Coccyx Pain Treatment & Management

Screening questions for possible malignancy should be completed prior to commencing focal treatment for coccydynia.

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.

Generally, all nonsurgical care of coccydynia can be performed on an outpatient basis, including follow-up visits and local injections.

A retrospective study by Scott et al indicated that pelvic floor physical therapy is an effective treatment for those who have chronic coccydynia even after coccygectomy. Among the 79 patients who finished therapy (a mean of nine physical therapy sessions), using numeric rating scales, the mean average pain rating and the mean highest pain rating fell from 5.08 to 1.91 and from 8.81 to 4.75, respectively. A secondary measure, the mean percent global improvement, was 71.9%. (Although physical therapy was the primary treatment in the study, baclofen, ganglion impar blocks, and coccygeus trigger point injections were also used.) ^[23]

With regard to surgical treatment, 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.

Avoidance

Patients with coccydynia usually know which activities to avoid in order to minimize exacerbation of their tailbone pain. Examples include prolonged sitting (eg, long car or airplane rides), bike riding, horseback riding, and canoeing.

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.

Surgical treatment for coccydynia includes coccygectomy, in the form of partial or complete surgical removal of the coccyx. ^{[9, 10]}

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).

Coccygectomy has been associated with relatively high rates of postoperative infection. 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 (thus more than one third of the patients)—4 patients with superficial infections and 3 patients with persistent drainage. ^[24]

In a retrospective study of 32 patients with coccydynia who were treated by an orthopedic spine surgeon, the investigators concluded that patients with coccydynia should be managed conservatively when possible, including with nonsteroidal anti-inflammatory drugs (NSAIDs) and repeat injections. In the study, 11 patients (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. ^[25] The authors felt that coccygectomy can offer reasonable results when conservative treatment fails but that patients should be cautioned about the high infection rate.

In another small case series, which reported on coccygectomy in 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. ^[26]

A study by Hanley et al stated that coccygectomy can produce significant patient-reported improvement in chronic, conservative-treatment–resistant coccyx pain at 2-year follow-up, with risk factors for the procedure’s failure including psychiatric illness, higher preoperative pain levels, the presence of more than three comorbidities, and preoperative opiate use. The study involved 94 patients. ^[27]

A retrospective study by Doursounian et al suggested that coccygeal spicules can be successfully treated with coccygectomy. The study involved 33 patients with spicules, all of whom had obtained insufficient relief from conservative treatment; they were followed up postsurgically for periods of 30-42 months (13 patients), 48-66 months (10 patients), and over 72 months (10 patients). Surgical outcomes were considered very satisfactory in 26 patients (79%) but were reported as unsatisfactory in seven patients (21%). ^[28]

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. ^[29]

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.

A retrospective, single-center study by Mulpuri et al of 173 patients who underwent coccygectomy found that individuals who were younger, who had no previous back surgery, and whose coccydynia did not arise from trauma were more likely to experience improvement in quality-of-life measures. (This differed from the above-mentioned study that found better surgical results in association with coccydynia preceded by trauma.) The infection rate (9.42%) was significantly lower than that reported in other studies, which the investigators suggested was attributable to the use of preoperative antibiotics and an “off-center” closure technique. Off-center closure may have reduced infection for multiple reasons, including decreased pressure on the incision owing to greater fat pad thickness beneath the incision. ^[30]

The ganglion impar (ganglion of Walther) is the terminal ganglion of the paravertebral sympathetic nervous system; it 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. ^{[31, 32, 33, 34, 35, 36, 37]}

One possible mechanism for persistent coccydynia is excessive activity or sensitivity of the ganglion impar, thus creating sympathetically maintained coccyx pain. ^[11]

Local injection of an anesthetic can effectively block the ganglion impar and thereby relieve coccyx pain. 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. ^[11]

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 existed 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 complete and permanent relief via a single ganglion impar block. ^[11]

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. Thus, in patients without complete resolution, repeat injections are often medically necessary and clinically helpful.

Techniques

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. 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), an omission with the potential to compromise 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. ^{[38, 39]} 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). ^[11]

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.

A report by Sencan et al indicated that the transsacrococcygeal approach to ganglion impar block administration is safe and effective in treating chronic coccydynia, with significant pain relief obtained in 42.9% of study patients with a normal coccyx and 61.9% of those with an immobile coccyx. All patients received a single treatment with the block. ^[40]

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 posterior region prior to the impar injection and to provide more complete relief of the coccydynia. Often, it makes sense to combine these injections on the same injection date, so that both anterior and posterior relief is obtained.

A case series reported good results from the administration of 20 ganglion impar blocks by physical medicine and rehabilitation physicians at New Jersey Medical School to patients who were suffering from persistent coccydynia despite treatment with oral medications, cushions, and other conservative therapies. 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 and with the relief generally lasting weeks to months or longer. For cases in which 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. ^[11] 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.

An important benefit to this approach over the transsacrococcygeal one is that 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. ^[34]

A study by Gopal and McCrory indicated that treatment of the ganglion impar with pulsed radiofrequency can improve pain in some patients with chronic coccydynia. In the retrospective review, 20 patients whose coccydynia did not respond to medical management underwent pulsed radiofrequency treatment, with follow-up at 6 and 12 months. In 15 patients, the mean pretreatment visual analogue scale score fell significantly, from 6.53 to 0.93. Treatment in the remaining patients was unsuccessful, with no change in the visual analogue scale score at follow-up. ^[41]

Sacrococcygeal joint injections

When the primary pain generator is thought to be at the sacrococcygeal joint, local injection can be administered to 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.

A study by Finsen et al found that in patients with chronic coccydynia who received one injection of either betamethasone (6 mg) or triamcinolone (20 mg), effective long-term pain relief (mean 36 mo) was achieved in 15% of the group, with the overall rate reaching 29% after 62 of the 241 patients received a second injection. The investigators also determined that triamcinolone was the more successful pain reliever and that patients who had been suffering from symptoms for less than 12 months were more likely to experience long-term relief. ^[42]

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.

Ischial bursa injections

The authors of this article have found that in cases in which 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).

Ablation injections may provide more long-lasting relief in appropriately selected patients. Ablation is the intentional destruction of human tissue for treatment purposes. For instance, ablation can be used to intentionally destroy nerve fibers at the coccyx, so that those nerves can no longer send pain signals to the brain. Thermocoagulation of the ganglion impar using radiofrequency ablation (RFA) has been reported. ^{[12, 13]} Ablation can also be accomplished chemically (eg, by carefully injecting neurotoxic agents such as phenol and/or ethyl alcohol directly onto the targeted nerve tissues). These coccygeal ablation injections have been in clinical use for multiple decades and thus are no longer considered experimental. ^[2]

Ablation is typically reserved for patients whose pain has failed to be adequately relieved via oral analgesic medications, cushions, coccyx steroid injections, and coccygeal sympathetic nerve blocks (ganglion impar). The ideal specific site for ablation may depend on the individual patient’s specific site of coccygeal pathology. Prior to ablation, a diagnostic injection (test injection, with local anesthetic) is generally performed to ascertain whether a specific target site is likely to provide relief if ablated. Patients who obtain substantial transient (anesthetic) relief via the diagnostic injection would be good candidates for subsequent nerve ablation at the same site where the diagnostic injection was done.

If ablation fails to provide as much relief as the anesthetic/test injection provided, the ablation may soon be repeated, to provide more complete destruction of those nerve fibers.

Even after successful relief via ablation, some patients may have eventual return of the some of their coccyx pain many months or years later, if the remaining coccygeal nerve fibers regrow collateral reinnervation to the sites denervated by the ablation. In those cases, repeat ablation may be performed.

Since ablation injections are intended to cause destructive (albeit therapeutic) changes, they should only be performed by physicians skilled and experienced in these procedures. In addition, they should be performed under image-guidance (eg, fluoroscopy, to add to the specificity of the targeted injection site) and using the smallest amount (eg, milliliters) of ablation necessary to provide the desired therapeutic relief.

Ablation injections may help some coccydynia patients avoid more invasive treatments, eg, helping them avoid surgical removal of the coccyx (coccygectomy).

A retrospective study by Adas et al indicated that radiofrequency therapy of the ganglion impar via a transsacrococcygeal approach can effectively treat chronic coccydynia. The investigators found that compared with pretreatment visual analogue scale scores, there was significant improvement in early, 1-month, and 6-month postprocedure scores, with successful outcomes reported for 90.2% of patients at 6 months. ^[43]

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. ^[2] 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 almost twice as frequently as did the control group, as determined at 1 month (36% vs 20%, P = .075) and at 6 months (22% vs 12%, P = .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. ^[44]