Coccygectomy for coccygeal spicule: a study of 33 cases

Coccydynia-The Efficacy of Available Treatment Options: A Systematic Review

STUDY DESIGN

Systematic Review.

OBJECTIVE

To evaluate the efficacy of available treatment options for patients with persistent coccydynia through a systematic review.

METHODS

Original peer-reviewed publications on treatment for coccydynia were identified using Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines by performing a literature search of relevant databases, from their inception to January 17, 2020, combined with other sources. Data on extracted treatment outcome was pooled based on treatment categories to allow for meta-analysis. All outcomes relevant to the treatment efficacy of coccydynia were extracted. No single measure of outcome was consistently present among the included studies. Numeric Rating Scale, (NRS, 0-10) for pain was used as the primary outcome measure. Studies with treatment outcome on adult patients with chronic primary coccydynia were considered eligible.

RESULTS

A total of 1980 patients across 64 studies were identified: five randomized controlled trials, one experimental study, one quasi-experimental study, 11 prospective observational studies, 45 retrospective studies and unpublished data from the DaneSpine registry. The greatest improvement in pain was achieved by patients who underwent radiofrequency therapy (RFT, mean Visual Analog Scale (VAS) decreased by 5.11 cm). A similar mean improvement was achieved from Extracorporeal Shockwave Therapy (ESWT, 5.06), Coccygectomy (4.86) and Injection (4.22). Although improved, the mean change was less for those who received Ganglion block (2.98), Stretching/Manipulation (2.19) and Conservative/Usual Care (1.69).

CONCLUSION

This study highlights the progressive nature of treatment for coccydynia, starting with noninvasive methods before considering coccygectomy. Non-surgical management provides pain relief for many patients. Coccygectomy is by far the most thoroughly investigated treatment option and may be beneficial for refractory cases. Future randomized controlled trials should be conducted with an aim to compare the efficacy of interventional therapies amongst each other and to coccygectomy.

Morphological Features of the Coccyx in the Turkish Population and Interrelationships Among the Parameters: A Computerized Tomography-Based Analysis

Introduction

The coccyx is well-known to be a highly variable structure considering its morphology. To our knowledge, the relationship between the coccygeal types and other morphological features has not been studied yet. In addition to the interrelations among morphological parameters, this study investigated the morphology and morphometry of coccyx more extensively in the adult Turkish population using computerized tomography images.

Methods

Five hundred subjects who underwent pelvic computerized tomography were included in this study. In addition to coccyx type and the counts of coccygeal vertebrae and segments, the presence of coccygeal deviation, sacrococcygeal joint (SCJ) fusion, SCJ subluxation, intercoccygeal joint (ICJ) fusion, and coccygeal spicule were evaluated. The coccygeal length, sacrococcygeal angle, and intercoccygeal angle were measured on the digital workstation. The findings were subjected to statistical analyses.

Results

The coccygeal vertebra count ranged between three to five, with an average of 4.04 ± 0.48. The range of coccygeal segment count was between one and five, with an average of 2.53 ± 1.02. ICJ fusion in any segment, SCJ fusion, and SCJ subluxation were identified in 397 subjects (79.4%), 343 subjects (68.6%), and 17 subjects (3.4%), respectively. The coccyx types from the most common to the least common were as follows: type 2, type 1, type 3, type 4, and type 5. Coccygeal deviation to the left side was observed in 71 subjects (14.2%), while coccygeal deviation to the right side was observed in 61 subjects (12.2%). A coccygeal spicule was identified in 73 subjects (14.6%). The subjects’ mean age demonstrated no significant difference considering the ICJ fusion (p=0.271), SCJ subluxation (p=0.51), coccygeal spicule (p=0.337), features of coccygeal deviation (p=0.83), and coccyx types (p=0.11). The subjects with SCJ fusion (50.7 ± 18.3 years) were significantly older than the subjects without SCJ fusion (46.5 ± 18.5 years) (p=0.016). The differences between the coccyx types considering the rate of SCJ fusion (p=0.002), ICJ fusion (p=0.04), and spicule presence (p<0.001) as well as the coccygeal vertebra count (p<0.001) were significant.

Conclusion

The presence of coccygeal spicule, a risk factor for coccydynia, is reported to be 14.6% in this study group that represents the Turkish population. This study indicates an association between the coccyx types and the frequency of SCJ fusion, ICJ fusion, and spicule presence and consequently suggests the significance of the coccyx type among the morphological features to cause susceptibility to coccydynia. Due to the multiplicity of the pain generators in the coccygeal region that is established by previous reports, the comparisons of different human populations and the knowledge on the interrelations between the morphologic parameters might facilitate the comprehension of the etiology of coccydynia. The clarification of interrelationship existence among the coccygeal morphological parameters requires further investigations.

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.

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.

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.

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.

Coccygeal Morphology on Multislice Computed Tomography in a Tertiary Hospital in India

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.