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Coccydynia

CASE PRESENTATION

A 40 year old female presents with pain over her “tailbone region” that has been somewhat progressive for the past year.  She works as a secretary and feels that the longer she sits, the more pressure she feels over this area.  You perform x-ray studies both sitting and standing and there is a posterior subluxation of the coccyx when sitting.  Which of the following are risk factors for this condition?

A. Female gender, obesity
B. Male gender, obesity
C. Low BMI, female
D. Low BMI, male

introduction

Coccydynia is a potentially disabling pain located in the coccygeal bone or the surrounding tissues. Despite being first described in 1859, several uncertainties exist on the origin of pain, predisposing factors and best treatment options.  The term originates from the Greek term “coccyx” meaning cuckoo’s beak and “dynia” meaning pain [1].  It is somewhat uncommon and may be seen by sports medicine providers.

The anatomy of the os coccygis varies. It consists of a number of rudimentary vertebrae ranging from 3 to 5 and varies in regard to the incidence of segmental fusion. The positioning of the coccyx has been described and classified into 4 types by Postacchini and Massobrio [2].  Coccydynia is most frequently associated with single-axis traumatic injury, childbirth, obesity, and rapid weight-loss related to gastric by-pass surgery [3].  The coccyx can function as a third leg of the tripod along with the ischial tuberosities and can be predisposed to injury with a fall.

Table 1.  Coccygeal morphology.  Adopted from [19].

Other less obvious sources of external trauma can include prolonged sitting on hard surfaces such as improperly cushioned wooden chairs. In 1950, Schapiro referred the disease as ‘television disease’ signifying an important role of postural adaptation as a predisposing factor for coccydynia [4].

Figure 2.  Picture depicting coccyx morphology.  Adopted from [13].

Secondary coccydynia may be caused by cancer pain, infection, or may be iatrogenic [5].  Previous surgery in the area can lead to inflammation, formation of granulation tissue, adhesions, and possibly a change in elasticity of the tissue surrounding the os coccygis, which, over the course of time, can lead to secondary coccydynia.  Extracoccygeal disorders may also manifest as coccydynia such as pilonidal cysts, perianal abscesses, hemorrhoids, and diseases of the pelvic organs.  Pain may also be referred from the lumbosacral spine, sacroiliac joints, piriformis muscle, and the sacrum [5].

Both obesity and female sex are known to be predisposing factors for coccydynia. A BMI of over 27.4 in females and 29.4 in males was found to be a risk factor for both traumatic and non-traumatic coccydynia [6].  The biomechanical basis of a higher incidence of coccydynia in association with obesity has been attributed to restricted sagittal pelvic rotation in obese individuals while sitting leading to protrusion, retroversion and excessive pressure over the tip of the coccyx.  Additionally, increased intra-pelvic pressure during sitting may lead to posterior subluxation of the jutting out tip of the coccyx.  Females owing to the inherent ligamentous laxity, susceptible coccygeal morphology and childbirth, were found to be five times more prone  to develop coccydynia than men [6].

Coccydynia presents most frequently in an acute form with mild symptoms, typically resolving with no treatment within weeks to months.  When pain does not resolve, treatment is primarily expectant and aimed at symptom management, as pain spontaneously improves in up to 90% of patients receiving conservative treatment [3].

However, for some patients the pain persists and remains refractory to initial conservative treatment. Chronic coccydynia is a condition for which there is limited understanding of the pathology and the effectiveness of different treatments [7]. Patients may experience a marked loss in quality of life and difficulty in performing everyday activities.  Sitting is often conspicuously painful, but can be exaggerated with sexual intercourse.  Some patients may also having difficulty defecating [3].

Plain radiographs are usually the first line imaging modality.  Dynamic imaging with standing and seated lateral radiography of the coccyx has been reported to reveal abnormal excessive coccygeal translational or angular motion in up to 69% of those with coccydynia [6]. Excessive motion has not been reported in those without pain. The two patterns of hypermobility associated with coccydynia are defined as (a) greater than 25% posterior subluxation (or luxation) with sitting compared with standing or (b) more than 25° of flexion when sitting compared with standing, with more than 35° being considered marked hypermobility [10].  If acute fracture is of concern, CT is typically required to make a definitive diagnosis. However, fracture may be discovered at radiography in a minority of cases.

Figure 3.  Figure illustrating subluxation of coccyx .  Adopted from [20].

Because of the increased direct seat pressure on the coccyx in thin individuals, hyperflexion or a posterior spicule are the more common impetus for pain, while posterior subluxation is the more common cause in obese individuals because of the increased intrapelvic pressure on the coccyx with sitting and lack of proper pelvic rotation to support the coccyx (Fig) [10].

There are various treatment options available for symptom relief, including conservative, pharmacological, and surgical treatment. Patients are advised to sit on a U-shaped cushion or a modified wedge-shaped cushion.  Other options are nonsteroidal anti-inflammatory drugs (NSAIDs), massage, stretching, physical therapy or interventional treatment, such as steroid injections, radiofrequency treatments (RFT), extracorporeal shockwave therapy (ESWT), and ganglion blocks [7-9].

Manual therapy, typically performed by a chiropractor, osteopath, or physical therapist, has a high success rate and includes soft-tissue therapy or massage with or without manipulation of the coccyx [11-13]. Manipulation may be attempted externally via cephalad traction of the superficial tissues overlying the sacrum and coccyx or internally via intrarectal contact of the coccyx with distraction of the sacrum superiorly using the opposite hand. Massage of the adjacent musculature that attaches to the coccyx (external or internal massage) is helpful in relieving pain in those with muscle spasm as a contributing factor, which is very common [13]. In those with posterior subluxation or elevated BMI, weight management should be addressed [6].

Most providers will attempt to perform or coordinate more interventional procedures if the more conservative measures fail.   Ganglion impar block (GIB) has a relatively higher reported clinical efficacy than other techniques. GIB has proven to be valuable in both evaluating and managing pain originating from sympathetic involvement or maintenance of the perineum and coccyx [15]. Utilizing a local anesthetic, GIB has been utilized as a diagnostic tool for assessing pelvic and rectal pain, primarily before neurolytic blockade. This enables the execution of a differential neural blockade by employing anatomical principles. It also serves as a therapeutic intervention for pain relief in these areas.  Sencan et al. compared the treatment outcomes of ganglion impar block (GIB) and caudal epidural steroid injection in patients with chronic coccydynia unresponsive to conservative treatment [14]. GIB may provide a more significant pain reduction in the short term (3 months), but long-term efficacy has been unclear.

Sacrococcygeal and intercoccygeal joint injections with ultrasound guidance may also be used. However, treatment involving the infiltration of local anesthetics and steroids around the coccyx is presumed to be administered into the coccygeal soft tissue or in the surrounding area, rather than intra-articularly. According to the findings of Mitra et al., patients were more likely to experience significant pain relief from steroid injections when the pain persisted for less than 6 months [16]. Wray et al. reported a success rate of 60% in a prospective study on the treatment of coccygodynia using ultrasound-guided injections [17]. This study did not provide explicit information on the methodology used to identify infiltration sites.

Figure 4.  Image depicting ultrasound image and guidance over sacrum/coccyx.  Adopted from [20].

Surgical interventions, including coccygectomy, are considered the final option and are pursued only when all other available treatment options have proven ineffective. Coccygectomy involves the surgical removal of the coccyx, typically at the proximal end near the sacrococcygeal junction.  Coccygectomy has reported success rates from 60% to 92%, and patients with severe degenerative changes tend to have a greater rate of pain relief than those with less severe changes. As with any surgery, infection is a risk factor but especially so in the coccygeal region, given the proximity to the anus. Infection and skin necrosis risk are as high as 50% with coccygectomy. However, 48 hours of prophylactic antibiotic therapy before surgery reduces this risk substantially [18].

Summary

In summary, coccydynia, which is frequently a self-limiting, mild condition with many unknown aspects of etiology despite being described in 1859.  Most patients respond to conservative measures.  It sometimes necessitates more aggressive treatments for certain patients and the underlying cause may be complex or multifactorial.  Injection procedures have been known to be effective in relieving pain and treating specific medical conditions.   However, there is no unanimous agreement on the most optimal injection site for these procedures yet.   Surgical procedures are reserved after other treatment options have been exhausted.

Case Conclusion

A. Both obesity and female sex are known to be predisposing factors for coccydynia. A BMI of over 27.4 in females and 29.4 in males was found to be a risk factor for both traumatic and non-traumatic coccydynia.  The biomechanical basis of a higher incidence of coccydynia in association with obesity has been attributed to restricted sagittal pelvic rotation in obese individuals while sitting leading to protrusion, retroversion and excessive pressure over the tip of the coccyx.  Additionally, increased intra-pelvic pressure during sitting may lead to posterior subluxation of the jutting out tip of the coccyx.  Females owing to the inherent ligamentous laxity, susceptible coccygeal morphology and childbirth, were found to be five times more prone  to develop coccydynia than men.

– Read More about Coccydynia on Wiki Sports Medicinehttps://wikism.org/Coccydynia

References

  1. Fogel GR, Cunningham PY, Esses SI. Coccygodynia: Evaluation and management. J Am Acad Orthop Surg. 2004;12(4): 49-54.
  2. Postacchini F, Massobrio M. Idiopathic coccygodynia. Analysis of fifty-one operative cases and a radiographic study of the normal coccyx. J Bone Joint Surg Am. 1983;65(8): 1116-1124
  3. Lirette LS, Chaiban G, Tolba R, Eissa H. Coccydynia: An overview of the anatomy, etiology, and treatment of coccyx pain. Ochsner J. 2014;14(1):84-87.
  4. SCHAPIRO S. Low back and rectal pain from an orthopedic and proctologic viewpoint; with a review of 180 cases. Am J Surg. 1950 Jan;79(1):117-28, illust. doi: 10.1016/0002-9610(50)90202-9.
  5. Nathan ST, Fisher BE, Roberts CS. Coccydynia: A review of pathoanatomy, aetiology, treatment and outcome. J Bone Joint Surg Br. 2010;92(12):1622-1627
  6. Maigne JY, Doursounian L, Chatellier G. Causes and mechanisms of common coccydynia: role of body mass index and coccygeal trauma. Spine (Phila Pa 1976). 2000 Dec 1;25(23):3072-9.
  7. Mouhsine E, Garofalo R, Chevalley F, et al. Posttraumatic coccygeal instability. Spine J. 2006;6(5):544-549
  8. Kleimeyer JP, Wood KB, Lønne G, et al. Surgery for refractory coccygodynia: Operative versus nonoperative treatment. Spine (Phila Pa 1976). 2017;42(16):1214-1219.
  9. Maigne JY, Chatellier G. Comparison of three manual coccydynia treatments: A pilot study. Spine (Phila Pa1976). 2001; 26(20):E479-E484
  10. Skalski, Matthew R., et al. “Imaging coccygeal trauma and coccydynia.” Radiographics 40.4 (2020): 1090-1106.
  11. Origo D, Tarantino AG, Nonis A, Vismara L. Osteopathic manipulative treatment in chronic coccydynia: a case series. J Bodyw Mov Ther 2018;22(2):261–265.
  12. Seker A, Sarikaya IA, Korkmaz O, Yalcin S, Malkoc M, Bulbul AM. Management of persistent coccydynia with transrectal manipulation: results of a combined procedure. Eur Spine J 2018;27(5):1166–1171.
  13. Scott KM, Fisher LW, Bernstein IH, Bradley MH. The Treatment of Chronic Coccydynia and Postcoccygectomy Pain With Pelvic Floor Physical Therapy. PM R 2017;9(4):367–376.
  14. Sencan S, Yolcu G, Bilim S, Kenis-Coskun O, Gunduz OH. Comparison of treatment outcomes in chronic coccygodynia patients treated with ganglion impar blockade versus caudal epidural steroid injection: a prospective randomized comparison study. Korean J Pain. 2022;35:106–13
  15. Lema MJ. Invasive analgesia techniques for advanced cancer pain. Surg Oncol Clin N Am. 2001;10:127–36. doi: 10.1016/S1055-3207(18)30089-9
  16. Mitra R, Cheung L, Perry P. Efficacy of fluoroscopically guided steroid injections in the management of coccydynia. Pain Physician. 2007;10:775–8.
  17. Wray CC, Easom S, Hoskinson J. Coccydynia. Aetiology and treatment. J Bone Joint Surg Br. 1991;73:335–8.

18. Cheng SW, Chen QY, Lin ZQ, et al. Coccygectomy for Stubborn Coccydynia. Chin J Traumatol 2011;14(1):25–28

19. Garg, Bhavuk, and Kaustubh Ahuja. “Coccydynia-A comprehensive review on etiology, radiological features and management options.” Journal of Clinical Orthopaedics and Trauma 12.1 (2021): 123-129.

20. Skalski, Matthew R., et al. “Imaging coccygeal trauma and coccydynia.” Radiographics 40.4 (2020): 1090-1106.