eMedicine Specialties > Physical Medicine and Rehabilitation > Lower Limb Musculoskeletal Conditions

Coccyx Pain: Treatment & Medication

Author: Patrick M Foye, MD, FAAPMR, FAAEM, Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain (Tailbone Pain, Coccydynia) Service (www.TailboneDoctor.com), University of Medicine and Dentistry of New Jersey, New Jersey Medical School
Coauthor(s): Charles J Buttaci, DO, PT, Pain Management, Northeast Orthopedics; Matthew Kirk Sorensen, EMT-B, Kean University
Contributor Information and Disclosures

Updated: Jan 29, 2009

Treatment

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.¹¹
• 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.¹²
• 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.¹³ 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.¹⁴
• 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.¹¹
• 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.¹⁵ 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^16,17,18
  • 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.¹⁹
  • One possible mechanism for persistent coccydynia is excessive activity or sensitivity of the ganglion impar, thus creating sympathetically maintained coccyx pain.²⁰
  • Local injection of an anesthetic can effectively block the ganglion impar and thereby relieve coccyx pain.^21,22
  • 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.²⁰
  • 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.²⁰
  • 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.²² 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.²¹ 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.^23,24
  • 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).²⁰ 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.²² 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.²⁰ 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.¹⁹
  • Thermocoagulation of the ganglion impar using radiofrequency ablation (RFA) has been reported.²⁵
• 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.²⁶
• 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

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

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.

Ibuprofen (Advil, Excedrin IB, Motrin, Ibuprin)

DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

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.

Acetaminophen (Aspirin Free Anacin, Feverall, Tylenol)

DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants.
Effective in relieving mild to moderate acute pain; however, has no peripheral anti-inflammatory effects. May be preferred in elderly patients because of fewer GI and renal side effects.

Tramadol (Ultram)

Inhibits ascending pain pathways, altering perception of and response to pain. Inhibits reuptake of norepinephrine and serotonin.

Pregabalin (Lyrica)

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.

Fentanyl citrate (Duragesic, Sublimaze)

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.

Oxycodone (OxyContin, OxyIR, Roxicodone)

Indicated for the relief of moderate to severe pain.

Oxycodone and acetaminophen (Percocet, Roxicet, Roxilox, Tylox)

Drug combination indicated for the relief of moderate to severe pain.

Anticonvulsants

Used as an adjuvant for neuropathic pain.

Gabapentin (Neurontin)

Membrane stabilizer, a structural analogue of the inhibitory neurotransmitter GABA, which, paradoxically, is thought not to exert an effect on GABA receptors. Appears to exert action via the alpha2-delta1 and alpha2-delta2 auxiliary subunits of voltage-gated calcium channels.
Used to manage pain and provide sedation in neuropathic pain.
Titration to effect can take place over several days (300 mg on d 1, 300 mg bid on d 2, and 300 mg tid on d 3).

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