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Daily D, Bridges J, Mo WB, Mo AZ, Massey PA, Zhang AS. Coccydynia: A Review of Anatomy, Causes, Diagnosis, and Treatment. JBJS Rev 2024; 12:01874474-202405000-00004. [PMID: 38709859 DOI: 10.2106/jbjs.rvw.24.00007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
» 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.
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Affiliation(s)
- Drayton Daily
- Department of Orthopaedic Surgery, Louisiana State University-Shreveport, Shreveport, Louisiana
| | - James Bridges
- School of Medicine, Louisiana State University-Shreveport, Shreveport, Louisiana
| | - William B Mo
- Department of Orthopaedic Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Andrew Z Mo
- Department of Orthopaedic Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Patrick Allan Massey
- Department of Orthopaedic Surgery, Louisiana State University-Shreveport, Shreveport, Louisiana
| | - Andrew S Zhang
- Department of Orthopaedic Surgery, Louisiana State University-Shreveport, Shreveport, Louisiana
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Benditz A. [Treatment options for coccygodynia]. ORTHOPADIE (HEIDELBERG, GERMANY) 2024; 53:100-106. [PMID: 38167710 DOI: 10.1007/s00132-023-04467-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/11/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND To this day, patients with coccyx problems are the most frequently underestimated patient population in orthopedic practices. The clinical picture of coccygodynia was first described in 1859. Nevertheless, discussions about the importance of coccyx problems remain a tiresome topic. All patients have in common that they have gone through a long ordeal with many therapists, examinations and therapeutic approaches without having received a real diagnosis. DIAGNOSTIC The main symptom of coccygodynia is the pain directly on the lowest segment of the coccyx, which often only occurs when sitting and is intensified by the change in position, usually from a sitting to a standing position. Trauma can only be described as the trigger in 50% of cases. Women are four times more likely to be affected than men. The gold standard for imaging should be viewed from standing and seated dynamic lateral radiographs of the coccyx. TREATMENT After the diagnosis has been made, conservative treatment should first be started with oral NSAIDs, relief with a coccyx cushion with a recess and, if necessary, physiotherapy to strengthen or loosen the pelvic floor. Local infiltrations with a glucocorticoid and local anesthetic directly in the painful area are also often promising. If the symptoms persist for more than 6 months, surgical treatment in the sense of removing the coccyx can be discussed with the patient. The literature shows a success rate of 80-90% if the indication was correct.
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Affiliation(s)
- Achim Benditz
- Klinikum Fichtelgebirge, Schillerhain 1-8, 95615, Marktredwitz, Deutschland.
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Kara D, Pulatkan A, Ucan V, Orujov S, Elmadag M. Traumatic coccydynia patients benefit from coccygectomy more than patients undergoing coccygectomy for non-traumatic causes. J Orthop Surg Res 2023; 18:802. [PMID: 37891674 PMCID: PMC10605957 DOI: 10.1186/s13018-023-04098-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 08/14/2023] [Indexed: 10/29/2023] Open
Abstract
PURPOSE Conservative treatment is the first step in the management of coccydynia. However, surgical treatment is required in cases where conservative treatment fails. The aim of this study was to compare the effect of traumatic and atraumatic etiologies on functional outcomes in patients who underwent coccygectomy for chronic coccydynia. METHODS Ninety-seven patients who underwent partial coccygectomy between October 2010 and December 2018 for the diagnosis of chronic coccygodynia were evaluated retrospectively. The patients were divided into two groups according to etiologies as atraumatic (group AT) and traumatic (group T). Concomitant disorders of the patients were recorded as psychiatric and musculoskeletal diseases. Visual Analog Scale (VAS) for low back pain, the Oswestry Disability Index (ODI) scale, Short Form-36 Physical Component Summary and Short Form-36 Mental Component Summary were used to evaluate the clinical outcomes pre- and postoperative at the last follow-up. RESULTS The mean follow-up time was 67.3 ± 13.9 (range; 44-115) months. Group AT and group T included 48 (mean age 37.1 ± 11.3 and 36 (75%) female) and 49 patients (mean age 36 ± 11 and 35 (71.4%) female), respectively. The groups were statistically similar in terms of age (p = 0.614), gender (p = 0.691), body mass index (p = 0.885), tobacco usage (p = 0.603) and duration of pain (p = 0.073). However, the rate of musculoskeletal and total concomitant disorders was higher in the Group AT than in Group T (p < 0.05). The average preoperative SF-36 MCS and SF-36 PCS scores improved at the last follow-up from 43.3 ± 6.2 and 35.6 ± 4.9 to 72 ± 14.1 and 58.3 ± 10.9, respectively. The preoperative VAS and ODI decreased from 8 ± 1.4 and 39.8 ± 8.5 to 2.6 ± 1.8 and 13.4 ± 8.9 at the last follow-up, respectively. CONCLUSION Successful results were obtained with surgical treatment in chronic coccygodynia. In addition, functional outcomes in patients with traumatic etiology are better than in atraumatic ones. Levels of evidence Level III; Retrospective Comparative Study.
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Affiliation(s)
- Deniz Kara
- Orthopaedic Department, Washington University School of Medicine, Saint Louis, MO, USA.
- Department of Orthopedics and Traumatology, Bezmialem Vakif University School of Medicine, Fatih, Istanbul, Turkey.
| | - Anil Pulatkan
- Department of Orthopedics and Traumatology, Bezmialem Vakif University School of Medicine, Fatih, Istanbul, Turkey
| | - Vahdet Ucan
- Department of Orthopedics and Traumatology, Bezmialem Vakif University School of Medicine, Fatih, Istanbul, Turkey
| | - Said Orujov
- Department of Orthopedics and Traumatology, Bezmialem Vakif University School of Medicine, Fatih, Istanbul, Turkey
| | - Mehmet Elmadag
- Department of Orthopedics and Traumatology, Bezmialem Vakif University School of Medicine, Fatih, Istanbul, Turkey
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[Coccygodynia-An often underestimated clinical picture]. Z Rheumatol 2023; 82:25-30. [PMID: 36053332 DOI: 10.1007/s00393-022-01254-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2022] [Indexed: 02/07/2023]
Abstract
One of the most frequently underestimated symptoms in orthopedic practices is coccygodynia. The clinical picture of coccygodynia was first described in 1859. Nevertheless, discussions about the importance of coccygeal problems remain a controversial topic. All patients have in common that they have gone through a long ordeal with many therapists, examinations and therapeutic approaches without having received a real diagnosis. The main symptom of coccygodynia is pain directly on the lowest segment of the coccyx, which often only occurs when sitting and is intensified by a change in position, usually from a sitting to a standing position. Trauma can only be described as the trigger in 50% of cases. Women are four times more likely to be affected than men. The gold standard for imaging should be viewed from standing and seated dynamic lateral radiographs of the coccyx. After the diagnosis has been made, conservative treatment should first be started with oral nonsteroidal anti-inflammatory drugs (NSAID), relief with a coccyx cushion with a recess and, if necessary, physiotherapy to strengthen or loosen the pelvic floor. Local infiltration with a glucocorticoid and a local anesthetic directly in the painful area are also often promising. If the symptoms persist for more than 6 months, surgical treatment in the sense of removing the coccyx can be discussed with the patient. The literature shows a success rate of 80-90% if the indications are correct.
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The effect of extracorporeal shock wave therapy in coccydynia: a systematic review and meta-analysis. CURRENT ORTHOPAEDIC PRACTICE 2022. [DOI: 10.1097/bco.0000000000001154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Andersen GØ, Milosevic S, Jensen MM, Andersen MØ, Simony A, Rasmussen MM, Carreon L. Coccydynia-The Efficacy of Available Treatment Options: A Systematic Review. Global Spine J 2022; 12:1611-1623. [PMID: 34927468 PMCID: PMC9393997 DOI: 10.1177/21925682211065389] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
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.
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Affiliation(s)
- Gustav Ø. Andersen
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark,Gustav Ø. Andersen, Department of Neurosurgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 165, Aarhus 8200 Denmark.
| | - Stefan Milosevic
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
| | - Mads M. Jensen
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
| | - Mikkel Ø. Andersen
- Center for Spine Surgery & Research, Middelfart Hospital, Østre Hougvej, Denmark
| | - Ane Simony
- Center for Spine Surgery & Research, Middelfart Hospital, Østre Hougvej, Denmark
| | | | - Leah Carreon
- Center for Spine Surgery & Research, Middelfart Hospital, Østre Hougvej, Denmark,Norton Leatherman Spine Center, Louisville, KY, USA
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Celenlioglu AE, Sir E. Predictive factors affecting treatment success in ganglion impar block applied in chronic coccygodynia. Reg Anesth Pain Med 2022; 47:rapm-2022-103582. [PMID: 35738667 DOI: 10.1136/rapm-2022-103582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 06/14/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND This study aimed to determine the predictive factors affecting the success of ganglion impar block applied in chronic coccygodynia. METHODS Patients who received ganglion impar block to treat coccygodynia between January 1, 2018 and January 1, 2021 were retrospectively screened. Of the 195 patients, 102 met the final analysis criteria and were included in the study. Demographic data, coccygodynia etiology, coccygodynia symptom duration, history of coccyx fracture, regular opioid use, and presence of other musculoskeletal chronic pain conditions accompanying coccygodynia were obtained from patient records. In addition, coccyx radiography was examined, and coccyx curvature type, permanent subluxation, and posterior spicule presence were evaluated. The criterion for treatment success was set as ≥50% reduction in Numerical Rating Scale pain scores in the third month after treatment. RESULTS Treatment was successful of the patients in 69.6% (95% CI 60.4% to 78.7%). A significant cut-off value (24.5 months) was determined for coccygodynia symptom duration using receiver operating characteristic analysis. Symptom duration above the cut-off value was defined as prolonged symptom duration. Multivariable logistic regression analysis was performed to determine the predictive factors affecting treatment success in the third month after injection. In the final model, the presence of permanent subluxation (yes vs no), and the prolonged symptom duration (yes vs no) were found to have significant effects on treatment success (OR 9.56, 95% CI 1.44 to 63.40, p=0.02; OR 137.00, 95% CI 19.59 to 958.03, p<0.001). CONCLUSION Treatment success of ganglion impar block for coccygodynia is high. However, longer preprocedure symptom duration and the presence of permanent subluxation were associated with a decrease likelihood of treatment success.
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Affiliation(s)
- Alp Eren Celenlioglu
- Department of Pain Medicine, University of Health Sciences Gulhane Training and Research Hospital, Ankara, Turkey
| | - Ender Sir
- Department of Pain Medicine, University of Health Sciences Gulhane Training and Research Hospital, Ankara, Turkey
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Ahadi T, Hosseinverdi S, Raissi G, Sajadi S, Forogh B. Comparison of Extracorporeal Shockwave Therapy and Blind Steroid Injection in Patients With Coccydynia: A Randomized Clinical Trial. Am J Phys Med Rehabil 2022; 101:417-422. [PMID: 34091468 DOI: 10.1097/phm.0000000000001802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Extracorporeal shockwave therapy (ESWT) emerged recently for the treatment of musculoskeletal conditions owing to its regenerative and anti-inflammatory effects. In this study, the aim was to compare the efficacies of ESWT and steroid injection in patients with coccydynia. DESIGN Thirty-four patients with coccydynia were randomized into two groups. In the ESWT group, patients received radial shockwave for three weekly sessions. The second treatment group received an injection of steroid in the tip of the coccyx or sacrococcygeal junction. Outcome measures were visual analog scale, Short-Form Health Survey, and Dallas Pain Questionnaire. Visual analog scale was measured at baseline and 1 wk, 1 mo, 2 mos, and 6 mos after the intervention. Short-Form Health Survey and Dallas Pain Questionnaire were assessed before and 1 mo after treatment. RESULTS The visual analog scale score was significantly decreased in all follow-ups in both groups. There was also a significant decrease between 1 wk and three other posttreatment visits in the ESWT treatment group. Time and group interaction effect was significant on the visual analog scale (F2.64, 84.63 = 2.95, P = 0.043), in favor of ESWT. Concerning the Short-Form Health Survey and Dallas Pain Questionnaire, only some dimensions improved. CONCLUSIONS ESWT is an effective intervention in patients with coccydynia and had more long-lasting efficacy than steroid in terms of pain relief over 6 mos of observation.
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Affiliation(s)
- Tannaz Ahadi
- From the Neuromusculoskeletal Research Center, Department of Physical Medicine and Rehabilitation (TA, GR, SS, BF), and Department of Physical Medicine and Rehabilitation (SH), Iran University of Medical Sciences, Tehran, Iran
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Sympathetic Blocks for Visceral Pain. Phys Med Rehabil Clin N Am 2022; 33:475-487. [DOI: 10.1016/j.pmr.2022.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Skalski MR, Matcuk GR, Patel DB, Tomasian A, White EA, Gross JS. Imaging Coccygeal Trauma and Coccydynia. Radiographics 2021; 40:1090-1106. [PMID: 32609598 DOI: 10.1148/rg.2020190132] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Matthew R Skalski
- From the Department of Radiology, Palmer College of Chiropractic-West Campus, 90 E Tasman Dr, San Jose, CA 95134 (M.R.S.); Department of Radiology, Cedars-Sinai Medical Center, Los Angeles, Calif (G.R.M.); and Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, Calif (D.B.P., A.T., E.A.W., J.S.G.)
| | - George R Matcuk
- From the Department of Radiology, Palmer College of Chiropractic-West Campus, 90 E Tasman Dr, San Jose, CA 95134 (M.R.S.); Department of Radiology, Cedars-Sinai Medical Center, Los Angeles, Calif (G.R.M.); and Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, Calif (D.B.P., A.T., E.A.W., J.S.G.)
| | - Dakshesh B Patel
- From the Department of Radiology, Palmer College of Chiropractic-West Campus, 90 E Tasman Dr, San Jose, CA 95134 (M.R.S.); Department of Radiology, Cedars-Sinai Medical Center, Los Angeles, Calif (G.R.M.); and Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, Calif (D.B.P., A.T., E.A.W., J.S.G.)
| | - Anderanik Tomasian
- From the Department of Radiology, Palmer College of Chiropractic-West Campus, 90 E Tasman Dr, San Jose, CA 95134 (M.R.S.); Department of Radiology, Cedars-Sinai Medical Center, Los Angeles, Calif (G.R.M.); and Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, Calif (D.B.P., A.T., E.A.W., J.S.G.)
| | - Eric A White
- From the Department of Radiology, Palmer College of Chiropractic-West Campus, 90 E Tasman Dr, San Jose, CA 95134 (M.R.S.); Department of Radiology, Cedars-Sinai Medical Center, Los Angeles, Calif (G.R.M.); and Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, Calif (D.B.P., A.T., E.A.W., J.S.G.)
| | - Jordan S Gross
- From the Department of Radiology, Palmer College of Chiropractic-West Campus, 90 E Tasman Dr, San Jose, CA 95134 (M.R.S.); Department of Radiology, Cedars-Sinai Medical Center, Los Angeles, Calif (G.R.M.); and Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, Calif (D.B.P., A.T., E.A.W., J.S.G.)
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Li SQ, Jiang L, Cui LG, Jia DL. Clinical efficacy of ultrasound-guided pulsed radiofrequency combined with ganglion impar block for treatment of perineal pain. World J Clin Cases 2021; 9:2153-2159. [PMID: 33850934 PMCID: PMC8017504 DOI: 10.12998/wjcc.v9.i9.2153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 03/10/2021] [Accepted: 03/16/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Ganglion impar block alone or pulsed radiofrequency alone are effective options for treating perineal pain. However, ganglion impar block combined with pulsed radiofrequency (GIB-PRF) for treating perineal pain is rare and the puncture is usually performed with X-ray or computed tomography guidance.
AIM To evaluate the safety and clinical efficacy of real-time ultrasound-guided GIB-PRF in treating perineal pain.
METHODS Thirty patients with perineal pain were included and were treated by GIB-PRF guided by real-time ultrasound imaging between January 2015 and December 2016. Complications were recorded to observe the safety of the ultrasound-guided GIB-PRF procedure, and visual analogue scale (VAS) scores at 24 h before and after treatment and 1, 3, and 6 mo later were analyzed to evaluate clinical efficacy.
RESULTS Ultrasound-guided GIB-PRF was performed successfully in all patients, and no complications occurred. Compared with pretreatment scores, the VAS scores were significantly lower (P < 0.05) at the four time points after treatment. The VAS scores at 1 and 3 mo were slightly lower than those at 24 h (P > 0.05) and were significantly lower at 6 mo after treatment (P < 0.05). There was a tendency toward lower VAS scores at 6 mo after treatment compared with those at 1 and 3 mo (P > 0.05).
CONCLUSION Ultrasound-guided GIB-PRF was a safe and effective way to treat perineal pain. The 6-mo short-term clinical efficacy was favorable, but the long-term outcomes need future study.
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Affiliation(s)
- Shui-Qing Li
- Department of Pain Medicine, Peking University Third Hospital, Beijing 100191, China
| | - Ling Jiang
- Department of Ultrasound, Peking University Third Hospital, Beijing 100191, China
| | - Li-Gang Cui
- Department of Ultrasound, Peking University Third Hospital, Beijing 100191, China
| | - Dong-Lin Jia
- Department of Pain Medicine, Peking University Third Hospital, Beijing 100191, China
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Coccydynia-A comprehensive review on etiology, radiological features and management options. J Clin Orthop Trauma 2021; 12:123-129. [PMID: 33716437 PMCID: PMC7920198 DOI: 10.1016/j.jcot.2020.09.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 09/10/2020] [Accepted: 09/20/2020] [Indexed: 11/20/2022] Open
Abstract
Coccydynia is a disabling condition characterized by pain in the coccyx region of the spine. The first description of the disease was given in as early as 1859. Since then a number of theories have been proposed by various researchers to explain the pathogenesis of the disease. Treatment options for coccydynia include ergonomic adaptation, manual therapy, injections and surgery. Despite being identified as a disease as early as 18th century, several uncertainties with respect to the origin of pain, predisposing factors and treatment outcomes of a wide range of treatment options persist till date. The current narrative review presents various aspects of the disease including pathoanatomy, clinical presentation, radiological features and management options for the disease.
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Malhotra N, Goyal S, Kumar A, Kanika, Singla V, Kundu ZS. Comparative evaluation of transsacrococcygeal and transcoccygeal approach of ganglion impar block for management of coccygodynia. J Anaesthesiol Clin Pharmacol 2021; 37:90-96. [PMID: 34103830 PMCID: PMC8174441 DOI: 10.4103/joacp.joacp_588_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 12/02/2020] [Accepted: 03/17/2021] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND AND AIMS Coccygodynia or Coccydynia is pain in the area of coccyx and ganglion impar block is commonly used technique for treatment of coccygodynia. MATERIAL AND METHODS Forty patients of either sex in the age group of 20-70 years suffering from coccygodynia, who failed to respond to six weeks of conservative treatment were enrolled in the study. All patients were subjected to detailed clinical history, examination in the Pain Management Centre (Pain Clinic) of our Institute and imaging studies were reviewed. The patients were randomly divided into two groups of 20 each by a computer generated randomization number table: Group-TS (n = 20): Patients were administered ganglion Impar block by trans-sacrococcygeal approach Group-TC (n = 20): Patients were administered ganglion Impar block by trans-coccygeal approach with 8 ml of 0.5% bupivacaine plus 2 ml of 40mg/ml methylprednisolone acetate under fluoroscopic guidance. RESULTS Both the techniques of ganglion Impar block were effective and provided good pain relief to the patients with coccygodynia. There was a statistically and clinically significant improvement in pain score after ganglion Impar block in both the groups at all time intervals during the study period. (p < 0.05). The mean pain score after ganglion Impar block was <2 at all time intervals throughout the three month study period in all patients in the two groups. All patients in both the groups had excellent satisfaction immediately after ganglion Impar block. Five patients each in both groups required second ganglion Impar block during the three months study period. CONCLUSION Both trans-sacrococcygeal and trans-coccygeal approaches of ganglion Impar block with a combination of local anaesthetic and steroid are safe and effective for management of coccygodynia. Trans-coccygeal ganglion Impar block through the first intra-coccygeal joint is better in terms of improvement in pain score, functional disability, patient satisfaction and ease of administration.
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Affiliation(s)
- Naveen Malhotra
- Department of Anesthesiology, Pt. B.D. Sharma PGIMS, Rohtak, Haryana, India
| | - Sudeep Goyal
- Department of Anesthesiology, Pt. B.D. Sharma PGIMS, Rohtak, Haryana, India
| | - Amit Kumar
- Department of Anesthesiology, Pt. B.D. Sharma PGIMS, Rohtak, Haryana, India
| | - Kanika
- Department of Anesthesiology, Pt. B.D. Sharma PGIMS, Rohtak, Haryana, India
| | - Vishal Singla
- Department of Anesthesiology, Pt. B.D. Sharma PGIMS, Rohtak, Haryana, India
| | - Zile Singh Kundu
- Department of Orthopaedics, Pt. B.D. Sharma PGIMS, Rohtak, Haryana, India
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Abstract
Aims We aimed to establish the short- and long-term efficacy of corticosteroid injection for coccydynia, and to determine if betamethasone or triamcinolone has the best effect. Methods During 2009 to 2016, we treated 277 patients with chronic coccydynia with either one 6 mg betamethasone or one 20 mg triamcinolone cortisone injection. A susequent injection was given to 62 (26%) of the patients. All were reviewed three to four months after injection, and 241 replied to a questionnaire a mean of 36 months (12 to 88) after the last injection. No pain at the early review was considered early success. When the patient had not been subsequently operated on, and indicated on the questionnaire that they were either well or much better, it was considered a long-term success. Results At the three- to four-month review, 22 (9%) reported that they had no pain. The long-term success of one injection was 15% and rose to 29% after a second injection. Logistic regression tests showed that both early success (odds ratio (OR) 5.5, 95% confidence interval (CI) 2.1 to 14.4; p = 0.001) and late success (OR 3.7, 95% CI 1.7 to 8.3; p = 0.001) was greater with triamcinolone than with betamethasone. Late success was greater for patients with symptoms for less than 12 months (OR 3.0, 95% CI 1.4 to 6.7; p = 0.006). We saw no complications of the injections. Conclusion We conclude that the effect of corticosteroid injection for coccygodynia is moderate, possibly because we used modest doses of the drugs. Even so, they seem worthwhile as they are easily and quickly performed, and complications are rare. If the choice is between injections of betamethasone or triamcinolone, the latter should be selected. Cite this article: Bone Joint Open 2020;1-11:709–714.
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Affiliation(s)
- Vilhjalmur Finsen
- Department of Orthopaedic Surgery, St. Olav's University Hospital, Trondheim, Norway.,Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Ante M Kalstad
- Department of Orthopaedic Surgery, St. Olav's University Hospital, Trondheim, Norway.,Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway.,Norwegian Armed Forces Joint Medical Services, Trondheim, Norway
| | - Rainer G Knobloch
- Department of Orthopaedic Surgery, St. Olav's University Hospital, Trondheim, Norway
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15
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Kuek DKC, Chung SL, Zishan US, Papanikitas J, Yanny S, Meagher T, Teh J, Hughes R, Liong WC, McKean D. Conus infarction after non-guided transcoccygeal ganglion impar block using particulate steroid for chronic coccydynia. Spinal Cord Ser Cases 2019; 5:92. [PMID: 31700690 PMCID: PMC6831570 DOI: 10.1038/s41394-019-0237-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 10/23/2019] [Accepted: 10/25/2019] [Indexed: 12/19/2022] Open
Abstract
Introduction Ganglion impar block (GIB) is a well-recognised treatment for chronic coccydynia. Several side effects have previously been described with this procedure, including transient motor dysfunction, bowel, bladder, and sexual dysfunction, neuritis, rectal perforation, impingement of the sciatic nerve, cauda equina syndrome, and infection. Case presentation We describe the first report of imaging-documented conus infarction after an unguided-GIB performed in theatre using particulate steroids for a 17-year-old patient with coccydynia. Immediately post-GIB, patient developed transient neurological deficits in her lower limbs of inability to mobilise her legs that lasted for 24 h. These include back and leg pain, decreased power and movement, increased tone, brisk reflexes, reduced light touch sensation and proprioception of legs up to the T10 level. Urgent MRI spine showed intramedullary hyperintense signal within the conus and mild restricted diffusion on the distal cord and conus, suggestive of an acute conus infarction. On follow-up, the GIB did not result in symptom improvement of coccydynia and there was persistent altered sensation of her legs. Discussion Various approaches of ganglion impar block have been described and performed in the past with different imaging techniques and injectants. A few cases of unusual neurological complications have been reported with the use of epidural steroid injections and ganglion impar block. Clinicians should be aware of the possible neurological complications following ganglion impar blocks and the risk of inadvertent intravascular injection of particulate steroids can potentially to be minimised by using imaging guidance.
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Affiliation(s)
| | - Siok Li Chung
- Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, Aylesbury, UK
| | | | - Joseph Papanikitas
- Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, Aylesbury, UK
| | - Sarah Yanny
- Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, Aylesbury, UK
| | - Tom Meagher
- Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, Aylesbury, UK
| | - James Teh
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Richard Hughes
- Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, Aylesbury, UK
| | - Wei Chuen Liong
- Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, Aylesbury, UK
| | - David McKean
- Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, Aylesbury, UK
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16
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Sousa Correia J, Silva M, Castro C, Miranda L, Agrelo A. The efficacy of the ganglion impar block in perineal and pelvic cancer pain. Support Care Cancer 2019; 27:4327-4330. [DOI: 10.1007/s00520-019-04738-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 03/07/2019] [Indexed: 11/30/2022]
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17
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Abdelghani M, Rabie M. Ganglion Impar. Pain 2019. [DOI: 10.1007/978-3-319-99124-5_182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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18
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Benditz A, König MA. [Therapy-resistant coccygodynia should no longer be considered a myth : The surgical approach]. DER ORTHOPADE 2018; 48:92-95. [PMID: 30535765 DOI: 10.1007/s00132-018-03665-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Coccygodynia is still often considered a mystery, and many patients are not taken seriously with their problems and pain. CASE A 51-year-old thin lady presented at our clinic with lifelong, persistent low back pain. The clinical examination indicated suspicion of coccygodynia. A functional X‑ray revealed a hypermobile os coccygeum with dorsal tilt. After a total coccygectomy via a y-shaped approach, she was completely pain free at the 12 months follow-up examination. No surgical site infection occurred in this period.
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Affiliation(s)
- A Benditz
- Orthopädische Klinik für die Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl-V-Allee 3, 93077, Bad Abbach, Deutschland.
| | - M A König
- Orthopädische Klinik für die Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl-V-Allee 3, 93077, Bad Abbach, Deutschland
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19
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Sencan S, Cuce I, Karabiyik O, Demir FU, Ercalik T, Gunduz OH. The influence of coccygeal dynamic patterns on ganglion impar block treatment results in chronic coccygodynia. Interv Neuroradiol 2018; 24:580-585. [PMID: 29969959 DOI: 10.1177/1591019918781673] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective Ganglion impar block (GIB) can be performed in patients with chronic coccygodynia who do not respond to conservative treatments. We investigated the effect of coccygeal dynamic patterns on the treatment outcome in patients with chronic coccygodynia treated with GIB. Materials and methods We retrospectively analyzed the data for patients diagnosed with chronic coccygodynia who underwent GIB only once by a transsacrococcygeal method under fluoroscopy guidance in our Pain Medicine Clinic. Patients were assessed with standard and dynamic coccyx radiographs and classified according to coccygeal mobility. Pain scores were assessed with a numerical rating scale (NRS) before and after the intervention (at 1 hour and 4, 12 and 24 weeks). A 50% or more reduction in the NRS score was accepted as significant pain relief. Results Of the 37 patients included in the study, 14 had normal coccyx (Group I) and 23 had immobile coccyx (Group II) based on the radiological evaluation. The NRS scores were significantly reduced in both groups on each follow-up visit but there was no significant difference between the two groups in terms of pre- and post-intervention NRS scores. Significant pain relief was achieved in 42.9% and 61.9% of patients in Group I and II at the last examination, respectively. Conclusion GIB administered by transsacrococcygeal method in patients with chronic coccygodynia is a safe and alternative treatment approach with reduced pain scores and low complication rates. In patients with chronic coccygodynia, having a normal or immobile coccyx does not appear to affect treatment outcomes.
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Affiliation(s)
- Savas Sencan
- 1 Department of Physical Medicine and Rehabilitation, Division of Pain Medicine, Marmara University Pendik Training and Research Hospital, Istanbul, Turkey
| | - Isa Cuce
- 2 Department of Physical Medicine and Rehabilitation, Adiyaman University Training and Research Hospital, Adiyaman, Turkey
| | - Ozgur Karabiyik
- 3 Department of Radiology, Kayseri Training and Research Hospital, Kayseri, Turkey
| | - Fatmagul U Demir
- 4 Department of Physical Medicine and Rehabilitation, Kayseri Training and Research Hospital, Kayseri, Turkey
| | - Tulay Ercalik
- 5 Department of Physical Medicine and Rehabilitation, Division of Pain Medicine, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Osman H Gunduz
- 6 Department of Physical Medicine and Rehabilitation, Division of Pain Medicine, Faculty of Medicine, Marmara University, Istanbul, Turkey
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20
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Kırcelli A, Demirçay E, Özel Ö, Çöven I, Işık S, Civelek E, Kabataş S. Radiofrequency Thermocoagulation of the Ganglion Impar for Coccydynia Management: Long-Term Effects. Pain Pract 2018; 19:9-15. [PMID: 29617062 DOI: 10.1111/papr.12698] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 03/26/2018] [Accepted: 03/28/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To investigate the short- and long-term effects of ganglion impar radiofrequency thermocoagulation (RFT) treatment in patients with chronic coccydynia. METHODS We retrospectively analyzed the medical records of patients who underwent RFT of the ganglion impar between 2009 and 2011. Pain intensity visual numeric scale (VNS) scores and Euroqol 5D (EQ-5D) index scores were recorded pre-intervention and post-intervention at the first, sixth, and twelfth months. The differences between pre-procedural VNS scores and post-procedural VNS scores at the first, sixth, and twelfth months were evaluated. The success of the intervention was recorded as the percentage difference between the pre-intervention VNS scores and post-intervention VNS scores at the first, sixth, and twelfth months. RESULTS The mean age of the patients, including 11 females (55%) and 8 males (45%), was 48.7 ± 14.3 years. The average follow-up duration was 17.3 ± 2.9 months. Statistically significant differences were observed between the pre- and post-procedure VNS scores (P < 0.0001). Improvements in VNS scores were correlated with improvements in EQ-5D index scores. Mid-term (sixth month) and long-term (twelfth month) evaluations after the intervention revealed that 67.4% and 61.1% of the patients had successful outcomes, respectively. CONCLUSION Our data suggested that RFT of the ganglion impar in patients with chronic coccydynia resulted in effective outcomes, and patients who responded to RFT had significantly lower post-RFT pain scores.
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Affiliation(s)
- Atilla Kırcelli
- Department of Neurosurgery, Başkent University, Istanbul, Turkey
| | - Emre Demirçay
- Department of Orthopedic Surgery, Başkent University, Istanbul, Turkey
| | - Ömer Özel
- Department of Orthopedic Surgery, Başkent University, Istanbul, Turkey
| | - Ilker Çöven
- Department of Neurosurgery, Konya Research Hospital, Konya, Turkey
| | - Semra Işık
- Department of Neurosurgery, Başkent University, Istanbul, Turkey
| | - Erdinç Civelek
- Department of Neurosurgery, Taksim Research Hospital, Istanbul, Turkey
| | - Serdar Kabataş
- Department of Neurosurgery, Taksim Research Hospital, Istanbul, Turkey
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21
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Chen Y, Huang-Lionnet JHY, Cohen SP. Radiofrequency Ablation in Coccydynia: A Case Series and Comprehensive, Evidence-Based Review. PAIN MEDICINE 2018; 18:1111-1130. [PMID: 28034983 DOI: 10.1093/pm/pnw268] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
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.
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Affiliation(s)
- Yian Chen
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Julie H Y Huang-Lionnet
- Department of Anesthesiology and Interventional Pain Medicine, Greenwich Anesthesiology Associates, Greenwich Hospital, Yale University, New Haven, Connecticut
| | - Steven P Cohen
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland.,Neurology and Physical Medicine & Rehabilitation, Departments of Anesthesiology and Physical Medicine and Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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22
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Sarmast AH, Kirmani AR, Bhat AR. Coccygectomy for Coccygodynia: A Single Center Experience Over 5 Years. Asian J Neurosurg 2018; 13:277-282. [PMID: 29682021 PMCID: PMC5898092 DOI: 10.4103/1793-5482.228568] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Arif Hussain Sarmast
- Department of Neurosurgery, Sher-I-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir, India
| | - Altaf Rehman Kirmani
- Department of Neurosurgery, Sher-I-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir, India
| | - Abdul Rashid Bhat
- Department of Neurosurgery, Sher-I-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir, India
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Abstract
The inputs from sympathetic ganglia have been known to be involved in the pathophysiology of various painful conditions such as complex regional pain syndrome, cancer pain of different origin, and coccygodynia. Sympathetic ganglia blocks are used to relieve patients who suffer from these conditions for over a century. Many numbers of local anesthetics such as bupivacaine or neurolytic agents such as alcohol can be chosen for a successful block. The agent is selected according to its duration of effect and the purpose of the injection. Most commonly used sympathetic blocks are stellate ganglion block, lumbar sympathetic block, celiac plexus block, superior hypogastric block, and ganglion Impar block. In this review, indications, methods, effectiveness, and complications of these blocks are discussed based on the data from the current literature.
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Affiliation(s)
- Osman Hakan Gunduz
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Marmara University, Istanbul, Turkey
| | - Ozge Kenis-Coskun
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Marmara University, Istanbul, Turkey
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24
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Current Treatments for Coccydynia. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2017. [DOI: 10.1007/s40141-017-0167-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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26
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Coccygodynia review: coccygectomy case series. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2017; 27:961-965. [PMID: 28386714 DOI: 10.1007/s00590-017-1947-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 04/01/2017] [Indexed: 10/19/2022]
Abstract
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.
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Marwan Y, Dahrab B, Esmaeel A, Ibrahim SA, Al-Failakawi J. Extracorporeal shock wave therapy for the treatment of coccydynia: a series of 23 cases. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2017; 27:591-598. [DOI: 10.1007/s00590-016-1896-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 12/23/2016] [Indexed: 11/25/2022]
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29
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Adas C, Ozdemir U, Toman H, Luleci N, Luleci E, Adas H. Transsacrococcygeal approach to ganglion impar: radiofrequency application for the treatment of chronic intractable coccydynia. J Pain Res 2016; 9:1173-1177. [PMID: 27994479 PMCID: PMC5153273 DOI: 10.2147/jpr.s105506] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
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.
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Affiliation(s)
- Cemil Adas
- Anesthesiology and Reanimation Clinic, Şişli Hamidiye Etfal Education and Research Hospital, Istanbul
| | - Ugur Ozdemir
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Şifa University, Izmir
| | - Huseyin Toman
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Canakkale Onsekiz Mart University, Canakkale
| | - Nurettin Luleci
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Algology Clinic, Maltepe University
| | - Emel Luleci
- Department of Health Education, Faculty of Health Education, Marmara University
| | - Hilal Adas
- Anesthesiology and Reanimation Clinic, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
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Marker DR, U-Thainual P, Ungi T, Flammang AJ, Fichtinger G, Iordachita II, Carrino JA, Fritz J. MR-guided perineural injection of the ganglion impar: technical considerations and feasibility. Skeletal Radiol 2016; 45:591-7. [PMID: 26791162 DOI: 10.1007/s00256-016-2333-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 01/03/2016] [Accepted: 01/07/2016] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Perineural ganglion impar injections are used in the management of pelvic pain syndromes; however, there is no consensus regarding the optimal image guidance. Magnetic resonance imaging (MRI) provides high soft tissue contrast and the potential to directly visualize and target the ganglion. The purpose of this study was to assess the feasibility of MR-guided percutaneous perineural ganglion impar injections. MATERIALS AND METHODS Six MR-guided ganglion impar injections were performed in six human cadavers. Procedures were performed with a clinical 1.5-Tesla MRI system through a far lateral transgluteus approach. Ganglion impar visibility, distance from the sacrococcygeal joint, number of intermittent MRI control steps required to place the needle, target error between the intended and final needle tip location, inadvertent punctures of non-targeted vulnerable structures, injectant distribution, and procedure time were determined. RESULTS The ganglion impar was seen on MRI in 4/6 (66 %) of cases and located 0.8 mm cephalad to 16.3 mm caudad (average 1.2 mm caudad) to the midpoint of the sacrococcygeal joint. Needle placement required an average of three MRI control steps (range, 2-6). The average target error was 2.2 ± 2.1 mm. In 6/6 cases (100 %), there was appropriate periganglionic distribution and filling of the presacrococcygeal space. No punctures of non-targeted structures occurred. The median procedure time was 20 min (range, 12-29 min). CONCLUSION Interventional MRI can visualize and directly target the ganglion impar for accurate needle placement and successful periganglionic injection with the additional benefit of no ionizing radiation exposure to patient and staff. Our results support clinical evaluation.
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Affiliation(s)
- David R Marker
- Russell H. Morgan Department of Radiology and Radiological Science, Musculoskeletal Radiology, Johns Hopkins University School of Medicine, 601 North Caroline Street, JHOC 3140A, Baltimore, MD, 21287, USA
| | - Paweena U-Thainual
- Department of Mechanical and Materials Engineering, Queen's University, 99 University Avenue, Kingston, ON, Canada
| | - Tamas Ungi
- School of Computing, Queen's University, 557 Goodwin Hall, Queen's University, Kingston, ON, Canada
| | - Aaron J Flammang
- Siemens Corporate Research, Center for Applied Medical Imaging, Baltimore, MD, USA
| | - Gabor Fichtinger
- School of Computing, Queen's University, 557 Goodwin Hall, Queen's University, Kingston, ON, Canada
| | - Iulian I Iordachita
- Department of Mechanical Engineering and Laboratory for Computational Sensing and Robotics, Johns Hopkins University, 3400 N. Charles St., Hackerman 112, Baltimore, MD, 21218, USA
| | - John A Carrino
- Russell H. Morgan Department of Radiology and Radiological Science, Musculoskeletal Radiology, Johns Hopkins University School of Medicine, 601 North Caroline Street, JHOC 3140A, Baltimore, MD, 21287, USA
| | - Jan Fritz
- Russell H. Morgan Department of Radiology and Radiological Science, Musculoskeletal Radiology, Johns Hopkins University School of Medicine, 601 North Caroline Street, JHOC 3140A, Baltimore, MD, 21287, USA.
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Gunduz OH, Sencan S, Kenis-Coskun O. Pain Relief due to Transsacrococcygeal Ganglion Impar Block in Chronic Coccygodynia: A Pilot Study. PAIN MEDICINE 2015; 16:1278-81. [PMID: 25801345 DOI: 10.1111/pme.12752] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Coccygodynia is a distressing condition that presents with pain around the coccyx. Impar (Walther) ganglion is a sympathetic ganglion located at the end of lumbosacral sympathetic chain. The objective of this study is to share our results and follow up of 34 ganglion impar blocks in 22 patients. DESIGN Retrospective pilot study. SETTING Interventional Pain Clinic in the Department of Physical Medicine and Rehabilitation in a university hospital. SUBJECTS Twenty-two patients with coccygodynia who did not respond to conservative treatment and then presented to interventional pain clinic of a PM&R department in a university hospital METHODS Pain was evaluated via 10-cm visual analog scale (VAS). VAS values were obtained before, 1 hour and 3 weeks after injection and during this study was conducted. RESULTS For achieving at least 50% relief of pain, the success rate of a first injection was 82%, but accounted for three technical failures. In patients with a successful outcome, relief lasted for a median duration of 6 months. Relief was reinstated for a median period of 17 months by a second injection in nine patients who presented for repeat treatment. No relief was achieved in two of these patients when they presented for a third treatment. CONCLUSIONS Ganglion impar block appears to be effective in patients who have coccygodynia resistant to conservative therapy, with high success rates and prolonged duration of effect. Controlled studies are required to reveal the mechanism of this effect.
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Affiliation(s)
- Osman Hakan Gunduz
- Marmara University School of Medicine, Department of Physical Medicine and Rehabilitation, Section of Pain Medicine, Istanbul, Turkey
| | - Savas Sencan
- Pain Medicine Fellow, Marmara University School of Medicine, Department of Physical Medicine and Rehabilitation, Section of Pain Medicine, Istanbul, Turkey
| | - Ozge Kenis-Coskun
- Physical Medicine and Rehabilitation Resident, Marmara University School of Medicine, Department of Physical Medicine and Rehabilitation, Istanbul, Turkey
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Howard PD, Dolan AN, Falco AN, Holland BM, Wilkinson CF, Zink AM. A comparison of conservative interventions and their effectiveness for coccydynia: a systematic review. J Man Manip Ther 2014; 21:213-9. [PMID: 24421634 DOI: 10.1179/2042618613y.0000000040] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
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.
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Affiliation(s)
- Paul D Howard
- Department of Physical Therapy, Jefferson School of Health Professions, Thomas Jefferson University, Philadelphia, PA, USA
| | - Andrea N Dolan
- Department of Physical Therapy, Jefferson School of Health Professions, Thomas Jefferson University, Philadelphia, PA, USA
| | - Anthony N Falco
- Department of Physical Therapy, Jefferson School of Health Professions, Thomas Jefferson University, Philadelphia, PA, USA
| | - Brett M Holland
- Department of Physical Therapy, Jefferson School of Health Professions, Thomas Jefferson University, Philadelphia, PA, USA
| | - Caitlin F Wilkinson
- Department of Physical Therapy, Jefferson School of Health Professions, Thomas Jefferson University, Philadelphia, PA, USA
| | - Anna M Zink
- Department of Physical Therapy, Jefferson School of Health Professions, Thomas Jefferson University, Philadelphia, PA, USA
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Fritz J, Chhabra A, Wang KC, Carrino JA. Magnetic resonance neurography-guided nerve blocks for the diagnosis and treatment of chronic pelvic pain syndrome. Neuroimaging Clin N Am 2013; 24:211-34. [PMID: 24210321 DOI: 10.1016/j.nic.2013.03.028] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Magnetic resonance (MR) neurography - guided nerve blocks and injections describe a techniques for selective percutaneous drug delivery, in which limited MR neurography and interventional MR imaging are used jointly to map and target specific pelvic nerves or muscles, navigate needles to the target, visualize the injected drug and detect spread to confounding structures. The procedures described, specifically include nerve blocks of the obturator nerve, lateral femoral cutaneous nerve, pudendal nerve, posterior femoral cutaneous nerve, sciatic nerve, ganglion impar, sacral spinal nerve, and injection into the piriformis muscle.
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Affiliation(s)
- Jan Fritz
- Musculoskeletal Radiology, The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins Hospital, 600 N Wolfe Street, Baltimore, MD 21287, USA.
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Przybylski P, Pankowicz M, Boćkowska A, Czekajska-Chehab E, Staśkiewicz G, Korzec M, Drop A. Evaluation of coccygeal bone variability, intercoccygeal and lumbo-sacral angles in asymptomatic patients in multislice computed tomography. Anat Sci Int 2013; 88:204-11. [PMID: 23700101 DOI: 10.1007/s12565-013-0181-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 05/08/2013] [Indexed: 12/01/2022]
Abstract
The coccyx is a highly variable structure in the human caudal spine. Previous studies have revealed a significant correlation between coccyx shape and the pain syndrome coccygodynia. The aim of this study was to carry out a complex morphological evaluation of the coccyx in a group of asymptomatic patients of different sex and age examined by multislice computed tomography (MSCT) of the pelvis for different clinical reasons. MSCT pelvis examinations from various nontraumatic clinical conditions from consecutive adult patients (250 males and 250 females of comparable age, mean 54.9 ± 14.8 years) were used. Based on middle sagittal plane reconstructions: coccyx configuration (types I-IV according to Postacchini and Massobrio classification, each successive type characterized by a more pronounced anterior position of coccyx), number of segments, length and angles (intercoccygeal and lumbo-sacral) were measured. The results obtained were analyzed statistically. The following types of coccyx were observed in the study group: type I in 16.2 %, type II 40.0 %, type III 32.4 %, and type IV 11.4 % cases. In most cases (50.8 %), three segments were noted. Lumbo-sacral angle varied from 15.6° to 66.4° (average 41.6° ± 7.7°), and intercoccygeal angle from 0° to 107° (average 51° ± 23.3°). A significant negative correlation between age and number of segments as well as age and intercoccygeal angle was observed. In males, the coccyx was significantly longer, while in females the intercoccygeal angle was significantly wider. Type I was significantly more frequent in males, while type IV was found more often in females. The results obtained differ from other results in the literature. Our research could be useful to determine population standards, and help (together with clinical history) future studies of associations between idiopathic coccygodynia and coccyx morphology.
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Affiliation(s)
- Piotr Przybylski
- First Department of Radiology with Telemedicine Unit, Medical University of Lublin, Jaczewskiego 8, 20-954, Lublin, Poland.
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Walters A, Muhleman M, Osiro S, Bubb K, Snosek M, Shoja MM, Tubbs RS, Loukas M. One is the loneliest number: a review of the ganglion impar and its relation to pelvic pain syndromes. Clin Anat 2013; 26:855-61. [PMID: 23339118 DOI: 10.1002/ca.22193] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2012] [Revised: 09/15/2012] [Accepted: 09/25/2012] [Indexed: 11/06/2022]
Abstract
The ganglion impar is often overlooked as a component of the sympathetic nervous system. Despite its obscurity, this ganglion provides a pathway for neurons by accommodating postganglionic sympathetics, visceral afferents, and somatic fibers traveling to and from the pelvis. Its classic anatomic location as described in the 1720's held up until recently, with the current literature now revealing a great deal of anatomical variability. This variation becomes important when the ganglion impar is used as a treatment target for patients with chronic pelvic pain - its primary clinical implication. The aim of this review was to provide a better understanding of the anatomy of ganglion impar, accounting for variation in size, shape, and location. In addition, the clinical importance and treatment modalities associated with the ganglion impar are outlined.
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Affiliation(s)
- Andrew Walters
- St. George's University School of Medicine, Grenada, West Indies; Carilion Clinic - Virginia Tech Carilion Family Medicine Residency Program, Roanoke, Virginia
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Cortiñas Sáenz M, Iglesias Cerrillo J, Vázquez Colomo C, Salmerón Vélez G, Quirante Pizarro A, Jerez Collado F. Infiltración del ganglio impar y caudal en el manejo de la coccigodinia traumática rebelde al tratamiento analgésico convencional. Rev Esp Cir Ortop Traumatol (Engl Ed) 2011. [DOI: 10.1016/j.recot.2011.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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38
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Cortiñas Sáenz M, Iglesias Cerrillo J, Vázquez Colomo C, Salmerón Vélez G, Quirante Pizarro A, Jerez Collado F. Infiltration of impar and caudal ganglia in the management of traumatic coccydynia refractory to conventional analgesic treatment. Rev Esp Cir Ortop Traumatol (Engl Ed) 2011. [DOI: 10.1016/j.recote.2011.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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39
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Waldman SD. Coccydynia. Pain Manag 2011. [DOI: 10.1016/b978-1-4377-0721-2.00103-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Les infiltrations du système nerveux sympathique dans la prise en charge thérapeutiques des douleurs pelvipérinéales chroniques. Prog Urol 2010; 20:1124-31. [DOI: 10.1016/j.purol.2010.08.047] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2010] [Accepted: 08/16/2010] [Indexed: 11/22/2022]
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