Orthopedic Reviews 2020; volume 12:8813

Resection of the coccyx as an treatment and injection therapy have failed outpatient procedure patients can be treated surgically with Correspondence: Ante M. Kalstad, coccygectomy.1,2 Department of Orthopaedic Surgery, St. Traditionally, coccygectomy patients Olav’s University Hospital, 7006 Trondheim, 1-3 Ante M. Kalstad, spend several days in hospital after their Norway. 1 Tel.: +47 90888107 Rainer G. Knobloch, operation. In the 1990s, the average stay 1,3 E-mail: [email protected] Vilhjalmur Finsen after this procedure was 7-10 days.3 1Department of Orthopaedic Surgery, Outpatient surgery (also known as day Key words: Coccyx; tailbone; coccygectomy; St. Olav’s University Hospital, surgery, same-day surgery or ambulatory outpatient surgery; ambulatory surgery. Trondheim; 2Norwegian Armed Forces surgery) refers to surgical procedures that are Funding: None. Joint Medical Services; 3Faculty of performed without staying overnight in the hospital. Following advances in peri- and Medicine, Norwegian University of Conflict of interest: The authors declare no postoperative pain control regimens and Science and Technology, NTNU, conflicts of interest. early rehabilitation protocols there has been Trondheim, Norway a trend in other areas of surgery towards Ethics approval: The study protocol was performing more outpatient procedures. In reviewed by the Regional committee for med- recent years, this has included procedures ical and health research ethics in Central such as unicompartmental knee arthroplasty, Norway (2016/460) who found that it did not Abstract and even total hip arthroplasty,4 commonly need their approval. regarded as an inpatient procedure. This We wished to determine if Availability of data and materials: Data and coccygectomy as an outpatient procedure is development has the benefit of reducing materials are available in the main text. a safe alternative to inpatient treatment. 68 costs and instigating early rehabilitation, without compromising results or patient Received for publication: 26 July 2020. patients were treated at our institution with 5,6 coccygectomy as an outpatient procedure satisfaction. Accepted for publication: 16 August 2020. In line with this trend, we have during a seven-year period. Out of these 61 This work is licensed under a Creative (90%) responded to final follow-up performed coccygectomy as an outpatient procedure in selected patients and now Commons Attribution NonCommercial 4.0 questionnaires after a minimum of one year. License (CC BY-NC 4.0). We recorded satisfaction with the outpatient wished to review our results. modality, and compared postoperative The purpose of this study was to ©Copyright: the Author(s), 2020 complications and long-term satisfaction determine if outpatient surgery of the coccyx Licensee PAGEPress, Italy with patients who had been operated as is a safe alternative to hospitalization. Orthopedic Reviews 2020;12:8813 inpatients during the same period. Out of the doi:10.4081/or.2020.8813 61 patients who responded to final follow up, 39 (64%) were satisfied with having the operation as an outpatient procedure. The Materials and Methods patients who would have preferred overnight The standard pain prescription was Patients were referred to us by general hospitalization generally felt that traveling paracetamol, tramadol, and diclofenac, practitioners and other hospitals when non- home the same day was painful. There was although some individualization was invasive treatment had failed. All diagnoses significantly less pain on the journey home performed as needed. were confirmed by a senior spinal surgical if the procedure had been performed under Out of the 68 outpatients, 52 had consultant (RGK) based on a thorough spinal anaesthesia. In terms of medical history, clinical examination and undergone a course of one to three complications, there were 10% reoperations imaging with either coccygeal radiographs, corticosteroid injections (42 had one due to deep infection in the outpatient group, MRI, or both. injection, 9 had two injections, and one had and 12% superficial wound infections In case of severe symptoms, patients three injections) without a lasting treated with oral antibiotics. The were initially offered targeted injections with satisfactory result. corresponding numbers for the in-patient a mixture of lidocaine and corticosteroid. If Surgery was performed under either group were 8% and 14%. The long-term this treatment failed to give lasting results, spinal or general anesthesia with antibiotic success rate was similar for both groups. patients were offered surgery. prophylaxis started preoperatively 87% of outpatients and 89% of inpatients (Cephalotin 2g intravenously every 90 reported that they would have consented to A total of 184 patients were operated in our department for coccydynia between minutes, 4 doses in total, and one oral dose the operation if they had known the result in of Metronidazole 1g). Resection of the advance. Coccygectomy as an outpatient 2009 and 2016. A total of 68 were operated coccyx was done at the most proximal procedure gives similar results to inpatient as outpatients while 116 were admitted to the mobile segment, with the technique treatment and can be regarded as an ward until the day after surgery. Selection described by Key,7 through a 4-5 cm midline acceptable alternative. Spinal anaesthesia was mainly on geographic grounds. Those incision and subperiosteal removal of the reduces postoperative pain on the journey who had less than two hour’s travel to their coccyx with monopolar and bipolar home. home were treated as outpatients provided they were classified as ASA 1 or 2 on the diathermy. Before closure, 20 ml of American Society of Anesthesiologists Ropivacaine 7.5 mg/mL was infiltrated into Introduction classification. These patients were the area. discharged from the hospital after a 3-6 hour Outpatients were telephoned by an Chronic coccydynia, or tailbone pain, postoperative observation period with orthopedic nurse on the day after surgery to may be severe and resistant to conservative prescriptions for oral pain medication and inquire about how they were doing and treatment. In cases where conservative follow-up instructions. address any postoperative concerns.

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Traditional physician-led morning rounds The remaining 39 were operated under a preferred a longer hospital stay. were performed for inpatients. general anaesthetic, and all were satisfied Others have found that there is less All patients were reviewed clinically 3- with this. Of the 61 outpatients at final postoperative pain in outpatient procedures 4 months after their operation and were follow-up, 39 were satisfied with having the such as knee arthroscopy and lower followed up with a questionnaire at a operation as an outpatient procedure, while abdominal surgery when performed under minimum of 12 months after treatment. If 18 explained that completing the journey spinal anaesthesia, rather than a general the operation had been performed as an home the same day had been more painful anaesthetic.8 Our findings show that the outpatient procedure, we included a separate than anticipated. The remaining four patients patients who were operated under spinal questionnaire to evaluate satisfaction with would have preferred overnight anaesthesia had significantly less pain on this modality. Patients who had not hospitalization for other practical reasons. 15 their journey home. As a consequence, we responded to the questionnaires were (83%) of the patients who felt the journey are now performing most coccygectomies reminded by telephone after 6 weeks and home had been too painful had been under spinal anaesthesia. received new questionnaires if they wished. operated under a general anaesthetic, while Reviewing our data, we have A total of 171 (92%) operated patients only 3 (17%) patients had had a spinal nevertheless been compelled to explore more responded to the final follow-up. We have, anaesthetic (p=0,048). Out of the 34 patients effective pain treatment protocols to make however, included all patients when with less than 30 minutes travel time home, the journey home more tolerable. The recording postoperative complications 10 (29%) reported dissatisfaction because addition of pre-operative gabapentin as an during the first three months after surgery. their journey was too painful. Among the 27 adjunct in multimodal pain management has The mean follow-up was 39 (range 12- patients with 30-120 minutes travel time, been advocated for several procedures9 and 85) months. In the outpatient group there eight (30%) reported the same. With regards has now been added to our protocol. Only were 9 males and 59 females. Their mean to the first day follow-up call by a nurse, one patient was dissatisfied with having a age at referral was 40 (17-70) years. In the only one was dissatisfied with this. nurse telephone for the first-day follow-up. hospitalized group there were 19 males and Complications This is an established method of follow-up 97 females. Their mean age was 37 (11-75) for other types of outpatient surgery10 and None of our outpatients were re- years. seems applicable to this procedure as well. hospitalized for postoperative pain Out of the 68 outpatients, 61 (90%) Coccygectomy as an outpatient management after their initial discharge. responded to our final follow-up. They had procedure has to our knowledge not Seven patients (10%) in the outpatient had symptoms of coccydynia for a mean of previously been described in the literature. group developed deep postoperative 36 (4-252) months before presentation. There is however considerable literature infection requiring operative debridement. There were six patients who were about other procedures that have recently They were re-operated 3-5 weeks after their intended as outpatients but converted to been transformed to outpatient initial surgery and went on to subsequent inpatients. Four were due to insufficient procedures.5,6,11 One of the key components healing. There were a further eight patients postoperative pain relief, one to dizziness, to this is patient selection. We have limited (12%) with spots of serous drainage from the and one to delayed start of surgery. our patient selection to postoperative travel wounds persisting beyond the first 1-2 We also recorded the time it had taken distances within 2 hours, granted that the weeks. As there were no other infective for patients to travel home after surgery. patients are medically fit, with an ASA score signs, they were regarded as superficial There were 34 patients residing in the same of <2. We had expected increasing travel municipality as our hospital, and therefore wound infections, and resolved with a course of oral antibiotics. time home after surgery to correlate with assumed to have less than 30 minutes travel more pain. Surprisingly, a similar proportion time home, and 27 patients who lived in In comparison, out of the 116 patients who were operated as inpatients, nine (8%) of patients reported undue pain on their surrounding municipalities and were journey home, regardless of how close to the assumed to need between 30 and 120 were subsequently re-operated due to infection, while 16 (14%) were treated with hospital they lived. Two of our outpatients minutes to get home. were adolescents (17 years) at the time of the Statistical testing of categorical data was antibiotics for superficial wound infections. There were no significant differences in operation. We have not performed this done with the chi-square test. procedure as an outpatient procedure in The study was reviewed by the Regional either postoperative infections or long-term satisfaction between the groups, nor any younger patients than 17 years, but have committee for medical and health research previously found that adolescent ethics in Central Norway (2016/460) who difference in satisfaction between patients with short or long journeys home after coccygectomy patients in general have found that it did not need their approval. 12 surgery. similar results to adults. There is comparable literature available on other orthopaedic outpatient procedures in adolescent populations,13 which would Results Discussion suggest that this could also be an acceptable treatment option. Our number of infections Satisfaction About one third of our outpatients stated leading to re-operations were 10% and 8% In the outpatient procedure group 53 that they would have preferred to stay at the for the out- and inpatient groups, but when (87%) reported that they would have hospital post-operatively, mainly because the counting superficial wound problems treated consented to the operation if they had known journey home had been painful. A limitation with antibiotics, the total number of the outcome in advance, compared to 98 of this study was that we did not have infections were found to be 22% for both (89%) of the inpatients. comparable data for the inpatients with groups. Coccygectomy traditionally carries Out of the 22 patients who had been regard to discomfort at the time of discharge. a high rate of postoperative infection and operated under spinal anaesthesia, 20 were It is likely that a considerable proportion of wound dehiscence. The rates are variable in satisfied with this, while two stated that they the inpatients may also have had enough the published literature. There have been would have preferred a general anaesthetic. pain at the time of discharge to have published series reporting infection rates

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