Coccydynia: a Story Retold

Open Access Austin Journal of Surgery Special Article - Brain Tumor Surgery Coccydynia: A Story Retold Sarmast AH*, Kirmani AR and Bhat AR Department of Neurosurgery, Sher I Kashmir Institute of Abstract Medical Sciences, India Coccydynia refers to a pathological condition in which pain occurs in the *Corresponding author: Arif Hussain Sarmast, coccyx or its immediate vicinity. The pain is usually provoked by sitting or rising Department of Neurosurgery, Sher I Kashmir Institute of from sitting. Most cases are associated with abnormal mobility of the coccyx, Medical Sciences, Dalipora Kawadara Srinagar Kashmir, which may trigger a chronic inflammatory process leading to degeneration of this India structure. The exact incidence of coccydynia has not been reported; however, factors associated with increased risk of developing coccydynia include obesity Received: May 06, 2016; Accepted: October 20, 2016; and female gender. Several non operative interventions are currently used Published: October 26, 2016 for the management of coccydynia including Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), hot baths, ring-shaped cushions, intrarectal massage and manipulation (manual therapy), steroid injection, dextrose prolotherapy, ganglion impar blocks, pulsed Radio Frequency Thermocoagulation (RFT) and psychotherapy. Several studies have reported good or excellent results after coccygectomy especially in patients who are refractory to conservative treatment. Keywords: Coccydynia; Coccygectomy; Sacrococcygeal joint Introduction those with type I [10]. Anterior subluxation is a rare lesion and tends to occur in type III and type IV patterns. Posterior subluxation is The word ‘coccyx’ has its ancestry from the Greek word used the more common in the straighter type I configuration [11]. beak of the cuckoo bird due to remarkable resemblance in appearance when viewed from the side [1-3]. Maigne et al. [11] also described four types of coccyges: rigid (with or without a spicule), normal mobility, hypermobile and dislocating. Any pain that occurs in the coccyx or its immediate vicinity is termed as coccydynia, inherently referring to varied pathological Incidence & Etiology condition which gives rise to it [4]. The pain symptoms may be The exact incidence of coccydynia has not been reported; however, particularly acute when external force acts directly on the tailbone; factors associated with increased risk of developing coccydynia this typically occurs during every-day activities such as sitting. Along include obesity and female gender. Women are 5 times more likely with the bilateral ischial tuberosities, the coccyx bears the brunt of to develop coccydynia than men. Adolescents and adults are more body weight during sitting. Notably, when a seated individual leans likely to present with coccydynia than children. Anecdotally, rapid back, the weight load is borne almost entirely by the coccyx, and gives weight loss canal so be a risk factor because of the loss of mechanical rise to classic pain syndrome when a person leans backwards [5]. cushioning. The most common etiology of coccydynia is external or internal trauma. External trauma usually occurs due to a backwards Surgical treatment for coccydynia has been viewed with caution fall, leading to a bruised, dislocated, or broken coccyx. The location of historically [4] as it has been associated with high complication rates the coccyx makes it particularly susceptible to internal injury during and variable effectiveness. Better outcomes with coccygectomy have childbirth, especially during a difficult or instrumented delivery. been reported more recently [6]. The term coccydynia was coined by Simpson in 1859 [7]. The pain is usually provoked by sitting or rising from sitting position as was described by Maigne et al. [8]. They found a high diagnostic value of this symptom in predicting instability. Most cases are associated with abnormal mobility of the coccyx, which may trigger a chronic inflammatory process leading to degeneration of this structure [9]. Postacchini and Massobrio described four types of configuration of the coccyx and designated them type I through type IV. In type I, the coccyx is curved slightly forward with its apex directed downward and caudally. In type II, the forward curvature is more marked and the apex extends straightforward. In type III, the coccyx most sharply angles forward (Figure 1). Finally in type IV, the coccyx is subluxated at the sacrococcygeal or intercoccygeal joint. The coccygeal configuration also appears to influence prevalence and causative lesion. Types II, III, and IV are more prone to become painful than Figure 1: Coccyx Lat configuration. Austin J Surg - Volume 3 Issue 3 - 2016 Citation: Sarmast AH, Kirmani AR and Bhat AR. Coccydynia: A Story Retold. Austin J Surg. 2016; 3(3): 1091. ISSN : 2381-9030 | www.austinpublishinggroup.com Sarmast et al. © All rights are reserved Sarmast AH Austin Publishing Group Minor trauma canal so occur from repetitive or prolonged sitting on out pilonidal sinus & rarely perianal abscess. Rectal examination hard, narrow, or uncomfortable surfaces [11-13]. allows the coccyx to be grasped between the forefingers and thumb. Manipulation will elicit pain and may reveal hyper mobility or hypo However, a study conducted by Maigne et al. has suggested that mobility of the sacro coccygeal joint [11]. Coccydynia is also qualified only a traumatic event occurring within 1 month of onset is significant as acute or chronic. Chronic coccydynia is defined as lasting > 2 in increasing the risk of instability and subsequent coccydynia months [17]. [11,14]. They demonstrated that the proportion of patients who develop instability following a traumatic event before 1 month of Differential diagnosis onset is nearly equal to the proportions that develop instability The differential diagnosis of coccydynia coccydynia is large and without a history of trauma (55 and 53%, respectively). By contrast, includes lumbar spondylosis or disc herniation, proctalgia fugax, the instability rate was found to be 77.1% when the traumatic event levator ani syndrome, Alcock canal syndrome, descending perineal was less than a month previously [11]. syndrome, piriformis syndrome, anogenital syndrome, perianal In addition, the coccygeal lesion pattern observed in obese, abscess or fitula, and rectal tumors or teratomas [18]. Tarlov cyst normal-weight, and thin coccydynia patients markedly differs. Obese has been reported as a rare cause of coccydynia [19]. Care must be patients have mainly posterior subluxation, normal-weight patients taken to exclude patients with offending local pathological conditions have mainly hyper mobility or radio graphically normal coccyges, and or atypical symptoms from consideration for coccygectomy. thin patients have mainly anterior subluxation and spicules [11,15]. Primary coccydynia is distinguished from referred coccydynia (so- called pseudococcygodynia) [20] by infiltrating the periosteum These findings suggest the following explanation. The coccyx of a at the tender point with 10 ml of 0.25% bupivacaine and 40 mg of leaner patient normally rotates during sitting so that the coccyx is in methylprednisolone acetate, which will elicit temporary symptomatic an optimal position to absorb the forces that are generated during this relief in primary coccydynia. Although the injection provides relief of activity. As the BMI increases, the degree of pelvic rotation with sitting coccydynia, the results are typically quite temporary, rendering this is reduced and the angle of incidence is increased. Consequently, the more useful as a diagnostic tool than as a feasible long term solution. coccyx in obese patients is more susceptible to sudden elevations in Nevertheless, repeated periosteal injections may be considered a intrapelvic pressure that occur with a fall and repeated sitting down. treatment option in selected cases. Those with pseudococcygodynia This increased exposure to pressure places the coccyx at an increased should not experience relief of pain with the injection, and these risk of posterior subluxation, which as mentioned previously is the patients must not be considered for coccygectomy. typical post-traumatic lesion. Normal and below-normal weight patients are more likely to develop coccydynia consequent to lesion Diagnosis; imaging studies patterns other than posterior subluxation as their coccyges rotate in Dynamic radiographs: Single position radiographs seldom a more optimal fashion to lessen forces from falls and sitting [11,15]. demonstrate any definitive morphologic differences between normal individuals and patients with coccydynia; hence these views are not Nontraumatic coccydynia can result from a number of causes, diagnostic [10]. Dynamic radiographs obtained in both the sitting including degenerative joint or disc disease, hyper mobility or and standing positions may be more useful than static X-rays because hypo mobility of the sacrococcygeal joint, infectious etiology, and they allow for measurement of the sagittal rotation of the pelvis variants of coccygeal morphology. Coccydynia can also be radicular and the coccygeal angle of incidence. A comparison of sitting and or referred pain, although this type of pain usually is not associated standing films will yield radiographic abnormalities in up to 70% of with the hallmark coccygeal tenderness on physical examination. symptomatic coccydynia cases [21]. Dynamic radiographs are usually Less commonly, neoplasms have been associated with coccydynia. taken

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