Coccydynia

Definition

 

Pain in region of coccyx

 

Epidemiology

 

Women

- often obese

- mean age 40 years

 

Aetiology

 

Fracture

 

Difficult vaginal delivery

 

Subluxation / hypermobile coccyx

 

Anatomy

 

3 or 4 fused coccygeal vertebrae

 

Triangular structure

 

Usually a joint with sacrum

- can be fused

 

Pathology

 

Symptomatic patients

- no evidence increased number of segments

- often more angular

- increased rate of sacral - coccygeal fusion

 

Symptoms

 

Pain in coccyx

Difficulty sitting

 

Signs

 

Painful to touch

 

Xray

 

Coccyx Xray

 

Dynamic radiographs

- standing and sitting radiographs

- looking for hypermobility

- > 25o

 

Note: Not all coccygodynia is from hypermobile coccyx

 

Spicule on coccyx

- may be seen in immobile coccygodynia

 

Bone scan / MRI

 

Show inflammation

 

Management

 

Non Operative

 

Options

 

Analgesia

Cushions

HCLA

 

HCLA

 

1.  HCLA

 

Mitra Pain Physician 2007

- injection HCLA under II in 14 patients

- patients with acute pain / < 6 months fared much better

 

2.  Manipulation

 

Maigne et al Spine 2006

- randomised trial of intra-rectal manipulation (x3) v physiotherapy

- mild improvements in group with manipulation

- best results in patients with acute, traumatic coccydynia

 

Operative

 

Excision of Coccyx

 

Preparation

 

Bowel prep

 

Oral metronidazole

- 24 hour treatment

- day before surgery

 

Pre-op and post operative antibiotics

- Penicillin / Gentamicin / Metronidazole

 

Technique

- patient prone on 4 poster

- want to flex hips as much as possible

- vertical incision away from perianal skin

- through fascia

- G max reflected

- subperiosteally dissect coccyx

- ensure don't leave tip

 

Results

 

Trollegard et al JBJS Br 2010

- 41 patients with coccygectomy

- post trauma / childbirth / idiopathic onset

- 33/41 good or excellent results

- 5 superfical infections