Coccygectomy for chronic refractory coccygodynia: clinical case series and literature review

Mind the gap: paramedian approach for coccygectomy

BACKGROUND CONTEXT

Coccydynia is pain in the coccyx that typically occurs idiopathically or from trauma. Most forms are self-limiting. However, if symptoms persist, nonsurgical treatment options can include offloading, NSAIDs, physical therapy, and steroid injections. If all treatment options fail, a growing body of evidence supports a coccygectomy for symptomatic relief. The standard approach for a coccygectomy involves a midline incision cephalad to the anus along the gluteal cleft. Historically, this method has had high rates of infection.

PURPOSE

To improve healing and decrease infection rate, we propose the paramedian approach to a coccygectomy. This approach has the benefit of distancing the surgical site from the anus, diminishing the crevice effect of the incision, and increasing the dermal and subdermal thickness for improved surgical closure.

STUDY DESIGN/SETTING

We present a case series study of 41 patients who underwent the paramedian approach coccygectomy using a 4 to 6 cm incision, approximately 0.5 to 1.5 cm lateral to the midline, for coccyx removal. These patients were evaluated postoperatively to determine infection rate and various outcome measures.

PATIENT SAMPLE

Forty-one patients suffering from refractory coccydynia had a coccygectomy via the paramedian approach between 2011 and 2022 by the senior author.

OUTCOME MEASURES

Outcome measures included self-reported measures (Oswestry Disability Index (ODI), Visual Analogue Scale (VAS) pain scale and satisfaction with procedure), physiologic measures (presence of infection and treatment provided) and functional measures (return to vocation/avocation).

METHODS

Data was compiled and transferred to Microsoft Excel and analyzed. Two-tailed T-tests were used to compare the patient improvement in VAS and ODI as appropriate for statistical analysis.

RESULTS

The patients' average age was 45.8 years. Patients' average body mass index was 27.9, with 71% of patients overweight or obese. A total of 68% of patients were female. Trauma was the most common precipitating factor (75.6%). Five patients presented with postoperative complications (12.1%), one requiring an incision and drainage, and four others were treated with antibiotics for wound erythema. Postoperative evaluations showed continual improvement, with the most significant improvement reported greater than 1-year postoperatively. The Visual Analogue Scale for pain dropped from 7.5 to 2.3 (p<.001), and the Oswestry Disability Index improved from 30.1 to 9.6 (p<.001). A total of 86.7% of patients reported either a good or excellent result.

CONCLUSION

Coccygectomies via the midline approach have a variable infection rate, likely due to proximity of the incision to the anus and due to the crevice effect of the gluteal cleft in terms of aeration. These contributing factors are overcome in the paramedian approach, making it an effective option for treating refractory coccydynia that is nonresponsive to conservative management.

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.

Neuromodulation Techniques in Chronic Refractory Coccydynia: A Narrative Review

Refractory coccydynia is a condition characterized by severe coccygeal pain and poses a challenging management dilemma for clinicians. Advancements in neuromodulation (NM) technology have provided benefits to people experiencing chronic pain that is resistant to standard treatments. This review aims to summarize the spectrum of current NM techniques employed in the treatment of refractory coccydynia along with their effectiveness. A review of studies in the scientific literature from 2012 to 2023 was conducted, revealing a limited number of case reports. Although the available evidence at this time suggests significant pain relief with the utilization of NM techniques, the limited scope and nature of the studies reviewed emphasize the need for large-scale, rigorous, high-level research in this domain in order to establish a comprehensive understanding of the role of NM and its effectiveness in the management of intractable coccydynia.

[Treatment options for coccygodynia]

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.

Traumatic coccydynia patients benefit from coccygectomy more than patients undergoing coccygectomy for non-traumatic causes

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.

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.

[Coccygodynia-An often underestimated clinical picture]

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.

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.

Coccygeoplasty: preliminary experience with this new alternative treatment of refractory coccydynia in patients with coccyx hypermobility

BACKGROUND

Coccydynia has many causes, including fracture, subluxation, and hypermobility of sacrococcygeal segments. Existing treatments are limited in their effectiveness. Coccygeoplasty (CP) is a relatively new, minimally invasive treatment that appears to address this difficult clinical challenge.

OBJECTIVE

To describe clinical results at the time of the procedure and at 3- and 12-months' follow-up of patients with coccydynia related to subluxation and coccyx hypermobility treated with the CP technique. Additionally, to determine if there is any correlation between the final imaging and clinical results at 3- and 12-months' follow-up.

METHODS

A prospectively maintained database was used, and all patients who underwent CP for chronic coccydynia between January 2005 and October 2018 were retrospectively reviewed. All the patients had painful hypermobility (greater than 25°) with anterior flexion confirmed on radiological imaging. Alternative causes of coccydynia were excluded using CT and MRI. Procedures were performed under local anesthesia with combined fluoroscopic and CT guidance. Clinical follow-up was performed at two time points: 3 and 12 months after treatment using the Visual Analogue Scale (VAS).

RESULTS

Twelve patients were treated in a single center. No procedural complications occurred. At 3- and 12-months' follow-up, the majority (75%) of patients had significantly lower VAS scores than at baseline, with mean changes of 3.5 and 4.9, respectively. There was no pain recurrence at 12 months and just one patient had no improvement of the pain. Follow-up CT images confirmed fixation of the sacrococcygeal bone segments in nine patients; however, no correlation was found between final imaging results and clinical outcome (p=0.1).

CONCLUSIONS

Patients with refractory painful coccyx subluxation and hypermobility undergoing CP have a favorable clinical response at 3- and 12-months' follow-up. Further studies are required to validate this technique and to identify predictors of treatment response. Coccygeoplasty may be considered a reasonable alternative to coccygectomy.

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.

Anococcygeal Nerve and Sitting Pain: Differential Diagnosis and Treatment Results

BACKGROUND

The plastic surgeon is often asked to reconstruct the sacral area related to pilonidal cysts or a tumor, or after other surgery, such as coccygectomy. When sitting pain is not due to the pudendal or posterior femoral cutaneous nerve injury, the anococcygeal nerve (ACN) must be considered. Clinically, its anatomy is not well known. Rather than consider coccygectomy when the traditional nonoperative treatment of coccydynia fails, resection of the ACN might be considered.

METHODS

A review of traditional anatomy textbooks was used to establish classical thoughts about the ACN. A retrospective cohort of patients with sitting pain related to the coccyx was examined, and those operated on, by resecting the ACN, were examined for clinicopathologic correlations.

RESULTS

When the ACN is described in anatomy textbooks, it is with varying distributions of innervated skin territory and nerve root composition. Most include an origin from sacral 5 and coccygeal 1 ventral roots. Most agree that the ACN forms on the ventral side of the sacrum/coccyx, alongside the coccygeus muscle, to emerge laterally and travel dorsally to innervate skin over the coccyx and lower sacrum. A review of 13 patients with sitting pain due to the ACN, from 2015 to 2019, demonstrated a mean age of 54.6 years. Eleven were female. The etiologies of ACN injury were falls (9), exercise (3), and complication from surgery (1). Six of the 9 patients who had surgery were able to be followed up with a mean length of 36.3 months (range, 11-63 months). Overall, 3 had an excellent result, 2 had a good result, and 1 was not improved. The one with a failed result showed improvement with coccygectomy.

CONCLUSIONS

The ACN must be included in the differential diagnosis of sitting pain. It is most often injured by a fall. The ACN can be evaluated with a diagnostic nerve block, can be identified at surgery, and can be resected, and its proximal end can be implanted into the coccygeus muscle. This surgery may prove an alternative to coccygectomy.

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.

Conservative treatment for chronic coccydynia: a 36-month prospective observational study of 115 patients

PURPOSE

To describe long-term outcomes of conservative treatment for chronic coccydynia.

METHODS

We conducted a 36-month prospective observational study. Adults with chronic coccydynia (> 2 months) were included. The first-line treatment was coccygeal corticosteroid injection. The second-line treatment was either manual therapy or coccygectomy. The primary endpoint was the mean variation from baseline of coccydynia intensity at 6 and 36 months, using a numeric rating scale (0, no pain; 10, maximal pain). Evolution was considered unfavorable when coccydynia intensity was > 3 of 10 points at 36 months or coccygectomy had been performed. We carried out bivariate and multivariate analyses to identify variables associated with an unfavorable evolution.

RESULTS

We included 115 participants. Mean (SD) age was 43.5 (12.3) years, duration of coccydynia 18.4 (21.6) months and coccydynia intensity 6.5 (2.0) of 10 points. Mean variations for coccydynia intensity were - 1.5 (3.0) at 6 months and - 2.8 (3.2) at 36 months. At 36 months, 59/115 (51%) participants had an unfavorable evolution. In bivariate analysis, posterior coccyx dislocations were numerically more frequent in participants with an unfavorable evolution compared to others (29/59 (48%) versus 17/56 (30%), p = 0.057). In multivariate analysis, longer duration of coccydynia was associated with an unfavorable evolution (OR = 1.04, 95% CI from 1.01 to 1.07, p = 0.023).

CONCLUSION

In adults with chronic coccydynia receiving conservative treatment, symptoms decrease overtime, but significantly persist at 36 months in more than half of them. For patients with posterior coccyx dislocation, coccygectomy may be considered rapidly.

Coccydynia-A comprehensive review on etiology, radiological features and management options

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.

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.

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.

[Undetected coccyx fracture in a woman with fibromyalgia]

This article presents the case of a 46-year-old woman with fibromyalgia with an undetected fracture of the coccyx. The heterogeneity of the symptoms of patients suffering from fibromyalgia including chronic widespread pain, vegetative and functional disorders, mental and physical exhaustion as well as sleep disorders can cause accidentally undetected comorbidities, especially if these are rare and predominantly present with pain as the main symptom. In the present case the reason for symptoms was detected only after 14 months of ineffective therapies and diagnostic procedures. The coccygeal pain was eliminated through a coccygectomy as ultima ratio. It should be nevertheless emphasized that patients with fibromyalgia suffer from a central pain-processing disorder. Indications for operative treatment must be very carefully considered. Surgery should only be considered in consultation with the patient and after failed conservative therapy.

Management of coccydynia in the absence of X-ray evidence: Case report

BACKGROUND AND IMPORTANCE

Coccydynia is a rare pain syndrome due to trauma to the coccyx that is diagnosed through history, physical, and sitting/standing lateral plain film radiographs. Coccydynia is typically managed conservatively with specialized cushions, NSAIDS, and physical therapy. In cases refractory to nonsurgical management, coccygectomy has a high success rate for pain reduction.

CLINICAL PRESENTATION

Our patient had coccygeal pain for three years and endorsed a mobile fragment that was not highlighted on plain film radiographs. After evaluation with MRI and CT, a coccygeal source of their pain was highlighted and partial coccygectomy was performed.

CONCLUSION

Post-operatively, patient endorsed major improvement in her pain at follow up. In a case of suspected coccydynia where initial imaging is inconclusive but clinical suspicion is very high, higher level imaging such as MRI or CT can reveal radiographic findings of coccydynia. MRI and CT can play a role in the diagnosis and treatment of coccydynia in the absence of x-ray evidence.

[Therapy-resistant coccygodynia should no longer be considered a myth : The surgical approach]

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.

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.

Surgery for Refractory Coccygodynia: Operative Versus Nonoperative Treatment

STUDY DESIGN

This is a retrospective cohort study.

OBJECTIVE

To evaluate the long-term outcomes for patients with refractory coccygodynia treated with coccygectomy compared to a nonsurgical regimen of sitting aids, physical therapy, medications, and injections.

SUMMARY OF BACKGROUND DATA

The surgical treatment of coccygodynia remains controversial. To date, there has only been one small comparative study of surgical versus nonsurgical treatment.

METHODS

From 2004 to 2014, 109 patients presenting with coccygodynia were treated with either total coccygectomy or a nonsurgical course of sitting aids, physical therapy, anti-inflammatory medications, and injections. All had at least 2 years of symptoms before surgery. The patient principally made the treatment decision, counseled by the treating physician. Before surgery, all subjects underwent at least 2 years of conservative treatment and three-dimensional imaging (computed tomography and/or magnetic resonance imaging). Subjects completed visual analog pain scales, EuroQol five-dimension, components of the PROMIS measure, and a novel Coccygodynia Disability Index evaluation. Work status, complications, and satisfaction were recorded.

RESULTS

A total of 61 patients received nonsurgical care; eight declined participation and five could not be located. Forty-eight patients underwent total coccygectomy; three declined participation and five could not be located. At an average 4.8 years of follow-up (range: 2-9), the nonsurgical visual analog pain scales was 5 and the surgical 2 (P = 0.001); 79% of surgically treated patients were improved at 2 years versus 43% for the nonsurgical group. EuroQol five-dimension (P = 0.002), Coccygodynia Disability Index (0.01), and PROMIS Pain interference scores (0.02) were also significantly improved in the surgical group. Eleven surgical patients (26%) had complications, all wound related with successful resolution; seven treated with dressing changes and four with surgical debridement.

CONCLUSION

Total coccygectomy is a safe and effective surgical treatment of coccygodynia refractory to nonoperative care. Patient-reported outcome measures were improved after surgery compared with nonsurgical management. Postoperative wound care remains a concern.

LEVEL OF EVIDENCE

4.

An evaluation of two different methods of coccygectomy in patients with traumatic coccydynia

Purpose

The aim of this study was to evaluate the results of partial and total coccyx excisions in patients with traumatic coccydynia resistant to conservative treatment.

Patients and methods

The study included 22 patients (from a total of 27) who underwent partial or total coccygectomy because of persistent coccydynia between December 2007 and January 2014. There were 15 females and 7 males with a mean age of 33.6 years (range 23–46 years). Partial coccygectomy was performed in 14 patients and total coccygectomy in 8. They were evaluated according to their pre- and postoperative visual analog scale (VAS) scores. The mean follow-up period was 28 months (range 16–48 months).

Results

The mean VAS scores in the total excision group were 8.88±0.64 preoperatively and 2.5±2.67 at the final postoperative follow-up examination. In the partial excision group, these values were 8.79±0.89 preoperatively and 2.5±2.85 postoperatively. No statistically significant difference was determined between the two groups with respect to the mean scores (p>0.05). No rectum injury was seen in any patient. When the VAS scores of the patients were evaluated as a whole, excellent and good results were obtained in 78%. Patient satisfaction with the operation was 90%.

Conclusion

Coccyx excision is a successful treatment method in patients with long-term coccydynia who are resistant to conservative treatment. Two different surgical methods can be applied in the treatment and both of them have low complication rates and high patient satisfaction.

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.

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.

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.

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.

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.

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.

Role for magnetic resonance imaging in coccydynia with sacrococcygeal dislocation

Sacrococcygeal dislocation is among the many causes of coccydynia. The etiological diagnosis of this fairly rare condition is difficult. Dynamic imaging is the only means of documenting the dislocation. We describe two cases of sacrococcygeal dislocation in patients presenting with coccydynia. Both patients reported a history of trauma in the more or less remote past, with no clear correlation with pain onset. Magnetic resonance imaging (MRI) of the sacrococcygeal junction showed local inflammatory lesions (bursitis, sacrococcygeal arthritis), providing a rationale for a local procedure. Analgesic therapy was inadequately effective and a local glucocorticoid injection into the sacrococcygeal junction was therefore recommended. One of the patients accepted this procedure and subsequently reported complete resolution of the symptoms.

Sacrococcygeal teratoma in infants and children

BACKGROUND

The purpose of this study is to share our experience with extensive sacrococcygeal teratoma, paying particular attention to neurological function, intraoperative hemorrhage, rate of tumor recurrence, and the surgical procedure.

METHODS

Infants and children with sacrococcygeal teratoma were selected and generally examined in order to detect other associated anomalies. Patients with giant sacrococcygeal tumor and high output heart failure were managed by the abdominosacral route while patients with small sacrococcygeal tumor and normal cardiac function were managed by the sacral approach. All operated patients were observed and followed-up regularly for a period of 1-3 years after tumor excision.

RESULTS

This study presents 22 patients with sacrococcygeal teratoma managed over a period of 40 months; 18 patients presented in the first 2 months of life and four children aged 2-4 years. Fifteen patients were treated by sacral excision and seven patients were corrected by abdomenosacral excision and temporary colostomy. Benign teratoma presented in 17 patients, one of whom died (6%), and five patients had malignant tumor, one of whom died (20%). The fecal and urinary state was good in all patients treated by the sacral route. Patients corrected by abdominosacral excision showed varied degrees of urinary incontinence and constipation. Survival in excised malignant tumor was good following chemotherapy; three patients received chemotherapy with a 70% survival rate.

CONCLUSION

Benign sacrococcygeal teratoma has an excellent outcome after early surgery, but the incidences of malignancy increase if resection is delayed.