Coccydynia Evaluation & Management

Bobby Nourani, DO Disclosures

None Coccydynia

● Coccyalgia, coccygodynia, tailbone pain ● Localized pain of the coccyx ● Unreported incidence ● Many causes ○Trauma ○Non-traumatic ● Clinical diagnosis ● Large differential diagnoses Causes

• Fall • Idiopathic • Fracture

• Child delivery • Bone spur • Cancer

• Local trauma • Arthritis • Infection DDX: Chordoma

• Primary bone tumor along the spine

• Most commonly in the cervical or sacral regions

• Slow growing sarcomas

• Account for 3% of bone tumors and 20% of all spinal tumors

• 1:1,000,000

• Metastesis in 30%-40%

• Most often diagnosed in 50s and 60s www.chordomafoundation.org Seated Devices

• Roho cushion

• Donut Persistent Coccydynia

! 10% will not respond to conservative management ! Persistent cases are debilitating ! Coccyx as pelvic floor insertion site ! Soft tissue continuity with spinal and cranial structures ! Reports of anatomically-related pain following injury Treatment Options for Persistent Coccydynia

●Limited ●Many non-invasive therapies being evaluated ●Pelvic floor PT ●Insufficient evidence to conclude superior interventions ●Coccygectomy as a “Last Resort” ●Absence of Safe, Effective Therapies Indications for OMT

• Tenderness to palpation reproducing the patient’s pain

• Local pain to palpation out of proportion to patient’s or physician’s expectations with asymmetry or restricted range of motion

• Autonomic findings: emotionally labile, outbursts, crying, unusual anger, fidgety, fast talking, constipation, headaches associated with back or tailbone pain

• Traumatic injury – fall, skiing, snowboarding, horseback riding, kick to the tailbone, painful or traumatic birth Evaluation • Physician palpates the following bony and soft tissue structures evaluating for tenderness, asymmetry, restrictions, and tissue texture changes: • Lateral surface of the sacrum and coccyx. Attachments Levator ani muscle, sacrotuberous and sacrospinous ligaments: Thumb pads contact the soft tissue immediately lateral to sacrum and coccyx. Apply pressure from lateral to medial until appreciating firm bony resistance. Evaluate for rotation and sidebending at the sacrococcygeal junction or coccygeal segments. • Midline sacrum from superior to inferior. Palpate for tenderness and/or joint laxity of the sacrococcygeal junction. Continue careful palpation down each segment of the coccyx inferiorly until the inferior surface of the coccyx is reached. Note tenderness or displacement in the coronal, sagittal, or vertical axis. • Sacrococcygeal junction: Evaluate right and left sides simultaneously using thumb pads • Inferior sacrum between sacral ala and superior coccyx • Horizontal axis of sacrococcygeal junction • Lateral surface of 1st coccygeal segment • Inferior surface of 1st coccygeal segment Evaluation Case Reports: Purpose

● Describe two patients’ experiences with persistent coccydynia

● Illustrate the need for evaluation of coccydynia

● Report the effect of transrectal osteopathic manipulation therapy (OMT) for persistent coccydyna

● Report the effect of prolotherapy for persistent coccydynia Methods

!Retrospective chart review of two patients !In-person and phone interviews !Consents obtained Case #1 Results ●Before treatment: Coccydynia 9/10; 2-3 headaches per week

●Immediate improvement

●Short-term improvement at 1 week

●Lasting improving at 21 months: Coccydynia 0/10; 0-1 headaches per week Case #1 Discussion & Conclusion ●Post-traumatic coccydynia unevaluated and untreated ●4 years of low back and hip work-up, unresolved coccydynia ●Refractory pain eventually involved other areas ●Impacted QOL ●Coccyx should be considered in work-up for potentially-related pain Anatomy

!Coccygeal - Sacrum connections: ○Anterior and posterior sacrococcygeal ligaments !Sacrococcygeal ligaments progress proximally ○Anterior and posterior longitudinal ligaments ○Attach to the occipital bone Bill Kuchera, DO Thank you

Bill Kuchera, DO Bobby Nourani, DO Treatment Preparation •Chaperone

•Informed consent

•Discussion with patient describing detailed procedure: setup, patient assistance, expected duration, goals of therapy, and endpoint

•Gloves

•Lubricant

•Gauze

•Waste basket Treatment, Part 1 • Patient position, Part 1: Prone. Chest and head resting against the table

• Physician position: To the side of patient, facing the patient’s head. Physician’s dominant hand should be closest to the patient Tx Part 1, Local Soft Tissue

• With internal index finger and external thumb contacting the soft tissue structures, evaluate for tenderness or restrictions of the following: • Annococcygeal ligament • Levator Ani • Pubococcygeus muscle • Iliococcygeus muscle • Ischiococcygeus muscle • Par Superficialis • Treat if there is tenderness or restricted range of motion • Soft tissue structures are more commonly treated with indirect methods, such as myofascial release, balance ligamentous tension, ligamentous articular strain, facilitated positional release, exaggerated method, or functional technique Tx Part 2, Bone & Dura

Transition from part 1 to part 2 of treatment is seamless with physician’s finger remaining intrarectal

Patient position: Prone-propped, aka Sphinx position Prone, lumbar hyperextension, resting on elbows Tx Part 2, Bone & Dura

• Physician’s internal index finger and external thumb contact the inferior tip of the coccyx. Evaluate for tenderness or restrictions of the following: • Distal coccygeal tip • Each coccygeal segment including attachments at the transverse processes of the first coccygeal segment • Sacrococcygeal junction • Lateral sacrococcygeal ligaments • Inferior sacrum • Anterior and Posterior longitudinal sacrococcygeal ligaments • Treat if there is tenderness or restricted range of motion • Patient actively assists in treatment by moving their head and neck slowly towards and away from the barrier in all three planes of motion - flexion/extension, sidebending, and rotation. Physician maintains balanced tension until improvement in sacrococcygeal somatic dysfunction is appreciated. Tx Part 3, Soft Tissue

• Patient in prone position. Chest and head resting against the table • Physician’s internal index finger and external thumb contact the following soft tissue structures and evaluate for tenderness or restrictions: • Mid-substance and pelvic attachments of sacrotuberous and sacrospinous ligaments • Levator Ani muscle • Annococcygeal ligament • Treat if there is tenderness or restricted range of motion • Soft tissue structures are more commonly treated with indirect methods, such as myofascial release, balance ligamentous tension, ligamentous articular strain, facilitated positional release, exaggerated method, or functional technique Post Tx Evaluation

• Reassess findings from earlier evaluation

• Compare for tissue texture changes, asymmetry, restrictions, and tenderness Case #2 Results

●Before treatment: Coccydynia 7/10

●Immediate improvement

●Short-term improvement: one week following treatment

●Lasting improvement, four months following treatment: Coccydynia 0/10 Case #2 Discussion & Conclusion

●Hip, low back, buttock, and tailbone pain

●OMT alone did not work

●Prolotherapy shows promise for refractory coccyalgia

●Indication for further research Intradiscal Injections • Best responders: Luxation or hypermobility patients

• Results within one week

• 2-4 months of relief in 60%-70%

• 12 months of relief in 30% Injections

• Ganglion Impar block for sympathetically maintained pain

• Steroid injections targeting bone spurs or hyper mobile segments

• Diagnostic lidocaine blocks

Complete Anatomy 2018 Coccygectomy

• Results are dependent on the surgeon, “learning curve” • 93% success rate for luxation and hypermobility greater than 25 degrees • 4-10 month recovery Imaging Standing vs seated lateral x-rays

1. Standing:15 min

2. Seated • Sitting on hard stool • Back slightly extended • Posture in position where pain is most pronounced • Wait for pain

Pathologic if more than 25 degrees variability Jean-Yves Maigne: Treatment strategies for coccydynia. 1998 Subluxation

Jean-Yves Maigne: Treatment strategies for coccydynia. 1998 Subluxation

Courtesy of Dr Jean-Yves Maigne, Paris, France Subluxation

Courtesy of Dr Jean-Yves Maigne, Paris, France Subluxation

Courtesy of Dr Jean-Yves Maigne, Paris, France Subluxation

Courtesy of Dr Jean-Yves Maigne, Paris, France Hypermobility

Pain often associated with more ventrally curved coccyx and lack of fusion of sacrococcygeal joint

Jean-Yves Maigne: Treatment strategies for coccydynia. 1998 Hypermobility

Courtesy of Dr Jean-Yves Maigne, Paris, France Bone Spur

• Account for 15% of cases • Seen on x-ray • Best visualized with CT or MRI • Coccyx is rigid Jean-Yves Maigne: Treatment strategies for coccydynia. 1998 Bone Spur

Maigne. MRI findings in the painful adult coccyx. 2012 Eur Spine J Quality Improvement Study Novel Transrectal OMT

• University of Wisconsin outpatient clinics

• Case series

• Brief pre, post, and follow-up questionnaire

• IRB exempt Evaluation Form Informed Consent

1.Patient’s role in the decision making process 2.Clinical issue 3.Suggested treatment 4.Option for no treatment, alternatives Informed Consent

5.Potential risks and benefits 6.Related uncertainties 7.Patient’s understanding 8.Patient’s preferences and consent Additional Communication

• Detailed review of procedure and goals

• Verbal vs. written consent Minors Refer to individual state laws on informed consent

• Communication

• Documentation

• Legal Guardian

• Chaperone Physician Documentation

• Informed consent obtained

• Review of intrarectal procedure

• Goals of therapy

• Alternatives

• Potential risks and benefits Physician Documentation

• Medical necessity

• Subjective supports indications for exam and treatment

• Objective supports treatments

• Complications Chaperone Documentation

1.Witnessed informed consent by the patient

2.Chaperoned the entire duration of the transrectal procedure References

• Gray’s Anatomy - 36th, 39th, 40th, & 41st editions

• Complete Anatomy 2019

• Jean-Yvez Maigne, MD

• Patrick M. Foye, MD

• ChordomaFoundation.org

• William Kuchera, DO

• Susan Standring, PhD References

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• Nathan ST, Fisher BE, Roberts CS. Coccydynia: a review of pathoanatomy, aetiology, treatment and outcome. J Bone Joint Surg Br. 2010;92(12):1622-1627. • Gray H, Warwick R, Williams PL. Gray's anatomy. Thirty-fifth British edition / ed. Philadelphia: Saunders; 1973. • Miles J. Personal experiences of coccyx pain. Coccyx pain Web site. http://www.coccyx.org/personal/index.htm. Updated July 2, 2017. Accessed July 7, 2017. • Thiele GH. Coccygodynia: Cause and Treatment. Dis Colon Rectum. 1963;6:422-436. • Capar B, Akpinar N, Kutluay E, Müjde S, Turan A. [Coccygectomy in patients with coccydynia]. Acta Orthop Traumatol Turc. 2007;41(4):277-280. References

• Trollegaard AM, Aarby NS, Hellberg S. Coccygectomy: an effective treatment option for chronic coccydynia: retrospective results in 41 consecutive patients. J Bone Joint Surg Br. 2010;92(2): 242-245. • Howard PD, Dolan AN, Falco AN, Holland BM, Wilkinson CF, Zink AM. A comparison of conservative interventions and their effectiveness for coccydynia: a systematic review. J Man Manip Ther. 2013;21(4):213-219. •Foye PM, Buttaci CJ. Coccyx Pain Clinical Presentation. Coccyx Pain Clinical Presentation: History, Physical Examination. http:// emedicine.medscape.com/article/309486-clinical. Published March 9, 2017. Accessed July 12,2017. •Foye PM, Buttaci CJ. Coccyx Pain Differential Diagnosis. Coccyx Pain Differential Diagnosis: Diagnostic Considerations, Differential Diagnosis. http://emedicine.medscape.com/article/309486-clinical. Published March 9, 2017. Accessed July 12,2017. • Wray CC, Easom S, Hoskinson J. Coccydynia. Aetiology and

treatment. J Bone Joint Surg Br. 1991;73(2):335-338. • References

• Maigne J, Chatellier G, Le Faou M, Archambeau M. The treatment of chronic coccydynia with intrarectal manipulation: a randomized controlled study. Spine 2006;31:E621–7. • Khatri SM, Nitsure P, Jatti RS. Effectiveness of coccygeal manipulation in coccydynia: a randomized control trial. Indian J Physiother Occup Ther. 2011;5:110–2 • Wu C, Yu K, Chuang H, Huang M, Chen T, Chen C. The application of infrared thermography in the assessment of patients with coccygodynia before and after manual therapy combined with diathermy. J Manipulative Physiol Ther. 2009;32:287–93 • Spinaris T, DO, DiGiovanna ELD, FAAO. An Osteopathic Approach to Diagnosis and Treatment. Second Edition ed. Philadelphia, PA: Lippincott Williams & Wilkins; 1997. • Emerson SS, Speece AJ. Manipulation of the coccyx with anesthesia for the management of coccydynia. J Am Osteopath Assoc. 2012;112(12):805-807. •