, 2012). ...
... The first coccygeal segment is the largest and has transverse processes that may articulate or fuse with the sacrum (Woon and Stringer, 2012). Although this fusion, named sacralization, was uncommon in both the present and previous studies (Woon et al., 2013b), it was found more frequently among males than females. ...
Article
To provide anatomical and morphological data regarding the coccyx using three-dimensional images, with a view to aiding the diagnosis of idiopathic coccydynia. One hundred and thirty-six normal adult pelvises were investigated. Three-dimensional models of the pelvis were reconstructed using software from computed tomography images of whole specimens. The following six coccyx parameters were measured: (1) width, (2) straight length, (3) thickness, (4) sacrococcygeal angle, (5) intercoccygeal angle, and (6) angle of lateral deviation of the coccyx. The presence of fusion between the sacral and coccygeal cornua, and between the sacrum and the transverse process of the coccyx was also investigated, and lateral deviations of the coccyx were classified and analyzed. Most of the measured coccyx parameters were larger in males than in females, with the exception of the sacrococcygeal and intercoccygeal angles. Unilateral or bilateral fusion of the sacral cornu and the coccygeal cornu was not a rare finding. With respect to the sacrum and the transverse process of coccyx, the separated type was more common than the fused type. The incidence and angle of lateral deviation of the coccyx varied widely between individuals. The present detailed description of the gross anatomy of the coccyx obtained using three-dimensional modeling will help toward understanding the mechanism underlying the development of idiopathic coccydynia. Fusion of the sacrum and coccyx or lateral deviation of the coccyx may cause coccydynia by compressing the coccygeal nerves. This article is protected by copyright. All rights reserved.
... It has been reported to be the source of pain in 2.7% of patients presenting to a hospital for back pain (1). Coccydynia was the cause of over 14 000 emergency department visits in the United States in 2014 (2), and over 1300 coccygectomies are performed in the United States each year (3). ...
... Additionally, the rectosacral ligament is seen anteriorly in the midline and is composed of the retrorectal fascia, which blends with the presacral fascia that attaches to the anterior sacrum and coccyx, blending with their periosteum (Fig 5). These fascial structures combined may be referred to as the Waldeyer fascia, or the presacral fascia alone may be considered the Waldeyer fascia (3,9). The parietal pelvic fascia that covers the piriformis, ischiococcygeus, and levator ani muscles blends medially with the presacral fascia (3) and could play a role in referred or traction-related coccyx pain. ...
... Some authors have suggested strict definitions for such terms (Brues, 1903;Lull, 1920;Hall, 2003), while others ignore strict definitions and use the terms more loosely (e.g. Miralles et al., 2012;Nweeia et al., 2012;Woon and Stringer, 2012). This study was undertaken to determine whether a consensus has developed in primary scientific literature of the twentieth and twenty-first centuries as to the proper level of strictness for terms for EDBS. ...
... PS açısından sakrokoksigeal bölge anatomisini 5.lumbal vertabradan son koksigeal vertebraya kadar değerlendirmek gerekmektedir. Literatürde lumbosakral, sakrokoksigeal, interkoksigeal ve sakrokoksigeal sinüs açıları, koksiks tipi ve koksiks patolojileri başta koksodinia olmak üzere ortopedi ve beyin cerrahları tarafından değerlendirilmiştir (5)(6)(7)(8). Pilonidal sinüs ile ilgili sadece bir çalışma yapılmış olup az hasta sayılı bu çalışmada sakrokoksigeal açı karşılaştırılmasında anlamlı sonuçlar bulunmamasına rağmen sakrokoksigeal bölge anatomisinin PS hastalığında önemli bir risk faktörü olduğunu düşünmekteyiz (9). Bu çalışmanın amacı; lumbo-sakro-koksigeal açılanmaların ve koksiks anatomisinin pilonidal sinüs açısından değerlendirilmesidir. ...
... The coccyx is the most distal component of the vertebral column, consisting of multiple segments, and serves as the site of attachment for muscles and ligaments that build the perineum. (1) Coccydynia constitutes less than 1% of all non-traumatic complaints of the spine. (2) Radiological and magnetic resonance imaging are important in diagnosis of coccydynia. ...
Article
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Objectives: To determine if there is any differences between the morphology and morphometry of the coccyx of idiopathic coccydynia and normal coccyx using magnetic resonance imaging and to study the effectiveness of dextrose prolotherapy injection as a treatment of coccydynia. Background: Coccydynia is pain around the coccyx without significant radiation .Chronic
... There have been a few studies on the normal in vivo morphology and measurements of the human coccyx in the Western population, but none in the Indian population [2,3]. The coccyx has been studied with the use of cadaveric materials [4], plain radiography [5], computed tomography (CT) [6], and magnetic resonance imaging (MRI) [3,7]. According to the Postacchini and Massobrio classification [5], the coccyx is divided into four types: type I, coccyx slightly curved forward with its apex directed downward and caudally; type II, coccyx with more marked forward curvature and forward-pointing apex; type III, coccyx with very sharp forward angulation; and type IV, coccyx showing subluxation at the sacrococcygeal or intercoccygeal joint. ...
Article
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Study Design A retrospective, cross-sectional study of 213 patients who presented for abdominal computed tomography (CT) scans to assess coccygeal morphology in the Indian population. Purpose There have been relatively few studies of coccygeal morphology in the normal population and none in the Indian population. We aimed to estimate coccygeal morphometric parameters in the Indian population. Overview of Literature Coccygeal morphology has been studied in European, American, Korean, and Egyptian populations, with few differences in morphology among populations. Methods A retrospective analysis of 213 abdominal CT scans (114 males and 99 females; age, 7–88 years; mean age, 47.3 years) was performed to evaluate the number of coccygeal segments, coccyx type, sacrococcygeal and intercoccygeal fusion and subluxation, coccygeal spicules, sacrococcygeal straight length, and sacrococcygeal and intercoccygeal curvature angles. Results were analyzed for differences in morphology with respect to sex and coccyx type. Results Types I and II coccyx were the most common. Most subjects had four coccygeal vertebrae; 93 subjects (43.66%) had partial or complete sacrococcygeal fusion. Intercoccygeal fusion was common, occurring in 193 subjects. Eighteen subjects had coccygeal spicules. The mean coccygeal straight length was 33.8 mm in males and 31.5 mm in females; the mean sacrococcygeal curvature angle was 116.6° in males and 111.6° in females; the mean intercoccygeal curvature angle was 140.94° in males and 145.10° in females. Conclusions Type I was the most common coccyx type in our study, as in Egyptian and Western populations. The number of coccygeal vertebrae and prevalence of sacrococcygeal and intercoccygeal fusion in the Indian population were similar to those in the Western population. The mean coccygeal straight length and mean sacrococcygeal curvature angle were higher in males, whereas the intercoccygeal curvature angle was higher in females. Information on similarities and differences in coccygeal morphology between different ethnic populations could be useful in imaging and treating patients presenting with coccydynia.
... A potential limitation to the application of the PCL MRI measuring system occurs when the field of view for pre-and postoperative pelvic MRI images does not capture a clearly defined sacrococcygeal joint. Anatomical variations in the structure of the sacrococcygeal region, including fusion of the sacrococcygeal joint may potentially make accurate identification problematic [19]. The HOR-2 measurement system could be then used to provide an alternate approach when use of the PCL measurement system is not possible. ...
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Background: There is a change in the position of the remaining anatomical structures of the lower urinary tract system following radical prostatectomy. The aims of this investigation were to describe three novel methods used to measure the displacement of i) the vesico-urethral junction (VUJ), proximal membranous urethra (PMU) and anorectal junction (ARJ) and ii) the VUJ angle of displacement in men following radical prostatectomy and determine their intra- and interrater reliability. Methods: Retrospective comparative measurement of twenty pre- and postoperative MRI scans was undertaken by one observer on two separate occasions and on one occasion by another observer. Three standardized midsagittal pelvimetry reference lines were used to describe three X, Y axis measurement systems. The displacement (mm) of the VUJ, PMU and ARJ, and the angle of displacement (degrees) of the VUJ was measured for each of the three methods. Interrater reliability of VUJ, PMU and ARJ displacement and the VUJ angle of displacement measurements was assessed using a two-way mixed-effects agreement intra-class correlation coefficient (ICC) with 95% confidence intervals (CI). Test-retest (intrarater) reliability was calculated using a two-way random effects consistency ICC with 95% CI for all displacement measures of the VUJ, PMU and ARJ for one observer between two days. Results: The pubococcygeal line (PCL) axis measurement system demonstrated good to excellent intrarater and interrater reliability (ICC 95% interval lower bound > 0.75) for the VUJ and PMU displacement and the VUJ angle of displacement measurements. Other measurement systems were less reliable and more variable. Conclusions: In this sample of 20 Korean patients with median prostate volume 27.5 mL and maximum volume 70 mL, the measurement methodology using the PCL consistently demonstrated good to excellent reliability and the lowest variability for the measurement of the displacement of the VUJ and PMU and the VUJ angle of displacement. The PCL methodology is recommended as the method of choice. Further studies should validate these results in patients with large prostate volumes.
... Both can cause cord compression leading to central cord syndrome. Traumatic disc herniation are best evaluated with MRI due to excellent contrast between disc, vertebral body and CSF on pulse sequences [6][7][8] (Table 1). Hence; under the light of above mentioned data, we planned the present study to compare the diagnostic value of CT and MRI in evaluating acute spinal injuries. ...
... The palpation of the coccyx could depend on the examiner's experience and skill, such as those who tend to palpate the tip of the coccyx (fourth coccygeal vertebra), or those who tend to palpate around the coccygeal cornu or first coccygeal vertebra. However, the coccyx has been relatively neglected in anatomical research 19) , at the present time, which leads to difficulty in discussing the reason in more detail. For the reasons mentioned above, we can conclude that the PSIS, acromion, and coccyx are not suitable as stable indicators. ...
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Objectives: Increasing attention has been paid to pelvic incidence (PI) as a potential parameter related to low back pain. However, little knowledge exists regarding potential anthropometric landmarks specialized for the estimation of PI. This study aimed to examine the inter- and intra-examiner reliability of potential anthropometric landmarks applicable to estimate PI. Methods: Twenty healthcare workers were recruited as participants. Three were experienced physiotherapists for more than 5 years in clinical practice. Eight anatomical landmarks were selected: (1) the acromion, (2) the upper edge of the iliac crest, (3) the posterior superior iliac spine (PSIS), (4) the anterior superior iliac spine (ASIS), (5) the upper edge of the greater trochanter, (6) the coccyx, (7) the lateral joint space of the knee, and (8) the lateral malleolus. Photographs of the right-side view of the subjects were used to determine the two-dimensional (x, y) coordinates of the landmarks. Results: Most landmark measurements reached acceptable levels for intra-examiner (ICC1, 0.64 to 0.98) and inter-examiner reliability (ICC3, 0.71 to 0.97). However, as possible anatomical landmarks, the PSIS (ICC1 0.65, ICC3 0.48), acromion (ICC3 0.66), and coccyx (ICC1 0.64) tended to have relatively low ICCs. Conclusions: Our study suggests that potential anthropometric landmarks on the body surface examined on palpation have acceptable intra- and inter-examiner reliability; however, identifying the acromion, PSIS, and coccyx as anatomical landmarks using the measurement method in this study remain difficult to be considered reliable.
... It is convex dorsally with its inferior aspect sloping anteriorly with slight flexion and extension ranging approximately 5-15 degrees for optimal force absorption in the seated position and in feces descent control. 3,5,6 It provides attachment of the sacroccygeal ligaments, anococcygeal ligaments, and the levator ani muscle. Adjacent to the structure, sacral nerve roots and the terminal end of the sympathethic chain, the ganglion impar, have closed anatomical relationships with the coccyx. ...
... The coccyx is the lowermost triangular bone of the vertebral column distal to the sacrum, formed of 3 to 5 coccygeal vertebrae, which are anatomically lacking the posterior arch structures, including; the pedicles, laminae, and spinous processes. [1][2][3] It has an essential function in weight-bearing during sitting, particularly when leaning backward. 2,4 The term coccydynia (coccygodynia) refers to pain in or around the coccyx that remains debated and undetermined. ...
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Study design: Retrospective case-control study. Objectives: To evaluate the sacrococcygeal morphologic and morphometric features in idiopathic coccydynia using magnetic resonance imaging (MRI). Methods: MRI scans from 60 patients with idiopathic coccydynia were compared with scans of 60 controls. Assessment of coccygeal morphology included coccygeal segmentation, coccygeal types, bony spicules, sacrococcygeal joint fusion, and intercoccygeal joint fusion and subluxation. Morphometric parameters included coccygeal straight and curved lengths, coccygeal curvature index, sacrococcygeal and intercoccygeal joint angles, sacral straight and curved lengths, sacral curvature index, sacral angle, sacrococcygeal straight and curved lengths, sacrococcygeal curvature index, and sacrococcygeal angle. Results: The coccydynia group included 28 males and 32 females, with a mean age of 36.1 years. Type II coccyx and bony spicules were more common in coccydynia, P = 0.003 and 0.01, respectively. Sacrococcygeal joints were fused less commonly in coccydynia, P = 0.02. Intercoccygeal joint subluxation was more common in coccydynia, P = 0.007. The sacral angle was lower in coccydynia, P = 0.01. The sacrococcygeal curved length was higher in coccydynia, P < 0.001. The sacrococcygeal curvature index was lower coccydynia, P < 0.001. In females only, the coccygeal curvature index was lower in coccydynia patients, P = 0.04. In males only, the intercoccygeal angle was lower in coccydynia patients, P = 0.02. Conclusions: Type II coccyx, bony spicules, intercoccygeal joint subluxation were more common, and sacrococcygeal joint fusion was less common in coccydynia patients. Sacral angle and sacrococcygeal curvature index were lower, while sacrococcygeal curved length was higher in coccydynia patients. Level of evidence: Level 3. Case-control study.
... [15] This study has certain important limitations; only children of Indian origin were studied; hence the results may not be applicable to all the races. Although in studies on adult patients, there have been racial variations in the coccygeal region, [22,23] their association with difficult CEBs is limited. Besides, we did not assess the block effect clinically and consider it to be major limitation of the study; variable duration of surgery and difficulty in assessment of block effect in paediatric population was the reason behind this decision. ...
Article
Background and aims: Caudal epidural block (CEB) is commonly performed using surface landmark-based technique in the paediatric patients, with a good success rate. Failure to perform CEB is usually attributable to anatomic variations. The aim of this study was to perform measurements of the anatomical landmarks that are generally used to perform CEB and find a relation between these measurements and successful needle placement. Methods: This was an observational study that included 114 patients, aged up to 15 years. Ultrasonography (USG) scan of the sacrococcygeal region with measurement of cornu height, skin to cornu distance, inter-cornu distance (ICD), vertical and oblique size of hiatus were done. Needle placement for CEB was done using the usual palpatory hiatal approach. Needle position was checked by using ultrasound. Spearman correlation coefficient and multi-variate logistic regression were used for measuring the correlation and predictors of correct needle placement, respectively. Results: Correct placement of needle was found in 84% patients. Statistically significant correlation was found between all the anatomical parameters. Regression analysis revealed that only ICD had a statistically significant contribution (OR1.67, 95% CI 1.024-2.7; P = 0.04) in predicting an incorrect needle placement. If ICD was less than 12.5 mm, it predicted a difficult needle placement; all the children were less than 1.5 years in age; AUC was 77%, P = 0.001, sensitivity 83% and specificity 76.5%. Conclusion: ICD can be used as predictor of difficult needle placement for CEB. USG guidance may be of help while performing CEB in children less than 1.5 years.
... Perkins reported that 75% had relief after injection and 92% after surgery. A few authors have commented on the role of steroid injection as a pre-operative test to assess the efficacy of surgery [44][45][46][47]. ...
Article
This literature review is intended to provide oversight on the anatomy, incidence, etiology, presentation, diagnosis, and treatment of coccydynia. Relevant articles were retrieved with PubMed using keywords such as “coccydynia”, “coccyx”, “coccyx pain”, and “coccygectomy. Literature accumulated for this study was accumulated from PubMed using sourcombined to form this study. Images were also added from three separate sources to aid in the understanding of the coccyx and coccydynia. Focal points of this study included the anatomy of the coccyx, etiology and presentation of coccydynia, how to properly diagnose coccydynia, and possible treatments for the variety of etioloces. The coccyx morphology is defined using different methods by different authors as presented in this study. There is no conclusive quantitative data on the incidence of coccydynia; however, there are important factors that lead to increased risk of coccydynia such as obesity, age, and female gender. Injury to the coccyx or coccygeal joints with surrounding tissue inflammation and contraction of the muscles attached to the coccyx causes coccydynia. Diagnosis is made predominantly in clinical examinations with static standard radiographs, CT, and routine blood tests. Treatment options include conservative care, physical therapy, intrarectal massage and manipulation, sacrococcygeal injections (including ganglion impar block), and coccygectomy. Many cases are resolved with conservative treatments, despite the wide array of etiologies for the diagnosis. In more extreme cases, physician intervention requires a multidisciplinary approach. Surgical treatment is used as a last resort.
... 15 The coccyx and the coccygeal ligaments were not included in the model considering their minor influence on the biomechanics of the SIJ. 23 The pelvic bones were modeled as trabecular cores enveloped by an external cortical layer ( Figure 2) with its thickness taken and adapted from. 15,24,25 The cortical layer of the iliac bones has regional thicknesses ranging from 0.05 to 5 mm, and the sacral one is 1 mm thick. ...
Article
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Background: Sacroiliac joint (SIJ) is a known chronic pain-generator. The last resort of treatment is the arthrodesis. Different implants allow fixation of the joint, but to date there is no tool to analyze their influence on the SIJ biomechanics under physiological loads. The objective was to develop a computational model to biomechanically analyze different parameters of the stable SIJ fixation instrumentation. Methods: A comprehensive finite element model (FEM) of the pelvis was built with detailed SIJ representation. Bone and sacroiliac joint ligament material properties were calibrated against experimentally acquired load-displacement data of the SIJ. Model evaluation was performed with experimental load-displacement measurements of instrumented cadaveric SIJ. Then six fixation scenarios with one or two implants on one side with two different trajectories (proximal, distal) were simulated and assessed with the FEM under vertical compression loads. Results: The simulated S1 endplate displacement reduction achieved with the fixation devices was within 3% of the experimentally measured data. Under compression loads, the uninstrumented sacrum exhibited mainly a rotation motion (nutation) of 1.38° and 2.80° respectively at 600 N and 1000 N, with a combined relative translation (0.3 mm). The instrumentation with one screw reduced the local displacement within the SIJ by up to 62.5% for the proximal trajectory vs. 15.6% for the distal trajectory. Adding a second implant had no significant additional effect. Conclusion: A comprehensive finite element model was developed to assess the biomechanics of SIJ fixation. SIJ devices enable to reduce the motion, mainly rotational, between the sacrum and ilium. Positioning the implant farther from the SIJ instantaneous rotation center was an important factor to reduce the intra-articular displacement. Clinical relevance: Knowledge provided by this biomechanical study enables improvement of SIJ fixation through optimal implant trajectory.
... the other hand, the S5 ventral ramus exits the sacral hiatus through the gap between the SC and CC underneath the intercornual ligament ( Figure 1C). 2 The two nerves fuse to become the anococcygeal nerve supplying the skin surrounding the anus. 1,2 Gruber et al. 3 demonstrated that the coccygeal nerve could be observed through a highfrequency transducer on top of the SC. However, at the aforementioned level, the coccygeal nerve may sometimes course underneath the sacrococcygeal ligament next to the medial wall of the SC, which makes it difficult to visualize. ...
... These structures prevent the sagging of pelvic contents. 4 The coccyx may be of four types. In type 1, it is slightly curved forward, in type 2, curvature points straight forward, in type 3, it acutely angled in forward direction and in type 4, there is sacrococcygeal or intercoccygeal joint subluxation. ...
Article
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The aim of this study was to evaluate the clinical outcome of coccygectomy those who were refractory to conservative treatment. Twenty patients (5 males, 15 females) underwent total coccygectomy when coccygodynia did not responding to medical treatment July 2013 to September 2018. All the patients timely attended with non-traumatic (n = 12) and traumatic (n = 8) cause with mean follow-up visits of 24 months (range 18-28 months). The outcome pain intensity was evaluated by visual analogue scale (VAS) in sitting position and during daily activities. Three patients had infection which improved after antibiotic therapy. The VAS improved from 6.4 ± 0.9 to 2.1 ± 0.9 for sitting and from 5.8 ± 0.9 to 1.6 ± 0.6 for daily activities. Improvement in pain and daily activities were significant at the final follow-up. Ninety percent patients were satisfied with the operation.
Article
Objectives: Coccydynia is a condition with a multitude of different causes, characterized by ill-defined management. There are multiple prospective studies, including several controlled trials, that have evaluated conservative therapies. Additionally, a plethora of observational studies have assessed coccygectomy, but few studies have reported results for nonsurgical interventional procedures. In this report, we describe the treatment results of 12 patients who received conventional or pulsed radiofrequency for coccydynia and systematically review the literature on management. Methods: We performed a retrospective data analysis evaluating patients who underwent pulsed or conventional radiofrequency treatment at Johns Hopkins Hospital and Walter Reed National Military Medical Center. A comprehensive literature review was also performed to contextualize these results. Results: The mean age of patients treated was 50.25 years (SD = 11.20 years, range = 32-72 years), with the mean duration of symptoms being 3.6 years (SD = 3.36 years, range 1-10 years). There were 10 males and two females in this cohort. Among patients who received radiofrequency treatment, the average benefit was 55.5% pain relief (SD = 30.33%, range = 0-100%). Those who underwent conventional (vs pulsed radiofrequency) and who received prognostic blocks were more likely to experience a positive outcome. There were two cases of neuritis, which resolved spontaneously after several weeks. Conclusions: Radiofrequency ablation of the sacrococcygeal nerves may serve as a useful treatment option for patients with coccydynia who have failed more conservative measures. Further research into this therapeutic approach and its benefit for coccydynia should incorporate a control group for comparison.
Article
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Background The sacrococcygeal morphology of Arabs and Europeans has been studied using computed tomography (CT) or magnetic resonance imaging to determine the cause of coccydynia. Studies have suggested differences in sacrococcygeal morphology among ethnic groups. However, there are no data on the sacrococcygeal anatomy of Koreans. Methods We conducted a retrospective analysis of 606 pelvic CT scans that were taken at Cheju Halla General Hospital between 2008 and 2014. Fractures of the sacrum or coccyx were excluded. Differences in the sacrococcygeal morphology among age groups stratified by decade of life and between genders were analyzed using sagittal plane pelvic CT scans. The morphological parameters studied were the sacral and coccygeal curved indexes, sacrococcygeal angle, intercoccygeal angle, coccygeal type, coccygeal segmental number, and sacrococcygeal fusion. Results The average sacral and coccygeal curved indexes were 6.15 and 7.41, respectively. The average sacrococcygeal and intercoccygeal angles were 110° and 49°, respectively. Type II coccyx was most common, and the rate of sacrococcygeal fusion was 34%. There was a moderate positive correlation between age and the sacral curved index (r = 0.493, p = 0.000) and a weak negative correlation between age and the coccyx curved index (r = −0.257, p = 0.000). There was a weak negative correlation between age and the intercoccygeal angle (r = −0.187, p = 0.000). The average intercoccygeal angle in males and females was 53.9° and 44.7°, respectively. Conclusions The sacrum tended to be more curved and the coccyx straighter with age. The coccyx was straighter in females than males. Knowledge of the sacrococcygeal anatomy of Koreans will promote better understanding of anatomical differences among ethnicities and future studies on coccydynia.
Article
Resumen El dolor lumbar es una patología frecuente. Aunque la evolución de la medicina ha permitido encontrar nuevos analgésicos, nuevas técnicas de diagnóstico radiológico y nuevos procedimientos neuroquirúrgicos, los resultados clínicos no son siempre satisfactorios y aún son muchos los pacientes con mejoría parcial y dolor crónico. Nosotros planteamos que la columna lumbar es una unidad funcional que incluye no solo la región estrictamente lumbar sino también las regiones sacra, coccígea y pélvica. Igualmente, dentro de esa unidad funcional lumbosacrococcígea (UFLSC) se incluyen no solo las estructuras óseas (vértebras) y cartilaginosas (discos intervertebrales) sino también las musculoligamentarias y neurales. En este artículo presentamos una revisión no sistemática de la bibliografía relacionada con los aspectos teóricos y clínicos que apoyan esta teoría. Estos conceptos servirán para establecer factores pronósticos para el tratamiento neuroquirúrgico del dolor lumbar. Nivel de evidencia clínica Nivel IV.
Chapter
The focus of this chapter will be on the anatomic structure of the pelvis and some of the changes it experiences as it progresses with age. Particular attention will be paid to how these structures and functions relate to both the surgeon and the physiologist, and the relevance of significant changes that occur through adulthood and older age—though many of these will be addressed in specific chapters later in this text.
Article
General purpose: To present a study that investigated sacrococcygeal skeletal structure as a possible nonmodifiable intrinsic risk factor for pressure injury and identify possible issues caused by its morphology. Target audience: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. Learning objectives/outcomes: After participating in this educational activity, the participant will:1. Recognize the background information the authors considered when planning and conducting their study of sacrococcygeal skeletal structure as a possible pressure injury risk factor.2. Identify the characteristics of the two groups of study participants.3. Choose the results of the study clinicians may consider when implementing evidence-based practice.
Conference Paper
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The arrival of leprosy in Italy is a very controversial topic, as is its diffusion in Europe. According to the most accredited theories on a molecular basis, leprosy spread in Eurasia from Eastern Africa about 80,000 years ago (Monot et al 2005) following the migratory routes of H. sapiens “out of Africa”. To date, in ancient time dissemination strategies seem to have followed terrestrial rather than maritime routes (at least until to the late Middle Ages), favored in this by the long incubation period of leprosy and its low pathogenicity. The suggestion of Monot based on the identification of SNPs can also be confirmed on a paleopathological basis. Although controversial the case of the oldest leprosy described is that reported in India and referable to about the second millennium BCE. In Italy the paleopathological history of leprosy is more recent at the moment. The oldest case is that identified in Casalecchio del Reno (Mariotti et al., 2005) in northern Italy referable to the 4th century BCE. All the other cases of leprosy described are mainly from the Roman and early Middle Ages and are mostly concentrated in central Italy, while late Middle Ages and Renaissance cases have been reported in southern Italy. From the chronological analysis of the findings it would seem that in Italy too the initial leprosy diffusion path has followed terrestrial routes coming from central and eastern Europe and reaching Italy through the Alps. This hypothesis could also be indirectly confirmed by the presence of leprosy in a protoBulgarian population allocated in the 7th century CE in central Italy and coming from Eastern Europe. In contrast, since the late Middle Ages the disease certainly spread also by sea as evidenced by the case of Montecorvino (Fg, Puglia) where a case of a Byzantine individual coming from the Anatolian coasts was described (Rubini et al., 2015). This was certainly due to the phenomenon of crusades in the Holy Land where the roundtrip routes often had a crossing point in southern Italy. The advent of the spread of leprosy also by sea route was the cause that made leprosy a global disease such as happened for the colonies of West African slaves deported to the US cotton plantations.
Conference Paper
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A site inspection at the Church of Santa Maria in Vico nel Lazio led to the discovery of a crypt whit numerous burials related to the medieval settlement, which is dated between the 13th and the 15th century. The human remains belongs to both male and female individuals and fully represent the demographic sample for the presence of either adults and infants. We present a skull of a woman which was about 30-35 years old. Despite of the young age she was affected by the complete loss of teeth, with a significant alveolar reabsorption. Most remarkably the calvarium shows numerous perforations with irregular or even jagged edges, along with the evident cribra on the right parietal bone, and the intense pyogenic activity which involves part of the frontal bone and the nasal bones. The differential diagnosis excludes either diseases that produces lesions similar to the observed ones (such the syphilis and the leukemia) or surgical complications (trepanation). Thus for the strictly characterizing morphology of the “open space” fenestrations, which most probably refer to the metastatic activity of a neuroblastoma.
Article
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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.
Chapter
Caudal canal injection offers an alternative approach to access the epidural space, especially when other approaches (interlaminar or transforaminal) are not feasible because of difficult anatomy. It is imperative to ensure an accurate placement of the needle to a successful procedure. The relevant anatomy, sonoanatomy, and a stepwise approach for needle placement into the caudal canal are described in this chapter.
Article
The aim of this study is to contribute to the determination of the normal values of human anogenital distance (AGD) and anal position index (API) in the antenatal period. 59 formalin-fixed human fetuses were examined. AGD was measured by the distance between the center of the anus and the posterior fourchette in females, and the distance between the center of the anus and the posterior scrotal raphe in males. API in female fetuses was determined with the formula API = fourchette–center of anus/fourchette-coccyx formula, and API = posterior scrotal raphe-center of anus/posterior scrotal raphe-coccyx in males. The mean AGDs of the female and male fetuses in the second trimester were 5.60 ± 1.60 mm and 9.64 ± 2.75 mm and 12.88 ± 4.14 mm and 17.26 ± 5.55 mm in the third trimester, respectively. The AGD values were found to be significantly higher in the males (p = 0.002). While the API values detected in the female and male fetuses were 0.43 ± 0.085 and 0.55 ± 0.072 in the second trimester, they were 0.46 ± 0.079 and 0.55 ± 0.058 in the third trimester. The API values were found to be significantly higher in the male fetuses (p < 0.001). When the distribution of API values of the fetuses in the second and third trimesters was examined, no significant difference was found (p = 0.499). In addition, no significant correlation was found between API and AGD values and percentile groups of fetuses (p ˃ 0.05). The AGD and API differed significantly between female and male fetuses starting from the antenatal second trimester, and the difference was preserved independently of the fetal percentile in the later stages of pregnancy.
Poster
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BACKGROUND & PURPOSE: To describe evaluation and treatment of painful side-bent fixation of the coccyx, describe the current knowledge gap, address the literature and present a case study. The fibrocartilaginous articulation of the 1 st coccygeal segment and the sacrum including the articular process (cornua) allow for flexion and extension, coccygeal side bending (CSB), and slight rotation. One article suggests: "the function of the coccygeal body, and the anatomy of the sacrococcygeal zygapophyseal joints are poorly documented." 1 There is scant mention of CSB in the literature 2, 3 as most imaging and case studies do not specifically screen for SBC focusing only on flexion/extension. 4, 5. Only one study was found describing CSB in 39% of symptomatic adults per CT scan. 6 Internet searches reveal very little on topic and although some clinicians do evaluate and treat it 7, 8, 9, 10, 11 finding reference to original sources is very difficult.
Poster
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Side bent coccyx evaluation and treatment
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Coccyx pain is known by multiple synonyms, including coccydynia, coccygodynia, and tailbone pain.[1] Simpson introduced the term coccydynia in 1859. Foye has referred to coccyx pain as the "lowest" (most inferior) site of low back pain.[1][2] There are many causes of coccygeal pain, ranging from musculoskeletal injuries (such as contusions, fractures, dislocations, and ligamentous instability) to infections (osteomyelitis) and fatal malignancies (such as chordoma).[1] Although many cases are self-limiting and resolve with little or no medical treatment, other cases are notoriously persistent, are challenging to treat, and are associated with severe and disabling chronic pain. Patients often report difficulty in getting a specific diagnosis for the cause of their coccyx pain and note that their treating clinicians seem dismissive of this condition.[2] Clinicians should understand the wide variety of modern options available to diagnose and treat coccydynia. Patients should be referred to a specialist if the etiology remains unclear or if the patient fails to get adequate relief. The overall scope of treatment includes avoiding exacerbating factors (sitting), use of cushions, oral or topical medications, and pain management injections performed under fluoroscopic guidance. Only a small percentage of coccydynia patients require surgical treatment, which is amputation of the coccyx (coccygectomy).[1]
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Background: Magnetic resonance imaging (MRI) is the modality of choice for evaluation of ligamentous and other spinal cord, soft tissue structures, disc, and occult osseous injuries. Objective evaluate the role of MRI as a non-invasive diagnostic tool in patient with spinal trauma.Methods: This study was conducted in department of radiodiagnosis, Sri Aurobindo institute of medical sciences and PG institute, Indore and approval from the ethical and research committee. The duration of this study was April 2018 to May 2020. We included 60 patients of spinal trauma referred for MRI in this study.Results: In 32 (53.3%) patients the mode of injury was road traffic accidents, in 23 (38.3%) patients it was fall and in 5 (8.3%) patients the mode of injury was any other mode. There was significant difference seen between the MR cord hemorrhage, cord compression, and code transaction.Conclusions: MRI is an excellent modality for imaging of acute spinal trauma. Normal cord on baseline MRI predicts excellent outcome. When comparing patients with complete, incomplete spinal cord injury (SCI) and spine trauma without SCI, significant difference was seen in cord hemorrhage, cord transection, cord compression.
Article
Introduction Coccydynia is a multifactorial complex clinical challenge. A multimodal approach with both conservative measures and procedural interventions is often recommended. We described a novel approach of radiofrequency (RF) ablation for the management of coccydynia. Methods Three patients with known history of coccydynia refractory to conservative therapy were referred to our clinic. All received different types of RF ablation before: one with anterior bipolar lesion with no analgesia benefit, one with posterior stripped lesion with good benefit but only after 8 weeks of pain flare and one received anterior monopolar lesion with 50% pain reduction for 2–3 months. All subjects underwent a novel RF ablation to the anterior surface of the sacrococcygeal and intercoccygeal joints with two bipolar lesions using multi-tined needles under fluoroscopy guidance. One bipolar lesion was between two needles: one in the sacrococcygeal and another in the intercoccygeal (between first and second coccyx) joints. Another bipolar lesion was between needles on both side of the sacrococcygeal joint. Results All experienced at least 65% pain relief for 6 months. The sitting endurance increased from less than 5 min to an average of 70 min. No adverse effect was observed in two and in the patient who used to have pain flare after lesioning, the pain flare lasted only for 2 weeks. Discussion The configuration of the two bipolar lesions with multi-tined needles in this case series stimulates the thinking of new approach for the ablation technique for pain from coccyx. Further prospective large case cohort study is needed.
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يتكون هذا الكتاب من أبواب ثلاثة رئيسية: أولها يعرض النموذج (الباراديم) التطوري، فيبين منهج الدارونية المتأسلمة وظهورها، وثانيها يعرض النموذج التطوري في بعض صوره العملية، وقد اخترت الفيلوجيني والباليوأنثروبوجي تحديدا، وأعرض في ختامه للاستخدامات العملية لهذه النماذج في بناء الحجاج الداروني المتأسلم، ثم الثالث، وأعرض فيه النقاش الشرعي لحجج الدارونية المتأسلمة، وكذلك كتاب أبي آدم للدكتور عبد الصبور شاهين، وأخيرا، فصل الختام، وأعرض فيه ملامح النظرية الإسلامية للخلق والتطور، كي تكتمل الصورة تماما عند القارئ، إذ أنه قد يشعر في مرحلة ما أن المسألة فوضوية، وأن الجميع لا يملك صورة عن الخلق من الأساس، وذاك خطأ.
Chapter
Caudal canal injections are commonly performed to access the epidural space when there is lumbosacral radicular or discogenic pain attributable to the lumbosacral nerves when other approaches are not suitable due to difficult anatomy. It is imperative that an accurate placement of the needle is key to a successful procedure. The relevant anatomy and sonoanatomy are described, and a stepwise approach into the caudal canal is discussed.KeywordsInjectionsEpiduralAnesthesiaCaudalUltrasonographyLow back painSciaticaSpinal stenosis
Chapter
The spine is a complex structure that serves vital functions for the human body. As an essential conduit of both nervous and vascular structures and the foundation for the musculoskeletal structure and function of the full body, the spine serves an indispensable role in normal human anatomy. A comprehensive understanding of the relationship of structures within and surrounding the spine is necessary to appreciate pathology and its management.
Article
The coccygeal plexus is formed in the pelvis by three nerve roots: the fourth and fifth sacral nerves and the first coccygeal nerve. From this position it branches into the anococcygeal nerves, which supply cutaneous innervation to the anococcygeal region.
Article
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The purpose of this paper is to provide a detailed radiologic description of the postnatal developmental anatomy of the sacrum and coccyx as revealed by MR imaging, helical CT, and conventional radiography. One hundred ten imaging examinations of the sacrococcygeal spine were performed in patients who were newborn to 30 years old. Imaging included conventional radiography (n = 63), three-dimensional gradient-recalled echo MR imaging (n = 10), and helical CT with sagittal and angled coronal reformations (n = 37). A detailed analysis was performed of the ossification and fusion of the primary and secondary ossification centers. The sacrum and coccyx were noted to develop from 58 to 60 sacral ossification centers and eight coccygeal centers, respectively. These centers were noted to ossify and fuse in an organized temporal pattern from the fetal period to the age of 30. The sacrum and coccyx are formed by a complex process that fuses primary and secondary ossification centers. Because the maturation process can be asymmetric, an understanding of this process may prove useful for distinguishing physeal plates from fracture lines.
Article
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Coccygodynia is a pathological condition associated with pain-discomfort all around the bottom end of the spine. The aetiology and the intensity of the symptoms may defer significantly. The effectiveness of the surgical treatment remains obscure. Our purpose, through this systematic review is to evaluate the results of surgical treatment of coccygectomy. Literature retrieval was performed by the use of the PubMed searching engine utilising the terms 'coccygodynia-coccygectomy' in the English language from January 1980 to January 2010. Case reports and tumour related case series were excluded as well as articles published in other languages. In total 24 manuscripts were analyzed. Only 2 of them were prospective studies whereas 22 were retrospective case series; five were classified as Level III studies and the remaining as Level IV studies. In total, 671 patients with coccygodynia underwent coccygectomy following failed conservative management. The sex ratio, male/female was 1:4.4. The most popular aetiology for coccygodynia was direct trauma in 270 patients. 504 of the patients reported an excellent/good outcome following the procedure. There were 9 deep and 47 superficial infections. Other complications included two haematomas, six delayed wound healings and nine wound dehiscence. The overall complication rate was 11%. Patients with history of spinal or rectal disorders, as well as idiopathic or with compensation issues, had less predictable outcome than those with history of trauma or childbirth. Coccygectomy can provide pain relief to as high as 85% of the cases. The most common reported complication was wound infection.
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The purpose of this study was to compare the clinical outcomes and wound complications in coccygectomy with or without subperiosteal resection. This retrospective study included 25 patients who underwent coccygectomy. Resection of all mobile coccygeal segments including the periosteum was performed in 11 patients (group 1) and resection was performed subperiostally sparing the periosteum in the remaining 14 patients (group 2). A visual analogue scale was used for pain assessment before and after the surgery both in sitting and standing positions. A questionnaire to evaluate subjective patient satisfaction was also used. The two groups were statistically similar in terms of age, sex, aetiology, duration of symptoms before surgery and follow-up time. Both surgical techniques resulted in a statistically similar clinical outcome. Overall, 84% of patients who underwent coccygectomy benefited from surgery. We observed four wound infections (two superficial and two deep) that caused delayed wound healing in group 1. The rate of infection in group 1 was statistically higher than in group 2. The results of this study suggest that periosteal preservation and closure are related to low risk of infection.
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L5-S1 instabilities can be fixated using minimally invasive presacral approach. The close relationship between the sacrum and neurovascular as well as intestinal structures may complicate the procedure during this approach. This requires knowledge regarding the normal anatomy of the presacral area to avoid the iatrogenic injuries. The aim of this study was to measure the distance between the sacrum and the structures anterior to it. The measurements were performed on ten cadavers fixed with formaldehyde and ten MR imaging studies on individuals without any pathology in the presacral area. The distances between the sacrum and the presacral structures (i.e., middle and lateral sacral arteries, sympathetic trunks, internal iliac arteries and veins, and colon/rectum) were measured. Cadaver study showed that the middle sacral artery was located on the right side in 55.0%, on the left side in 31.7%, and on the midline in the 13.3% of cases. The distance between the sacral midline and middle sacral artery was found to be 8.0 +/- 5.4, 9.0 +/- 4.9, 8.7 +/- 6.0, 8.6 +/- 6.4, and 4.7 +/- 5.0 mm at the levels of S1-2, S2-3, S3-4, S4-5, and S5-coccyx, respectively. The distance between the sacral midline and the sympathetic trunk ranged between 22.4 +/- 5.8 and 9.5 +/- 3.2 mm in different levels between S1 and coccygeal level. The study also showed that the distance between the posterior wall of the intestine (colon/rectum) and the ventral surface of the sacrum can be as close as 11.44 +/- 7.69 mm on MR images. This study showed that there was close distance between the sacral midline and the structures anterior to it. The close relationships, as well as the potential for anatomical variations, require the use of sacral and presacral imaging before presacral approach.
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Several reports of coccygodynia have been confined to the causes, the methods of treatment, and the methods of radiological examination. As far as we know, there has been no previous study about the objective measurement of the coccyx. The purpose of this study was to find the possible cause of idiopathic coccygodynia by comparing the clinical and radiological differences between traumatic and idiopathic coccygodynia by innovative objective clinical and radiological measurements. Thirty-two patients with coccygodynia were evaluated retrospectively. We divided the patients into two groups. Group 1 consisted of 19 patients with traumatic coccygodynia and group 2 consisted of 13 patients with idiopathic coccygodynia. We reviewed medical records and checked age, sex distribution, symptoms, and treatment outcome in each group. We also reviewed coccyx AP and lateral views of plain radiological film and measured the number of coccyx segments and the intercoccygeal angle in each group. The intercoccygeal angle devised by the authors was defined as the angle between the first and last segment of the coccyx. We also checked the intercoccygeal angle in a normal control group, which consisted of 18 women and 2 men, to observe the reference value of the intercoccygeal angle. The outcome of treatment was assessed by a visual analogue scale based on the pain score. Statistical analysis was done with Mann-Whitney U test and Chi-square test. Group 1 consisted of 1 male and 18 female patients, while group 2 consisted of 2 male and 11 female patients. There were no statistically significant differences between the traumatic and idiopathic coccygodynia groups in terms of age (38.7 years versus 36.5 years), male/female sex ratio (1/18 versus 2/11), and the number of coccyx segments (2.9 versus 2.7). There were significant differences between the traumatic and idiopathic coccygodynia groups in terms of the pain score (pain on sitting: 82 versus 47, pain on defecation: 39 versus 87), the intercoccygeal angle (47.9 degree versus 72.2 degrees), and the satisfactory outcome of conservative treatment (47.4% versus 92.3%). The reference value of the intercoccygeal angle in the normal control group was 52.3 degrees, which was significantly different from that of the idiopathic group. In conclusion, the intercoccygeal angle of the idiopathic coccygodynia group was greater than that of the traumatic group and normal control group. Based on the results of this study, the increased intercoccygeal angle can be considered a possible cause of idiopathic coccygodynia. The intercoccygeal angle was a useful radiological measurement to evaluate the forward angulation deformity of the coccyx.
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Background.—Rarely encountered nonpathologic structures may pose diagnostic problems and cause unnecessary special investigations. More importantly, however, they may be falsely accused as culprits in unrelated pathologic processes. Glomus coccygeum is one such structure. Glomus bodies (including coccygeal glomus) consist of modified smooth muscle cells arranged in layers around small vascular channels. When found in distal extremities, they generally do not represent a diagnostic problem; however, large glomus bodies present in a pericoccygeal location (glomus coccygeum) may cause significant problems for a surgical pathologist unfamiliar with this structure. Design.—We reviewed 37 coccygeal bones removed during rectal resection for carcinoma (rectal and uterine) and for various other reasons, among which was a single case of coccygodynia. Immunohistochemical and ultrastructural examinations were performed in selected cases. Results.—Sharply circumscribed glomus bodies composed of various proportions of glomus cells without atypia or pleomorphism and without expansile growth or infiltration of surrounding soft tissue or bone were identified in 50% of cases. Size varied significantly (maximum 4 mm), but paradoxically the smallest glomus body (less than 1 mm) was found in the case of coccygodynia. Glomus coccygeum posed a significant diagnostic challenge to the pathologists involved in these cases, as the retrospective review found that it was diagnosed correctly in only 3 cases. Conclusions.—Glomus coccygeum is a nonpathologic structure that exhibits significant variation in size and proportion of the constitutive elements. Immunohistochemical demonstration of smooth muscle actin and neuron-specific enolase in glomus cells may be beneficial for accurate identification of this organelle.
Article
Objectives: In humans the glomus coccygeus was described in 1860 by Luschka. It is present at the coccyx tip and corresponds to a complex anastomosis between the median sacral artery and vein, and it is innervated by sympathetic fibers. In rats and mice it has been located in the tail ventral face. Its function is not known. According to our previous work, which demonstrated that hematopoiesis is under a noradrenergic control and based on the presence of epithelioid cells and sympathetic innervation, we assumed that the coccygeal gland might influence hematopoiesis via neuroendocrine or neural mechanisms. Therefore, the present study was undertaken to analyze the effect of glomus coccygeus on hematopoiesis. Material and Methods: Peripheral blood leukocyte and platelet concentrations as well as body temperature (BT) and body weight (BW), and norepinephrine (NE), adrenaline (A) and dopamine (DA) content in bone marrow of Luschkaectomized (LCGx), Sham LCGx operated (ShLCGx) and normal mice (Co) were investigated. Results: We found that in LCGx vs. ShLCGx and Co, platelets and neutrophils increased while lymphocytes decreased. The effect of LCGx was significant from day 0 until day 65. Total leukocytes, monocytes, granulocytes, eosinophils and BT did not show any variation. Moreover, 22 days after the operation the amount of NE, A and DA seemed to be decreased in LCGx vs. ShLCGx while the difference was less evident between ShLCGx vs. Co. Conclusions: This study suggests for the first time a possible hematopoietic function and an immunomodulatory activity of the ″Luschka's body″ or Coccygeal body by a modulation of the sympathetic nervous system.
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In 1859 Simpson dignified persistent pain in the coccyx with a new and since popular term, "coccygodynia." Unfortunately, coccygodynia is descriptive in an anatomic and a symptomatic sense only and discourages diagnosis on an etiologic basis. "The Standard Classified Nomenclature of Disease"1 classifies painful coccyx as due to infection (tuberculosis or osteomyelitis) or to trauma (fracture, dislocation and contusion and tear of ligaments). This diagnostic classification also places the responsibility of finding an explanation for the pain on the physician and, fortunately, does not permit him to use the old non-diagnostic symptomatic designation.HISTORY The first recorded coccygectomy was done by Jean Louis Petit2 in 1726, for what was probably tuberculosis. Blundell3 in 1840 advised resection of the coccyx for relief of pain of indeterminate origin. Nott4 (1844) receives the credit for the first resection in this country, in a patient with "neuralgia" due to caries
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Anterior sacral anatomy was studied to allow safe sacral screw placement. The study included 27 bony sacra. Intrapelvic dissections were performed. Cadaveric specimens were dissected and photographed. The position and angulation of the first sacral foramen was extremely variable. After the position of the L5 root, sacral roots, and iliac vessels, was considered, safe posterior sacral screw implantation could be assured through placement above the level of the first sacral foramen directed medially toward the promontory, parallel to the superior sacral end-plate. Complications of indiscriminate screw placement included L5-root damage, iliac vein penetration, and intractable perineal pain due to sacral root injury. Preoperative computed tomography with the scanner gantry tilted to parallel the superior sacral end-plate defined the great vessels, neural foramens, inclination of the superior sacral end-plate, and prominence of the posterior ileum. Surgical accuracy was evaluated after surgery with computed tomography.
Article
Study Design. A total of 208 consecutive coccydynia patients were examined with the same clinical and radiologic protocol. Objectives. To study radiographic coccygeal lesions in the sitting position, to elucidate the influence of body mass index on the different lesions, and to establish the effect of coccygeal trauma. Summary of Background Data. A protocol comparing standing radiographs and radiographs subsequently taken in the painful sitting position in coccydynia patients and in controls has shown two culprit lesions: posterior luxation and hypermobility. Obesity and a history of trauma have been identified as risk factors for luxation. Methods. Dynamic radiographs were obtained. The body mass index was compared with the coccygeal angle of incidence, sagittal rotation of the pelvis when sitting down, and the presence and time of previous trauma. The patients with the newly described lesions were examined after an anesthetic block under fluoroscopic guidance. Results. Two new coccygeal lesions are described (anterior luxation and spicules). Obesity was found to be a risk factor. The body mass index determines the way a subject sits down, and lesion patterns were different in obese, normal-weight, and thin patients (posterior luxation: 51%, 15.2%, 3.7%; hypermobility: 26.5%, 30.3%, 14.8%; spicules: 2%, 15.9%, 29.6%; normal: 16.3%, 32.6%, 48.1%, respectively;P < 0.0001). Trauma affected the type of lesion only if it was recent (<1 month before the onset of coccydynia), in which case the instability rate increased from 55.6% to 77.1%. Backward-moving coccyges were at greatest risk of trauma. Conclusions. This protocol allows identification of the culprit lesion in 69.2% of cases. The body mass index determines the causative lesion, as does trauma sustained within the month preceding the onset of the pain.
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This large treatise (1209 pages) can be considered the most complete textbook of clinical anatomy available today. The text in the book is aided by outstanding figures from the 11 editions of John C. Boileau Grant's classical anatomical atlases. These are very capably re-edited and supplemented by hundreds of creative and illuminating anatomical and clinically relevant art produced by Dr Anne M. R. Agur.
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Principal vertebral segments and individual vertebrae of 83 Asian skeletons were weighed and the data treated statistically.Average weight in grams per unit vertebra in the cervical segment was 6.3, in the thoracic, 8.7, in the lumbar, 17.9 and in the sacrum, 10.6. Mean weights of segments of this series were the lightest of the populations compared except those of the American White and Japanese females. Individual vertebral weights increased in caudad sequence except that the first two cervical and first two thoracic were respectively heavier than the third cervical and third thoracic. Mean weights of the twelfth thoracic, fifth lumbar and the sacrum were approximate multiples of that of the seventh cervical. The third cervical was the lightest in the column.The cervical segment represented 15% of the weight of the entire column, the thoracic segment 36%, lumbar 31%, sacral 18% and coccygeal 0.4%. Relative weights of individual vertebrae corresponded closely with those of other populations compared.Coefficients of variation ranged from 16% in the cervical segment, 19% in the thoracic, 17% in the lumbar, 18% in the sacral to 48% in the coccygeal. Variation was least in the second cervical and greatest in the third thoracic vertebra.
Article
Recent investigators suggest that dermatomes extend as consecutive bands from the dorsal median line and question the existence of dorsal axial lines. Our observations were made on serial sections of human embryos and fetuses prepared with neurofibrillar stains. Cervical nerves 1, 6, 7 and 8 failed to have cutaneous branches in most cases, the remainder usually had cutaneous branches. With a few exceptions in T 1, all thoracic dorsal rami had cutaneous branches. Usually T 1, 2 and 3 became cutaneous through medial branches, while T 9 through 12 did so through lateral branches. However T 4 through 8 constitute a transition zone where many of these nerves became cutaneous through both medial and lateral branches. Thoracic 4, 5 and 6 tended to have cutaneous distribution through medial branches, but T 7 and 8 through lateral branches. All lumbar dorsal rami having cutaneous distribution did so through lateral branches, but independent branches became progressively less frequent below L 1. Lumbar 4 lacked direct cutaneous branches in most cases and succeeding nerves in all cases. These nerves form the dorsal sacral plexus. The deficit in cutaneous distribution of lower lumbar rami was not as pronounced as in the lower cervical region. A deficit is significant in relation to dorsal axial lines.
Article
Background Coccygodynia can cause severe pain and disability in patients. There are contradictions in the literature regarding the final results of coccygectomy for coccygodynia. We evaluated the long-term effects of coccygectomy on the intensity, characteristics, and manifestation of pain caused by coccygodynia to determine the adequacy of operation among treatment modalities. Materials and methods Thirty-four patients with coccygodynia were treated by coccygectomy. In 22 cases, trauma, and in one case childbirth was the cause. 11 cases were regarded as idiopathic. The intensity, characteristics of pain, and the most painful activities were evaluated at an average of 7.6 (3–18) years of follow-up time. Results Before the operation, all 34 patients had pain while sitting, moreover, 26 of them had pain during standing, walking, at night or a combination of these. 21 patients had intolerable or very intensive, mainly acute, sharp or burning pain. 11 patients had dyschesia, 2 had dysuria and 6 had dyspareunia. At follow-up, 7 patients were completely free of pain, 15 others had moderate, 11 medium, and only one patient had severe, but none had intolerable pain. Only seven patients had acute, sharp or burning pain postoperatively. The decrease of average pain score from 8.0 to 3.2 was significant (P < 10−12). The number of the patients with dyschesia and dyspareunia decreased from 11 to 7 and from 6 to 3, respectively. Two patients had dysuria, but their complaints did not change after the operation. One of the two patients who needed reoperation had an excellent final result, while the other remained unchanged. 12 and 16 patients (together 82%) regarded the final result of the operation excellent and good, respectively. The condition of five others did not change, while one became worse. The patients with younger age, smaller body mass index, and less co-morbidities had better final result. There were no serious complications. Conclusion Coccygectomy for coccygodynia is a safe method to decrease the intensity of pain and other complaints of the patients. The operation can be the choice of treatment if conservative measures fail.
Article
Little is known about the morphometric properties of the sacrotuberous ligament (ST) and the sacrospinous ligament (SS). The influence of ligaments on pelvic stability and the extent of reconstruction in case of instability are controversially discussed. The ST and the SS of 55 human subjects fixed in alcohol solution and of four fresh cadavers were measured. Both ligaments were defined as geometric figures. The ST was a contorted bifrustum, while the SS was a contorted frustum, both with elliptic planes. In all cases investigated, the ST and the SS fibres were twisted. For men, the ST and the SS had a mean length of 64 and 38 mm. For women, lengths of 70 and 46 mm were measured in the ST and the SS. The ST length, height and cross-sectional area showed gender-specific differences at statistically significant level. The ST and the SS volumes correlated closely, regardless of gender or side. Measurements of fresh ligaments of four unfixed cadavers showed similar results. The data obtained were then used to generate computer-based three-dimensional models of both ligaments, using the Catia® software. Conclusively, the virtually generated ST and SS are suitable models to be included in pelvic fracture simulation, using the finite element method.
Article
Coccydynia is a painful disorder characterised by coccygeal pain which is typically exaggerated by pressure. It remains an unsolved mystery because of the perceived unpredictability of the origin of the pain, some psychological traits that may be associated with the disorder, the presence of diverse treatment options, and varied outcomes. A more detailed classification based on the aetiology and pathoanatomy of coccydynia helps to identify patients who may benefit from conservative and surgical management. This review focuses on the pathoanatomy, aetiology, clinical features, radiology, treatment and outcome of coccydynia.
Article
The pubic symphysis is a unique joint consisting of a fibrocartilaginous disc sandwiched between the articular surfaces of the pubic bones. It resists tensile, shearing and compressive forces and is capable of a small amount of movement under physiological conditions in most adults (up to 2 mm shift and 1° rotation). During pregnancy, circulating hormones such as relaxin induce resorption of the symphyseal margins and structural changes in the fibrocartilaginous disc, increasing symphyseal width and mobility. This systematic review of the English, German and French literature focuses on the normal anatomy of the adult human pubic symphysis. Although scientific studies of the joint have yielded useful descriptive data, comparison of results is hampered by imprecise methodology and/or poorly controlled studies. Several aspects of the anatomy of the pubic symphysis remain unknown or unclear: the precise attachments of surrounding ligaments and muscles; the arrangement of connective tissue fibres within the interpubic disc and the origin, structure and function of its associated interpubic cleft; the biomechanical consequences of sexual dimorphism; potential ethnic variations in morphology; and its precise innervation and blood supply. These deficiencies hinder our understanding of the normal form and function of the joint, which is particularly relevant when attempting to understand the mechanisms underlying pregnancy-related pubic symphyseal pain, a neglected and relatively common cause of pubic pain. A better understanding of the normal anatomy of the human pubic symphysis should improve our understanding of such problems and contribute to better treatments for patients suffering from symphyseal pain and dysfunction.
Article
Coccygodynia is painful condition localized in the region of the coccyx. In most cases a traumatic etiology is present. In the idiopathic form other causes such as infections and tumor have to be excluded. Coccygodynia can also be the result of pain referred from visceral structures due to conditions such as disorders of the rectum, the colon sigmoideum, and the urogenital system. In case of a traumatic etiology the diagnosis is made based on the typical medical history whereby the pain is provoked by prolonged sitting and cycling. Lateral images of the coccyx are always indicated. The same is true for manual examination of the coccyx. In case of absence of provocation of the coccygeal pain by prolonged sitting and manual examination neurological causes such as lumbar disc hernias are a possible reason for the coccygodynia. In the acute phase the first choice of treatment are NSAIDs. Treatment for patients with severe pain in the chronic phase consists of manual therapy and/or a local injection of local anesthetic and corticosteroid into the painful segment (2 C+). Other interventional treatments such as intradiscal injections, ganglion impar block, radiofrequency treatment and caudal block are advised only under study conditions (0). Coccygectomy is not recommended because of long-term moderate results and the chance of major complications.
Article
In contrast to the attachments to the pubis and rectum, there is little information on fetal development of the coccygeal attachment of the levator ani muscles. We find that at 9 weeks, the coccygeus muscle is a large muscle facing the piriformis or gluteus maximus and inserting onto the ischial spine, whereas the levator ani is restricted to the area near the pubis. By 12 weeks, the levator ani also obtains attachment to the ischial spine immediately ventral to the coccygeus muscle. The most superior part of the coccygeus muscle occupies a space at an angle between the pelvic splanchnic and pudendal nerves. Notably, medial to the coccygeus muscle, a third parasagittal muscle (previously termed the sacrococcygeus anterior) appears by 12 weeks, increases in mass by 18 weeks, and connects and mixes with the dorsal end of the levator ani by 18-20 weeks. Thus, the coccygeal attachment of the levator ani appears not to depend on the dorsal extension of the muscle itself but on fusion with the sacrococcygeus anterior. Therefore, the final levator sheet is formed medial (internal) to the coccygeus muscle and originates from two distinct anlage.
Article
Between 1993 and 2008, 41 patients underwent total coccygectomy for coccydynia which had failed to respond to six months of conservative management. Of these, 40 patients were available for clinical review and 39 completed a questionnaire giving their evaluation of the effect of the operation. Excellent or good results were obtained in 33 of the 41 patients, comprising 18 of the 21 patients with coccydynia due to trauma, five of the eight patients with symptoms following childbirth and ten of 12 idiopathic onset. In eight patients the results were moderate or poor, although none described worse pain after the operation. The only post-operative complication was superficial wound infection which occurred in five patients and which settled fully with antibiotic treatment. One patient required re-operation for excision of the distal cornua of the sacrum. Total coccygectomy offered satisfactory relief of pain in the majority of patients regardless of the cause of their symptoms.
Article
Although the normal adult human intervertebral disc is considered to be avascular, vascularised cellular fibrous tissue can be found in pathological conditions involving the disc such as disc herniation. Whether lymphatics vessels form a component of this reparative tissue is not known as the presence or absence of lymphatics in herniated and normal disc tissue is not known. We examined spinal tissues and discectomy specimens for the presence of lymphatics. The examination used immunohistochemistry to identify the specific lymphatic endothelial cell markers,podoplanin and LYVE1. Lymphatic vessels were not found in the nucleus pulposus or annulus fibrosus of intact, non-herniated lumbar and thoracic discs but were present in the surrounding ligaments. Ingrowth of fibrous tissue was seen in 73% of herniated disc specimens of which 36% contained LYVE1+/podoplanin + lymphatic vessels. Lymphatic vessels were not seen in the sacrum and coccyx or biopsies of four sacrococcygeal chordomas, but they were noted in surrounding extra-osseous fat and fibrous tissue at the edge of the infiltrating tumour. Our findings indicate that lymphatic vessels are not present in the normal adult intervertebral disc but that, when there is extrusion of disc material into surrounding soft tissue, there is ingrowth of reparative fibrous tissue containing lymphatic vessels. Our findings also indicate that chordoma, a tumour of notochordal origin, spreads to regional lymph nodes via lymphatics in para-spinal soft tissues.
Article
The knowledge of sacral hiatus anatomy is imperative in clinical situations requiring caudal epidural block for various diagnostic and therapeutic procedures of the lumbosacral spine to avoid failure and dural injury. In this study, a detailed anatomic study of the sacral region was carried out on 49 male adult Indian cadavers. Dorsal surface of sacral region was dissected to study sacral cornua, sacral hiatus, and the dimensions of triangle formed by the right and left posterosuperior iliac spines with apex of the hiatus. Midsagittal sections were subjected for various anatomical measurements. The angle of needle insertion and the depth of caudal space were noted. Cornu was not palpable bilaterally in 7 (14.3%) and palpable unilaterally in 12 (24.5%) specimens. Mean (standard deviation) distance between apex of hiatus and coccyx tip was 57.5 (8.7) mm and length of sacrococcygeal ligament was 34.2 (7.4) mm. The dimensions of the triangle were found to be interchangeable in 25 cadavers. Once the needle is introduced into the canal after penetrating the sacrococcygeal ligament, it should not be advanced >5 mm to prevent dural puncture. The level of maximum curvature of sacrum was S3 in 34 (69.4%) of cases. The dural sac was found to terminate at S2 in 41 (83.6%). The mean (SD) angle of depression of the needle was 65.7 (5.5) (range 58-78). The measurements described for the identification of the sacral hiatus, optimal angle of depression, and depth of the needle may improve the safety and reliability of a caudal epidural block.
Study of 100 specimens permits the statement that there is a constant existence in the sacro coccygeal region of angio glomic formations in relation with the collateral and terminal branches of the middle sacral artery. These corpuscles, the most distal of which had been described by Luschka (1857) under the name of ''coccygeal gland'', have, in fact, no glandular character whatever. They should be eliminated from the group of paraganglions (notably from that of the chromaffin paraganglions) and rather deserve the name of coccygeal glomi. Their analogy with the glomerula caudalia of other mammals suggests that this is a case of involutive formations in connection with the regression of the caudal region. Nevertheless, certain identities of structure with the carotid glomus should not cause the elimination of a chemoreceptor function of these corpuscles.
Article
Anterior sacral anatomy was studied to allow safe sacral screw placement. The study included 27 bony sacra. Intrapelvic dissections were performed. Cadaveric specimens were dissected and photographed. The position and angulation of the first sacral foramen was extremely variable. After the position of the L5 root, sacral roots, and iliac vessels, was considered, safe posterior sacral screw implantation could be assured through placement above the level of the first sacral foramen directed medially toward the promontory, parallel to the superior sacral end-plate. Complications of indiscriminate screw placement included L5-root damage, iliac vein penetration, and intractable perineal pain due to sacral root injury. Preoperative computed tomography with the scanner gantry tilted to parallel the superior sacral end-plate defined the great vessels, neural foramens, inclination of the superior sacral end-plate, and prominence of the posterior ileum. Surgical accuracy was evaluated after surgery with computed tomography.
Article
The sacral and coccygeal vertebrae at 8 postovulatory weeks (the end of the embryonic period proper) have been studied by means of graphic reconstructions. The cartilaginous sacrum is now a definitive unit composed of five separable vertebrae, each of which consists of a future centrum and bilateral neural processes. The base of each neural process consists of an anterolateral or alar element, not present in the lumbar region, and a posterolateral part, which includes costal and transverse elements. The usual illustrations, in which the costal component is placed in the alar element, are incorrect. The future dorsal foramina (containing dorsal rami) face laterally in the embryo and are in line with the thoracicolumbar intervertebral foramina. Considerable differential growth is required to change the dorsal openings from a lateral to a dorsal positions. The intervertebral foramina transmit ventral rami, but pelvic foramina are not yet present. The lumbosacral plexus is completed by S.N.1-3; S.N.4, 5 and Co.N.1 form the pelvic plexus. The inferior hypogastric plexus and the hypogastric nerves are present. The sacrum takes part in the spina bifida occulta that characterises the entire length of the embryonic vertebral column. The coccygeal vertebrae, which are variable, were 4-6 in number in the present series. The first is the best developed. The ventriculus terminalis ends usually at the level of Co.V.1 and the spinal cord generally at Co.V.5. The coccygeal notochord ends commonly in bifurcation or trifurcation. 'Haemal arches' were not observed.
Article
Study of the pelvis in 143 different mammals reveals that in quadrupeds the ischial spines are barely noticeable and are located posteriorly near the sacrum. In humans, the ischial spines are prominent and more anteriorly located. As a consequence of their position and size, the ischial spines in humans become an obstacle to parturition. Herein a theory is proposed to account for what appears to be an incongruous development and orientation of the ischial spines in humans. The pelvic diaphragm is a vertical pelvic "wall" in tailed mammals and is composed of muscles involved mostly with the motion of the tail. In humans, the muscles of the pelvic diaphragm have a very different anatomical orientation. They form a horizontal pelvic "floor," and their functions are first to support the abdominopelvic organs and resist intra-abdominal pressure that is exerted from above, and second, as levator ani, to control the anal sphincter. In humans the muscles and fascias of the pelvic diaphragm are inserted on the ischial spines either directly or indirectly through the sacrospinous ligament and the tendinous arch of the pelvic fascia. The result is a medial pull on the ischial spines to produce a more rigid and narrower pelvic floor. An inconstant ossification center for the ischial spines make them more prominent. The backward tilt of the sacrum placed the bispinal line in a diameter position. Pongids and even fossil hominids occupy an intermediate position between tailed mammals and Homo sapiens. The present form of the pelvis in Homo sapiens may be determined by a significant genetic component but may also be partly acquired during childhood and adolescence.
Article
It is well known that the sacrococcygeal joint may be obliterated by ossification, producing fusion of the first coccygeal segment with the sacrum. There is a conspicuous lack of quantitative information on the occurrence of such bony fusion. It is generally regarded to be characteristic of old age, whilst conflicting statements surround the question of sex differences in its frequency. This report describes the occurrence of sacrococcygeal fusion in two adult British populations, one from Aberdeen and the other from London. In the Aberdeen group, both males and females had a similarly high incidence. In the London group, the males exhibited an intermediate rate whereas the females showed a relatively low occurrence. In London, the males showed a delayed onset of sacrococcygeal fusion with significantly fewer cases occurring below 40 years of age. In contrast, the London females showed a similar frequency of fusion below and above age 40. The effects of age could not be analysed in the Aberdeen group owing to the paucity of subjects below middle age. The findings of this investigation indicate that the occurrence of sacrococcygeal fusion is not related exclusively to age and sex. It is postulated that other factors of a genetic and/or environmental nature are involved.
Article
The development of the structural pattern of the lower sacral and coccygeal segments of the spinal cord in human, rabbit and monkey embryos and fetuses has been studied. The changes observed in serial sections from above downward are outlined, beginning with typical sections through the lower sacral cord. Among the changes, other than diminution in size of the spinal cord and reduction in size of the lower spinal nerves, there is a gradual disappearance of the posterior funiculus. As this occurs the gray matter appears to spread dorsally and the central canal widens. The gray matter becomes reduced in size and the lateral funiculus extends farther dorsally. A little lower down, the gray matter of the alar plate is reduced further in size and there is corresponding enlargement of the central canal. This enlargement constitutes the terminal ventricle. The spinal cord rapidly becomes smaller as both the fibers and the gray matter are diminished. In some specimens, fibers decussate dorsal to the lower end of the terminal ventricle. Little remains of the lower end of the spinal cord except the ependymal wall of the central canal and the surrounding fiber bundles. The shape and size of the lower end of the central canal is subject to variations.In the lower part of the spinal cord a longitudinal bundle on each side is formed by fiber contributions from the anterior horn cells in the basal plates. This bundle contributes fibers to the fifth sacral and the first and second coccygeal nerves. It is designated the sacrococcygeal fasciculus.
Article
We studied the normal radiographic anatomy of the coccyx in 120 asymptomatic subjects and performed a retrospective review of the results in fifty-one patients who had had a partial or total coccygectomy for idiopathic coccygodynia during a twenty-year period. Of the asymptomatic subjects, the sacrococcygeal joint was fused in forty-four (37 per cent); the first intercoccygeal joint, in twelve (10 per cent); and the second intercoccygeal joint, in fifty-two (43 per cent). Four types of configuration of the coccyx were identified on the lateral radiographs. In Type I the coccyx was curved slightly forward, whereas in Type II the curve of the coccyx, which pointed straight forward, was more marked. In Type III the coccyx was angulated forward sharply, and in Type IV it was subluxated at the sacrococcygeal or the intercoccygeal joint. Most subjects (68 per cent) had a Type-I configuration. Of the fifty-one patients with idiopathic coccygodynia, twenty-six (51 per cent) showed fusion of the sacrococcygeal joint; six (12 per cent), of the first intercoccygeal joint; and twenty-five (49 per cent), of the second intercoccygeal joint. In most patients (69 per cent) the coccyx had a Type-II, III, or IV configuration. Thirty-one patients had undergone a partial coccygectomy and twelve, a total coccygectomy; in the remaining eight patients the extent of the coccygectomy could not be determined. The results of surgery were excellent or good in thirty-two (88 per cent) of the thirty-six patients who were followed for at least two years.(ABSTRACT TRUNCATED AT 250 WORDS)
Article
We undertook an anatomical and histological study to differentiate glomus-cell tumors of the pericoccygeal tissues from the normal coccygeal body. Removal of the coccyx was performed on five consecutive autopsy specimens from patients with no history of coccygeal symptoms. In each specimen, the coccygeal body (glomus coccygeum) was identified grossly and histologically. The histological appearance was indistinguishable from that of photomicrographs published in case reports of patients with glomus tumors of the coccyx. It is likely that the so-called tumors reported previously were in actuality normal glomus bodies.
Article
The pelvic segment of the sympathetic trunk was examined in 100 human fetuses of both sexes. Special attention was paid to the trunk topography in this segment, the shape, the size and the number of ganglia. In the sacral segment, in the majority of cases, trunks of 4 (36%) and 5 (34.5%) ganglia were observed, with the number of ganglia varying from 2 to 7. On the basis of the identified segments, the occurrence of deviations from the segmental structure of the sympathetic trunk such as the absence, doubling or fusion of ganglia was analysed. The absence of ganglia was observed first of all at the level of lower segments of the sympathetic trunk, while the processes of doubling and the fusion of ganglia occurred more frequently in its upper segments. Both trunks were also compared as regards the number of ganglia. The relation of ganglia 4:5 (22%) was observed most often. A complete symmetry of sympathetic trunks was found in 14 fetuses. In the coccygeal segment of the trunk, fundamental types of its structure were distinguished. In over a half of cases (62%), the impar ganglion occurs in this segment.
Article
17 Pelvic halves of 9 cadavers (15 halves of 8 males and 2 of a female) were dissected under a stereomicroscope in order to examine the topographical relationships among the nerves supplying the sphincter ani externus, levator ani and coccygeus with respect to their origin, course and distribution. 4 Nerves supplying the sphincter ani externus were observed. They are classified into 2 groups according to their origin and course. Either the perineal branch of the 4th sacral nerve or the muscular branch of the anococcygeal nerves arising from S4-Col descends vertically and pierces the coccygeal attachment of the pelvic diaphragm to reach and supply the posterior extremity of the sphincter ani externus. The perineal and inferior rectal nerves originating in the pudendal plexus send many branches to the sphincter ani externus, which usually enter its upper margin and then descend successively through its deep, superficial and subcutaneous portions to supply them. After perforating the sphincter ani externus, several fibers issuing from these branches run along the so-called longitudinal conjoined muscle and pass through the intersphincteric space to end in the subepithelial part of the anal canal. The perineal and inferior rectal nerves are distributed to the anterior one half to one-fourth and the posterior one half to three-fourths of the muscle, respectively. This finding indicates that there exists a small area of dual innervation. 4 Nerves supplying the levator ani were observed next. They are classified into 3 groups according to their origin and course. The nerve to the levator ani (n. musculi levatoris ani) originates in the pudendal plexus and enters the pelvic surface to be distributed to the entire muscle except its rectal attachment. The perineal and inferior rectal nerves enter the rectal attachment of the levator ani from the outside. That the rectal attachment of the levator ani is always innervated by the perineal and inferior rectal nerves suggests that this muscular portion has been derived not from the primitive mass of the levator ani but from a portion of the primitive sphincter ani externus or the sphincter cloacae. The visceral branches arising from the posterior horn of the pelvic plexus occasionally send out slender twigs to the rectal attachment of the levator ani from the inside. The coccygeus is supplied by the coccygeal nerve (n. musculi coccygici) which enters the muscle at its upper posterior margin or its pelvic surface. The pudendal plexus is formed by the ventral primary rami of S2, S3 and S4. The branches of the pudendal plexus are classified into 2 groups, medial and lateral, according to their origin from the plexus. To the medial group belong the nerves which arise near the paramedian loop between S3 and S4. They are composed of 3 layers: the pelvic splanchnic nerves situated ventrally; the nerve to the levator ani situated intermediately; and the coccygeal nerve situated dorsally. The lateral group contains the nerves which originate in the pudendal plexus slightly medial to its communication with the sacral plexus. They are divided into 3 layers: the dorsal nerve of the penis or clitoris situated ventrally; the perineal nerve situated intermediately; and the inferior rectal nerve situated dorsally. Depending on the site of perforation of the lateral cutaneous branches of the intercostal nerves, the superficial layer of the ventral trunk musculature (designated as VI by Nishi) is classified into 2 divisions, dorsal (d) and ventral (v), each of which is subdivided into medial (d 1 and v 1) and lateral (d 2 and v 2) parts. In other words, VI is subdivided into 4 parts, d 1, d 2, v 2 and v 1, situated dorsal to ventral in this order. They respectively correspond to the external oblique system (Oe), the dorsal half of the internal oblique system (Oi), the ventral half of the internal oblique system (Oi) and the rectus system (R) of Nishi's classification. On the basis of the sites of origin and stratificational interrelationships of the principal nerves supplying the muscles, it is concluded that the coccygeus, sphincter ani externus and levator ani belong to d 1 (Oe), d 2 plus v 2 (Oi) and v 1 (R), respectively.
Article
Coccygodynia is an uncommon condition of diverse causes. A few cases were attributed to so-called pericoccygeal glomus tumors. However, the pericoccygeal soft tissues normally contain numerous small glomus bodies and a larger one known as the glomus coccygeum, which can reach several millimeters in diameter. Most reported cases of alleged pericoccygeal glomus tumors represent normal, incidentally discovered coccygeal glomus bodies. Recently, an intracoccygeal glomus tumor was reported as a cause of coccygodynia. However, we suspected that glomera can also occur normally within the coccyx itself. Twenty coccyges from fetuses, newborns, infants, and adults were obtained at autopsy, embedded in toto, and examined histologically in step sections. Intracoccygeal glomera were present in six of the nine pediatric specimens and all 11 adult specimens. All were microscopic structures, and none appeared to have caused bony destruction or erosion. They did not differ from the structures previously reported as alleged intracoccygeal "glomus tumors." Pericoccygeal and intracoccygeal glomus bodies are normal findings in humans at all ages. They should not be mistaken for tumors, and their role in the pathogenesis of coccygodynia is questionable.
Article
Ninety-one patients with common coccygodynia and 47 control subjects prospectively underwent dynamic radiographic imagery. To standardize the radiologic protocol to better define normal and abnormal mobility of the coccyx, and to study clinical parameters useful in classifying and differentiating the lesions. In a previous study, comparison of films taken in the sitting and standing positions allowed to individualize two distinct coccygeal lesions: luxation and hypermobility. Measurement technique was precise and reproducible, but the control group was not pain-free. No specific clinical features were described. Standing films were made first. Control subjects were healthy volunteers. The following items were recorded: presence of an initial traumatic event, elapsed time before investigation, body mass index, presence of an acute pain when passing from sitting to standing, effect of intradiscal steroid injection, and angle of the coccyx with respect to the seat. Hypermobility was defined as a flexion of more than 25 degrees, luxation by displacement of more than 25% of the coccyx. The base angle is a good predictor of the direction in which the coccyx moves when sitting. In the "luxation" group, a history of initial trauma, a shorter clinical course, pain when standing up, increased body mass index, and satisfactory results with intradiscal injection were found more frequently than in the "normal" group. The "hypermobility" group had characteristics between these two groups. Common coccygodynia is associated in 48.4% of patients with a luxation or hypermobility of the coccyx. A distinct clinical presentation was found in individuals with luxation of the coccyx.