Surgical treatment of coccygodynia: an analytic review of the literature

Coccygectomy for refractory coccydynia, old-fashioned but effective procedure: A retrospective analysis

PURPOSE

Coccydynia, characterized by persistent pain in the coccygeal region, significantly impacts patients' quality of life. While various treatment modalities exist, including conservative measures and surgical interventions like coccygectomy, optimal management remains unclear. This retrospective cohort study aimed to compare the clinical outcomes, functional improvements, and quality of life in patients with chronic coccydynia undergoing either infiltrative treatment or coccygectomy.

METHODS

Data from patients treated at our institution from January 2018 to December 2022 were analyzed. Participants meeting inclusion criteria were divided into two groups: Group A underwent coccygectomy, while Group B received conservative therapy. Clinical assessments, radiographic evaluations, and patient-reported outcomes were collected preoperatively and at follow-up intervals.

RESULTS

Of the 223 initially examined patients, 55 met inclusion criteria. Group A (n = 21) underwent coccygectomy, while Group B (n = 34) received conservative therapy. Both groups showed significant pain reduction post-intervention, with sustained improvement in Group A. Functional outcomes favoured Group A, with significant improvements in disability and quality of life measures. Complications were minimal, with only one case of superficial wound infection in Group A.

CONCLUSION

Our findings suggest that coccygectomy provides superior and lasting pain relief, functional improvement, and quality of life improvement compared to conservative therapy. While complications were minimal, further research with larger cohorts is warranted to validate these results and explore long-term outcomes. Despite its historical association with complications, advancements in surgical techniques and perioperative care have led to improved outcomes and reduced complication rates. Thus, coccygectomy should be considered in the treatment algorithm for patients with debilitating coccydynia.

Iatrogenic rectal perforation after coccygeal radiofrequency ablation

Coccygodynia (pain of the coccygeal bone) can be treated locally with anti-inflammatory drugs, local steroid injections, surgical removal of the coccyx and, more recently, with radiofrequency thermal ablation. Complications, such as perforation of the colon, can occur as a consequence of the close relationship between the rectum and the sacrococcyx and with the heat from the thermal ablation expanding to the surrounding tissue causing delayed damage with severe consequences. The treatment of this complication requires the combined effort of the gastrointestinal surgeon as well as a gastroenterologist. In this case report, we describe the treatment of this complication and the clinical course after a perforation of the rectum due to thermal ablation of the coccyx to treat long-standing coccygodynia.

Coccydynia: A Review of Anatomy, Causes, Diagnosis, and Treatment

» Coccydynia is a painful condition affecting many patients at the terminal caudal end of the spine.» An understanding of coccyx anatomy and variations of morphology is necessary for proper diagnosis. A multifactorial etiology for pain may be responsible for this clinical entity.» Several treatment options exist. Successful outcomes for patients depend on individual patient characteristics and the etiology of pain.

Clinical Outcome of Coccygectomy Using a Paramedian Curvilinear Skin Incision in Adults and Children With Meta-Analysis of the Literature Focusing on Postoperative Wound Infection

STUDY DESIGN

A single surgeon case series and meta-analysis of literature.

OBJECTIVE

To evaluate the clinical outcome and patient satisfaction following coccygectomy for coccygodynia in adults and children using a curvilinear paramedian skin incision and to conduct a meta-analysis of the literature to determine the associated infection rate with different surgical factors.

METHODS

45 consecutive patients (40 adults and 5 children) underwent surgical coccygectomy for persistent coccygodynia symptoms using a paramedian curvilinear incision. Postoperative clinical outcome scores, patients' satisfaction and wound complications were assessed. A systematic literature search using specific MesH terms was then conducted covering the period from 1980 to 2020. Only those studies reporting infection rates post coccygectomy were included in a meta-analysis.

RESULTS

The average age of patients was 39 years with a mean duration of symptoms prior to surgery of 7.4 years. The mean Oswestry Disability Index improved from 29 to 7.7 (P < .001). The mean pain Visual analogue scale improved from 8 to 2 (P < .001) and the median patient satisfaction score was 8 (out of 10) suggesting good to excellent outcome. The clinical improvement was the same in children and adults. There was a total of 5 (11%) wound infections, 2 of which needed surgical debridement. Meta-analysis of the included studies showed that the use of prophylactic antibiotics for 24 hours, nonabsorbable skin sutures and glue were associated with low infection rate.

CONCLUSIONS

Coccygectomy using curvilinear paramedian skin incision for chronic coccygodynia is an effective procedure with similar or lower complication rates as reported in the literature.

Coccygectomy in the Treatment of Chronic Coccydynia

STUDY DESIGN

This is a retrospective cohort study.

OBJECTIVE

The aim of this article was to evaluate the results of patients operated for chronic coccydynia, and determine any factors that could affect outcomes.

SUMMARY OF BACKGROUND DATA

Patients with coccydynia who do not respond to conservative treatment will often profit from coccygectomy. Studies of results and complications vary considerably and often report on a limited number of patients. Methods. A total of 184 patients were operated with coccygectomy in our department and followed-up with questionnaires after a minimum of 1 year post-operatively. Treatment results were compared to their preoperative state, and any complications or reoperations were recorded and analyzed. Results. A total of 171 patients (93%) responded to final follow-up. The overall success rate was 71%, defined by patients being either completely well or much better at final follow-up. Furthermore, 89% off all patients would have consented to the operation if they had known the outcome in advance. The rate of post-operative infections was reduced from 10% to 2% by increasing the duration of prophylactic postoperative antibiotics from 24 to 48 hours (P = 0.018).

CONCLUSION

Coccygectomy, for patients where conservative measures have failed, seems to give acceptable levels of success and high levels of patient satisfaction. The main complication after this procedure is infection, and the risk can be somewhat reduced by using antibiotic prophylaxis for 48 hours after surgery.

LEVEL OF EVIDENCE

4.

The Surgical Role in the Management of Persistent Coccygodynia in Adolescent and Pediatric Patients: A Retrospective Case Series

Background: Coccygodynia has been described as a disabling pain in the coccyx usually associated with sitting or with changing position from a sitting to a standing position. Pain may radiate to the sacrum, to the lumbar spine, or laterally to the buttocks. Treatment has rarely been studied in the adolescent population. Purposes/Questions: This study aimed to assess pain relief and satisfaction after partial or total coccygectomy in pediatric and adolescent patients suffering from coccygodynia that was resistant to conservative treatment. Methods: A retrospective, consecutive case series was performed to review the data from the hospital records of 29 patients who underwent partial or total coccygectomy from January 2016 to January 2020 in a university hospital setting. Patients suffered from coccygodynia resistant to conservative treatment. The study included 16 female (55%) and 13 male (45%) patients who ranged in age from 3 to 15 years. Patient records were assessed for postoperative complications, period of hospital stay, time to regain normal activity, postoperative pain improvement (using a 4-point Likert scale), and patients' or parents' satisfaction (using a 5-point questionnaire). Results: Total coccygectomy was performed in 19 patients and partial coccygectomy in 10 patients. Only 1 patient had a superficial infection after surgery. The length of hospital stay was 1.44 ± 0.97 days. Time to regain normal activity was 24.68 ± 4.32 days. Pain relief was excellent (complete pain relief) in 23 cases (79.3%) and good (relief of most pain but mild discomfort after prolonged sitting) in 6 cases (20.7%). There were no reports of fair (minimal or no pain relief) or poor (pain worse than before surgery) pain relief. In terms of patient or parent satisfaction, no one reported being "absolutely dissatisfied," 1 person was "dissatisfied" (3.4%), 3 people were "neither dissatisfied nor satisfied" (10.4%), 9 were "satisfied" (31%), and 16 were "absolutely satisfied" (55.2%). Conclusion: This case series suggests that coccygectomy may be a feasible management option for pediatric and adolescent patients, with favorable outcomes including pain relief, patient or parent satisfaction, and early return to activity.

Comparison of treatment outcomes in chronic coccygodynia patients treated with ganglion impar blockade versus caudal epidural steroid injection: a prospective randomized comparison study

BACKGROUND

Coccygodynia is one of the chronic, refractory painful musculoskeletal disorders. Interventional procedures are applied to patients unresponsive to initial treatment in coccygodynia. This study aims to compare the treatment outcomes of ganglion impar block (GIB) and caudal epidural steroid injection (CESI) in patients with chronic coccygodynia.

METHODS

This study was a prospective randomized comparison study conducted between June 2019 and January 2021. Patients diagnosed with chronic coccygodynia were randomly divided into two groups: the GIB group and the CESI group. The severity of pain, presence of neuropathic pain, and quality of life were evaluated using the Numeric Rating Scale, Leeds Assessment of the Neuropathic Symptoms and Signs Scale, and Short Form-12 Health Survey (SF-12), respectively.

RESULTS

A total of 34 patients in each group were included in the final analyses. While there was a significant decrease in pain intensity in both groups in the 3-month follow-up, this decrease was more significant in the GIB group at the 3rd week. There was a significant improvement in the SF-12 physical score and the number of patients with neuropathic pain in both groups in the 3rd week, but this improvement was not observed in the 3rd month.

CONCLUSIONS

Although GIB may provide more pain relief in short term, both GIB and CESI are useful treatment methods in coccygodynia unresponsive to more conservative treatments.

Coccygectomy for refractory coccygodynia: a systematic review and meta-analysis

PURPOSE

We sought to systematically assess and summarize the available literature on outcomes following coccygectomy for refractory coccygodynia.

METHODS

PubMed, Scopus, and Cochrane Library databases were systematically searched in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data concerning patient demographics, validated patient reported outcome measures (PROMs) for pain relief, disability outcomes, complications, and reoperation rates were extracted and analyzed.

RESULTS

A total of 21 studies (18 retrospective and 3 prospective) were included in the quantitative analysis. A total of 826 patients (females = 75%) received coccygectomy (720 total and 106 partial) for refractory coccygodynia. Trauma was reported as the most common etiology of coccygodynia (56%; n = 375), followed by idiopathic causes (33%; n = 221). The pooled mean difference (MD) in pain scores from baseline on a 0-10 scale was 5.03 (95% confidence interval [CI]: 4.35 to 6.86) at a 6-12 month follow-up (FU); 5.02 (95% CI: 3.47 to 6.57) at > 12-36 months FU; and 5.41 (95% CI: 4.33 to 6.48) at > 36 months FU. The MCID threshold for pain relief was surpassed at each follow-up. Oswestry Disability Index scores significantly improved postoperatively, with a pooled MD from baseline of - 23.49 (95% CI: - 31.51 to - 15.46), surpassing the MCID threshold. The pooled incidence of complications following coccygectomy was 8% (95% CI: 5% to 12%), the most frequent of which were surgical site infections and wound dehiscence. The pooled incidence of reoperations was 3% (95% CI: 1% to 5%).

CONCLUSION

Coccygectomy represents a viable treatment option in patients with refractory coccygodynia.

Improvement in Pain Following Ganglion Impar Blocks and Radiofrequency Ablation in Coccygodynia Patients: A Systematic Review

Nearly 90% of cases of coccydynia can be managed with conservative medical treatment; the remaining 10% need other invasive modalities for pain relief, such as ganglion impar block (GIB) or radiofrequency ablation (RFA) of the ganglion impar. A systematic research was conducted of PubMed, MEDLINE, and Google Scholar to identify studies reporting pain relief in terms of visual analogue scale (VAS), or its counterparts, following GIB or RFA in coccydynia patients with the purpose to determine the efficacy of GIB and RFA of the ganglion impar in controlling pain in coccydynia patients. Seven studies were delineated, with a total of 189 patients (104 in GIB group and 85 in RFA group). In the GIB group, the mean VAS improved from 7.83 at baseline to 3.11 in the short-term follow-up, 3.55 in the intermediate-term follow-up, and 4.71 in the long-term follow-up. In the RFA group, the mean VAS improved from 6.92 at baseline to 4.25 in the short-term follow-up, and 4.04 in the long-term follow-up. In the GIB group, a 13.92% failure rate (11/79) and a 2.88% complication rate (3/104) were reported, while in the RFA group, a 14.08% failure rate (10/71) and no complications (0%) were reported. Total success rate was > 85% with either modality. Ganglion impar block and RFA of the ganglion impar are reliable and probably excellent methods of pain control in coccydynia patients not responding to conservative medical treatment. However, a demarcation between responders, non-responders, and late non-responders should be considered, and larger studies with a longer follow-up (> 1 year) are needed.

Factors associated with patient-reported outcomes following coccygectomy for chronic coccydynia

Aims

The aim of this study was to identify factors associated with poor outcome following coccygectomy on patients with chronic coccydynia and instability of the coccyx.

Methods

From the Danish National Spine Registry, DaneSpine, 134 consecutive patients were identified from a single centre who had coccygectomy from 2011 to 2019. Patient demographic data and patient-reported outcomes, including pain measured on a visual analogue scale (VAS), Oswestry Disability Index (ODI), EuroQol five-dimension five-level questionnaire, and 36-Item Short-Form Health Survey questionnaire (SF-36) were obtained at baseline and at one-year follow-up. Patient satisfaction was obtained at follow-up. Regression analysis, including age, sex, smoking status, BMI, duration of symptoms, work status, welfare payment, preoperative VAS, ODI, and SF-36 was performed to identify factors associated with dissatisfaction with results at one-year follow-up.

Results

A minimum of one year follow-up was available in 112 patients (84%). Mean age was 41.9 years (15 to 78) and 97 of the patients were female (87%). Regression showed no statistically significant association between the investigated prognostic factors and a poor outcome following coccygectomy. The satisfied group showed a statistically significant improvement in patient-reported outcomes at one-year follow-up from baseline, whereas the dissatisfied group did not show a significant improvement.

Conclusion

We did not identify factors associated with poor outcome following coccygectomy. This suggests that neither of the included parameters should be considered contraindications for coccygectomy in patients with chronic coccydynia and instability of the coccyx.

Cite this article: Bone Jt Open 2021;2(7):540–544.

Imaging Coccygeal Trauma and Coccydynia

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.

Three-dimensional evaluation of the coccyx movement between supine and standing positions using conventional and upright computed tomography imaging

Currently, no three-dimensional reference data exist for the normal coccyx in the standing position on computed tomography (CT); however, this information could have utility for evaluating patients with coccydynia and pelvic floor dysfunction. Thus, we aimed to compare coccygeal parameters in the standing versus supine positions using upright and supine CT and evaluate the effects of sex, age, and body mass index (BMI) on coccygeal movement. Thirty-two healthy volunteers underwent both upright (standing position) and conventional (supine position) CT examinations. In the standing position, the coccyx became significantly longer and straighter, with the tip of the coccyx moving backward and downward (all p < 0.001). Additionally, the coccygeal straight length (standing/supine, 37.8 ± 7.1/35.7 ± 7.0 mm) and sacrococcygeal straight length (standing/supine, 131.7 ± 11.2/125.0 ± 10.7 mm) were significantly longer in the standing position. The sacrococcygeal angle (standing/supine, 115.0 ± 10.6/105.0 ± 12.5°) was significantly larger, while the lumbosacral angle (standing/supine, 21.1 ± 5.9/25.0 ± 4.9°) was significantly smaller. The migration length of the tip of the coccyx (mean, 7.9 mm) exhibited a moderate correlation with BMI (r = 0.42, p = 0.0163). Our results may provide important clues regarding the pathogenesis of coccydynia and pelvic floor dysfunction.

Coccygectomy for Chronic Refractory Coccygodynia in Pediatric and Adolescent Patients

Aims:

Coccygodynia (also known as coccydynia and coccyalgia) described for the first time by Simpson in 1859. It is a disabling pain in the coccyx usually provoked by sitting or changing position from a sitting to a standing position. Treatment started with adjustment of ergonomics as specialized cushion for sitting, application of local heat, and oral analgesics. The aim of this study was to assess the results of total or partial coccygectomy for patients suffering from chronic refractory coccygodynia and not improving on conservative treatment in pediatrics and adolescents.

Methods:

The study included 22 patients, 8 of them with chronic refractory coccygodynia not responding to conservative management underwent partial or total coccygectomy using Key's surgical exposure after good preoperative preparation.

Results:

This study included 5 females (62.5%) and 3 males (37.5%), their ages ranged from 7 to 15 years. The results were excellent in 75% of patients and good in the remaining cases. The mean length of hospital stay was 1.43 ± 0.98 days. No significant intraoperative or postoperative complications were reported. The parents were satisfied in almost all cases in the long term follow up.

Conclusions:

Coccygodynia is a disabling problem, especially in pediatric patients. Coccygectomy is a feasible management option and has a favorable outcome when performed for an appropriate indication.

The effect of injection therapy and operation of coccydynia on the schooling and physical activity of adolescent patients

Pain while sitting is the most common complaint among patients with Coccydynia. In young patients this may seriously affect their schooling which usually involves long periods of sitting. We studied if this improved after either injection therapy or surgery. During a seven-year period 32 adolescents with a mean age of 15 (range: 11-17) years were treated in our department because of coccydynia. They were followed up with mailed questionnaires at a minimum of 12 months after treatment and 28 (88%) responded. Three were no longer attending school and were excluded. Of the remainder, 12 received only injection therapy while 13 were operated upon. Mean follow-up time was 36 (14-66) months. Eight reported absence from school during the month before treatment, but only one during the week before review (pÃ0.01). There was significant improvement in sitting during class and physical exercise at school and when engaging in general sports (pÃ0.01). We can not exclude that improvements would have occurred spontaneously, but this seems unlikely as symptoms had persisted for more than two years before treatment. We conclude that in juveniles, an additional benefit of treating coccydynia with corticosteroid injection or operative resection is that their ability to attend school and take part in sports improves significantly.

Normal Preoperative Images Do Not Indicate a Poor Outcome of Surgery for Coccydynia

STUDY DESIGN

This is a retrospective cohort study.

OBJECTIVE

To evaluate the long-term outcomes after surgery for refractory coccygodynia in patients with normal imaging studies compared with patients where imaging shows an anomaly.

SUMMARY OF BACKGROUND DATA

Patients with coccydynia who do not respond to conservative treatment will often profit from coccygectomy. Most surgeons employ plain radiographs or magnetic resonance imaging (MRI) in their preoperative work-up. These will often show anomalies, but in some cases they do not. We investigated whether these patients do less well than those with abnormal images.

METHODS

We operated on 184 patients with coccydynia during a 7-year period and 171 (93%) responded to follow-up questionnaires after 37 (range: 12-85) months. Images of 33 patients were normal and 138 showed some coccygeal pathology. Surgery was considered to have been unsuccessful when respondents stated at review that they were somewhat better, unchanged, or worse.

RESULTS

There were no clinically or statistically significant differences in outcome between the groups. Surgery was unsuccessful in 24% of patients with normal images and in 32% among those with abnormal images. The median pain scores (0-10) during the week before review were two (interquartile range [IQR]: 0-3) and one (IQR: 1-5) in the two groups respectively. Similar proportions in the two groups stated that they would not have consented to surgery if they had known the outcome in advance.

CONCLUSION

Patients with severe coccydynia who have not responded to conservative treatment should not be denied surgery only because their radiographs or MRI studies look normal.

LEVEL OF EVIDENCE

4.

Coccygectomy for coccygodynia: a cohort study with a long-term follow-up of up to 29 years

PURPOSE

We aim to critically review the effectiveness and safety of coccygectomy with special regard to long-term outcomes.

METHODS

Coccygectomy was performed in our clinic in 38 patients between 1990 and 2019. All these patients (32 females vs. 6 males) have failed to respond to conservative treatment for at least 6 months prior to surgery. All patients were available for follow-up after mean 12,3 years (2 months to 29 years, 11 patients had a minimum FUP of 24 years). We evaluated all patients clinically and radiologically.

RESULTS

Nineteen patients reported traumatic and 17 patients reported idiopathic onset of their symptoms; one patient had clinical symptoms after childbirth and another patient had coccygodynia after extensive low back surgery. 36 of our 38 patients were free of pain at least 6 months after surgery and had good or excellent clinical results according to the VAS which improved from 6.37 (SD 1.08) preoperatively to 0.68 (SD 0.99) at the recent follow-up. Two patients showed an ODI > 22 at the recent follow-up (24 and 28) and 32 had an ODI equal or under 4. There was no statistical significant difference in terms of clinical outcome between the different radiological types of the coccyx. Postoperative complications were rare: 1 superficial infection and one re-operation 6 months after initial surgery due to an pre-existing exostosis which had not been removed at the index surgery; no neurological complications and no major bleeding occurred. No patient had recurrent onset of coccygodynia. 37 out of 38 patients would have coccygectomy again.

CONCLUSIONS

Coccygectomy is a safe treatment option in patients with coccygodynia and shows excellent long-term results. We recommend to perform coccygectomy if patients fail to respond to conservative treatment for 6 months.

LEVEL OF EVIDENCE

IV.

Polymethylmetacrylate Cement Augmentation of the Coccyx (Coccygeoplasty) for Fracture: A Case Report

Background:

Coccydynia is a painful condition of the sacrococcygeal region, with symptoms associated with sitting and rising from a seated position. It is frequently related to trauma and idiopathic causes, and the pain is mostly chronic. Percutaneous vertebroplasty and sacroplasty are the methods that are widely used for treating compression fractures and sacral insufficiency fractures, respectively. However, the success of polymethylmethacrylate injection in the treatment of osteoporotic coccyx fractures and coccydynia is still unknown.

Case Report:

A 68-year-old man was admitted to our clinic with complaints of pain in the sacrococcygeal and perianal regions. In the imaging studies, a fracture line in the fifth sacral and first coccygeal segments was observed as evidenced by a bony edema. Since the patient’s pain did not improve with conservative methods, we treated him with coccygeoplasty. No complication was encountered. The day after the operation, he was discharged from the hospital with complete pain relief. The patient confirmed having no pain on the third postoperative month and so did not need any analgesics.

Conclusion:

Coccyceoplasty may be a good treatment option for retractable pain in patients with acute or subacute osteoporotic coccygeal fractures and coccydinia with edema.

Epidemiology and risk factors of coccyx fracture: A study using national claim database in South Korea

INTRODUCTION

Coccyx fracture usually is a low-energy trauma caused by a backward fall onto a slippery floor of ice. The exact epidemiology of the coccyx fracture is not known. Moreover, the effects of seasonality and weather on the fracture incidence have not been reported. The purpose of this study was to evaluate the annual incidence, gender-preponderance, age-distribution, seasonal variation and climatic risk factors of the coccyx fracture.

METHODS

We identified coccyx fractures, which occurred in South Korea from 2010 to 2018, using nationwide data of Korean Health Insurance Review and Assessment Service (HIRA). International Classification of Diseases-10th Revision (ICD-10) code S322 was used for the identification. Annual incidence of the coccyx fracture was calculated, and the fractures were correlated with gender, age, month of diagnosis and climatic factors.

RESULTS

A total of 238,906 patients were diagnosed with coccyx fracture with an average of 26,545 patients at year. Male to female ratio was 1:2.6. The annual incidence of coccyx fracture was 119.75/100,000 persons in 2018; 33.44/100,000 in male and 86.30/100,000 in female. The incidence rate was the highest at puberty (age of 10-14 years) in male, and at menopause (age of 50-54 years) in female. The incidence was frequent in winter followed by summer. The incidence of coccyx fracture was negatively correlated with the temperature (Pearson correlation factor= -0.67, P<0.01) in winter, while it was positively correlated with the temperature in summer (Pearson correlation coefficient = 0.66, p<0.01). In generalized linear model, old age, female gender, recent year, summer and winter, low temperature and high amount of precipitation appeared as risk factors for coccyx fracture.

CONCLUSIONS

The epidemiologic patterns of coccyx fracture were comparable to other osteoporotic fractures. Findings of our study can be used for epidemiological awareness and prevention campaigns of coccyx fracture.

Influence of psychiatric disorders and chronic pain on the surgical outcome in the patient with chronic coccydynia: a single institution's experience

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.

The treatment of coccydynia in adolescents: A case-control study

Aims

To determine if the results of treatment of adolescents with coccydynia are similar to those found in adults. Adult patients with coccydynia may benefit from injection therapy or operative treatment. There is little data evaluating treatment results in adolescents. We have treated adolescent patients similarly to adults and compared the outcomes.

Methods

Overall, 32 adolescents with coccydynia were treated at our institution during a seven-year period; 28 responded to final follow-up questionnaires after a minimum of one year, 14 had been treated with only injection therapy, and 14 had been operated with coccygectomy. We collected data with regards to pain while sitting, leaning forward, rising from a sitting position, during defecation, while walking or jogging, and while travelling in trains, planes, or automobiles. Pain at follow-up was registered on a numeric pain scale. Each adolescent was then matched to adult patients, and results compared in a case control fashion. The treatment was considered successful if respondents were either completely well or much better at final follow-up after one to seven years.

Results

Out of the 28 treated adolescents, 14 were regarded as successfully treated. Seven were somewhat better, and the remaining seven were unchanged. In the adult control group the corresponding number was 15 successfully treated, eight patients were somewhat better, and five were unchanged. Six of the 14 successfully treated adolescents had been operated. There were no significant differences between the groups in the various registered domains, or on numeric pain scale.

Conclusion

Treatment results in adolescent patients seem similar to those in adults. The long-term success rate of injection therapy is low. In case of injection treatment failure, operation may be considered, also in adolescents.

Morphological evaluation of the coccyx with multidetector computed tomography

PURPOSE

This study aims to evaluate the morphology of the coccyx in adults with multidetector computed tomography and to contribute to the classification of the coccyx using intercoccygeal and sacrococcygeal angle measurements.

METHODS

The pelvic computed tomography images of 224 patients were retrospectively evaluated. The multiplanar reconstruction and 3D volume rendering images of the coccyx were obtained from all patients at sagittal and coronal planes. The morphology of the coccyx, number of bone segments, the presence of scoliosis, and presence of sacrococcygeal and intercoccygeal fusion were evaluated. After the measurement of coccygeal length, width, and thickness, intercoccygeal and sacrococcygeal angles were also calculated in all patients.

RESULTS

The morphological classification showed that 136 patients (60.7%) had type 1, 65 patients (29%) had type 2, and 17 patients (7.6%) had type 3 coccyx. The intercoccygeal angle was zero degree in five patients (type 0) and one patient had retroverted coccyx (type 5). The coccyx had four segments in 155 patients (69.2%), three segments in 52 patients (23.2%), five segments in 15 patients (6.7%), two segments in one patient (0.4%), and one segment in one patient (0.4%).

CONCLUSION

We determined patients with an intercoccygeal angle of zero degree, which is not mentioned in the literature before, and we propose to use the term "type 0" for these patients in the classification of coccyx. The coccygeal measurements and classification will be instructive for the radiologists and have a guiding role for the future studies.

Radiofrequency Ablation in Coccydynia: A Case Series and Comprehensive, Evidence-Based Review

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.

Coccygectomy for Coccygodynia: A Single Center Experience Over 5 Years

Introduction:

Coccygodynia refers to a pathological condition in which pain occurs in the coccyx or its immediate vicinity. The pain is usually provoked by sitting or rising from sitting. Several studies have reported good or excellent results after coccygectomy especially in patients who are refractory to conservative treatment.

Aims and Objectives:

This study aims to evaluate the role and effectiveness of coccygectomy in chronic refractory coccygodynia.

Materials and Methods:

Between January 2011 and January 2015, 16 consecutive patients (4 males and 12 females) who underwent surgical coccygectomy were enrolled prospectively in the study. All patients suffered from treatment-resistant coccygodynia and had exhausted conservative therapeutic options for at least 6 months before undergoing surgery. The same surgeon performed a complete coccygectomy on all patients. Postoperative outcomes included measurements of pain relief and degree of patient satisfaction with the procedure's results.

Results:

The average age of patient was 37.93 years (range: 25–53 years), and the male to female ratio was 1:3. The median duration of patient-reported symptoms prior to surgery was 24 months. The most common cause of coccygodynia was direct or indirect trauma, recorded in 11 patients (68.75%). Idiopathic coccygodynia was five cases (31.25%). The number of patients with outcomes rated as “excellent,” “good,” “fair,” and “poor” were 12, 2, 1, and 1, respectively. The favorable result (excellent or good) was 87.5%. The self-reported visual analog scale (VAS) was significantly improved by surgery. The mean VAS preoperatively was 9.62, and postoperatively it was 2.25 (P < 0.001). There were two infections (12.5%) among the 16 patients which were managed conservatively.

Conclusions:

Coccygectomy for chronic intractable coccygodynia is simple and effective, with a low complication rate.

Coccygodynia review: coccygectomy case series

BACKGROUND

Coccygodynia is a pain of the coccyx that is typically exaggerated by pressure. Management includes anti-inflammatory medications, physiotherapy, and coccyx manipulation. Coccygectomy is the surgical approach for treating coccygodynia when the conservative management fails. Generally, coccygectomy yields good results. Its most common complication is wound infection.

OBJECTIVE

To determine the effectiveness of coccygectomy in patients with coccygodynia.

METHODS

A retrospective review of 70 patients (52 females and 18 males) with coccygodynia at King Khalid University Hospital in Riyadh was carried out, and the outcomes were studied. Twenty patients did not respond to conservative management; therefore, bimanual coccyx manipulation was done. Eleven were identified with instability and did not respond to coccygeal manipulation. Coccygectomy was performed on 8 patients while 3 declined.

RESULTS

All patients who underwent coccygectomy showed improvement of their symptoms. One case of superficial wound infection and delayed wound healing was encountered.

CONCLUSION

Coccygectomy provides effective pain relief to patients not responding to conservative therapies.

Transsacrococcygeal approach to ganglion impar: radiofrequency application for the treatment of chronic intractable coccydynia

Objective

Coccydynia is defined as pain in the coccygeal region. Among the many causes of coccydynia, the most common cause is trauma as a result of falling on the buttocks, repetitive microtrauma, or childbirth. Several methods are currently used for the treatment of coccydynia, including nonsteroidal anti-inflammatory drugs, intrarectal manipulation, epidural injections, ganglion impar blocks, and radiofrequency treatment (RFT). Wemm and Saberski used the transacrococcygeal methods to reduce tissue trauma. RFT is a percutaneous minimally invasive procedure. In this study, we aimed to assess the effect of the transsacrococcygeal approach on ganglion impar RFT in patients with chronic coccydynia.

Methods

We retrospectively examined the data of 41 patients at the Department of Anesthesiology and Reanimation, Faculty of Medicine, Maltepe University (Pain Clinic), between January 1, 2010, and December 31, 2012.

Results

The mean age of the patients was 46.68±11.00 years (range 28–67 [46] years). The average pain duration was 3.10±1.37 years. The difference between visual analog scale scores of the pre-and postprocedure was statistically significant. In the examinations carried out in the sixth month of the treatment, 90.2% of patients had a successful outcome, whereas treatment failed in 9.8% of patients. According to our patients’ data, most of them had pain due to a trauma, were female, and overweight. Visual analog scale difference between preprocedure and early postprocedure, preprocedure and first month, preprocedure and sixth month were statistically significant (P=0.001).

Conclusion

Based on the lower pain scores and low complication rates after the operations, the results suggest that application of RFT on ganglion impar by the transsacrococcygeal approach is an effective and safe method for the treatment of chronic coccydynia. Patient selection, technique, and experience are the most important factors affecting the success of this method.

Analysis of Sacrococcygeal Morphology in Koreans Using Computed Tomography

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.

Coccygectomy for patients with chronic coccydynia: a prospective, observational study of 98 patients

AIMS

The purpose of this prospective study was to evaluate the outcomes of coccygectomy for patients with chronic coccydynia.

PATIENTS AND METHODS

Between 2007 and 2011, 98 patients underwent coccygectomy for chronic coccydynia. The patients were aged > 18 years, had coccygeal pain, local tenderness and a radiological abnormality, and had failed conservative management. Outcome measures were the Short Form 36 (SF-36), the Oswestry Disability Index (ODI) and a visual analogue scale (VAS) for pain. Secondary analysis compared the pre-operative features and the outcomes of patients with successful and failed treatment, two years post-operatively. The threshold for success was based on a minimum clinically important difference (MCID) on the ODI of 20 points. All other patients, including those lost to follow-up, were classified as failures.

RESULTS

There was significant improvement in all ten components of the SF-36 (p < 0.05), the ODI (23 points) and VAS (39 points) (p < 0.0001). A total of 69 patients (70.4%) met the designated MCID threshold for a successful outcome. The failure group consisted of 25 patients (25.5%) who did not reach the MCID and four (4.1%) who were lost to follow-up. Six patients (6.1%) in the failure group had ODI scores that were no better or worse than that pre-operatively. The patients in whom treatment failed had significantly worse pre-operative scores for the ODI (p = 0.04), VAS (p = 0.02) and on five of ten SF-36 components (p < 0.04). They also had a higher incidence of psychiatric disorders, pre-operative opiate use and more than three comorbidities.

TAKE HOME MESSAGE

Coccygectomy for chronic coccydynia results in significant improvement in patient-reported outcomes at two years. Failure is associated with certain pre-operative characteristics such as psychiatric illness, poor quality of life features, higher levels of pain, and use of opiates.

The Treatment of Chronic Coccydynia and Postcoccygectomy Pain With Pelvic Floor Physical Therapy

BACKGROUND

Coccydynia is a challenging disorder that often is refractory to treatments such as medications and injections. Physical therapy for coccydynia rarely has been studied.

OBJECTIVE

To evaluate the efficacy of pelvic floor physical therapy for reducing pain levels in patients with coccydynia.

DESIGN

Retrospective chart review.

SETTING

The pelvic floor rehabilitation clinic of a major university hospital.

PATIENTS

A total of 124 consecutive patients over age 18 with a chief complaint of coccydynia between 2009 and 2012. A subgroup of 17 of the 124 patients had previously undergone coccygectomy with continued pain postoperatively.

METHODS OR INTERVENTIONS

The primary treatment intervention was pelvic floor physical therapy aimed at pelvic floor muscle relaxation. Secondary treatment interventions included the prescription of baclofen for muscle relaxation (19% of patients), ganglion impar blocks (8%), or coccygeus trigger point injections (17%).

MAIN OUTCOME MEASURES

Primary outcome measures included final minimum, average, and maximum pain numeric rating scales. A secondary outcome measure was the patient's subjective percent global improvement assessment. Baseline demographics were used to determine which pretreatment characteristics were correlated with treatment outcomes.

RESULTS

Of the 124 patients, 93 participated in pelvic floor physical therapy and were included in statistical analysis. For the 79 patients who completed treatment (with a mean of 9 physical therapy sessions), the mean average pain ratings decreased from 5.08 to 1.91 (P < .001) and mean highest pain ratings decreased from 8.81 to 4.75 (P < .001). The mean percent global improvement was 71.9%. Mean average pain ratings in postcoccygectomy patients improved from 6.64 to 3.27 (P < .001). Greater initial pain scores and a history of previous injections were correlated with P < .001 pain scores on completion of physical therapy. Pain duration and history of trauma did not affect treatment outcomes.

CONCLUSIONS

Pelvic floor physical therapy is a safe and effective method of treating coccydynia.

LEVEL OF EVIDENCE

III.

Effects of Extracorporeal Shock Wave Therapy on Pain in Patients With Chronic Refractory Coccydynia: A Quasi-Experimental Study

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.

Coccygectomy for coccygeal spicule: a study of 33 cases

PURPOSE

To report the results of coccygectomy for coccygeal spicule.

METHODS

We report the results of a retrospective series of 33 patients who underwent coccygectomy for coccygeal spicule. There were 31 women and 2 men. The mean age was 42 ± 12 years (range 23-62). There was a pit in the skin overlying the spicule in 14 cases and the spicule was bulky in 8 cases. In three cases, weight loss had preceded the occurrence of the coccygodynia. The coccyx was rigid or had very reduced mobility (less than 5°) in 25 cases and normal mobility (between 5° and 20° of flexion) in 8 cases. All the patients had initially been managed conservatively with injections targeted on the spicule. As they did not obtain sufficient relief, they were offered surgery. Ten patients were followed up for more than 72 months, 10 patients for 48-66 months, and 13 for 30-42 months. The outcome analysis involved functional criteria only.

RESULTS

Twenty-six patients (79%) had a very satisfactory outcome and 7 (21%) an unsatisfactory outcome. When asked 'Would you have the surgery again?', only one patient answered in the negative.

CONCLUSIONS

Surgical treatment for coccygeal spicules that are causing coccygodynia and are resistant to conservative treatment gives satisfactory outcomes, similar to those obtained from surgery for instability of the coccyx.

Coccygectomy as a surgical option in the treatment of chronic traumatic coccygodynia: a single-center experience and literature review

Study Design

Retrospective cohort study.

Purpose

Trauma is the most common cause for chronic coccygodynia. The present study aims at presenting our results after complete removal of the coccyx for refractory traumatic coccygodynia in terms of pain level, complication rates, and patients' overall satisfaction.

Overview of Literature

There is limited extant literature describing the success rate and complications in refractory isolated traumatic coccygodynia.

Methods

From January 2011 to January 2012, 10 consecutive patients with posttraumatic coccygodynia (six males and four females; mean age, 42 years) were enrolled in our study. Conservative treatment of the condition had failed in all patients. The same surgeon performed a complete coccygectomy on all patients. Postoperative outcomes included measurements of pain relief and degree of patient satisfaction with the procedure's results.

Results

In our selected cohort, all patients indicated complete pain relief or significant pain improvement in follow up-care and would recommend this procedure. One patient developed a subcutaneous hematoma that required surgical intervention.

Conclusions

Our results suggest that complete removal of the coccyx relieves pain in patients with refractory chronic traumatic coccygodyniaand is therefore a reasonable treatment option after conservative treatment failure.

Repair of a coccygeal hernia with a biological mesh

•

We present a case of coccygeal hernation after coccygectomy.

•

Hernia repair was performed with a biological mesh via an direct approach.

•

Only 8 other cases could be identified in literature.

Coccygeal herniation after coccygectomy is rare. Little is known about the management of this complication. We present a case of a 44 year old women with a coccygeal herniation 7 years after coccygectomy. She was treated two times for an infected pilonidal sinus with incision and drainage. After the last incision and drainage she had complaints of a painful swelling in the sacral area and difficulty with evacuation of her stools. A defaecography showed a coccygeal herniation. An additional MRI of the pelvic region showed a defect with a diameter of approximately 38 mm. We performed a hernia repair with a biological mesh (Strattice™ surgical mesh, LifeCell Corporation USA) via a sacral approach. Her recovery was complicated by a small wound dehiscence without clinical signs of infection. The sacral wound healed per secundam. Her complaints had completely disappeared. A defaecography 2 months after surgery showed no residual herniation. To our knowledge, it is the first reported case of a coccygeal hernia repair with a biological Strattice™ surgical mesh.

Diagnosis and treatment of a rectal-cutaneous fistula: a rare complication of coccygectomy

BACKGROUND

Coccygectomy may be indicated for the treatment of debilitating coccygodynia unresponsive to non-operative treatment. Perineal contamination and postoperative wound infection following coccygectomy remains a major concern. We present a rare post-coccygectomy complication of rectal-cutaneous fistula. To our knowledge no such case has been previously described.

CASE PRESENTATION

A 24-year-old woman presented with recurrent wound infections 1 year after coccygectomy at another institution, which persisted despite two surgical debridements and antibiotic treatment. Wound cultures showed non-specific poly-microbial bacterial growth. MRI scan of the spine and pelvis revealed a sinus track and soft tissue edema with no evidence of abscess or osteomyelitis. Methylene blue injection to the sinus tract confirmed the presence of a rectal-cutaneous fistula. The patient underwent further debridement, fistulectomy and synchronous defunctioning colostomy and resection of the involved colon segment. The wound healed by secondary intention with complete resolution of the infection. Re-anastomosis and closure of the colostomy was performed 6 months later. At 2-year follow-up, the patient had no signs of infection and her initial coccygeal symptoms had improved.

CONCLUSION

Postoperative infection following coccygectomy remains a major concern. A discharging sinus at the surgical site may suggest the presence of a rectal-cutaneous fistula, which requires a combined approach of spinal and colorectal surgeons. Methylene blue injection to the sinus tract may facilitate the diagnosis of a rectal-cutaneous fistula.

Clinical decision making for the evaluation and management of coccydynia: 2 case reports

STUDY DESIGN

Case report.

BACKGROUND

Coccydynia is a painful condition of the sacrococcygeal region, with symptoms associated with sitting and rising from a seated position. There is no gold standard for diagnosis of this condition; however, coccyx mobility assessment, pain provocation testing, and imaging have been proposed as reasonable diagnostic approaches. Once correctly diagnosed, treatment options for coccydynia include conservative management and surgical excision. The purpose of this report is to describe the different but successful clinical management strategies of 2 patients with coccydynia.

CASE DESCRIPTION

Two women, 26 and 31 years of age, presented to physical therapy with persistent coccygeal pain that increased with prolonged sitting and intensified when transitioning from sit to stand. One patient had a traumatic onset of symptoms, in contrast to the other patient, for whom prolonged sitting was the precipitating factor. Both individuals were considered to have hypomobility of the sacrococcygeal joint, as assessed through intrarectal mobility testing, which also reproduced their symptoms. In both patients, examination of the lumbar spine was negative for alleviation or reproduction of symptoms. The patient with a traumatic onset of symptoms was referred to physical therapy at the onset of her symptoms, whereas the patient with a nontraumatic onset of symptoms was initially treated with a cortisone injection and, when symptoms returned 1 year later, was referred to physical therapy. Both individuals underwent manual therapy to the sacrococcygeal joint over 3 treatment sessions.

OUTCOMES

The patient with traumatic onset of symptoms had almost complete resolution of symptoms, whereas the patient with a nontraumatic onset only had temporary relief. This patient required further diagnostic examination and surgical excision.

DISCUSSION

Although the mechanisms of injury were different, both patients presented with similar clinical symptoms, and both were considered to have coccydynia through coccyx mobility assessment and pain provocation testing. Successful clinical outcomes were achieved in both cases; however, the interventions were significantly different. Level of Evidence Therapy, level 4.

Favourable outcomes of coccygectomy for refractory coccygodynia

INTRODUCTION

Coccygodynia is a condition associated with severe discomfort in the region of the coccyx. While traditional procedures had poor outcomes and high complication rates, recent literature suggests better outcomes and lower complication rates with coccygectomy.

METHODS

Data were collected retrospectively from clinical notes. A questionnaire was used to evaluate the outcomes. The outcome measures included pain analogue score (PAS) in sitting and during daily activities as well as patients' overall pain relief. Overall improvement in pain and complications were documented.

RESULTS

Between 2000 and 2010, 14 patients underwent total coccygectomy for refractory coccygodynia. All patients were available for follow-up appointments and the follow-up duration ranged from 24 to 132 months (mean: 80 months). The aetiology was traumatic in eight patients and non-traumatic in six. The PAS improved from a median of 9 to 4 for sitting and from 7.5 to 2.5 for daily activities. One patient had mild discharge for more than two weeks. No patients required further surgery. Twelve patients (85.7%) had excellent or good pain relief. Only one patient was unsatisfied. A Wilcoxon signed-rank test revealed significant improvement in pain when sitting (p<0.05) and during activities of daily living (p<0.05) at the final follow-up visit. A Mann-Whitney U test did not show a significant difference in improvement in PAS between the traumatic and non-traumatic groups (p=0.282 and 0.755).

CONCLUSIONS

In our series, total coccygectomy offered satisfactory relief of pain in the majority of patients with a low wound complication rate.

A comparison of conservative interventions and their effectiveness for coccydynia: a systematic review

STUDY DESIGN

Systematic literature review.

OBJECTIVE

To investigate the various conservative interventions for coccydynia and determine their effectiveness.

BACKGROUND

Coccydynia is the term used to describe pain in the coccygeal region. Pain in this region is typically caused by local trauma. Sitting is typically the most painful position for patients having coccydynia. Various methods of treating coccydynia are found in the literature but to our knowledge no systematic review has been performed that compared the effectiveness of these interventions.

METHODS

Searches were performed for research studies using electronic databases (Cochrane Library, CINAHL, Medline, PEDro, Scopus, and Sports Discus) from January 2002 through July 2012. The quality of the papers was assessed using the GRADE approach.

RESULTS

Seven papers were located that satisfied the inclusion and exclusion criteria (2 RCTs, 5 observational studies). The level of evidence ranged from moderate to very low quality and recommendations for use ranged from weak recommendations for use to weak recommendations against use.

CONCLUSIONS

Due to the dearth of research available and the low levels of evidence in the published studies that were located we are unable to recommend the most effective conservative intervention for the treatment of coccydynia. Additional research is needed regarding the treatment for this painful condition.

The anatomy of the sacrococcygeal cornual region and its clinical relevance

There has been no systematic study of the anatomy of the region between the sacral and coccygeal cornua. Reference texts describe an intercornual ligament connecting these structures. The aim of this study was to investigate the anatomy of this region, which may be relevant to unexplained cases of coccygeal pain (coccydynia) and local nerve blocks. The bony anatomy of the sacrococcygeal (SC) cornual region was analyzed in 33 CT scans obtained from supine adults of mostly European origin with no known SC pathology, 7 μCT scans of cadaver SC specimens, and 105 Asian Indian adult skeletons. A further five cadaver SC specimens were examined histologically. SC cornual fusion was seen in 45% of CT/μCT scans (mean age 67 years, 20 males) and in 20% of adult skeletons (78 males); there was no association with age or sex. In the absence of SC fusion, the mean intersacrococcygeal cornual gap was 7.1 ± 2.4 mm; this was bridged by an intercornual ligament composed of parallel vertical collagen fibers reinforced by elastin fibers on its anterior surface. Small nerve branches were observed adjacent to the ventral aspect of the intercornual ligament and, in one case, traversing the ligament. Ipsilateral sacral and coccygeal cornua are therefore normally bridged by an intercornual ligament that is probably innervated. The cornua are fused on one or both sides in 20-45% of adults. These findings may have implications for some cases of coccydynia and for anesthetists performing local nerve blocks.

Acute traumatic instability of the coccyx: results in 28 consecutive coccygectomies

INTRODUCTION

Coccygeal instability includes hypermobility, subluxation and fracture-dislocation. Surgical resection is still controversial, with intractable post-traumatic coccygodynia being an indication to surgery.

MATERIALS AND METHODS

From 2001 to 2010, we enrolled 31 patients with post-traumatic coccygodynia (19 females, 12 males; mean age 31 years, range 21-47). Conservative treatment failed in 28 patients, who underwent surgical resection of the coccyx. Twenty-one were total, while seven were partial coccygectomies. At follow-up (mean 33 months; range 24-70), clinical outcomes evaluation included measurement of complications rate, pain relief and satisfaction degree.

RESULTS

Nineteen patients experienced complete pain relief, while two had incomplete, and four had no relief. Partial coccygectomies were associated with poor results. Twenty-one patients were satisfied, whilst four were not.

CONCLUSIONS

Coccygectomy is the treatment of choice for post-traumatic instability. Patients' selection allowed excellent or good results. This study favors a more aggressive approach including total resection of the coccyx.

Magnetic resonance imaging morphology and morphometry of the coccyx in coccydynia

STUDY DESIGN

Retrospective case-control study.

OBJECTIVE

To determine if differences exists between the bony anatomy of the coccyx in patients with coccydynia and that in subjects with no known coccygeal pathology.

SUMMARY OF BACKGROUND DATA

Numerous bony characteristics of the coccyx have been described in patients with coccydynia but their significance is uncertain. This study aimed to evaluate these in patients with coccydynia and compare them with normal coccyges.

METHODS

Magnetic resonance scans of the coccyx from 107 adults (mean age, 43 ± 12 yr; 84 females) with clinically diagnosed coccydynia were retrospectively analyzed and compared with 112 computed tomographic scans from sex-matched adults with normal coccyges. The following were assessed: coccygeal segmentation; sacrococcygeal and intercoccygeal joint fusion, angles, and curvature; bony spicule formation; and subluxation.

RESULTS

Compared with normal, females with coccydynia had a more ventrally curved coccyx (curvature index, 85 ± 7 vs. 90 ± 5; P< 0.01), a lower prevalence of sacrococcygeal joint fusion (27% vs. 58%, P< 0.01), and a higher frequency of bony spicule formation (44% vs. 19%, P< 0.01). Males with coccydynia showed a trend toward a more ventrally curved coccyx (curvature index: 86 ± 6 vs. 89 ± 5, P< 0.08), and a lower prevalence of sacrococcygeal (27% vs. 60%, P< 0.02) and intercoccygeal (0% vs. 22%, P< 0.02) joint fusion. Combining statistically significant coccygeal parameters in a logistic regression model yielded sensitivity, specificity, and positive predictive values of 72%, 71%, and 73%, respectively in females and 52%, 92%, and 73%, respectively in males.

CONCLUSION

This is the most detailed comparison of coccygeal morphology and morphometry in adults with and without coccydynia investigated using cross-sectional imaging. Anatomical differences in joint fusion and coccygeal curvature may either predispose to the development of coccydynia or arise as a result of this condition.

Coccygodynia and coccygectomy

OBJECTIVE

A review of the literature on coccygectomy and our patients was performed to assess the effectiveness of coccygectomy for chronic refractory coccygodynia.

METHODS

An English language PubMed search was conducted with the terms "coccygodynia" and "coccygectomy" from January 1980 to January 2012. We retrospectively reviewed the medical records and performed telephone questionnaire on 61 patients who underwent coccygectomy at UCDMC between 1997 and 2009.

RESULTS

There were 28 case series from 1980 to 2012 for a total of 742 patients who underwent coccygectomy following failed conservative management. The mean age ranged from 26.4 to 52.8 years. The most common cause was direct trauma (58.5%) with a male:female ratio of 1:5.2. Most patients (84%) had a good to excellent outcome after coccygectomy. The most common complication is wound infection (10.0%). The overall complication rate was 13.3%. Similarly, 84.6% of patients from our own surgical case series reported good to excellent outcomes with 11.5% wound infection.

CONCLUSION

Coccygectomy is an effective treatment for chronic refractory coccygodynia. The surgery isrelatively simple to perform but precaution must be taken to avoid wound infection.

CT morphology and morphometry of the normal adult coccyx

PURPOSE

Lack of data on the in vivo morphology and morphometry of the normal adult coccyx hampers understanding of radiological abnormalities in idiopathic coccydynia. The aim of this study was to investigate normal adult sacrococcygeal morphometry.

METHODS

Retrospective analysis of 112 adult CT scans (mean age 63 ± 14.6 years, 50 males) evaluated the following: number of coccygeal segments; joint fusion; coccygeal spicules, subluxation, sacralization, and scoliosis; sacrococcygeal straight and curved lengths and curvature indices; sacrococcygeal and intercoccygeal angles; and lateral deviation of the coccyx tip.

RESULTS

Four coccygeal segments were present in 76 % of scans. Sacrococcygeal fusion was present in 57 % and intercoccygeal fusion was increasingly common more caudally; there was no significant association with age or gender. A bony spicule was present in 23 %. Subluxation was rare. Nine of 12 coccyges with a retroverted tip were female. Mean coccygeal curved length was 4.4 ± 0.8 cm in men and 4.0 ± 0.8 cm in women (P < 0.01). Mean angle between first and last coccygeal segments was 138° ± 25° in men and 147° ± 25° in women (P = 0.08). There was no significant correlation between coccygeal length or curvature and stature, age or BMI.

CONCLUSIONS

In this first detailed study of the CT morphology and morphometry of the adult coccyx, sacrococcygeal and intercoccygeal joint fusion was common. Female coccyges were shorter, straighter, and may be more prone to retroversion, factors that may be relevant to the markedly higher prevalence of idiopathic coccydynia in women.