Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Coccyx Pain Workup

  • Author: Patrick M Foye, MD; Chief Editor: Consuelo T Lorenzo, MD  more...
 
Updated: May 26, 2016
 

Approach Considerations

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.[3] Patients with coccydynia often report frustration with physicians who minimize their symptoms or tell them that the pain is "all in their head."[5] 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).[3]

Patients with coccydynia deserve appropriate workup, treatment, and compassion, the elements of care provided to patients with other neurologic or musculoskeletal chronic pain syndromes.

Electrodiagnostics

Electromyography (EMG) and nerve conduction studies (NCSs) are usually unnecessary in cases of isolated coccydynia. However, electrodiagnostics are potentially helpful in cases in which concomitant lumbosacral radiculopathy is suspected.

Anesthesia response

The patient's response to injection of local anesthetic agents, with or without corticosteroids, can provide helpful information regarding whether the patient's 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.

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. Some patients may experience exacerbation during the first few days after the injection procedure, but this is generally only temporary and self-limited.

Histologic findings

A single case series of 8 patients who 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.[12]

Lab work

No specific blood work is recommended for coccydynia.

Next

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.[14, 15]

However, be aware that there is 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. This preinjury variability 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.

Lateral view

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.

Some French clinicians advocate radiographically assessing sacrococcygeal mobility through the comparison of lateral radiographs performed while the patient is seated versus standing.[14, 15] Within most radiology departments, however, such dynamic radiography is not widely performed or readily available.

Anteroposterior view

In the anteroposterior (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.

Coned-down view

In addition to obtaining the standard 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 (see the image below). 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 at the coccyx, making the coccygeal segments difficult to clearly visualize.

Lateral view of the pelvis and coccyx. The bracket 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).
Previous
Next

Lumbosacral MRI

Lumbosacral magnetic resonance imaging (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 radiologic imaging of the coccyx.

Lumbosacral MRI would be most helpful in cases in which 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 to 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 patient’s overall history and physical so that the physician can make an educated determination as to whether the lumbosacral MRI findings represent pain generators or incidental findings.

Previous
Next

Bone and CT Scanning of the Coccyx

In most cases of coccydynia, bone and computed tomography (CT) scanning are not necessary. In cases of suspected fracture with negative or inconclusive plain radiographic findings, however, these studies can 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.

Bone and CT scanning studies may particularly be considered in medicolegal cases in which objective evidence is needed regarding the presence or absence of a coccygeal fracture or in cases in which bony cancer or metastases are being considered.

Note that bone scans that only include AP and/or PA views generally fail to show the coccyx, since coccygeal visualization is obstructed by the nuclear medicine materials pooling in the bladder prior to urination. Using oblique and lateral views, rather than just the AP or PA views, can help avoid this problem.

Previous
Next

CT Scanning and MRI of the Pelvis

CT scanning and/or MRI of the pelvis can be helpful in cases in which intrapelvic pathology (ovarian, cervical, colon, testicular, or prostate cancer or their associated metastases) is suspected.[16] 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 with regard to showing pathology of the ovaries, uterus, prostate, urinary bladder, and bowels. Also, unlike MRI, CT scanning carries notable risks of radiation exposure.

Previous
 
 
Contributor Information and Disclosures
Author

Patrick M Foye, MD Director of Coccyx Pain Center, Professor and Interim Chair of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School; Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, University Hospital

Patrick M Foye, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, International Spine Intervention Society, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists

Disclosure: Nothing to disclose.

Coauthor(s)

Charles J Buttaci, DO, PT Pain Management, Northeast Orthopedics

Charles J Buttaci, DO, PT is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Osteopathic College of Physical Medicine and Rehabilitation, International Spine Intervention Society

Disclosure: Nothing to disclose.

Leia Rispoli Rutgers New Jersey Medical School

Disclosure: Nothing to disclose.

Chief Editor

Consuelo T Lorenzo, MD Medical Director, Senior Products, Central North Region, Humana, Inc

Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Acknowledgements

Michael T Andary, MD, MS Professor, Residency Program Director, Department of Physical Medicine and Rehabilitation, Michigan State University College of Osteopathic Medicine

Michael T Andary, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, and Association of Academic Physiatrists

Disclosure: Allergan Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching

Debra Ibrahim New York College of Osteopathic Medicine

Disclosure: Nothing to disclose.

Evish Kamrava St George's University School of Medicine

Disclosure: Nothing to disclose.

Robert L Sheridan, MD Assistant Chief of Staff, Chief of Burn Surgery, Shriners Burns Hospital; Associate Professor of Surgery, Department of Surgery, Division of Trauma and Burns, Massachusetts General Hospital and Harvard Medical School

Robert L Sheridan, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, and American College of Surgeons

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Dev Sinha, MD Resident Physician, Department of Physical Medicine and Rehabilitation, University of Pennsylvania Health Systems

Disclosure: Nothing to disclose.

Matthew Kirk Sorensen Rutgers New Jersey Medical School

Disclosure: Nothing to disclose.

Acknowledgments

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.

References
  1. Lirette LS, Chaiban G, Tolba R, Eissa H. Coccydynia: an overview of the anatomy, etiology, and treatment of coccyx pain. Ochsner J. 2014 Spring. 14 (1):84-7. [Medline]. [Full Text].

  2. Howorth B. The painful coccyx. Clin Orthop. 1959. 14:145-60.

  3. Wray CC, Easom S, Hoskinson J. Coccydynia. Aetiology and treatment. J Bone Joint Surg Br. Mar 1991. 73(2):335-8. [Medline]. [Full Text].

  4. Nathan ST, Fisher BE, Roberts CS. Coccydynia: a review of pathoanatomy, aetiology, treatment and outcome. J Bone Joint Surg Br. 2010 Dec. 92(12):1622-7. [Medline].

  5. Foye PM. Stigma against patients with coccyx pain. Pain Med. 2010 Dec. 11(12):1872. [Medline].

  6. Richette P, Maigne JY, Bardin T. Coccydynia related to calcium crystal deposition. Spine. 2008 Aug 1. 33(17):E620-3. [Medline].

  7. Foye PM. Coccydynia (coccyx pain) caused by chordoma. Int Orthop. 2007 Jun. 31(3):427. [Medline]. [Full Text].

  8. Foye PM. Finding the causes of coccydynia (coccygeal pain). J Bone Joint Surg Br. Jan 18 2007. [Full Text].

  9. Dang L, Liu X, Dang G, et al. Primary tumors of the spine: a review of clinical features in 438 patients. J Neurooncol. 2015 Feb. 121(3):513-20. [Medline].

  10. Maigne JY, Doursounian L, Chatellier G. Causes and mechanisms of common coccydynia: role of body mass index and coccygeal trauma. Spine. 2000 Dec 1. 25(23):3072-9. [Medline].

  11. Foye PM. A new diagnostic test for coccyx pain (tailbone pain): seated MRI. Am J Phys Med Rehabil. Mar 2008. 87(3):S36.

  12. Balain B, Eisenstein SM, Alo GO, et al. Coccygectomy for coccydynia: case series and review of literature. Spine. 2006 Jun 1. 31(13):E414-20. [Medline].

  13. Maigne JY, Chatellier G, Faou ML, et al. The treatment of chronic coccydynia with intrarectal manipulation: a randomized controlled study. Spine. 2006 Aug 15. 31(18):E621-7. [Medline].

  14. Foye PM, Schoenherr L, Kim JH. Coccydynia (coccyx pain) after colonoscopy. Am J Phys Med Rehabil. Mar 2008. 87(3):S36.

  15. Maigne JY, Guedj S, Fautrel B. [Coccygodynia: value of dynamic lateral x-ray films in sitting position]. Rev Rhum Mal Osteoartic. 1992 Nov 30. 59(11):728-31. [Medline].

  16. Maigne JY, Tamalet B. Standardized radiologic protocol for the study of common coccygodynia and characteristics of the lesions observed in the sitting position. Clinical elements differentiating luxation, hypermobility, and normal mobility. Spine. 1996 Nov 15. 21(22):2588-93. [Medline].

  17. Wood KB, Mehbod AA. Operative treatment for coccygodynia. J Spinal Disord Tech. Dec 2004. 17(6):511-5. [Medline].

  18. Kerr EE, Benson D, Schrot RJ. Coccygectomy for chronic refractory coccygodynia: clinical case series and literature review. J Neurosurg Spine. 2011 May. 14(5):654-63. [Medline].

  19. Alo GO, Eisenstein SM, Darby A. The sacro-coccygeal joint in coccydynia. J Bone Joint Surg Br. 1998. 80-B(2S):196.

  20. Foye PM. Reasons to delay or avoid coccygectomy for coccyx pain. Injury. 2007 Nov. 38(11):1328-9. [Medline].

  21. Hodges SD, Eck JC, Humphreys SC. A treatment and outcomes analysis of patients with coccydynia. Spine J. 2004 Mar-Apr. 4(2):138-40. [Medline].

  22. Hanley EN, Ode G, Jackson Iii BJ, Seymour R. Coccygectomy for patients with chronic coccydynia: a prospective, observational study of 98 patients. Bone Joint J. 2016 Apr. 98-B (4):526-33. [Medline].

  23. Doursounian L, Maigne JY, Jacquot F. Coccygectomy for coccygeal spicule: a study of 33 cases. Eur Spine J. 2015 Jan 6. [Medline].

  24. Pennekamp PH, Kraft CN, Stütz A, et al. Coccygectomy for coccygodynia: does pathogenesis matter?. J Trauma. 2005 Dec. 59(6):1414-9. [Medline].

  25. Borgia CA. Coccydynia: its diagnosis and treatment. Mil Med. 1964 Apr. 129:335-8. [Medline].

  26. Foye PM. Ganglion impar blocks for chronic pelvic and coccyx pain. Pain Physician. 2007 Nov. 10(6):780-1. [Medline]. [Full Text].

  27. Foye PM. Safe ganglion Impar blocks for visceral and coccyx pain. Techniques in Regional Anesthesia and Pain Management. April 2008. 12(2):122-123.

  28. Foye PM. Ganglion impar blocks via coccygeal versus sacrococcygeal joints. Reg Anesth Pain Med. 2008 May-Jun. 33(3):279-80. [Medline].

  29. Foye PM. Ganglion impar injection techniques for coccydynia (coccyx pain) and pelvic pain. Anesthesiology. 2007 May. 106(5):1062-3; author reply 1063. [Medline].

  30. Foye PM. New approaches to ganglion impar blocks via coccygeal joints. Reg Anesth Pain Med. 2007 May-Jun. 32(3):269. [Medline].

  31. Foye PM. Treatment of tailbone pain (coccyx pain, coccydynia) by injection of local anesthetic to the ganglion Impar. www.Tailbone.info. Available at http://tailbone.info/ganglionimparinjections.html. Accessed: Jul 14 2007.

  32. Oh CS, Chung IH, Ji HJ, et al. Clinical implications of topographic anatomy on the ganglion impar. Anesthesiology. Jul 2004. 101(1):249-50. [Medline].

  33. Buttaci CJ, Foye PM, Stitik TP, et al. Coccydynia successfully treated with ganglion impar blocks: a case series. Am J Phys Med Rehabil. Mar 2005. 84(3):218.

  34. Kuthuru M, Kabbara AI, Oldenburg P, et al. Coccygeal pain relief after transsacrococcygeal block of the ganglion Impar under fluoroscopy: a case report. Arch Phys Med Rehabil. Sep 2003. 84(9):E24.

  35. Gopal H, McCrory C. Coccygodynia treated by pulsed radio frequency treatment to the Ganglion of Impar: a case series. J Back Musculoskelet Rehabil. 2014 Feb 20. [Medline].

  36. Kabbara AI. Transsacrococcygeal ganglion impar block for postherpetic neuralgia. Anesthesiology. Jul 2005. 103(1):211-2. [Medline].

  37. Atim A, Ergin A, Bilgiç S, Deniz S, Kurt E. Pulsed radiofrequency in the treatment of coccygodynia. Agri. 2011 Jan. 23(1):1-6. [Medline].

  38. Plancarte R, Amescua C, Patt RB, et al. Presacral blockade of the ganglion of Walther (ganglion Impar). Anesthesiology. 1990. 73(3a):A751.

  39. Foye PM, Buttaci CJ, Stitik TP, et al. Successful injection for coccyx pain. Am J Phys Med Rehabil. Sep 2006. 85(9):783-4. [Medline].

  40. Reig E, Abejón D, Del Pozo C, et al. Thermocoagulation of the ganglion impar or ganglion of walther: description of a modified approach. Preliminary results in chronic, nononcological pain. Pain Pract. 2005 Jun. 5(2):103-10. [Medline].

 
Previous
Next
 
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).
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.
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.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.