You are in: eMedicine Specialties > Orthopedic Surgery > SPINE CoccygodyniaArticle Last Updated: Feb 10, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: Michael J Lyons, DO, Clinical Professor of Orthopedic Surgery, Pikeville College School of Osteopathic Medicine; Chief of Surgery, Department of Orthopedic Surgery, Kentucky River Medical Center Michael J Lyons is a member of the following medical societies: American Association of Physician Specialists Editors: K Daniel Riew, MD, Professor, Department of Orthopedic Surgery, Washington University School of Medicine; Chief, Cervical Spine Surgery, Department of Orthopedic Surgery, Barnes-Jewish Hospital; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; William O Shaffer, MD, Associate Professor & Residency Program Director, Department of Orthopedic Surgery, University of Kentucky at Lexington; Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital; Mary Ann E Keenan, MD, Professor, Vice Chair for Graduate Medical Education, Department of Orthopedic Surgery, University of Pennsylvania School of Medicine; Chief of Neuro-Orthopedics Program, Department of Orthopedic Surgery, Hospital of the University of Pennsylvania Author and Editor Disclosure Synonyms and related keywords: coccydynia sprain of the posterior fibers of the sacrococcygeal joint capsule, contusion to the tip of the coccyx and surrounding soft tissue, fracture of the coccyx, coccyalgia, coccydynia levator syndrome, coccyx pain, back pain, coccygeal pain INTRODUCTIONSection 2 of 12
  The term coccygodynia (ie, coccydynia) has been defined as pain in and around the region of the coccyx. It was described as early as the 1600s, but the term actually was first used by Simpson in 1859. The term coccyx actually comes from the Greek term kokkoux for cuckoo, as it resembles the shape of a cuckoo's beak. This condition is quite rare and accounts for less than 1% of all back pain conditions reported to physicians. It is 5 times more common in women, supposedly because the coccyx is more exposed and prominent in women than in men. Various authors have described the typical patient with coccydynia as a female with a thin body who has either sustained direct trauma to the coccyx or injured the coccyx during childbirth. For excellent patient education resources, visit eMedicine's Back, Ribs, Neck, and Head Center. Also, see eMedicine's patient education articles Tailbone (Coccyx) Injury and Back Pain. History of the ProcedureSurgical treatment has traditionally involved a coccygectomy. This surgery is rarely performed anymore. Recently, a limited coccygectomy has been proposed that involves only the resection of the mobile or hypermobile segment of the coccyx. ProblemCoccygodynia is a cause of lower back pain. FrequencyCoccygodynia accounts for less than 1% of all reported causes of lower back pain. It is 5 times more common in women than men. EtiologyVarious etiologies have been described for this condition. The most common are direct falls resulting in direct injury to the sacrococcygeal synchondrosis. These can occur either from a kick, an injury on a trampoline when one hits the bar or springs that surround the trampoline jumping pad, or from falling from a horse or skis. The result is an injury or partial dislocation of the sacrococcygeal junction that causes abnormal movement of the coccyx, especially when sitting pressure is applied to this region. Resulting pain can involve the levator ani muscle and the anococcygeal, sacrotuberal, and sacrospinal ligaments, as well as the gluteus maximus muscles. Another common etiology is childbirth. The coccyx (tailbone) is considered by some authors to be in the way during childbirth. At the end of the third trimester, certain hormonal changes enable the synchondrosis between the sacrum and the coccyx to soften and become more mobile. This increased mobility of the 3-5 segment fused or unfused coccyx allows for more flexion and extension, which may result in stretching and a permanent change in the resting tension of the ligaments and muscles that surround and attach to the coccyx. Unlike fractures, which can remodel, injuries to this region can result in this synchondrosis being repeatedly forced out of its normal position, causing inflammation of the tissues surrounding the coccyx. Up to one third of all cases of coccygodynia are idiopathic in nature. Other less common causes of this condition include piriformis pain, pudendal nerve injury or neuropathic pain secondary to repeated damage to nerves (eg, in bike riders), pilonidal cyst formation, so called Tarlov cysts or meningeal cysts, obesity (due to excess pressure on the coccyx when sitting), and a bursitislike condition that can arise in slim patients who have little buttocks fat padding, allowing the tip of the coccyx to rub against the subcutaneous tissues, causing friction. PathophysiologyCommon pathophysiologic pathways for this condition may include the following:
ClinicalHistory may consist of either a direct fall or contusion to the sacrococcygeal region. This can result in a fracture of the coccyx or fracture dislocation of the coccygeal vertebrae. The other most common cause revealed by history is childbirth. Coccygodynia can be due to repetitive strain, such as in cycling and rowing. Prolonged sitting in a soft seat with direct pressure on the coccyx (as in computer users) is also noted on history. Anal intercourse has been mentioned as a cause of coccydynia. Physical examination should include direct palpation of the coccyx for tenderness. In true coccydynia, the coccygeal region usually is markedly tender. If the coccygeal region is not tender, the examiner should consider other diagnoses, such as lumbar disk disease or herniated disk. A rectal and pelvic examination also should be performed to check for any masses (tumors). INDICATIONSSection 3 of 12
Failure to respond to reasonable conservative management, failure to have pain and symptoms adequately controlled with this management, or worsening symptoms in a well-screened patient are indications for surgical intervention. RELEVANT ANATOMYSection 4 of 12
The anatomy of the sacrococcygeal region is well known to most orthopedists. Of importance is the motion of the sacrococcygeal segment with the iliac wings as well as the action of the levator ani muscle, the anococcygeal and sacrotuberal ligaments, the sacrospinal ligament, and the gluteus maximus muscle of the buttock. All can be involved in sacrococcygeal dysfunction. CONTRAINDICATIONSSection 5 of 12
Criteria for surgery are, at best, vague at present; therefore, the surgical contraindications are also not well defined. The presence of an active infection would be a contraindication. Patients who demonstrate a neurotic-type behavior and patients who have pending litigation due to an accident or an on-the-job injury (worker's compensation) should be evaluated carefully. WORKUPSection 6 of 12
Lab Studies
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Diagnostic Procedures
TREATMENTSection 7 of 12
Medical therapyTreatment for coccydynia generally falls into either conservative management or surgical intervention categories. Typically, conservative management begins with the use of a nonsteroidal anti-inflammatory drug to reduce inflammation and pain coupled with a donut-shaped pillow or a gel cushion to decrease coccygeal pressure and local irritation. Many physicians also advise the patient to use hot sitz-type baths to further soothe the irritated coccygeal soft tissues. If this therapy fails, usually after a minimum of 2 months, most authors consider injection of corticosteroid or a physiotherapeutically applied (ultrasound phonophoresis or iontophoresis) topical corticosteroid and analgesic combination. Wray et al, in a study published in the Journal of Bone and Joint Surgery, found that 60% of patients responded to local anesthetics and corticosteroids. The same study showed that 85% responded to this regimen and digital manipulation of the coccygeal ligaments as well as the muscles of the pelvic floor. Various massage and manipulation techniques have been described to help decrease coccygeal pain, but most have been shown to be only temporarily effective. Other proposed treatments are acupuncture reflex therapy. A cryoanalgesia probe inserted percutaneously through the sacral hiatus into the sacral canal to produce anesthesia at the lower sacral nerve roots has been used. This seems to work best when used multiple times with prolonged freezing. Fluoroscopically guided intradiscal injections of a "caine"-like anesthetic plus a corticosteroid seemed to work well for those coccyges that were found to be hypermobile or prone to luxation. If traditional injection therapies fail, Holubec et al have described a neurolytic technique in which lidocaine is injected at the junction of the sacrum and coccyx just in front of the junction. This is directed at the fourth and fifth sacral nerves and the coccygeal nerve. If this provides good pain relief, then a radiofrequency thermocoagulation probe can be inserted at the same site and used to ablate these nerves. In general, prolonged conservative treatment is usually successful in treating this condition. For those that have persistent coccygeal pain that does not respond to the various treatments outlined above or is not controlled with them, surgery may be an option. Surgical therapySurgical treatment has traditionally involved a coccygectomy. This surgical procedure is well described in many standard textbooks on either spine surgery or orthopedic surgery. While this surgery is rarely performed anymore, the actual procedure is relatively simple for any surgeon who knows the region well anatomically. Usual operative time is less than an hour for experienced surgeons. Recently, a limited coccygectomy has been proposed that involves only the resection of the mobile or hypermobile segment of the coccyx. This has been identified by fluoroscopic evaluation and local anesthetic injection prior to any surgery being attempted. Preoperative detailsA typical preoperative patient evaluation is appropriate. Failure of conservative management and absence of pending litigation are typical criteria for surgery. A routine laboratory workup is performed per hospital protocol. Intraoperative detailsThe procedure is well described in textbooks on the spine. It involves a midline incision of approximately 4-5 cm made directly over the coccyx. This is an area usually devoid of any muscle tissue. A careful subperiosteal dissection is made, with care being taken to avoid violating the rectum, and the coccyx is freed from the soft tissue and any sacral attachments. Postoperative detailsRoutine wound care is established, with special caution to aggressively treat any wound healing problems or infections. COMPLICATIONSSection 8 of 12
Coccygectomy complications include infection if the rectal vault is violated. If the surgical plane of dissection strays from the subperiosteal region around the coccyx, the rectum may inadvertently be entered. Various authors have also described both local wound problems and deep wound problems, especially scarring, with this procedure. Scar tissue can lead to "nociceptors" around the coccyx to continue to be irritated, causing continued pain and discomfort. No incidences of nerve root damage have been reported with this procedure since no significant nerve roots are normally in this region. OUTCOME AND PROGNOSISSection 9 of 12
Coccygeal pain (coccydynia) is usually managed with conservative measures. Prolonged conservative treatment is usually successful in treating this condition. The key to treatment is to allow enough time for the symptoms to respond to therapy. In some cases, surgical intervention may be indicated. With proper patient selection (no litigation or worker's compensation claims pending), the overall success rate can approach 90%. If surgery is performed, 6 months to 1 year may elapse after surgery before a patient may be pain free. FUTURE AND CONTROVERSIESSection 10 of 12
Discussion continues about the specific indications for surgical intervention when conservative therapy fails. Failure to respond to intradiscal injections with a "culprit lesion" of either luxation or hypermobility may help determine who may respond to surgical intervention. MULTIMEDIASection 11 of 12
REFERENCESSection 12 of 12
Article Last Updated: Feb 10, 2006 | |||||||
