Approach Considerations
A wide variety of therapeutic methods have been proposed for the treatment of coccygodynia (coccydynia). [24] However, conservative management continues to be the mainstay of treatment. [3]
Surgical treatment is reserved for patients who do not respond to conservative management and involves the removal of the coccyx (ie, coccygectomy). [25, 26, 27] A normal appearance of the coccyx on preoperative imaging should not be considered a sufficient justification for denying patients surgical treatment when conservative management has been unsuccessful. [28]
A newer surgical procedure that has been suggested as a potential alternative for the treatment of refractory coccygodynia in patients with coccyx hypermobility is coccygeoplasty. [29]
Pharmacologic Therapy
Nonsteroidal anti-inflammatory drugs (NSAIDs) may be given to decrease the pain associated with inflammation, and laxatives may be given as stool softeners to reduce the pressure on the coccyx during defecation. These are helpful in the short term but must be combined with precautions such as using soft seats and avoiding hard seats; ring-shaped cushions may be helpful.
Injection of a local anesthetic at the site of maximum tenderness can be helpful both diagnostically (in confirming the diagnosis) and therapeutically (in relieving pain). This can be followed by injection of a steroid at the same site through the same needle left in situ.
In a study evaluating the results of dextrose prolotherapy for recalcitrant coccygodynia, Khan et al reported it to be an effective treatment option in patients with chronic nonresponding coccygodynia and advised using it in these patients before they undergo any major surgical procedure (eg, coccygectomy). [30]
Although injection is popular in practice, there is no clear consensus in the literature regarding its appropriate use. Response rates vary, as does the duration of relief.
Levesque et al studied the use of a high-concentration capsaicin patch in 60 patients with pelvic neuralgia and found that such treatment was effective and well tolerated, without serious adverse effects. [31] Of the 60 patients, 24% reported feeling "much" or "very much" improved, with an average 58% improvement and a 3.4-point reduction in pain intensity on a numerical rating scale. Of the patients who achieved a good response, those with coccygodynia appeared to have the best results: 37% reported feeling "much" improved, with an average 63% improvement.
Other Nonoperative Therapies
Ergonomic adaptation includes strapping of the buttocks, postural training, and the use of a rubber ring or a firm corset. [3] A sitz bath over a tub of warm water may be helpful in relieving pain.
Thiele massage is a particular method of massaging the posterior pelvic floor muscles, including the coccygeus. Thiele stated that in coccygodynia, the levator ani and the coccygeus are tender and spastic, whereas the tip of the coccyx usually is not tender. [8] He advised massage of the levator muscles along the long direction of the muscle fibers on both sides.
Although Thiele massage was found to be helpful in treating pain due to muscle spasm, it remained unhelpful in patients with pain due to coccygeal mobility. In the technique described by Mennell, [32] the coccyx is grasped between the thumb and the index finger inserted into the anal canal, then manipulated. In addition, Maigne et al advised keeping the coccyx in a hyperextended position with the help of an index finger applied over its anterior aspect and counterpressure applied by the other hand over the posterior aspect of the sacrum. [33]
Another type of manipulation has been proposed in which the coccygeus, the levator ani, and the external sphincter are stretched by keeping the coccyx still with one finger internally and one externally. This particular technique is helpful in patients with restricted sacrococcygeal extension.
Radiofrequency (RF) ganglion impar block for pericoccygeal pain due to carcinoma, first described by Plancarte et al in 1990, [34] has been adopted for alleviation of pain in patients with severe coccygodynia.
Atim et al presented long-term results from 21 patients treated for coccygodynia with caudal epidural pulsed RF, all of whom had failed to respond to previous conservative treatment. [35] At 6 months after RF treatment, 12 patients (57%) had excellent results, five (24%) had good results, and only four (19%) had poor results.
Gopal et al retrospectively reviewed 20 patients treated with pulsed RF applied to the ganglion impar, reporting a successful outcome (defined as >50% improvement in visual analogue scale [VAS] score at 6 months and 12 months) in 75% of patients and an unsuccessful outcome in 25%. [36]
In a study of 39 patients with chronic coccygodynia, Sir et al (N = 39) compared pulsed RF (n = 14) with blockade of the ganglion impar (n = 25) in terms of pain intensity and patient satisfaction. [37] They found that pulsed RF neuromodulation, compared with blockade of the impar ganglion, provided significantly longer pain relief and reduced the risk of recurrence of pain in these patients.
Although extracorporeal shock wave therapy (ECSWT) has been widely used in different musculoskeletal conditions, its use in patients with coccygodynia is a comparatively recent development.
Marwan et al studied the effect of ECSWT in relieving the pain of coccygodynia in two patients, each of whom underwent a total of three treatment sessions (one session weekly for 3 consecutive weeks). [38] Pain intensity showed a persistent decrease through the 12-month follow-up period, as evidenced by the pretherapy and posttherapy Numeric Pain Scale and VAS scores. Marwan et al subsequently reported on a larger group of patients (N = 23) and documented comparably favorable outcomes. [39]
Lin et al compared ECSWT (n = 20) with physical therapy with interferential current (n = 21) in patients with coccygodynia over a period of 4 weeks and found that the former modality reduced the discomfort and disability caused by coccygodynia more satisfactorily than the latter did. [40] Although both VAS and Oswestry disability index (ODI) scores were significantly decreased after treatment in both groups, the decrease in the VAS score was significantly greater in the ECSWT group. The patients in the ECSWT group also had significantly higher subjective satisfaction scores.
Haghighat et al, in a quasiexperimental study aimed at assessing the efficacy of ECSWT for reducing pain in 10 patients with chronic coccygodynia, found that although decreases in VAS scores from baseline were achieved at 4 weeks and at 2 months after treatment, the decreases did not persist. [41] At 7 months after therapy, there was no significant decrease in VAS from baseline.
Cases have been reported in which neuromodulation (eg, spinal cord stimulation or dorsal root ganglion stimulation) was used to treat chronic coccygodynia [42] ; however, further study is required to determine the effectiveness of such approaches for this indication.
Coccygectomy
Two main techniques of coccygectomy have been described in the literature, as follows:
A minimally invasive endoscopic approach for performing complete coccygectomy in the setting of chorinic refractory coccygodynia was described in a case report by Roa et al. [45]
Powers technique
The patient is positioned prone, with the buttocks firmly strapped laterally for ease of exposure. A midline incision is developed down to the bone, and the sacrococcygeal joint is exposed proximally up to the tip of the coccyx distally. A subperiosteal plane is developed along the anterior surface of the coccyx, and the coccyx is lifted up. Amputation is carried out just proximal to the sacrococcygeal joint.
Gardner technique
A 7.5-cm incision is made, extending from just proximal to the sacrococcygeal joint up to the buttock crease. This incision is brought down to the fascia and the insertion of the gluteus maximus directly over the bone.
Coccygeal vessels are ligated, and the tip of the coccyx is elevated by means of blunt dissection. The tip of the coccyx is separated from the external sphincter ani by means of sharp dissection. The coccyx is then elevated from the underlying rectum and the dense fascia that separates the two. With the help of a moist sponge, the fascia and the rectum are mobilized up to the sacrococcygeal joint, and the coccyx is excised by means of sharp dissection at the sacrococcygeal joint.
Complications
The most common complication with coccygectomy is wound infection due to the presence of the abundant perineal skin flora as contaminants. Delayed wound healing is almost the rule, and pain relief may not occur for many months, even after surgical treatment. Other complications include the risk of injury to the rectum and the sphincter ani.
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Coccyx is usually formed of 3-5 rudimentary vertebrae.
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Coccyx as compared with cuckoo's beak.
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Coccygeal configuration types I, II, III, and IV (from left to right). Type I: Coccyx is curved slightly forward, with its apex directed downward and caudally. Type II: Forward curvature is more marked, and apex extends straight forward. Type III: Coccyx most sharply angulates forward. Type IV: Coccyx is subluxated at sacrococcygeal joint or at intercoccygeal joint.
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Dynamic radiographs obtained from patient with coccygodynia.
