Medication Summary
As previously stated, early interventions (eg, oral medications, injections, physical therapy) are presumed to decrease the chance that acute coccydynia will become chronic.
Once the coccyx pain has become chronic (persisting for more than 3-6 mo), it may be less likely to resolve by natural recovery alone, more likely to continue indefinitely, more likely to be resistant to treatment, and more likely to require a multimodal treatment approach (eg, oral medications combined with local injections).
Nonsteroidal anti-inflammatory drugs, analgesics, and anticonvulsants can all be used to manage pain in patients with coccydynia.
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
Class Summary
NSAIDs have analgesic, anti-inflammatory, and antipyretic activities. The mechanism of action may be inhibition of cyclo-oxygenase (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, Motrin, Caldolor, Neoprofen, Ibu)
This is a classic anti-inflammatory used for patients with mild to moderate pain. It inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Analgesics, Other
Class Summary
Pain control is essential to quality patient care. Analgesics ensure patient comfort and have sedating properties that may be beneficial for patients who experience pain.
Acetaminophen (Aspirin Free Anacin, FeverAll, Tylenol, Mapap)
Acetaminophen is a first-line medication for treating pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants.
It is effective in relieving mild to moderate acute pain; however, acetaminophen has no peripheral anti-inflammatory effects. It may be preferred in elderly patients because of fewer GI and renal side effects.
Tramadol (Ultram, Ryzolt, Rybix ODT)
Tramadol inhibits ascending pain pathways, altering the patient's perception of and response to pain. It inhibits the reuptake of norepinephrine and serotonin.
Pregabalin (Lyrica)
Pregabalin is a structural derivative of gamma-aminobutyric acid (GABA); its mechanism of action is unknown. Pregabalin binds with high affinity to the alpha2-delta site (a calcium channel subunit). It reduces the calcium-dependent release of several neurotransmitters in vitro, possibly by modulating calcium channel function. Pregabalin has been approved by the US Food and Drug Administration (FDA) for the treatment of neuropathic pain associated with diabetic peripheral neuropathy or postherpetic neuralgia.
Fentanyl citrate (Duragesic, Abstral, Actiq, Fentora, Onsolis)
Fentanyl citrate is a synthetic opioid that has 75-200 times more potency and a much shorter half-life than morphine sulfate. It has fewer hypotensive effects than morphine and is safer in patients with hyperactive airway disease because of minimal or no associated histamine release. By itself, fentanyl citrate causes little cardiovascular compromise, although the addition of benzodiazepines or other sedatives may result in decreased cardiac output and blood pressure.
Fentanyl citrate is highly lipophilic and protein-bound. Prolonged exposure to it leads to accumulation of the drug in fat and delays the weaning process. Consider continuous infusion because of the medication's short half-life.
The parenteral form is the drug of choice for conscious-sedation analgesia. Fentanyl citrate is ideal for analgesic action of short duration during anesthesia and the immediate postoperative period. It is an excellent choice for pain management and sedation with short duration (30-60 min) and is easy to titrate. The drug's effects are easily and quickly reversed by naloxone.
After the initial parenteral dose of fentanyl citrate, subsequent parenteral doses should not be titrated more frequently than every 3 or 6 hours thereafter.
The 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-hour dosing intervals; however, some patients require dosing intervals of 48 hours.
Oxycodone (OxyContin, Roxicodone)
Oxycodone is indicated for the relief of moderate to severe pain.
Oxycodone and acetaminophen (Percocet, Roxicet, Endocet, Primlev, Tylox)
This drug combination is indicated for the relief of moderate to severe pain.
Anticonvulsants, Other
Class Summary
These are used as adjuvants for neuropathic pain.
Gabapentin (Neurontin)
Gabapentin is a membrane stabilizer. A structural analogue of the inhibitory neurotransmitter GABA, gabapentin paradoxically is thought not to exert an effect on GABA receptors. It appears to exert its action via the alpha2-delta1 and alpha2-delta2 auxiliary subunits of voltage-gated calcium channels.
Gabapentin is used to manage pain and provide sedation in neuropathic pain. Titration to effect can take place over several days (300mg on day 1, 300mg twice on day 2, and 300 mg 3 times on day 3).
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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).
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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.
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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.
