AUTHOR AND EDITOR INFORMATION

Section 1 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

INTRODUCTION

Section 2 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Background

Coccyx pain (tailbone pain) can frustrate patients and significantly impair quality of life, but relief is possible.

Coccyx pain was first documented in 1588, and the term coccygodynia was coined by Simpson in 1859.¹ Currently, the term coccydynia is used somewhat more commonly than coccygodynia. The 2 terms are interchangeable and indicate pain localized to the coccyx. Neither term specifies the underlying etiology. Coccyx pain can occur from local trauma or a tumor, but most cases are idiopathic and have no identifiable cause.²

Patients with coccyx pain often report that their physicians minimize, dismiss, or belittle their symptoms.² Tailbone pain is often relatively severe and persistent, causing significant compromise of the patient's ability to perform or endure various activities. Physicians who understand coccydynia and the available treatment options can provide a great service to this otherwise neglected patient population.

Pathophysiology

The word coccyx comes from the Greek word for cuckoo, the name apparently having been derived from the tailbone’s shape, which resembles that of a cuckoo’s beak.¹ The coccyx is the terminal end of the spine, just inferior to the sacrum. The human coccyx is composed of 3-5 individual segments (coccygeal vertebrae), with variations occurring with regard to the number of segments, the overall angulation (curve) of the coccyx, and the degree of articulation versus fusion between the individual segments. In 80% of patients, the coccyx is made up of 4 coccygeal vertebrae.

Typically, the coccyx is concave anteriorly and convex posteriorly. The human coccyx is often considered a vestigial remnant or corollary of a tail; thus, the coccyx is colloquially referred to as the tailbone.

Anatomy and function of the coccyx

In humans, the coccyx serves important functions, including as an attachment site for various muscles, tendons, and ligaments. Physicians and patients should remember the importance of these attachments when considering surgical removal of the coccyx.

Muscles inserting on the anterior coccyx include the levator ani, which is sometimes considered as several separate muscle parts, including the coccygeus, iliococcygeus, and pubococcygeus muscles. This important muscle group supports the pelvic floor (preventing inferior sagging of the intrapelvic contents) and plays a role in maintaining fecal continence. A midline component is the anococcygeal raphe, whereby the coccyx supports the position of the anus.¹ Muscles originating on the posterior coccyx include the gluteus maximus, which is the largest of the gluteal (buttock) muscles and which functions to extend the thigh during ambulation.

Multiple important ligaments attach to the coccyx.¹ The anterior and posterior sacrococcygeal ligaments attach the sacrum to the coccyx (similar to the functions of the anterior and posterior longitudinal ligaments spanning cervical, thoracic, and lumbosacral spinal segments). Laterally, the transverse process of the coccyx serves as an attachment site for the lateral sacrococcygeal ligaments (arising from the inferolateral sacrum), as well as for fibers from the sacrospinous ligament (arising laterally from the spine of the ischium) and the sacrotuberous ligament (connecting the sacrum with the ischial tuberosity but with fibers attaching to the coccyx as well).

The coccyx serves as somewhat of a weight-bearing structure when a person is seated, thus completing the tripod of weight bearing composed of the coccyx and the bilateral ischium. The ischial weight-bearing surfaces are, more specifically, at the ischial tuberosities and inferior rami of the ischium. The coccyx bears more weight when the seated person is leaning backward; therefore, many patients with coccydynia sit leaning forward (flexing at the lumbosacral and hip regions), which shifts more of the weight to the bilateral ischium rather than the coccyx. Alternatively, patients with coccydynia may sit leaning toward one side so that the body weight is exerted mainly on one ischial tuberosity or the other, with less pressure on the coccyx. Such side leaning may lead to concomitant ischial bursitis in addition to the antecedent coccydynia.

The base of the coccyx articulates with the sacral apex via the sacrococcygeal junction. The sacrococcygeal articulation and intracoccygeal articulations contain fibrocartilaginous discs, comparable to the intervertebral discs present at other spinal levels. The apex (distal tip) of the coccyx is typically rounded but may be bifid.

Frequency

United States

Coccydynia is considered to be relatively uncommon, but data are lacking on the exact incidence and prevalence.

Mortality/Morbidity

Although coccydynia is generally not associated with increased mortality, it is often associated with substantial morbidity. Patients with coccydynia often report severe and persistent pain that compromises functional activities requiring sitting and diminishes their quality of life.

Race

No specific racial differences have been reported for coccydynia.

Sex

Coccydynia is seen in males and females; however, women seem to be affected more frequently than men.² One gender-specific risk factor in females is trauma related to giving birth; substantial pressure may be placed on the coccyx as the baby descends through the mother's pelvis.

Age

Coccydynia can occur in children and adults. Degenerative changes of the sacrococcygeal junction and the intracoccygeal junctions, as well as fusion at these sites, seem to increase with age.

CLINICAL

Section 3 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

History

The history obtained from a patient with coccydynia involves details regarding the coccydynia itself and other underlying conditions that may refer pain to the coccyx region.

• Localization of pain - The patient should be asked to indicate or point to the painful site or sites.
• Severity of coccyx pain - The patient should be asked to rate the level of coccygeal pain (0-10 scale) when it is at its best and at its worst and to indicate overall pain severity.
• Duration and onset date of coccydynia - The patient should be asked whether any identifiable traumatic incident, recent or remote, occurred.
• Exacerbating factors - The patient should be asked whether there is pain associated with, for example, prolonged sitting or sitting on hard versus soft surfaces, as well as with sexual intercourse, standing up after sitting, or bowel movements.
• Sitting tolerance - The patient should be asked to quantify how many minutes of sitting can be tolerated before the pain mandates changing position.

Other elements of the patient's history that should be obtained include the following:

• Cushions tried - Such as donut cushions, which have a circular hole in the middle, or wedge cushions, which have a triangular wedge cut out posteriorly
• Oral medications tried and response to these
• Interventional pain management procedures and response to these - Such as caudal or other epidurals, local anesthetic blocks, and steroid injections, as well as whether these were administered blindly or guided fluoroscopically
• Gastrointestinal (GI) symptoms - Constipation; diarrhea; bright-red blood per rectum; melena (black, tarry stool); and fecal incontinence
• • GI workup - Such as GI consult, colonoscopy, or rectal exam
• Urinary symptoms - For instance, urinary incontinence, or dysuria
  
  
  • Urinary diagnostic workup - Such as urology consult or urinalysis
• Female intrapelvic history - Such as uterine fibroids or ovarian cysts
• Female obstetric history - Childbirth, vaginal or cesarean delivery, and any associated difficulties at the time
• Female menopausal status - Premenopausal, perimenopausal, or postmenopausal
• Lower limb neurologic symptoms - Such as radicular pain or lower limb numbness or weakness
• Concomitant ischial bursitis - Such as unilateral or bilateral ischial buttock pain due to leaning to either side to avoid sitting with pressure on the midline/coccyx region
• Body weight - Such as any significant increase or decrease in body weight preceding the onset of the symptoms.
• History of cancer - Especially colon, prostate, ovarian, cervical, testicular, or other intrapelvic malignancies.
• Risk factors for cancer - Blood per rectum, abnormal vaginal bleeding, unexplained weight loss, fevers, or chills

Physical

• Palpation
• • Sacrococcygeal palpation involves identifying and exerting pressure onto the sacrococcygeal junction and the coccyx, noting whether the presenting symptoms localize well to that site (ie, exquisite tenderness at the coccyx and/or sacrococcygeal junction, with only mild or absent tenderness at adjacent structures).
  • Some clinicians palpate the coccyx via an internal/external approach by using a gloved hand with 1 or 2 fingers placed inside the rectum (anterior to the coccyx) and another 1 or 2 fingers palpating externally (posterior to the coccyx). In this way, some clinicians also attempt to assess for increased or decreased sacrococcygeal mobility. Patients with severe coccydynia may have difficulty tolerating this examination.
  • Palpation of other (noncoccygeal) lumbosacral structures is important to help rule out pain generators from the ischial bursae, sacroiliac joints, lumbosacral facet joints, and lumbosacral or gluteal muscles.
• Neurologic examination - Strength, sensation, and muscle-stretch reflexes can be assessed throughout the bilateral lower limbs to assess for any lumbosacral radiculopathy.
• Lumbosacral range of motion - This can be assessed in multiple planes, including documentation of pain with these motions, particularly if the presenting symptoms are reproduced.
• GI and gynecologic physical examination - Depending on the patient's history and the clinician's expertise, abdominal and gynecologic physical examinations may be performed. Manual digital rectal examination can assess for hemorrhoids or other intrarectal masses.

Causes

• Some causes of coccyx pain include trauma, fractures, dislocations, and malignancies (either primary or metastatic).
• Sources of trauma include childbirth, falls, prolonged sitting, and colonoscopy.
• Some cases of coccydynia are idiopathic, without any identified etiology.

DIFFERENTIALS

Section 4 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Other Problems to Be Considered

Coccygeal fracture
Sacrococcygeal dislocation
Intracoccygeal dislocation (dislocation of one coccygeal segment from another)
Intrapelvic malignancy and/or metastatic lesions
Ischial bursitis
Sacroiliac joint pain
Ovarian cyst
Fibroid uterus
Hemorrhoids
Pilonidal cyst
Endometriosis

WORKUP

Section 5 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Lab Studies

• No specific blood work is recommended for coccydynia.

Imaging Studies

• Plain radiographs
• • Plain radiographs are typically the initial imaging study of choice for patients with coccydynia, especially in cases of focal sacrococcygeal trauma.
  • Plain radiographs may reveal fractures, abnormal sacrococcygeal curvature, osteophytes, or dislocations of the sacrococcygeal junction or intracoccygeal segments.^{3, 4}
  • However, the existence of substantial baseline, preinjury coccygeal variability—with regard to the angulation of the coccygeal vertebrae and the sacrococcygeal joint, the degree of fusion between the coccygeal vertebrae and the sacrococcygeal joint, and the total number of coccygeal vertebrae—creates challenges when interpreting sacrococcygeal imaging studies. It may become difficult to know whether apparent abnormalities truly signal acute or ongoing pathology or just represent normal, baseline anatomic variability.
  • In addition to obtaining the standard anteroposterior (AP) and lateral lumbosacral radiographs, explicitly requesting coned-down (focused) views of the coccyx itself is often important to ensure adequate visualization and an appropriate degree of radiographic exposure. Standard sacrococcygeal radiographs include the entire sacrum and coccyx, the lower lumbar region, and frequently the bilateral ilia and hip joints. Thus, images that are not coned-down to focus on the coccyx often result in suboptimal radiographic exposure there, making the coccyx difficult to clearly visualize.
• • In the lateral view, the easiest way to identify the sacrococcygeal junction typically is to look just anteroinferior to the sacral cornua and anterior to the coccygeal cornua. The cornua are horn-shaped, bony projections; 2 sacral cornua (the right and left cornua) extend inferiorly from the sacrum, and 2 coccygeal cornua extend superiorly from the coccyx. On the lateral radiographic view, the 2 sacral cornua seem to overlap and appear as one, with a similar overlapping noted for the coccygeal cornua.
  • In the AP view, the first (most superior) coccygeal vertebra can be distinguished from the other coccygeal vertebrae by the presence of the bilateral coccygeal cornu posteriorly and the bilateral transverse processes laterally. (The transverse processes of the first coccygeal segment are much wider and much more prominent than are the transverse processes of the inferior coccygeal vertebrae.)
  • The apex of the coccyx is usually rounded, but a bifid appearance can sometimes be appreciated in the AP radiographic view. The apex is typically midline but may deviate laterally.
  • Some French clinicians advocate radiographically assessing sacrococcygeal mobility through the comparison of lateral radiographs performed while the patient is seated versus standing.^{3, 4} Within most radiology departments, however, such dynamic radiography is not widely performed or readily available.
• Lumbosacral Magnetic Resonance Imaging (MRI)
• • Lumbosacral MRI studies usually fail to include the coccyx unless a specific request is made for coccygeal visualization. Thus, patients whose imaging studies have been limited to a standard lumbosacral MRI scan (without plain radiographs first and without additional MRI of the coccyx) have often received no actual radiologic imaging of the coccyx at all.
• • Lumbosacral MRI would be most helpful in cases where the coccygeal pain is suspected to be referred from anatomic structures located more superiorly within the spine (ie, at the lumbar or sacral regions).
  • Lumbosacral MRI can help diagnose lumbosacral disc pathology, degenerative joint disease of the lumbosacral facet joints (zygapophyseal joints), and pathology of the sacroiliac joints. However, the notable caveat is that many degenerative changes of these structures are considered to be a normal, often nonsymptomatic, part of the aging process. Thus, any such abnormalities must be put into the context of the overall history and physical so that the physician can make an educated determination as to whether the lumbosacral MRI findings represent actual pain generators or incidental findings.
• Bone scan and computed tomography (CT) scan of the coccyx
• • In cases of suspected fracture with negative or inconclusive plain radiographic findings, bone or CT scanning could be performed to better delineate the bony anatomy. This is notable because normal coccygeal variability and technical difficulties with radiographic exposure sometimes limit the ability of plain radiographs to aid in the diagnosis of a coccygeal fracture.
• • In most cases of coccydynia, bone and CT scanning are not necessary.
  • These studies can be considered particularly in medicolegal cases where objective evidence is needed regarding the presence or absence of a coccygeal fracture or in cases where bony cancer or metastases are being considered.
• CT scanning and/or MRI of the pelvis
• • CT scanning and/or MRI of the pelvis can be helpful in cases where intrapelvic pathology (ovarian, cervical, colon, testicular, or prostate cancer or their associated metastases) is suspected.
  • CT scanning may be particularly helpful with bony lesions and is less expensive than MRI.
  • MRI is superior to CT scanning at visualization of soft-tissue structures, including at showing pathology of the ovaries, uterus, prostate, urinary bladder, and bowels.
  • Also, unlike MRI, CT scanning carries notable risks of radiation exposure.

Other Tests

• Electromyography (EMG) and nerve conduction studies (NCSs)
• • EMG and NCSs are usually unnecessary in cases of isolated coccydynia.
  • Electrodiagnostics are potentially helpful in cases where concomitant lumbosacral radiculopathy is suspected.

Procedures

• The patient's response to injection of local anesthetic agents, with or without corticosteroids, can provide helpful information regarding whether the patient's actual pain generator has been accurately identified. However, the injection response may not be considered truly diagnostic of whether the pain generator is a specific anatomic structure unless the injection is performed with the guidance of fluoroscopy or other imaging aids. Similarly, if large volumes of fluid are injected, extravasation from the targeted site decreases the diagnostic specificity. See Treatment for further details regarding these injections.
• One case series indicates that a positive coccygeal discogram is correlated with better outcome from surgery, but these results were based on small numbers, including just 2 surgical patients who had positive preoperative discograms and 2 surgical patients who had negative preoperative discograms.⁵ Further, the usefulness of a positive discogram at predicting surgical outcome intuitively seems to be contraindicated by a separate, histologic study showing that disc degeneration at the sacrococcygeal joint in 5 patients was associated with poor surgical outcome in all 5 cases.⁶

Histologic Findings

A single case series of 8 patients that had undergone coccygectomy (surgical removal of the coccyx) revealed that in 5 patients, the main histologic change was disc degeneration at the sacrococcygeal joint; the surgical outcome was poor in all 5 patients. Two other cases had degenerative articular cartilage changes at the sacrococcygeal joint, and the postsurgical outcome was excellent in 1 of these patients and good in the second one.⁶

TREATMENT

Section 6 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Rehabilitation Program

Physical Therapy

Relatively few physical therapists have expertise in pelvic pain syndromes, pelvic floor muscle dysfunction, and/or pelvic floor rehabilitation. A small but growing number of therapists are receiving specialized training in this area. Thus, inquiring as to the degree of experience of a given therapist is important. Physical therapy for coccydynia may involve manually working on tight, painful muscular structures such as the levator ani, coccygeus, or piriformis muscles. Myofascial release techniques may be used. Local modalities also may be helpful.

Medical Issues/Complications

• Screening questions for possible malignancy should be completed prior to commencing focal treatment for coccydynia.
• Complications from focal injections seem to be uncommon if the injections are performed using a sterile technique and fluoroscopy or other image guidance to assist in accurate placement. Only a small percentage of patients experience exacerbation from the injection procedure itself, and this is generally only temporary.
• Coccygectomy has been associated with relatively high rates of postoperative infection.⁷
• Surgical treatment can also create risk of injury to the rectum and may potentially lead to fecal incontinence.

Surgical Intervention

• Surgical treatment for coccydynia includes coccygectomy, in the form of partial or complete surgical removal of the coccyx.
• Care must be taken during the surgery to avoid injury to the rectum, which is located just anterior to the coccyx.
• The ganglion impar also is located just anterior to the coccyx, so a potential risk of injury to the sympathetic nervous system exists during coccygectomy.
• The multiple muscular and ligamentous attachments to the coccyx present additional anatomic concerns for patients undergoing coccygectomy. For example, the levator ani and other pelvic floor muscles attach directly to the coccyx; thus, some degree of sagging of the pelvic floor is possible after coccygectomy. Another important attachment to the coccyx is the sphincter ani externus, which is responsible for bowel continence (thus raising the possibility of surgical complications, such as fecal incontinence).
• In a retrospective study of 32 patients with coccydynia who were treated by an orthopedic spine surgeon, 11 (34%) underwent surgical treatment via coccygectomy. Marked improvement was reported in 9 (82%) of the surgical patients, but 3 (27%) of the 11 developed wound infections and 1 (9%) developed wound dehiscence.⁸ The study's authors concluded that patients with coccydynia should be managed conservatively when possible, including with nonsteroidal anti-inflammatory drugs (NSAIDs) and repeat injections. The authors also felt that coccygectomy can offer reasonable results when conservative treatment fails but that patients should be warned of the high rate of infection.
• Another small case series reported on coccygectomy for 16 patients with chronic coccydynia (8 patients with posttraumatic coccydynia and 8 patients with nontraumatic coccydynia). Superior surgical results were reported in patients whose coccydynia had been preceded by trauma.⁹
• A case series of 20 patients treated with total coccygectomy reported that 90% of the patients eventually felt improvement, but overall postoperative complications included 7 wound problems—4 patients with superficial infections and 3 patients with persistent drainage.⁷
• Overall, a number of small to modest-sized case series have seemed to indicate that a significant quantity of properly selected patients may receive relief via coccygectomy but that postoperative complications (especially infection) are common.
• Although a number of small studies have reported significant rates of symptomatic relief via coccygectomy, the authors of these reports have generally indicated that surgery was performed in only a small percentage of the patients presenting with coccydynia. For example, one study reported that of all patients with coccydynia referred for orthopedic surgical consultation, only 15% underwent surgical treatment.¹⁰ Further, most of the authors of the surgical studies have recommended a thorough course of nonsurgical treatment (eg, oral medications, series of injections) prior to considering surgery.

Consultations

Physicians who are unfamiliar with treating coccydynia or are inexperienced at administering the injections that are commonly used as treatment may wish to consult a pain management physician (eg, a physical medicine and rehabilitation physician, or an anesthesiologist) with expertise in this area.

Other Treatment

• Ganglion impar sympathetic nerve blocks
  • The ganglion impar (ganglion of Walther) is the terminal ganglion of the paravertebral sympathetic nervous system.
  • The ganglion impar is the only nonpaired sympathetic ganglion.
  • The ganglion impar is usually located anterior to the sacrococcygeal junction, the first intracoccygeal junction, or the first coccygeal vertebra.¹¹
  • One possible mechanism for persistent coccydynia is excessive activity or sensitivity of the ganglion impar, thus creating sympathetically maintained coccyx pain.¹²
  • Local injection of an anesthetic can effectively block the ganglion impar and thereby relieve coccyx pain.^{13, 14}
  • In a published report by Foye and colleagues, nerve blocks using local anesthetics with a fast onset (eg, lidocaine) were shown to provide substantial relief even by the time a patient sat up on the procedure table.¹²
  • After the local anesthetic block wears off, some of the coccyx pain may start to return, but generally, it returns at a much lower severity than prior to the injection. Physical medicine and rehabilitation coccydynia physicians and researchers at New Jersey Medical School refer to this new plateau of severity as "resetting the thermostat."
  • Published reports document that some patients with coccydynia receive 100% complete and permanent relief via a single ganglion impar block.¹²
  • In patients with less than 100% permanent relief, repeat ganglion impar blocks have been shown to provide additional benefit, further lowering the plateau level of pain.¹⁴ Thus, repeat injections are not mandatory but are often helpful.
  • Older techniques for performing the ganglion impar block involved approaching the anterior sacrococcygeal region by using a curved needle inserted below the distal coccygeal tip.¹³ The older technique required a larger-diameter and longer-length needle (in particular, the longer length of that needle being inserted into the patient) compared with the current (transsacrococcygeal) approach, which uses a short, thin needle.
  • In the past, many coccygeal procedures were performed without image guidance (blind injection, such as without fluoroscopy), which would have been expected to compromise both the accuracy and safety of the injection.
  • The more recent transsacrococcygeal approach to the ganglion impar involves inserting a thin needle into the sacrococcygeal junction, from posterior to anterior.^{15, 16}
  • More specifically, the transsacrococcygeal approach for ganglion impar sympathetic blockade uses a lateral fluoroscopic view to visualize the sacrococcygeal junction. A small, 25-gauge spinal needle is then inserted through the junction until the needle tip is just anterior to that articulation. Radiographic contrast can be used to confirm that the needle placement is not intravascular, not too far anterior (within the rectum), and not too superficial (within the sacrococcygeal disc).¹² The procedure is only minimally invasive. It requires a sterile technique (particularly given the proximity to the anus and rectum) and fluoroscopic guidance to ensure safe and accurate needle placement.
  • The ganglion impar block (which is anterior to the coccyx) can be preceded by a separate local anesthetic block of the coccygeal nerve (a somatic, nonsympathetic nerve posterior to the coccyx) to anesthetize the region prior to the impar injection and to provide more complete relief of the coccydynia.
  • A case series reported the results of 20 ganglion impar blocks by physical medicine and rehabilitation physicians at New Jersey Medical School in patients with persistent coccydynia despite oral medications, cushions, and other conservative treatments.¹⁴ The results showed that each of the 20 injections provided significant relief in these patients. The percentage of relief obtained per injection varied from 20-75%, with most patients reporting 50-75% relief obtained per injection, the relief generally lasting weeks to months or longer. For cases where patients had incomplete relief after a given injection, additional analgesic benefit was obtained from subsequent injections. Thus, repeat injections were often helpful.
  • Foye and colleagues at New Jersey Medical School also published a new, slightly more direct approach to ganglion impar injections.¹² Specifically, they reported the option of passing the needle through the first intracoccygeal joint (the space between the first and second coccygeal segments) instead of through the sacrococcygeal joint. This approach provides the following important improvements over the transsacrococcygeal approach:
    
    
    • The first intracoccygeal joint is often easier to visualize, since it is not obstructed by the sacral or coccygeal cornua.
    • This site is slightly closer to the location of the ganglion impar, according to cadaver dissection studies.¹¹
  • Thermocoagulation of the ganglion impar using radiofrequency ablation (RFA) has been reported.¹⁷
• Sacrococcygeal joint injections
• • In cases where the primary pain generator is thought to be at the sacrococcygeal joint, local injection can be performed into this site.
  • Image guidance (eg, fluoroscopy) can be helpful to ensure accurate placement, particularly because the joint space is typically narrow and individual anatomic coccygeal variability may make surface palpation alone unreliable.
  • Injection with local anesthetic (eg, lidocaine) alone (ie, without any corticosteroids) may serve as a diagnostic injection if fluoroscopy and contrast have first confirmed accurate placement within the joint.
  • Injection with corticosteroids may be helpful in cases of focal inflammation at the sacrococcygeal joint (eg, after local trauma and perhaps with degenerative changes at this site).
  • If injected too superficially (posterior to the sacrococcygeal junction), corticosteroids may theoretically cause subcutaneous fat atrophy at this site.
• Epidural steroid injections - Although many pain management centers perform caudal epidural steroid injections for coccydynia, a relative paucity of published research supports epidural steroid use for coccyx pain.
• Manipulation (mobilization)
• • Osteopathic, chiropractic, or other manual medicine techniques to mobilize the coccyx are sometimes performed by clinicians who feel that the sacrococcygeal segments of a given patient have decreased mobility.
  • Manipulation with fingers placed inside the rectum may theoretically have a role in helping to relocate a dislocated coccygeal vertebra.¹ Adequate anesthesia may be necessary for the patient to tolerate the relocation.
  • Since effectively bracing/immobilizing a dislocated coccyx in the relocated position is not possible, it is unclear whether relocation via manipulation provides sustained improvement in position.
  • A randomized study in patients with chronic coccydynia found that 51 patients treated with intrarectal manipulation had good results twice as frequently as the control group—at 1 month (36% vs 20%, P = 0.075) and at 6 months (22% vs 12%, P = 0.18). The main predictors of a good outcome were a stable coccyx, shorter symptom duration, traumatic etiology, and a lower score in the affective (emotional) parts of the McGill and Dallas questionnaires. The authors concluded that intrarectal manipulation had "mild effectiveness" for chronic coccydynia.¹⁸
• Ischial bursa injections - The authors of this article have found that in cases where ischial bursitis is suspected as a substantial component of the patient's buttock pain, local injection of the bursa can be performed either with local anesthetic alone (diagnostic injection) or with corticosteroids (therapeutic injection).

MEDICATION

Section 7 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

The goals of pharmacotherapy are to prevent complications and reduce morbidity.

Drug Category: Nonsteroidal anti-inflammatory drugs

These have analgesic, anti-inflammatory, and antipyretic activities. The mechanism of action may be inhibition of cyclooxygenase (COX) activity and prostaglandin synthesis. Other mechanisms may include inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions.

Drug Category: Analgesics

Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties that are beneficial for patients who experience pain.

Drug Name	Tramadol (Ultram)
Description	Inhibits ascending pain pathways, altering perception of and response to pain. Inhibits reuptake of norepinephrine and serotonin.
Adult Dose	50 mg PO up to qid prn pain
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; opioid-dependent patients; concurrent use of MAOIs or within 14 days; use of SSRIs, TCAs, opioids; acute alcohol intoxication
Interactions	Significantly decreases carbamazepine effects; cimetidine increases toxicity, risk of serotonin syndrome with coadministration of antidepressants
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Can cause dizziness, nausea, constipation, sweating, pruritus; additive sedation with alcohol and TCAs; abrupt discontinuation can precipitate opioid withdrawal symptoms; adjust dose in liver disease; development of tolerance or dependency with extended use; swallow extended-release product whole, do not chew, crush, or split

Drug Name	Pregabalin (Lyrica)
Description	Structural derivative of GABA. Mechanism of action unknown. Binds with high affinity to alpha2-delta site (a calcium channel subunit). Reduces calcium-dependent release of several neurotransmitters in vitro, possibly by modulating calcium channel function. FDA approved for neuropathic pain associated with diabetic peripheral neuropathy or postherpetic neuralgia.
Adult Dose	Up to 100 mg PO qid
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity
Interactions	May cause additive effects on cognitive and gross motor functioning when coadministered with drugs that cause dizziness or somnolence
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Discontinue gradually (over a minimum of 1 wk) to minimize increased seizure frequency in patients with seizure disorders; may cause insomnia, nausea, headache, or diarrhea with abrupt withdrawal; common adverse effects include dizziness, somnolence, blurred vision, weight gain, and peripheral edema; may elevate creatinine kinase level, decrease platelet count, and increase PR interval; doses >300 mg/d associated with higher rate of adverse effects and treatment discontinuation; decrease dose with renal impairment (ie, CrCl <60 mL/min)

Drug Name	Fentanyl citrate (Duragesic, Sublimaze)
Description	A synthetic opioid 75-200 times more potent and with a much shorter half-life than morphine sulfate. Has fewer hypotensive effects and is safer in patients with hyperactive airway disease than morphine is because of minimal to no associated histamine release. By itself, it causes little cardiovascular compromise, although the addition of benzodiazepines or other sedatives may result in decreased cardiac output and blood pressure. Highly lipophilic and protein-bound. Prolonged exposure leads to accumulation in fat and delays weaning process. Consider continuous infusion because of the short half-life of fentanyl. Parenteral form is DOC for conscious sedation analgesia. Ideal for analgesic action of short duration during anesthesia and immediate postoperative period. Excellent choice for pain management and sedation with short duration (30-60 min) and easy to titrate. Easily and quickly reversed by naloxone. After initial parenteral dose, subsequent parenteral doses should not be titrated more frequently than q3h or q6h thereafter. Transdermal form is used only for chronic pain conditions in opioid-tolerant patients. When using the transdermal dosage form, most patients are controlled with 72 h dosing intervals; however, some patients require dosing intervals of 48 h. Easily and quickly reversed by naloxone.
Adult Dose	Apply a 25-100 mcg/h transdermal system q48-72h
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; hypotension or potentially compromised airway where it would be difficult to establish rapid airway control
Interactions	Phenothiazines may antagonize analgesic effects of opiate agonists; tricyclic antidepressants may potentiate adverse effects of fentanyl when both drugs are used concurrently
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Caution in hypotension, respiratory depression, constipation, nausea, emesis, and urinary retention; idiosyncratic reaction, known as chest wall rigidity syndrome, may require neuromuscular blockade in order to increase ventilation

Drug Name	Oxycodone (OxyContin, OxyIR, Roxicodone)
Description	Indicated for the relief of moderate to severe pain.
Adult Dose	Immediate release: 5 mg PO q6h prn Controlled release: 10 mg PO bid
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity
Interactions	Phenothiazines may antagonize analgesic effects; MAOIs, general anesthesia, CNS depressants, and tricyclic antidepressants may increase toxicity
Pregnancy	B - Usually safe but benefits must outweigh the risks. D - Unsafe in pregnancy
Precautions	Caution in COPD, emphysema, and renal insufficiency

Drug Name	Oxycodone and acetaminophen (Percocet, Roxicet, Roxilox, Tylox)
Description	Drug combination indicated for the relief of moderate to severe pain.
Adult Dose	1-2 tab or cap PO qid prn pain
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity
Interactions	Phenothiazines may decrease analgesic effects of this medication; toxicity increases with coadministration of either CNS depressants or tricyclic antidepressants
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Duration of action may increase in the elderly; be aware of total daily dose of acetaminophen patient is receiving; do not exceed 4000 mg/24h of acetaminophen; higher doses may cause liver toxicity

Drug Category: Anticonvulsants

Used as an adjuvant for neuropathic pain.

FOLLOW-UP

Section 8 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Further Inpatient Care

• Inpatient care is not usually necessary, except in surgical patients (status, postcoccygectomy).

Further Outpatient Care

• Generally, all nonsurgical care of coccydynia can be performed on an outpatient basis, including follow-up visits and local injections.

Transfer

• If the treating physician is not experienced or knowledgeable in treating coccydynia, he or she may wish to transfer the patient to a health care provider with particular expertise in this area.

Deterrence

• Patients with coccydynia usually know which activities to avoid in order to minimize exacerbation of their tailbone pain. Examples include prolonged sitting (eg, long car or airplane rides), bike riding, horseback riding, and canoeing.

Complications

• As noted above, coccygectomy can be associated with significant rates of postoperative infection and persistent drainage, as well as the potential risk of fecal incontinence.
• Complications of focal, fluoroscopically guided injections are rare and are generally limited to mild, temporary exacerbation of pain in a small percentage of patients.

Prognosis

• While some patients with coccydynia have complete relief via natural recovery over time, others develop a persistent, chronic pain syndrome at the coccyx region.
• Once the coccyx pain has become chronic (persisted for more than 6 mo), it may be less likely to resolve by natural recovery alone, more likely to continue indefinitely, more likely to be resistant to treatment, and more likely to require a multimodal treatment approach (eg, oral medications combined with local injections).
• Early interventions (eg, oral medications, injections, physical therapy) are presumed to decrease the chance that acute coccydynia will develop into chronic coccydynia.

Patient Education

• The author of this eMedicine article (Dr. Foye) has provided further information available online on the topic of tailbone pain at the following websites:
   
  • Coccyx Pain Relief (a Blog about coccyx pain)
  • Injections used to treat coccyx pain (tailbone pain) without surgery, at www.Tailbone.info
  • Radio interviews with Dr. Foye, specifically discussing tailbone pain. You can listen to the interviews for free online, to learn more about coccyx pain.
  • Dr. Foye's website on tailbone pain, at www.TailboneDoctor.com

MISCELLANEOUS

Section 9 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Medical/Legal Pitfalls

• Screening questions should be used to minimize the chance that the physician will fail to diagnose intrapelvic pathology, such as malignancy.
• Blind injections (eg, without fluoroscopic guidance) in the coccygeal region may increase the risk of injury to nearby structures, such as the rectum.
• Prior to proceeding with any surgical treatments, patients need to be aware of the various surgical risks.

Special Concerns

• Some physicians may have an unintentional bias against patients with coccydynia, inappropriately attributing the pain to underlying psychological conditions, such as anxiety, neurosis, or even hysteria.² Patients with coccydynia often report frustration with physicians who minimize their symptoms or tell them that the pain is "all in their head." However, behavioral assessments of patients with coccydynia have shown a psychological profile similar to that of any other group of patients (ie, without any increased evidence of overt psychopathology). Patients with coccydynia deserve appropriate workup, treatment, and compassion, the elements of care provided to patients with other neurologic or musculoskeletal chronic pain syndromes.

ACKNOWLEDGMENTS

Section 10 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Dr. Foye acknowledges and appreciates the numerous patients with coccyx pain who have traveled—often substantial distances—to see him over the years. Much has been learned by listening to descriptions of their symptoms and to their stories, by discovering how suffering from coccyx pain impacts the quality of their lives, and by analyzing their favorable responses to nonsurgical treatment. Their substantial contributions to the coccydynia knowledge base have helped in the treatment of many subsequent patients with coccyx pain, not only in Dr. Foye's practice, but (through his publications in this area) elsewhere as well. Dr. Foye finds it to be a gratifying privilege to help so many of these patients find relief.

MULTIMEDIA

Section 11 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Media file 1:  Coccyx pain (coccydynia, or tailbone pain) is typically worse when the patient is sitting. Often, the pain is even worse when sitting leaning slightly backward, since this increases the weight bearing on the coccyx, as shown in this image. Dynamic radiographs of the coccyx involve obtaining coned-down (focused) views of the coccyx while the patient is seated (eg, in his or her most painful position). Often, this involves having the patient lean backward 0-40°, depending on the symptoms. Radiographs obtained in this position are compared with those obtained in a non–weight-bearing position (eg, side lying) to assess for instability or dislocations in the seated position.
	View Full Size Image
Media type:  Image

Media file 2:  Lateral view of the pelvis and coccyx. The bracket shows the area of focus for radiographs that would provide a coned-down view of mainly the coccyx and distal sacrum. A more common lateral view would often also include larger bony structures, such as the lumbar spine and femur, all of which would make it difficult to optimize visualization of the small bones of the coccyx. In patients with coccyx pain, these coned-down, lateral views of the coccyx can provide important diagnostic information. Coned-down images obtained in the weight-bearing (seated) position can be compared with those obtained in a non–weight-bearing position (eg, side lying), thus allowing assessment for dynamic instability (eg, dislocations that occur only while seated).
	View Full Size Image
Media type:  Image

Media file 3:  Patients with a painful coccyx often find it more comfortable to sit leaning slightly forward, as shown in this image. This forward-leaning position minimizes any weight bearing on the coccyx itself and thus minimizes the exacerbation of coccyx pain. As shown, when a patient sits leaning forward, most of the weight bearing occurs bilaterally through the inferior ischial regions of the pelvis and the posterior thigh (femur) regions.
	View Full Size Image
Media type:  Image

REFERENCES

Section 12 of 12

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

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20. Foye PM. Finding the causes of coccydynia (coccygeal pain). J Bone Joint Surg Br [serial online]. January 18, 2007;Accessed April 16, 2007. Available at http://www.jbjs.org.uk/cgi/eletters/88-B/10/1388.
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Article Last Updated: Aug 3, 2007