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. 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 muscle can help. 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 coccy- godynia can occur with an immobile coccyx. Only occasionally have post- traumatic 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 , 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 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 . 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 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 . 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 pel- vic 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 pa- tients 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 coccygo- dynia and reported abnormalities in 70%. The normal coccyx pivots slight- ly (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. D, Coccygeal spicule (arrow) arising from the dorsal surface of coccygeal segment. segments in the seated views have an- terior hypermobility >25° (Figs. 2, B and 3). Subluxation or posterior dis- placement of the mobile segment of ma. Physical therapy consisting of injections and manipulations were re- the coccyx is seen when the patient diathermy and ultrasound may pro- peated. If the patient did not respond, is seated (Figs. 2, C and 4, A). A spic- vide temporary relief. a coccygectomy was done 6 weeks ule of the distal tip (Fig. 2, D) is seen Wray et al5 used a stepwise treat- later. The cure rate with injection most commonly with an immobile ment, with each step somewhat more alone was 59% but was 85% with ma- coccyx (<5° of motion with sitting).2 invasive than the previous. First, nipulation and injection.5 Although methylprednisolone (40 mg) and relapses occurred in the injection Advanced Imaging Modalities bupivacaine (10 mL 0.25%) were in- group (21%) and the manipulation Technetium Tc 99m bone scans jected around the side and tip of the group (28%), repeat treatment in each may show inflammation in the area coccyx. With persistent coccygodynia, group achieved good success. Coc- of subluxation or hypermobility. the coccyx was reinjected and manip- cygectomy was done in 20% of pa- Magnetic resonance images also may ulated under general anesthesia by tients and had a success rate of 91%. demonstrate edema in such areas of repeatedly flexing and extending it Maigne and Chatellier6 prospec- inflammation (Fig. 4, B). Neither im- for a minute. If the treatment was suc- tively compared levator ani muscle aging modality can definitively diag- cessful initially but pain recurred, the massage, joint mobilization, and mild nose coccygodynia, nor are they as ac- curate as the compared standing and seated dynamic radiographs. Provoc- ative tests, such as needling of the painful coccygeal joint to produce pain, and relief with injection of lo- Figure 3 Lateral radiographic seated view of a 45-year-old woman with increased- cal anesthetic are helpful in diagnos- flexion coccygodynia (arrow). She fell on her ing all patients with subluxation or 2.5 years before presentation and had hypermobility and nearly half of progressive symptoms, including painful 3 bowel movements and inability to sit on a those with normal mobility. chair. Physical examination revealed a tender and nonmobile coccyx with an exquisitely ten- der distal coccygeal segment on rectal exam- ination. At 1 year postcoccygectomy, she had Nonsurgical Management complete relief from her symptoms and was able to sit normally. (Courtesy of Paul A. Nonsurgical management options in- Anderson, MD, Madison, WI.) clude nonsteroidal anti-inflammatory and analgesic medications, rest, hot baths, and a cushion to protect the coccygeal region from repetitive trau-

Vol 12, No 1, January/February 2004 51 Coccygodynia: Evaluation and Management

sisting of complete coccygectomy or simply excision of the mobile segment, should be done only after nonsurgi- cal management fails.4 Absence of physical findings or significant abnor- mal psychologic evaluation is a con- traindication to surgery. In carefully selected patients, especially those with dynamic radiographic instability or hypermobility, success rates range from 60% to 91%4,5,7-11 (Table 1). In a patient with normal coccygeal mobil- ity who fails nonsurgical care, coc- cygectomy may be recommended. However, the surgical result is less pre- dictably favorable than in patients with dynamic radiographic coccygeal in- stability or hypermobility.

Technique The patient should take an oral mechanical bowel preparation, such as saline and polyethylene glycol so- Figure 4 A 19-year-old man fell on his buttocks 2 years before presentation and had im- lution (4 L), the day before surgery. mediate onset of coccygodynia. His symptoms were chronic and disabling. A, Lateral ra- Oral neomycin, erythromycin, or diograph demonstrates posterior subluxation of the coccygeal mobile segment. B, Sagittal metronidazole are given three times T2-weighted spin-echo magnetic resonance image shows edema of the distal coccygeal seg- ments, especially the subluxated coccygeal segment. the day before surgery. Appropriate prophylactic antibiotics for bowel surgery are given 1 hour before sur- stretching of the levator ani, without ration), 8 weeks of rest with use of a gery. Postoperatively, most authori- the addition of injections. At 6 stool softener, adjustable seating, and ties recommend two or three more months, successful treatment was nonsteroidal anti-inflammatory med- doses.12 29.2% with massage, 16% with mo- ication are prescribed. If this fails to Coccygectomy is done with the pa- bilization, and 32% with stretching, relieve the symptomatic coccygo- tient in the prone position with the for a total of 25.7% overall success. dynia or the patient presents with hips and knees flexed. A vertical in- When a patient had a satisfactory re- chronic symptoms (>2 months’ dura- cision is made over the coccyx, ex- sult, it was invariably achieved with- tion), a workup is done, including tending from just above the sacrococ- in a week. Good results tended to re- standing and seated radiographs of cygeal joint into the buttock crease main stable. Patients with normal the coccyx in addition to MRI to eval- without extending it to the perianal mobility of the coccyx fared the best uate for injury edema, tumor, or oth- skin. The incision is carried down (43% success at 6 months). Those with er pathology. Stretching, massage, through the fascia and gluteus max- an immobile coccyx fared the worst and injection are usually initiated at imus muscle with meticulous dissec- (16%). The outcomes for those with this time. If these treatments are un- tion directly to the bone. Subperi- instability subluxation (22.2%) and successful or if pain recurs, coccygec- osteal dissection should be done by hypermobility (25%) were modestly tomy may be offered. gradually working side to side. The successful. Massage and stretching coccyx then should be elevated either were more effective than manipula- by working from the tip proximally tion. When therapy failed, patients Surgical Management or from the side, under direct vision. went on to injections or surgery. All segments must be removed. The Based on these studies, we have The indication for coccygectomy is sig- tip of the coccyx, which is most like- developed an evaluation and treat- nificant, disabling coccygodynia with ly to be left inadvertently, should be ment algorithm for coccygodynia5-7 radiographic subluxation; instability; separated sharply from the underly- (Fig. 5). When a patient presents with or a spicule, particularly on the tip of ing and dense fascia. With acute coccygodynia (≤2 months’ du- an immobile coccyx.2,7 Surgery, con- blunt dissection, the rectum and

52 Journal of the American Academy of Orthopaedic Surgeons Guy R. Fogel, MD, et al

History of coccygodynia confined to coccyx, no associated back pain

≤8 weeks >8 weeks

Rest; avoid sitting on coccyx; use Standing and seated radiographs stool softener, NSAIDS, anal- gesics as needed for 8 weeks

Normal Hypermobility, subluxation, mobility spicule on tip of coccyx Not improved

MRI coccyx for edema, tumor, other etiology Symptomatic relief

May offer stretching/massage of levator ani muscle and/or corticosteroid/anesthetic injection in areas of radiographic abnormality

If successful, Unsuccessful may repeat

Recurrence Offer coccygectomy

Unsuccessful; Successful; continued complete relief coccygodynia in 3-6 months

Figure 5 Evaluation and management of coccygodynia.

dense fascia then are freed to the lev- tation of the coccygeal specimen and tention, the result may be successful. el of the sacrococcygeal joint. This limit damage to the rectum and its Wound infection and delayed wound joint then may be transected and the venous drainage, which can decrease healing rates range from 2% to coccyx removed. postoperative drainage and increase 22%.4,5,7-10 In a very thin patient with The wound bed should be closely the risk of infection. a kyphotic sacrum, the remaining end examined and palpated for any re- of the sacrum may be prominent and maining segments of bone. Radio- Complications be a source of continued pain that is graphs generally are not necessary. The primary complication is not easily managed. The end of the sacrum may be perineal contamination of the wound. smoothed by rasp, rongeur, or burr. Usually a wound infection is super- Bleeding from the hemorrhoidal ficial or is a simple wound dehiscence Summary venous complex of the rectum may and will heal with intravenous anti- require ligation. Meticulous hemosta- biotics and local wound care. Deep Dynamic radiographs can help iden- sis and a tight layered closure to oblit- infection must be débrided and tify causative abnormalities in most erate dead space should be done. This drained. Antibiotics should be given. patients with coccygodynia, and technique should decrease fragmen- Even with healing by secondary in- those with normal coccygeal mobil-

Vol 12, No 1, January/February 2004 53 Coccygodynia: Evaluation and Management

Table 1 Outcomes From Coccygectomy

Study No. Patients Follow-up (yrs) Outcome

Postacchini and 36 7.8 (mean) 12 excellent, 20 good, 2 fair, 2 poor Massobrio4 Wray et al5 23 2.75 (mean) 21 excellent Maigne et al7 37 2 (minimum) 23 excellent, 11 good, 3 poor Hellberg and 55 15 (mean) 32 cured, 13 improved, 5 slightly improved, 5 dissatisfied Strange-Vognsen8 Grosso and van Dam9 9 4.7 (mean) 3 complete, 5 partial, 1 slight relief Eng et al10 27 1.5 (minimum) 9 cured, 9 improved, 6 slightly improved, 3 not improved Bayne et al11 48 7 (mean) 29 acceptable ity also may be successfully treated. nonsurgical management fails, coc- normal coccygeal mobility who fail Corticosteroid and anesthetic injec- cygectomy is usually successful in nonsurgical care, but results are less tions combined with massage or carefully selected patients with dy- predictably favorable than in patients stretching of the levator ani muscle namic instability. Coccygectomy may with dynamic radiographic coccygeal are successful in most patients. When be recommended in patients with instability or hypermobility.

References

1. Maigne JY, Tamalet B: Standardized ra- 4. Postacchini F, Massobrio M: Idiopathic coccyx. Acta Orthop Scand 1990;61: diologic protocol for the study of com- coccygodynia: Analysis of fifty-one op- 463-465. mon coccygodynia and characteristics erative cases and a radiographic study 9. Grosso NP, van Dam BE: Total coc- of the lesions observed in the sitting po- of the normal coccyx. J Bone Joint Surg cygectomy for the relief of coccygo- sition: Clinical elements differentiating Am 1983;65:1116-1124. dynia: A retrospective review. J Spinal luxation, hypermobility, and normal 5. Wray CC, Easom S, Hoskinson J: Coc- Disord 1995;8:328-330. mobility. Spine 1996;21:2588-2593. cydynia: Aetiology and treatment. 10. Eng JB, Rymaszewski L, Jepson K: Coc- 2. Maigne JY, Doursounian L, Chatellier J Bone Joint Surg Br 1991;73:335-338. cygectomy. J R Coll Surg Edinb 1988;33: G: Causes and mechanisms of common 6. Maigne JY, Chatellier G: Comparison of 202-203. : Role of body mass index three manual coccydynia treatments: A 11. Bayne O, Bateman JE, Cameron HU: and coccygeal trauma. Spine 2000;25: pilot study. Spine 2001;26:E479-E484. The influence of etiology on the results 3072-3079. 7. Maigne JY, Lagauche D, Doursounian L: of coccygectomy. Clin Orthop 1984;190: 3. Maigne JY, Guedj S, Straus C: Idiopath- Instability of the coccyx in coccydynia. 266-272. ic coccygodynia: Lateral roentgenograms J Bone Joint Surg Br 2000;82:1038-1041. 12. Norden CW: Antibiotic prophylaxis in in the sitting position and coccygeal dis- 8. Hellberg S, Strange-Vognsen HH: Coc- orthopedic surgery. Rev Infect Dis 1991; cography. Spine 1994;19:930-934. cygodynia treated by resection of the 13(suppl 10):S842-S846.

54 Journal of the American Academy of Orthopaedic Surgeons