Figure - available from: European Journal of Orthopaedic Surgery & Traumatology
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A lateral X-ray of the coccyx in a non-weight-bearing position with the coccyx lying at 55° angled forwards in relation to the distal sacrum (a), a lateral X-ray of coccyx in sitting position shows that the coccyx’s inclination in relation to the distal sacrum has increased considerably from 55° to 74.8° (b). Both findings confirm anterior subluxation
Source publication
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 com...
Citations
... However, the majority of cases are linked to recent lumbar spine surgery, epidural injections and rectal surgery, whilst some cases of coccygodynia are idiopathic, or most subjects have a preceding traumatic event, such as falling on their tailbone, or the roots of this problem may even stem from childbirth (5). Posttraumatic coccygeal instability might lead to hypermobility or subluxation of the coccyx with chronic inflammatory alterations that may further lead to sacrococcygeal joint arthritis (6). Microtrauma deriving from inadequate body positioning, such as prolonged periods of motorcycle or bicycle riding, may lead to a chronic sprain of the coccyx (7,8). ...
... In the literature, coccygeal discopathy as a causal factor of coccygodynia has not been previously Clinical Medicine noted. To the best of our knowledge, only a few cases have been reported with coccygeal herniation derived from trauma, arthritis, a tumor or after coccygectomy (6,9,10). ...
Objective. The aim of the present study was to describe the causes involved in the pathophysiology of coccydynia, emerging from the coccyx or the anatomical tailbone region.
Case Report. We present the case of a 64-year-old man with pain in the coccyx and numbness in the perianal area. After clinical examination and imaging evaluation, including plain X-rays and magnetic resonance, coccygeal disc disease was identified. Other findings, such as tumor and fracture were excluded. We decided to undertake conservative management and the pain was eventually relieved. This is the first case report of coccygodynia and perianal numbness attributed to coccygeal disc disease.
Conclusion. Although there is no standard treatment, coexisting coccygeal disc disease should be always taken into account, with clinical and imaging examinations being considered of major importance to establish both medical diagnosis and treatment.
... Most patients are suffering from a long ordeal, leading to inadequate stigmatization with psychiatric and a delayed true diagnosis [2,6,7]. Although conservative treatment is deemed the gold standard [2,3,[7][8][9][10][11][12][13], many authors report good to excellent results after surgical intervention via coccygectomy [6,[14][15][16][17][18][19][20][21][22][23]. Clear clinical selection criteria for surgery, however, are still ill-defined [24]. ...
Background
Treatment of coccygodynia is still a challenging entity. Clear surgical selection criteria are still lacking. The aim of the investigation was to establish a novel radiological classification for surgical decision-making in coccygodynia cases.Material and methodsRetrospective analysis of standing and sitting X-rays of coccygodynia patients referred to a single centre from 2018 to 2020. The sacro-coccygeal angle (SCA), the intra-coccygeal angle (ICA) and the difference of the intervertebral disc height (∆IDH) were measured. All coccyges were distributed in subtypes and correlated with the patients’ treatment.ResultsIn total, 138 patients (female/male: 103/35) with a mean age of 45.6 ± 15.4 years were included in the study. In total, 49 patients underwent coccygectomy. Four different subtypes of displaced coccyges were identified: Type I with a non-segmented coccyx, anterior pivot, increased SCA and ICA from standing to sitting, ∆IDH = 1.0 ± 1.5 mm. Type II with a multisegmented coccyx, anterior pivot, increased SCA and ICA standing/sitting, ∆IDH = 1.1 ± 1.6 mm. Type III showed a posterior pivoted coccyx, negative SCA and ICA, ∆IDH = 0.6 ± 1.6 mm. Type IV is characterized by an anterior–posterior dissociation of the tail bone with a positive SCA, and the ICA shifted from a posterior to an anterior orientation. ∆IDH was − 0.6 ± 1.8 mm.Conclusion
The presented radiological classification could help to facilitate the surgical decision-making for patients with displaced os coccyx. In addition, lateral and sitting X-rays were easy to perform and did not need unnecessary ionizing radiation like in CT scans and were more cost-effective than MRI investigations. The subtypes III and especially IV were more likely leading to surgery.
... 5,9,16,19,26 The rate of wound complications and infection has varied considerably in the literature (Range 0%-36%) with an overall pooled infection rate of 7.7%. 3,5,6,10,11 Surgeons have resorted to different measures to reduce the risk of infections including diet restrictions, 10,13,18,23,27,31 enema bowel preparations, 5,7,9,10,16,23,24 different skin incisions , 12,13,20 modified deep dissection techniques, 10,11,23 multilayer closure, 7,9,19,22 the usage of drains to reduce the risk of haematoma, 10,21,22,24 different regimes of antibiotics 9,23,25 the use of specific wound dressings 5,7,23,27 and strict postoperative wound care protocols. 9,23,26 Belgic et al. claimed in a case control study that subperiosteal dissection significantly reduces the 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.
... Diagnosis of this condition is clinical and made by obtaining a proper history and physical examination. Coccygodynia is notoriously difficult to manage, and often leads to chronic pain (1)(2)(3)(4)(5)(6)(7)(8). Chronic, refractory coccygodynia describes coccygeal pain that has persisted despite multiple attempts at therapeutic management. ...
... In the last decade, surgical removal of the coccyx, or coccygectomy, has grown in popularity for the use of treatment-resistant coccygodynia. Coccygectomies have been shown to be effective in relieving pain symptoms; however, this invasive intervention is not without risk (4)(5)(6)(7)(8). Complications such as infection, wound dehiscence, delayed healing, wound hematomas, intestinal tract injury, and rectal prolapse have been documented in the literature (8). ...
... The purpose of this case report is to describe the successful use of the sacral region as a target for retrograde placement of SCS leads in the management of intractable coccygodynia. Coccygodynia has proven to be a difficult condition to manage and reports of chronic, treatment-resistant types are abundant in the literature (1)(2)(3)(4)(5)(6)(7)(8). There is currently no consensus for optimal management and related studies have failed to report consistent findings (1). ...
BACKGROUND: Coccygodynia is a notoriously difficult condition to manage. Spinal cord stimulation (SCS) may be a promising therapeutic option for those suffering from chronic coccygeal pain. To our knowledge, there are limited reports of using SCS to target the sacral region for the treatment of intractable coccygodynia. CASE REPORT: A 50-year-old woman with refractory coccygodynia underwent permanent implantation of an SCS device following a successful SCS trial. SCS leads were inserted using a retrograde approach to target S2-S4 bilaterally. During follow-up, the patient reported > 90% improvement of coccygeal pain and her selfreported quality of life dramatically improved. CONCLUSION: This case report describes the successful use of the sacral region as a target for SCS in the management of intractable coccygodynia. SCS may be considered an effective treatment option when all other conventional methods have failed. KEY WORDS: Coccygodynia, neuromodulation, sacral nerve stimulation, spinal cord stimulation
... Sacrococcygeal pain is five times more likely in women than in men [5,6]. It is widely accepted that the therapeutic algorithm is as follows [7][8][9][10][11][12][13][14][15]. ...
... Despite favourable clinical data [7,9,11,12] surgical excision of the coccyx for the treatment of therapy-resistant coccygodynia is often delayed for a long time due to various concerns. The main reasons are well reported high infection rates [10,[12][13][14], the rarity of the condition [12], and absent ill-defined selection criteria to identify patients who may benefit from this type of surgery. ...
Purpose
We aim to critically review the effectiveness and safety of coccygectomy with special regard to long-term outcomes.
Methods
Coccygectomy was performed in our clinic in 38 patients between 1990 and 2019. All these patients (32 females vs. 6 males) have failed to respond to conservative treatment for at least 6 months prior to surgery. All patients were available for follow-up after mean 12,3 years (2 months to 29 years, 11 patients had a minimum FUP of 24 years). We evaluated all patients clinically and radiologically.
Results
Nineteen patients reported traumatic and 17 patients reported idiopathic onset of their symptoms; one patient had clinical symptoms after childbirth and another patient had coccygodynia after extensive low back surgery. 36 of our 38 patients were free of pain at least 6 months after surgery and had good or excellent clinical results according to the VAS which improved from 6.37 (SD 1.08) preoperatively to 0.68 (SD 0.99) at the recent follow-up. Two patients showed an ODI > 22 at the recent follow-up (24 and 28) and 32 had an ODI equal or under 4. There was no statistical significant difference in terms of clinical outcome between the different radiological types of the coccyx. Postoperative complications were rare: 1 superficial infection and one re-operation 6 months after initial surgery due to an pre-existing exostosis which had not been removed at the index surgery; no neurological complications and no major bleeding occurred. No patient had recurrent onset of coccygodynia. 37 out of 38 patients would have coccygectomy again.
Conclusions
Coccygectomy is a safe treatment option in patients with coccygodynia and shows excellent long-term results. We recommend to perform coccygectomy if patients fail to respond to conservative treatment for 6 months.
Level of evidence
IV
... Coccygectomy is indicated in refractory cases, with the priority given for patients with radiological abnormality either hypermobility or spicules of the coccyx [18][19][20]. ...
Objectives
The aim of this study was to evaluate the outcomes of coccygectomy for patients with refractory coccydynia as regards the intensity of pain and the satisfaction of the cases.
Methods
It is a retrospective study conducted upon 14 patients presented with refractory coccydynia; conservative treatment failure for a period of at least 6 months before surgery from 2016 to 2019. The follow up of the cases was for at least 6 months after surgery.
Results
From 14 cases, 13 cases were female (92.86%) and one male (7.14%): 9 cases (64.29%) were traumatic and 5 cases (35.71%) were idiopathic. Visual analogue scale (VAS) was significantly decreased at 1, 3 and 6 months postoperatively and at the end of the study compared to preoperative VAS. Complete subsidence of preoperative pain (VAS= 0) was noted in 6 cases (35.71%), improvement was in 7 cases (50%) (VAS <4) and VAS decreased from 8 to 6 in only one case (7.14%). Absolute satisfaction was noted in 85.72 % of total cases, 7.14 % was satisfied’ and 7.14 % was dissatisfied. Regarding postoperative complications; one patient had wound dehiscence and another patient had local wound infection.
Conclusions
Coccygectomy is an effective surgical method for relieving pain in patients with refractory coccydynia with minimal complications.
... The pathophysiology of coccygodynia is unknown, but the majority of cases are related to trauma from childbirth, recent lumbar spine surgery, epidural injections, and rectal surgery [2], while some cases of coccygodynia are idiopathic, most patients have a preceding traumatic event such as falling on their tailbone. Post-traumatic coccygeal instability can result in hypermobility or subluxation of the coccyx with chronic inflammatory changes that result in sacrococcygeal joint arthritis [3,4]. Microtrauma from inadequate body positioning such as prolonged periods of bicycle and motorcycle riding can cause chronic sprain of coccyx [5]. ...
... Patients with coccygodynia may have abnormal dynamic x-rays where rotation is < 5°(immobility), > 25°(hypermobility), or displaced [10]. In most cases, computed tomography (CT) imaging or magnetic resonance imaging (MRI) is used to rule out acute pelvic trauma, tumor, and abscesses [3]. Other differential diagnosis includes pelvic tumors, ovarian carcinoma, or lumbar degenerative disc disease. ...
... Awwad et al. 2017 [3] Retrospective 70 ...
Purpose of review:
Coccygodynia is pain within the coccyx area. The diagnosis is made clinically with symptoms of pain in the coccyx region and worsening pain in sitting position. The initial treatment is conservative therapy. For patients who do not respond to conservative therapies, there are further interventions available. This includes local injection of local anesthetics and steroids, neurolysis of sacral nerve roots, caudal epidural block, pulse radiofrequency (PRF), intra-rectal massage and manipulation, ganglion impar block, levator ani massage and stretching, coccyx manipulation, and coccygectomy. The purpose of this review is to evaluate the efficacies of these interventions in the treatment of coccygodynia.
Recent findings:
Literature search was performed with the keywords including coccygodynia, treatment, and coccygectomy, on PubMed and Google Scholar between August 2012 and August 2017. Thirteen studies with patients age 18 and over who underwent treatments for coccygodynia were selected for analysis. These treatments include conservative therapies (physical therapy and capsaicin patch), interventional techniques (local injections with steroids and local anesthetic, pulsed radiofrequency ablation of ganglion impar, extracorporeal shock wave therapy), and surgical techniques (complete and partial coccygectomies). The results from these studies demonstrated that most patients had significant pain relief with these techniques. Our literature review demonstrated various interventions including coccygectomy can be effective in the treatment of coccygodynia refractory to conservative therapies. There is a growing body of clinical evidence to support that coccygectomy is an effective treatment for patients with debilitating pain who had failed interventional therapies. Further randomized control studies should be conducted to examine duration of pain relief after coccygectomy and associated surgical complications.
» 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.
Currently, there are no clear clinical guidelines for the diagnosis and treatment of coccygodynia. There are still debatable issues related to the choice of the most optimal diagnostic method, evaluation of the effectiveness of blockades, establishment of indications for surgical treatment and the determination of the most appropriate method of surgery. The features of the anatomical structure of the coccyx are considered in the scientific paper. The clinical picture and neurological symptoms of coccygodynia are described in detail. Modern instrumental methods of diagnosis of this disease (spondylography, MSCT, MRI) are presented. Modern scientific works on evaluating the effectiveness of conservative and surgical treatment have been studied. The methods of surgical treatment of patients with coccygodynia are analyzed. Indications for surgical treatment and the results of surgeries in patients with coccygodynia are considered. In addition, the authors presented their classification of coccygodynia.
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.
