Preprocedural Planning
In order to assess the stability of the coccyx, anteroposterior (AP) and lateral radiographs are taken. Plain radiographs may reveal fractures, dislocations, osteophytes, and abnormal sacrococcygeal curvature. However, whether the radiologic findings can be a definite pointer to indicate surgery remains undetermined.
Dynamic radiographs are usually taken to assess the hypermobility of the sacrococcygeal region. The first radiograph is taken when the patient is standing for at least 10 minutes in order to get the coccyx in a neutral position. The patient is then asked to sit with the back straight and the thighs horizontal. Next, he or she is asked to bend backwards until pain is reproduced, at which point a second radiograph is taken. Posterior subluxation is observed when a reduction in standing position occurs. Hypermobility of the coccyx is described as flexion of more than 25º on lateral radiographs. [16]
The intercoccygeal angle (see the image below) is the angle between the midline of the first coccygeal segment and the last (fourth) coccygeal segment. This is the objective measurement of forward angulation of the coccyx. In comparisons of the intercoccygeal angles in traumatic and idiopathic coccygodynia, [17] it was found that the intercoccygeal angle was a useful radiologic measurement that could accurately assess the increased angular deformity of the coccyx; it was also found that the intercoccygeal angle was greater in idiopathic cases than in traumatic cases and could be a potential cause of coccygodynia (coccydynia).
Intercoccygeal angle is angle between midline of first coccygeal segment and last (fourth) coccygeal segment. This serves as objective measurement of forward angulation of coccyx.
Magnetic resonance imaging (MRI) of the lumbosacral area should be performed to rule out spinal canal, disk, or spinal cord pathology. Also, assessment of the surrounding sacrococcygeal region should be made to exclude rare but sinister pathologic conditions (eg, neoplasm).
Patient Preparation
Before being listed for coccygectomy, each patient must have failed medical therapy and nonsurgical treatment. [18, 19] This includes the failure of manipulation under anesthetic (MUA) and at least two attempts at local anesthetic and steroid infiltration.
Usually, a low-residue diet is started 5 days before surgery, and a Fleet enema is given 24 hours before or on the day of the procedure. Some surgeons start the low-residue diet just 1 day before surgery. An increased risk of wound infection after coccygectomy has been reported; therefore, preoperative antibiotics are given after induction of anesthesia. Anecdotally, this is due to the anatomic region where the surgery is performed.
The patient is placed in a prone position on bolsters, and the operating table is flexed at the patient’s waist. The buttocks are separated by a hard tape to afford proper exposure of the area.
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Transverse process of coccyx provides attachment to lateral sacrococcygeal ligaments.
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Intercoccygeal angle is angle between midline of first coccygeal segment and last (fourth) coccygeal segment. This serves as objective measurement of forward angulation of coccyx.
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Coccygectomy: surgical technique.
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Coccygectomy. After coccyx is removed, distal prominent end of sacrum is beveled.
