RESEARCH ARTICLE Acta Medica Alanya 2020;4(1): 61-67. ARAŞTIRMA DOI:10.30565/medalanya.636497 Morphometric evaluation of coccyx in patients with coccydynia and classification Koksidinialı Hastalarda koksiksin morfometrik değerlendirilmesi ve klasifikasyonu Birol Özkal1*, Seda Avnioğlu2, Büşra Candan2 1 Alaaddin Keykubat University, Faculty of Medicine, Department of Neurosurgery, Alanya /Antalya, Turkey. 2 Alaaddin Keykubat University, Faculty of Medicine, Department of Anatomy, Alanya /Antalya, Turkey. ABSTRACT ÖZ Aim: This study aimed to aimed to classiffication the morphological and pathological Amaç: Koksidinalı hastalarda morfolojik ve patolojik anatominin özellikleri sınıflan- anatomic features of patients with coccydynia. dırmayı amaçladık. Patients and Method: Patients over 16 years of age who were admitted to Alanya Hastalar ve Yöntem: Nisan 2015 - Nisan 2018 tarihleri arasında Alanya Alaaddin Alaaddin Keykubat University Educational Research Hospital with complaints of coc- Keykubat Üniversitesi Eğitim Araştırma Hastanesine koksidina yakınması ile başvu- cydynia between April 2015 and April 2018, were included in the study. The sitting ran 16 yaş ve üzerindeki hastalar çalışmaya dahil edildi. Hastaların oturarak ve ayak- and standing coccyx and anterior-posterior pelvic radiographs of the patients were ta çekilen koksiks ve ön-arka pelvis grafileri retrospektif olarak incelendi. examined retrospectively. Bulgular: Koksiksin skolyozunun, hipermobilitesinin ve dislokasyonunun sakrokoksi- Results: It was observed that coccyx scoliosis, hypermobility, and dislocation were geal açılanma ile ilişkili olmadığı görüldü. Hastaların oturarak ve ayakta çekilen unrelated to sacrococcygeal angulation. There was a positive correlation between koksiks grafi ölçümlerinde sakrokoksigeal ve interkoksigeal açıları arasında pozitif sacrococcygeal and intercoccygeal angles in the measurements of sitting and stand- yönlü anlamlı bir ilişki bulundu. Ameliyat olmamış hastalarda sakrum ve koksiks uzu- ing coccyx radiographs of the patients. There was a correlation between the length nluğu arasında ve interkoksigeal açı ve koksiks uzunluğu arasında ilişki bulundu. of the sacrum and length of the coccyx and also the intercoccygeal angle and coccyx Erkeklerde sakrokoksigeal eklem uzunluğu ile sakrokoksigeal açı ilişkili bulundu. length in the unoperated patients. There was a positive correlation between length of Kadınlarda sakrokoksigeal eklemde füzyonun daha düşük olduğu tespit edildi. the sacrococcygeal joint and sacrococcygeal angle in males. Fusion in the sacrococ- Sonuç: Koksidina yakınması ile gelen hastalar değerlendirilirken koksiksin tüm cygeal joint was less in females. düzlemlerde hareket edebilen ve patoloji geliştirebilen bir omurga segmenti olduğu Conclusion: In the evaluation of patients with coccydynia, it should not be forgotten unutulmamalıdır. Bu hastaların yan ve AP pozisyonda oturarak ve ayakta çekilen di- that the coccyx is a spinal segment which can move in all planes and develop pathol- namik direkt grafilerle değerlendirilmesi patolojinin bulunmasında etkili bir yöntemdir. ogy. Side and AP positioned sitting and standing dynamic radiography is an effective Koksidinalı hastalarının sınıflandırılmasında her üç düzlemde patoloji içeren yeni method for the detection of pathology in this patients. New classification including pa- sınıflandırma gereklidir. Sınıflandırmamızın bu eksikliği gidereceğini düşünmekteyiz. thology in all three planes is needed in the classification of patients with coccydynia. We believe that our classification will eliminate this deficit. Keywords: coccydynia, coccyx, classification, Morphology Anahtar Sözcükler: Koksidinia, Koksiks, Sınıflandırma, Morfoloji Received:22.10.2019 Accepted:26.01.2020 Published (Online):02.03.2020 *Corresponding author: Birol Özkal. Alaaddin Keykubat University, Faculty of Medicine, Department of Neurosurgery. Alanya /Antalya, Turkey. Phone:+905425832869 e-mail: [email protected] ORCID: 0000-0002-4056-6936 To cited: Özkal B, Avnioğlu S, Candan B. Morphometric evaluation of coccyx in patients with coccydynia and classification. Acta Med. Alanya 2020;4(1):61-67. doi:10.30565/medalanya.636497 Acta Medica Alanya JAN- APR 2020 Open Access http://dergipark.gov.tr/medalanya 61 This article is distributed under the terms of the Creative Commons Attribution 4.0 International License. Özkal B. et al. Morphometri of patients with coccydynia and classification INTRODUCTION April 2018 with complaints of coccydynia were screened retrospectively. Patients with clear he coccyx is a conical, distal-most section of imaging of sitting and standing, side direct coccyx the spine, usually consisting of 3-4 segments. T radiography, and direct posteroanterior pelvis Although the sacrococcygeal junction may rarely radiography were included in the study. Patients fuse, it usually remains mobile for life [1,2]. with tumors in the coccyx region and patients who Coccydynia was first used by Simpson in 1859 to had previously undergone surgery in this region describe pain surrounding the coccyx exacerbated for another reason were excluded from the study. by sitting [1-3]. Its etiology includes sitting for long Our work was approved by the Ethics Committee periods of time, falling, traumas that may occur of Alaaddin Keykubat University (date 06.07.2018 during birth or spinal surgery, and less frequently, number 2 decision 8). chordoma, intraductal schwannoma, perineural On the direct coccyx radiographs of the patients, cysts, giant-cell tumor, and intraosseous lipoma. sacrum length, coccyx length, sacrococcygeal However, cases where the cause is not found are joint length, sacrococcygeal angle and also quite frequent [1-3]. Conservative methods intercoccygeal angle were measured. The number such as use of donut-shaped cushions, rest, of coccyx segments and presence of fusion in the medical treatment, physical therapy, massage, sacrococcygeal joint were evaluated. Additionally, radiotherapy, psychotherapy, sacral rhizotomy, intercoccygeal and sacrococcygeal angles were manipulation, epidural injection, and local injection measured for scoliosis, and degree of dislocation have been successfully applied in the treatment in patients with dislocation was measured with of coccydynia [1-4]. Coccygectomy surgery is dynamic radiography. For dynamic radiography, performed in patients who do not benefit from direct side coccyx radiographs of the patients conservative treatment methods [3,5]. were taken in standing position and after 15 Direct coccyx radiography along with computed minutes of standing, in an upright sitting position tomography (CT), three dimensional CT, and (Figure 1a,b). The angle between the midpoint of magnetic resonance imaging (MRI) is used to the sacrum’s upper endplate and the midpoint of evaluate patients with coccydynia, which is more the upper endplate of the first coccyx segment frequently observed in women than in men. (cocx 1), and the angle between the line drawn However, direct radiography is frequently used for from there to the end of the coccyx was evaluated evaluation due to its fast results, ease of access, as sacrococcygeal angle (Figure 2a). The angle low price, and easy dynamic filming [6-9]. between the line drawn from the first cocx midpoint to the second cocx rear lower corner and It has been reported that the morphological and the line drawn from this point to the extreme end pathoanomical features of the coccyx are important of the coccyx was evaluated as the intercoccygeal in the development of coccydynia. Clinical studies angle (Figure 2b). On the anterior-posterior pelvic use the Postacchini-Massobrio classification, radiography, the angle between the line drawn which is based on the angle of the sagittal plane from the midpoint of the upper endplate of the between the sacrum and the coccyx, and revised sacrum to the midpoint of the upper endplate of in 2010 to assess the coccyx. The movement and cocx 1 and the line drawn from this point to the tip hypermobility of the coccyx’s sagittal, coronal, and of the coccyx was evaluated as the scoliosis angle horizontal plane may lead to coccydynia [1,2,10- (Figure 3). Patients who underwent surgery were 12]. In this study, we aimed to classiffication the identified among these patients. morphological and pathological anatomic features Statistical Analysis of patients with coccydynia. All measurements were evaluated by anatomists PATIENTS AND METHODS using the Winsoft RIS / PACS Ver.2.2.39 In our study, patients aged 16 years or older imaging server. IBM SPSS for Windows version who were admitted to Alanya Education and 20.0 software program (IBM Corp., Armonk, Research Hospital between April 2015 and NY, USA) was used for statistical analysis. Acta Medica Alanya 2020:4:1 62 Özkal B. et al. Morphometri of patients with coccydynia and classification Correlation between sacrum and coccyx length, between intercoccygeal angle and coccyx length, between joint length and sacrococcygeal angle, and between sacrum and coccyx length and intercoccygeal angle of patients who were and weren’t operated were evaluated by Pearson correlation tests. Correlation between number of segments and angle types and the relationship between non-operative status and angle types were assessed with the Chi Square test. The Figure 3. The region marked α is assessed as the scoliosis angle t-test was used to determine whether there was a significant difference between intercoccygeal RESULTS angle and sacrococcygeal angle and number A total of