Coccygodynia: Evaluation and Management

Coccygodynia: Evaluation and Management Guy R. Fogel, MD, Paul Y. Cunningham III, MD, and Stephen I. Esses, MD Abstract Coccygodynia is pain in the region of the coccyx. In most cases, abnormal mobility incidence of fusions between seg- is seen on dynamic standing and seated radiographs, although the cause of pain is ments.4 Symptomatic patients have a unknown in other patients. Bone scans and magnetic resonance imaging may show slightly higher incidence of sacral coc- inflammation and edema, but neither technique is as accurate as dynamic radiog- cygeal fusion and a more angular sag- raphy. Treatment for patients with severe pain should begin with injection of local ittal alignment of the coccyx than anesthetic and corticosteroid into the painful segment. Coccygeal massage and stretch- asymptomatic patients.4 No pathologic ing of the levator ani muscle can help. Coccygectomy is done only when nonsur- findings have been noted in the id- gical treatment fails, which is infrequent. Coccygectomy usually is successful in care- iopathic or hypermobile segments in fully selected patients, with the best results in those with radiographically demonstrated patients with coccygodynia. The ab- abnormalities of coccygeal mobility. normal subluxation and hypermobil- J Am Acad Orthop Surg 2004;12:49-54 ity appear to cause pain, but coccygodynia can occur with an immobile coccyx. Only occasionally have posttraumatic nonunion, arthritis, or Coccygodynia, pain in the region of Anatomy malunion been found in surgical spec- the coccyx, typically is triggered by imens. or occurs while sitting. The intensity Five fused sacral and three or four of the pain varies and sometimes is fused coccygeal vertebrae form the ter- aggravated by arising from a seated minal end of the spinal column. Pri- Etiology position. Less severe symptoms may mary ossification centers are evident be managed by changing the sitting in the 9th to 10th week of gestation The clinical factors associated with position or injecting the painful area in the axial skeleton, but the coccyx coccygeal abnormalities are obesity, with local anesthetic and corticoste- does not begin to ossify until after birth. roids. Orthopaedic surgeons often In the sagittal plane, the sacrum is ky- see patients with more severe and photic and connects the lumbosacral Dr. Fogel is Spine Fellow, Department of Ortho- disabling symptoms, which in se- junction to the coccyx. The inferior sa- pedic Surgery, Baylor College of Medicine, Hous- lected cases can be managed suc- cral apex at S5, the sacral cornu, ar- ton, TX. Dr. Cunningham is Medical Research cessfully with surgery. ticulates with the coccygeal cornu, a Fellow, Department of Orthopedic Surgery, Bay- Coccygodynia is five times more facet-disk complex on the dorsal ar- lor College of Medicine. Dr. Esses is Professor of Orthopedics and Brodsky Chair of Spinal Surgery, prevalent in women than men. Al- ticulating surface of the coccyx. This Department of Orthopedic Surgery, Baylor Col- though it can occur over a wide age articulation can be a symphysis or a lege of Medicine. range, mean age of onset is 40 years. synovial joint. The coccyx is a trian- Coccygodynia has many causes, but gular structure comprising three or four None of the following authors or the departments it may be posttraumatic, beginning coccygeal units that usually are fused, with which they are affiliated has received anything of value from or owns stock in a commercial com- after a fracture or contusion or after although the first coccygeal segment pany or institution related directly or indirectly a difficult vaginal delivery.1-3 In the may not fuse with the second. The sa- to the subject of this article: Dr. Fogel, Dr. Cun- largest number of cases, the tip of crococcygeal joint also may be fused. ningham, and Dr. Esses. the coccyx is subluxated or hyper- The coccyx provides attachments for mobile, which can be seen on dy- the gluteus maximus muscle, coccygeal Reprint requests: Dr. Esses, Baylor College of Med- icine, Suite 1900, 6560 Fannin, Houston, TX namic radiographs taken with the muscle, and anococcygeal ligament. 77030. patient standing and seated1-3 (Fig. There are no significant differenc- 1). The cause of pain is unknown in es between asymptomatic patients and Copyright 2004 by the American Academy of patients with normal coccygeal mo- those with coccygodynia in the num- Orthopaedic Surgeons. bility.2 ber of coccygeal segments or in the Vol 12, No 1, January/February 2004 49 Coccygodynia: Evaluation and Management ecation. Women with a history of vaginitis, discharge, or associated pelvic pain should be referred for gyne- cologic consultation. Concomitant constipation should be managed ap- propriately. If the patient has blood in the stool, a tumor or metastasis should be considered. Physical Examination The surrounding skin and soft tis- sue should be inspected for evidence of pilonidal cysts or fistulas. External Figure 1 Maigne’s technique1 for comparing positions of sacral and coccygeal vertebrae palpation or rectal examination may from lateral standing and seated radiographs. A, Standing view. B, Seated view. C, Super- reveal bone spicules, local swelling, imposed views with the sacrum aligned by rotating the seated view through an angle of sag- or coccygeal masses. The coccyx ittal pelvic rotation (I) shows coccygeal angulation and subluxation (II) and the angle at which the coccyx strikes the seat surface (III). should be palpated externally,and the distal segment should be manipulat- ed rectally to detect pain generated antecedent trauma or childbirth, and and sinuses, and perirectal abscess- by motion of the coccygeal segments. exacerbation of pain with arising es.4 Low back pain has occurred con- Local tenderness may occur on the su- from sitting. Obesity, which decreas- currently with coccygodynia. In one perficial coccygeal surface or only on es pelvic rotation when the patient series, 24 of 50 patients (48%) also had manipulation of the coccygeal tip by sits, is three times more common in lumbar disk herniation or bulge with- rectal examination. Tenderness may patients with coccygodynia than in out sciatica or low back pain,5 so al- be greatest at the sacrococcygeal joint the normal population.2 However, the though low back pain is common, it rather than at the coccygeal tip.2 A incidence of radiographically demon- appears to be separate from coccygo- palpable internal mass (eg, chordo- strated coccygeal instability is the dynia. In the series of Postacchini and ma) on the anterior surface of the coc- same regardless of a history of remote Massobrio,4 87% of patients with low cyx or sacrum may be evident on rec- trauma, which suggests that only re- back pain at the time of coccygecto- tal examination. Every examination cent trauma (within 3 months) caus- my had an excellent or good result. should include a stool guaiac to de- es coccygodynia. Patients with nor- The only poor results were in patients tect occult blood. mal coccygeal mobility have the with low back pain and a configura- idiopathic type, which may be asso- tion of the coccyx wherein the first ciated with pelvic floor spasticity or coccygeal segment is partially fused Imaging Evaluation other anomalies of the midpelvic to the sacrum. muscles. Coccygodynia occurring Single-Position Radiographs with an immobile coccyx frequently Because orthogonal anteroposteri- is associated with bursitis of the ad- Clinical Evaluation or and lateral radiographs of the coc- ventitia at the coccygeal tip. Other cyx seldom show differences between suggested etiologies include post- Symptoms normal individuals and those with traumatic arthritis of the sacrococ- Onset of pain may be insidious, re- coccygodynia, these views are usual- cygeal joint and ununited fractures sulting in a possibly long delay from ly not diagnostic.5 Postacchini and or dislocations of the coccyx. Abnor- onset to diagnosis. Patients usually Massobrio4 reported that, in both mal psychological states as a cause of present with pain in and around the healthy and symptomatic patients, coccygodynia have been largely dis- coccyx without significant low back 83% to 95% had two or three coc- proved as behavioral testing of these pain or radiating or referred pain. The cygeal segments. The sacrococcygeal patients reveals personality profiles pain is localized to the sacrococcygeal joint was fused in 51% of the patients similar to other patient groups.5 Oth- joint or mobile segment of the coccyx with idiopathic coccygodynia (26/ er causes of pain in the region of the and may be relieved by sitting on the 51), usually the first intercoccygeal sacrum and coccyx are lesions of the legs or on either buttock. Chronic joint was mobile, and the second in- lumbar disks, arachnoiditis of the pain is that which persists >2 months. tercoccygeal joint was fused in 49% lower sacral nerve roots, tumors of Patients may feel a frequent need to (25/51).4 The curvature of the sacrum the coccyx or sacrum, pilonidal cysts defecate or may have pain with def- was flexed or anterior in 68% of 50 Journal of the American Academy of Orthopaedic Surgeons Guy R. Fogel, MD, et al asymptomatic patients and in 31% of patients with coccygodynia. The tip curved forward sharply in 23% and subluxated posteriorly in 22% of patients with coccygodynia.4 Dynamic Radiographs Maigne and colleagues1-3,6 com- pared standing and sitting lateral ra- diographic views of the coccyx in a total of 582 patients with coccygodynia and reported abnormalities in 70%. The normal coccyx pivots slightly (5° to 25°) either posteriorly or an- teriorly with sitting and returns to its Figure 2 The anatomic signs of coccygodynia.1 A, Normal standing appearance of the coc- original position with standing (Fig. cyx. B, Increased flexion mobility of the coccyx when patient is seated. C, Posterior sublux- 2, A). Abnormalities of the coccygeal ation of the coccyx when patient is seated.

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