coccygodynia evaluation and management

Coccygodynia: Evaluation and Management

Guy R. Fogel, MD, Paul Y. Cunningham III, MD, and Stephen I. Esses, MD

Abstract

Coccygodynia, pain in the region ofthe coccyx, typically is triggered byor occurs while sitting. The intensityof the pain varies and sometimes isaggravated by arising from a seatedposition. Less severe symptoms maybe managed by changing the sittingposition or injecting the painful areawith local anesthetic and corticoste-roids. Orthopaedic surgeons oftensee patients with more severe anddisabling symptoms, which in se-lected cases can be managed suc-cessfully with surgery.

Coccygodynia is five times moreprevalent in women than men. Al-though it can occur over a wide agerange, mean age of onset is 40 years.Coccygodynia has many causes, butit may be posttraumatic, beginningafter a fracture or contusion or aftera difficult vaginal delivery.1-3 In thelargest number of cases, the tip ofthe coccyx is subluxated or hyper-mobile, which can be seen on dy-namic radiographs taken with thepatient standing and seated1-3 (Fig.1). The cause of pain is unknown inpatients with normal coccygeal mo-bility.2

Anatomy

Five fused sacral and three or fourfused coccygeal vertebrae form the ter-minal end of the spinal column. Pri-mary ossification centers are evidentin the 9th to 10th week of gestationin the axial skeleton, but the coccyxdoes not begin to ossify until after birth.In the sagittal plane, the sacrum is ky-photic and connects the lumbosacraljunction to the coccyx. The inferior sa-cral apex at S5, the sacral cornu, ar-ticulates with the coccygeal cornu, afacet-disk complex on the dorsal ar-ticulating surface of the coccyx. Thisarticulation can be a symphysis or asynovial joint. The coccyx is a trian-gular structure comprising three or fourcoccygeal units that usually are fused,although the first coccygeal segmentmay not fuse with the second. The sa-crococcygeal joint also may be fused.The coccyx provides attachments forthe gluteus maximus muscle, coccygealmuscle, and anococcygeal ligament.

There are no significant differenc-es between asymptomatic patients andthose with coccygodynia in the num-ber of coccygeal segments or in the

incidence of fusions between seg-ments.4 Symptomatic patients have aslightly higher incidence of sacral coc-cygeal fusion and a more angular sag-ittal alignment of the coccyx thanasymptomatic patients.4 No pathologicfindings have been noted in the id-iopathic or hypermobile segments inpatients with coccygodynia. The ab-normal subluxation and hypermobil-ity appear to cause pain, but coccy-godynia can occur with an immobilecoccyx. Only occasionally have post-traumatic nonunion, arthritis, ormalunion been found in surgical spec-imens.

Etiology

The clinical factors associated withcoccygeal abnormalities are obesity,

Dr. Fogel is Spine Fellow, Department of Ortho-pedic Surgery, Baylor College of Medicine, Hous-ton, TX. Dr. Cunningham is Medical ResearchFellow, Department of Orthopedic Surgery, Bay-lor College of Medicine. Dr. Esses is Professor ofOrthopedics and Brodsky Chair of Spinal Surgery,Department of Orthopedic Surgery, Baylor Col-lege of Medicine.

None of the following authors or the departmentswith which they are affiliated has received anythingof value from or owns stock in a commercial com-pany or institution related directly or indirectlyto the subject of this article: Dr. Fogel, Dr. Cun-ningham, and Dr. Esses.

Reprint requests: Dr. Esses, Baylor College of Med-icine, Suite 1900, 6560 Fannin, Houston, TX77030.

Copyright 2004 by the American Academy ofOrthopaedic Surgeons.

Coccygodynia is pain in the region of the coccyx. In most cases, abnormal mobilityis seen on dynamic standing and seated radiographs, although the cause of pain isunknown in other patients. Bone scans and magnetic resonance imaging may showinflammation and edema, but neither technique is as accurate as dynamic radiog-raphy. Treatment for patients with severe pain should begin with injection of localanesthetic and corticosteroid into the painful segment. Coccygeal massage and stretch-ing of the levator ani muscle can help. Coccygectomy is done only when nonsur-gical treatment fails, which is infrequent. Coccygectomy usually is successful in care-fully selected patients, with the best results in those with radiographically demonstratedabnormalities of coccygeal mobility.

J Am Acad Orthop Surg 2004;12:49-54

Vol 12, No 1, January/February 2004 49

antecedent trauma or childbirth, andexacerbation of pain with arisingfrom sitting. Obesity, which decreas-es pelvic rotation when the patientsits, is three times more common inpatients with coccygodynia than inthe normal population.2 However, theincidence of radiographically demon-strated coccygeal instability is thesame regardless of a history of remotetrauma, which suggests that only re-cent trauma (within 3 months) caus-es coccygodynia. Patients with nor-mal coccygeal mobility have theidiopathic type, which may be asso-ciated with pelvic floor spasticity orother anomalies of the midpelvicmuscles. Coccygodynia occurringwith an immobile coccyx frequentlyis associated with bursitis of the ad-ventitia at the coccygeal tip. Othersuggested etiologies include post-traumatic arthritis of the sacrococ-cygeal joint and ununited fracturesor dislocations of the coccyx. Abnor-mal psychological states as a cause ofcoccygodynia have been largely dis-proved as behavioral testing of thesepatients reveals personality profilessimilar to other patient groups.5 Oth-er causes of pain in the region of thesacrum and coccyx are lesions of thelumbar disks, arachnoiditis of thelower sacral nerve roots, tumors ofthe coccyx or sacrum, pilonidal cysts

and sinuses, and perirectal abscess-es.4 Low back pain has occurred con-currently with coccygodynia. In oneseries, 24 of 50 patients (48%) also hadlumbar disk herniation or bulge with-out sciatica or low back pain,5 so al-though low back pain is common, itappears to be separate from coccygo-dynia. In the series of Postacchini andMassobrio,4 87% of patients with lowback pain at the time of coccygecto-my had an excellent or good result.The only poor results were in patientswith low back pain and a configura-tion of the coccyx wherein the firstcoccygeal segment is partially fusedto the sacrum.

Clinical Evaluation

SymptomsOnset of pain may be insidious, re-

sulting in a possibly long delay fromonset to diagnosis. Patients usuallypresent with pain in and around thecoccyx without significant low backpain or radiating or referred pain. Thepain is localized to the sacrococcygealjoint or mobile segment of the coccyxand may be relieved by sitting on thelegs or on either buttock. Chronicpain is that which persists >2 months.Patients may feel a frequent need todefecate or may have pain with def-

ecation. Women with a history ofvaginitis, discharge, or associated pel-vic pain should be referred for gyne-cologic consultation. Concomitantconstipation should be managed ap-propriately. If the patient has bloodin the stool, a tumor or metastasisshould be considered.

Physical ExaminationThe surrounding skin and soft tis-

sue should be inspected for evidenceof pilonidal cysts or fistulas. Externalpalpation or rectal examination mayreveal bone spicules, local swelling,or coccygeal masses. The coccyxshould be palpated externally, and thedistal segment should be manipulat-ed rectally to detect pain generatedby motion of the coccygeal segments.Local tenderness may occur on the su-perficial coccygeal surface or only onmanipulation of the coccygeal tip byrectal examination. Tenderness maybe greatest at the sacrococcygeal jointrather than at the coccygeal tip.2 Apalpable internal mass (eg, chordo-ma) on the anterior surface of the coc-cyx or sacrum may be evident on rec-tal examination. Every examinationshould include a stool guaiac to de-tect occult blood.

Imaging Evaluation

Single-Position RadiographsBecause orthogonal anteroposteri-

or and lateral radiographs of the coc-cyx seldom show differences betweennormal individuals and those withcoccygodynia, these views are usual-ly not diagnostic.5 Postacchini andMassobrio4 reported that, in bothhealthy and symptomatic patients,83% to 95% had two or three coc-cygeal segments. The sacrococcygealjoint was fused in 51% of the patientswith idiopathic coccygodynia (26/51), usually the first intercoccygealjoint was mobile, and the second in-tercoccygeal joint was fused in 49%(25/51).4 The curvature of the sacrumwas flexed or anterior in 68% of

Figure 1 Maigne’s technique1 for comparing positions of sacral and coccygeal vertebraefrom lateral standing and seated radiographs. A, Standing view. B, Seated view. C, Super-imposed views with the sacrum aligned by rotating the seated view through an angle of sag-ittal pelvic rotation (I) shows coccygeal angulation and subluxation (II) and the angle at whichthe coccyx strikes the seat surface (III).


50 Journal of the American Academy of Orthopaedic Surgeons

asymptomatic patients and in 31% ofpatients with coccygodynia. The tipcurved forward sharply in 23% andsubluxated posteriorly in 22% of pa-tients with coccygodynia.4

Dynamic RadiographsMaigne and colleagues1-3,6 com-

pared standing and sitting lateral ra-diographic views of the coccyx in atotal of 582 patients with coccygo-dynia and reported abnormalities in70%. The normal coccyx pivots slight-ly (5° to 25°) either posteriorly or an-teriorly with sitting and returns to itsoriginal position with standing (Fig.2, A). Abnormalities of the coccygealsegments in the seated views have an-terior hypermobility >25° (Figs. 2, Band 3). Subluxation or posterior dis-placement of the mobile segment ofthe coccyx is seen when the patientis seated (Figs. 2, C and 4, A). A spic-ule of the distal tip (Fig. 2, D) is seenmost commonly with an immobilecoccyx (<5° of motion with sitting).2

Advanced Imaging ModalitiesTechnetium Tc 99m bone scans

may show inflammation in the areaof subluxation or hypermobility.Magnetic resonance images also maydemonstrate edema in such areas ofinflammation (Fig. 4, B). Neither im-aging modality can definitively diag-nose coccygodynia, nor are they as ac-curate as the compared standing andseated dynamic radiographs. Provoc-ative tests, such as needling of thepainful coccygeal joint to producepain, and relief with injection of lo-cal anesthetic are helpful in diagnos-ing all patients with subluxation orhypermobility and nearly half ofthose with normal mobility.3

Nonsurgical Management

Nonsurgical management options in-clude nonsteroidal anti-inflammatoryand analgesic medications, rest, hotbaths, and a cushion to protect thecoccygeal region from repetitive trau-

ma. Physical therapy consisting ofdiathermy and ultrasound may pro-vide temporary relief.

Wray et al5 used a stepwise treat-ment, with each step somewhat moreinvasive than the previous. First,methylprednisolone (40 mg) andbupivacaine (10 mL 0.25%) were in-jected around the side and tip of thecoccyx. With persistent coccygodynia,the coccyx was reinjected and manip-ulated under general anesthesia byrepeatedly flexing and extending itfor a minute. If the treatment was suc-cessful initially but pain recurred, the

injections and manipulations were re-peated. If the patient did not respond,a coccygectomy was done 6 weekslater. The cure rate with injectionalone was 59% but was 85% with ma-nipulation and injection.5 Althoughrelapses occurred in the injectiongroup (21%) and the manipulationgroup (28%), repeat treatment in eachgroup achieved good success. Coc-cygectomy was done in 20% of pa-tients and had a success rate of 91%.

Maigne and Chatellier6 prospec-tively compared levator ani musclemassage, joint mobilization, and mild

Figure 2 The anatomic signs of coccygodynia.1 A, Normal standing appearance of the coc-cyx. B, Increased flexion mobility of the coccyx when patient is seated. C, Posterior sublux-ation of the coccyx when patient is seated. D, Coccygeal spicule (arrow) arising from thedorsal surface of coccygeal segment.

Figure 3 Lateral radiographic seated viewof a 45-year-old woman with increased-flexion coccygodynia (arrow). She fell on herbuttocks 2.5 years before presentation and hadprogressive symptoms, including painfulbowel movements and inability to sit on achair. Physical examination revealed a tenderand nonmobile coccyx with an exquisitely ten-der distal coccygeal segment on rectal exam-ination. At 1 year postcoccygectomy, she hadcomplete relief from her symptoms and wasable to sit normally. (Courtesy of Paul A.Anderson, MD, Madison, WI.)

Guy R. Fogel, MD, et al


stretching of the levator ani, withoutthe addition of injections. At 6months, successful treatment was29.2% with massage, 16% with mo-bilization, and 32% with stretching,for a total of 25.7% overall success.When a patient had a satisfactory re-sult, it was invariably achieved with-in a week. Good results tended to re-main stable. Patients with normalmobility of the coccyx fared the best(43% success at 6 months). Those withan immobile coccyx fared the worst(16%). The outcomes for those withinstability subluxation (22.2%) andhypermobility (25%) were modestlysuccessful. Massage and stretchingwere more effective than manipula-tion. When therapy failed, patientswent on to injections or surgery.

Based on these studies, we havedeveloped an evaluation and treat-ment algorithm for coccygodynia5-7

(Fig. 5). When a patient presents withacute coccygodynia (≤2 months’ du-

ration), 8 weeks of rest with use of astool softener, adjustable seating, andnonsteroidal anti-inflammatory med-ication are prescribed. If this fails torelieve the symptomatic coccygo-dynia or the patient presents withchronic symptoms (>2 months’ dura-tion), a workup is done, includingstanding and seated radiographs ofthe coccyx in addition to MRI to eval-uate for injury edema, tumor, or oth-er pathology. Stretching, massage,and injection are usually initiated atthis time. If these treatments are un-successful or if pain recurs, coccygec-tomy may be offered.

Surgical Management

The indication for coccygectomy is sig-nificant, disabling coccygodynia withradiographic subluxation; instability;or a spicule, particularly on the tip ofan immobile coccyx.2,7 Surgery, con-

sisting of complete coccygectomy orsimply excision of the mobile segment,should be done only after nonsurgi-cal management fails.4 Absence ofphysical findings or significant abnor-mal psychologic evaluation is a con-traindication to surgery. In carefullyselected patients, especially those withdynamic radiographic instability orhypermobility, success rates rangefrom 60% to 91%4,5,7-11 (Table 1). In apatient with normal coccygeal mobil-ity who fails nonsurgical care, coc-cygectomy may be recommended.However, the surgical result is less pre-dictably favorable than in patients withdynamic radiographic coccygeal in-stability or hypermobility.

TechniqueThe patient should take an oral

mechanical bowel preparation, suchas saline and polyethylene glycol so-lution (4 L), the day before surgery.Oral neomycin, erythromycin, ormetronidazole are given three timesthe day before surgery. Appropriateprophylactic antibiotics for bowelsurgery are given 1 hour before sur-gery. Postoperatively, most authori-ties recommend two or three moredoses.12

Coccygectomy is done with the pa-tient in the prone position with thehips and knees flexed. A vertical in-cision is made over the coccyx, ex-tending from just above the sacrococ-cygeal joint into the buttock creasewithout extending it to the perianalskin. The incision is carried downthrough the fascia and gluteus max-imus muscle with meticulous dissec-tion directly to the bone. Subperi-osteal dissection should be done bygradually working side to side. Thecoccyx then should be elevated eitherby working from the tip proximallyor from the side, under direct vision.All segments must be removed. Thetip of the coccyx, which is most like-ly to be left inadvertently, should beseparated sharply from the underly-ing rectum and dense fascia. Withblunt dissection, the rectum and

Figure 4 A 19-year-old man fell on his buttocks 2 years before presentation and had im-mediate onset of coccygodynia. His symptoms were chronic and disabling. A, Lateral ra-diograph demonstrates posterior subluxation of the coccygeal mobile segment. B, SagittalT2-weighted spin-echo magnetic resonance image shows edema of the distal coccygeal seg-ments, especially the subluxated coccygeal segment.



dense fascia then are freed to the lev-el of the sacrococcygeal joint. Thisjoint then may be transected and thecoccyx removed.

The wound bed should be closelyexamined and palpated for any re-maining segments of bone. Radio-graphs generally are not necessary.The end of the sacrum may besmoothed by rasp, rongeur, or burr.Bleeding from the hemorrhoidalvenous complex of the rectum mayrequire ligation. Meticulous hemosta-sis and a tight layered closure to oblit-erate dead space should be done. Thistechnique should decrease fragmen-

tation of the coccygeal specimen andlimit damage to the rectum and itsvenous drainage, which can decreasepostoperative drainage and increasethe risk of infection.

ComplicationsThe primary complication is

perineal contamination of the wound.Usually a wound infection is super-ficial or is a simple wound dehiscenceand will heal with intravenous anti-biotics and local wound care. Deepinfection must be débrided anddrained. Antibiotics should be given.Even with healing by secondary in-

tention, the result may be successful.Wound infection and delayed woundhealing rates range from 2% to22%.4,5,7-10 In a very thin patient witha kyphotic sacrum, the remaining endof the sacrum may be prominent andbe a source of continued pain that isnot easily managed.

Summary

Dynamic radiographs can help iden-tify causative abnormalities in mostpatients with coccygodynia, andthose with normal coccygeal mobil-

≤8 weeks

Not improved

>8 weeks

Normal mobility

Symptomaticrelief

Unsuccessful

Offer coccygectomyRecurrence

Standing and seated radiographs

Hypermobility, subluxation,spicule on tip of coccyx

MRI coccyx for edema,tumor, other etiology

If successful,may repeat

Unsuccessful; continued

coccygodynia

Successful; complete relief in 3-6 months

History of coccygodyniaconfined to coccyx,

no associated back pain

May offer stretching/massage of levator ani muscle and/or corticosteroid/anesthetic injection

in areas of radiographic abnormality

Rest; avoid sitting on coccyx; usestool softener, NSAIDS, anal-gesics as needed for 8 weeks

Figure 5 Evaluation and management of coccygodynia.

Guy R. Fogel, MD, et al


ity also may be successfully treated.Corticosteroid and anesthetic injec-tions combined with massage orstretching of the levator ani muscleare successful in most patients. When

nonsurgical management fails, coc-cygectomy is usually successful incarefully selected patients with dy-namic instability. Coccygectomy maybe recommended in patients with

normal coccygeal mobility who failnonsurgical care, but results are lesspredictably favorable than in patientswith dynamic radiographic coccygealinstability or hypermobility.

References1. Maigne JY, Tamalet B: Standardized ra-

diologic protocol for the study of com-mon coccygodynia and characteristicsof the lesions observed in the sitting po-sition: Clinical elements differentiatingluxation, hypermobility, and normalmobility. Spine 1996;21:2588-2593.

2. Maigne JY, Doursounian L, ChatellierG: Causes and mechanisms of commoncoccydynia: Role of body mass indexand coccygeal trauma. Spine 2000;25:3072-3079.

3. Maigne JY, Guedj S, Straus C: Idiopath-ic coccygodynia: Lateral roentgenogramsin the sitting position and coccygeal dis-cography. Spine 1994;19:930-934.

4. Postacchini F, Massobrio M: Idiopathiccoccygodynia: Analysis of fifty-one op-erative cases and a radiographic studyof the normal coccyx. J Bone Joint SurgAm 1983;65:1116-1124.

5. Wray CC, Easom S, Hoskinson J: Coc-cydynia: Aetiology and treatment.J Bone Joint Surg Br 1991;73:335-338.

6. Maigne JY, Chatellier G: Comparison ofthree manual coccydynia treatments: Apilot study. Spine 2001;26:E479-E484.

7. Maigne JY, Lagauche D, Doursounian L:Instability of the coccyx in coccydynia.J Bone Joint Surg Br 2000;82:1038-1041.

8. Hellberg S, Strange-Vognsen HH: Coc-cygodynia treated by resection of the

coccyx. Acta Orthop Scand 1990;61:463-465.

9. Grosso NP, van Dam BE: Total coc-cygectomy for the relief of coccygo-dynia: A retrospective review. J SpinalDisord 1995;8:328-330.

10. Eng JB, Rymaszewski L, Jepson K: Coc-cygectomy. J R Coll Surg Edinb 1988;33:202-203.

11. Bayne O, Bateman JE, Cameron HU:The influence of etiology on the resultsof coccygectomy. Clin Orthop 1984;190:266-272.

12. Norden CW: Antibiotic prophylaxis inorthopedic surgery. Rev Infect Dis 1991;13(suppl 10):S842-S846.

Table 1Outcomes From Coccygectomy

Study No. Patients Follow-up (yrs) Outcome

Postacchini andMassobrio4

36 7.8 (mean) 12 excellent, 20 good, 2 fair, 2 poor

Wray et al5 23 2.75 (mean) 21 excellentMaigne et al7 37 2 (minimum) 23 excellent, 11 good, 3 poorHellberg andStrange-Vognsen8

55 15 (mean) 32 cured, 13 improved, 5 slightly improved, 5 dissatisfied

Grosso and van Dam9 9 4.7 (mean) 3 complete, 5 partial, 1 slight reliefEng et al10 27 1.5 (minimum) 9 cured, 9 improved, 6 slightly improved, 3 not improvedBayne et al11 48 7 (mean) 29 acceptable



coccygodynia evaluation and management

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