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Coccydynia

From WikiSM

Other Names

  • Coccydynia
  • Tailbone Pain
  • Coccyx pain
  • Coccygodynia
  • Chronic coccydynia
  • Postpartum coccydynia

Background

  • This pain refers to atraumatic pain caused by or attributed to the coccyx

History

  • First termed and described by Simpson in 1859[1]

Epidemiology

  • Nathan et al[2]
    • Accounts for less than 1% of all back conditions
    • More common in women than men
  • Mean age is approximately 40
    • Increased rate of adults, adolescents compared to children[3]
Anterior and posterior illustrations of the coccyx[4]
Morphology types of the coccyx[4]

Introduction

General

  • Often considered a diagnosis of exclusion, frequently confused with lumbar pain
  • Several distinguishing features characterize coccydynia
  • Multiple etiologies can be responsible for this pain, however it is often idiopathic
  • 90% of patients do well with conservative management

Etiology: Trauma

  • Most common reason, cited in about 50% of all coccyx pain[5]
  • Trauma from a fall/ accident is cited as the most common reason in one study[6]
  • Trauma can range from mild to severe
    • Contusion with or without bony or ligamentous damage
    • To dislocated fracture of the sacrococcygeal synchondrotic complex
  • Childbirth
    • Trauma can occur internally as well
    • Childbirth places the coccyx at particular risk of injury during a difficult or instrumented delivery

Etiology: Anatomic Variances

  • Variances in coccygeal morphology can also contribute to coccydynia[7]
    • See illustration(s)
  • Type 1: Ventral curvature of the coccyx, with apex directed caudally
    • Found in more than 50% of the population
  • Type 2: Sharper ventral curvature of the coccyx, with apex directed anteriorly
    • Found in 8% to 32% of the population
  • Type 3: Acutely angulated coccyx, with apex directed anteriorly
    • Found in 4% to 16% of the population
  • Type 4: Subluxed sacrococcygeal or intercoccygeal joint
    • Found in 1% to 9% of the population
  • Type 5: Retroverted and posterior angulated apex
    • Found in 1% to 11% of the population
  • Type 6: Scoliosis or laterally subluxed coccyx
    • Found in 1% to 6% of the population
  • Woon et al[8]
    • Majority of patients with coccydynia had type I, Type II morphology
    • Lower number of patients with fused sacrococcygeal joint, higher percentage of bony spicules (female), higher intercoccygeal joint subluxation (males)
  • Shams et al[9]
    • 83.4% of patients with coccydynia had type 2 morphology
    • Higher occurrence of bony spicules, intercoccygeal joint subluxation, lower sacrococcygeal joint fusion

Etiology: Mobility

  • Theorized as a generator of coccydynia
  • 4 classes of coccygeal mobility[10]
    • Luxation (backward displacement of the coccyx while sitting)
    • Hypermobility (>25° of coccygeal flexion while sitting)
    • Immobile (<5° of coccygeal flexion or extension while sitting)
    • Normal mobility (between 5° and 25° of coccygeal flexion while sitting
  • Maigne et al[10]
    • Luxation or hypermobility could be the source of pain in idiopathic cases
    • ~50% of patients with coccydynia had luxation or hypermobility compared to 2% in controls
  • Maigne et al follow up study[11]
    • Posterior luxation (22%), anterior luxation (5.3%), hypermobility (27.4%)

Etiology: Other

  • Other causes reported in the literature
    • Tuberculosis
    • Malignancy
    • Infection
    • Excessive calcium deposits
  • Post operative infection following
    • Pilonidal cyst excision
    • Rectal prolapse

Anatomy of the Coccyx

  • Triangular shaped bone consisting of 3-5 vertebral segments
  • Sits at the caudal end of the spine
  • Articulates with sacrum to form sacrococcygeal joint
  • Attachment sites for multiple stabilizing ligaments
  • Muscle attachments: gluteus maximus, coccygeus, levator ani
  • Aids in sitting and supporting body weight

Associated Conditions

Risk Factors

Female Gender

  • Female > male by 5 fold
  • Proposed reasons
    • Inherently increased ligamentous laxity
    • Susceptible coccygeal morphology
    • Child-birthing processes

Other risk factors

  • Obesity
    • Occurs 3 times more commonly than in nonobese patients[3]
  • Contact sports
  • Osteoporosis

Differential Diagnosis

Differential Diagnosis Coccydynia

  • Coccyx fracture
  • Coccyx dislocation
  • Coccyx instability
  • Dysmorphology
  • Degenerative arthritis
  • Neuropathic pain
  • Pelvic floor spasm
  • Pilonidal cyst
  • Thrombosed hemorrhoids
  • Sacroiliac Pain
  • Infection/ osteomyelitis
  • Malignancy
  • Sciatica
  • Hemorrhoids
  • Piriformis Syndrome
  • Paraganglioma of the coccyx

Differential Diagnosis Back Pain

Clinical Features

History

  • Most commonly presents with midline lower back pain
  • Patients can typically pinpoint their pain at the "tailbone"
    • Just cephalad to the anus
  • Worse with sitting
    • Also when leaning back
  • Patients may report having to adjust how they sit
    • For exampling, sit forward in a flexed position
    • Place most of weight on one buttock
  • May be worse during defecation, sexual intercourse

Physical Exam

  • Directly tender over the coccyx
  • Rectal exam: exquisite tenderness when coccyx is grasped between two fingers, manipulated
  • May exhibit hyper/hypomobility
  • Inspect skin for the presence of pilonidal cyst, other skin lesions

Special Tests

  • Needs to be updated

Evaluation

Coccygeal angulation: (a) Type I is gently curved with the coccygeal tip directed inferiorly, (b) Type II is more curved with an anteriorly directed tip, (c) Type III is acutely angled anteriorly, (d) Type IV demonstrates anterior subluxation.[12]
Sharp forward angulation of the coccyx between its 1st and 2nd segments.[13]

Radiographs

  • Standard Radiographs Coccyx
  • Skalski et al: consider dynamic radiographs[14]
    • Obtain standing and sitting lateral radiographs
    • Excessive motion found in 69% of patients with coccydynia
    • No excessive motion in asymptomatic patients
    • Hypermobility: 25% translation (coccyx), 25° of flexion (sacrococcygeal) joint with sitting or standing

CT

  • May show fracture if radiographs inconclusive or equivocal
  • Can help better evaluate sacral morphology
  • Assess for fusion of the sacrococcygeal joint

MRI

  • Potential finings
  • Hyperintensity on T2 sequences around the sacrococcygeal joint or intercoccygeal discs

Classification

  • Not applicable

Management

Coccyx Pillow

Nonoperative

  • Indications
    • Represents the vast majority of care options
  • Warm bath soaks
  • Stool softeners
  • NSAIDS
    • Hodges et al: 60% of patients improved with NSAIDS and local CSI only[15]
  • Coccyx Cushion
    • U-shaped or wedge-shaped cushions are preferred over donut/O-shaped cushions
    • The open area can be positioned towards the back to prevent pressure from the seat being applied to the coccyx
  • Physical Therapy
    • Pelvic floor therapy has been shown to help
    • Program published by Scott et al (described below) resulted in 62% improvement in pain[16]
  • Cognitive Behavioral therapy
  • Manipulation through intrarectal route
    • May result from tense pelvic floor musculature, stiff coccyx
    • Digital rectal manipulation may potentially relax the muscles
  • Transcutaneous Electrical Nerve Stimulation (TENS)
    • Consider external and/or internal technique

Procedures

Operative

  • Indications
    • Failure of conservative therapy
  • Technique
    • Surgical resection of the coccyx
    • Coccygectomy
    • Coccygeoplasty

Rehab and Return to Play

Rehabilitation

  • One pelvic floor therapy program[16]
    • Used in patients with overactive pelvic floor muscles
    • Down training these muscles using
    • Diaphragmatic breathing
    • Perineal bulges (also known as reverse Kegels)
    • Stretching
    • Posture retaining exercises,
    • Vaginal or anal dilators

Return to Play/ Work

  • Needs to be updated

Prognosis and Complications

Prognosis

  • Conservative management
    • 90% of cases improve with conservative management
  • Surgical management
    • Patients who underwent coccygectomy for traumatic etiologies did better than those who had idiopathic pain[5]

Complications

  • Chronic Pain

See Also

Internal

External

References

  1. ↑ Simpson JY. On coccyodynia, and the diseases and deformities of the coccyx. Med Times Gaz. 1859;40:1-23.
  2. ↑ Nathan ST, Fisher BE, Roberts CS. Coccydynia: a review of pathoanatomy, aetiology treatment and outcome. J Bone Joint Surg Br. 2010;92(12):1622–7.
  3. ↑ 3.0 3.1 Garg B, Ahuja K. Coccydynia: a comprehensive review on etiology, radiological features and management options. J Clin Orthop Trauma. 2021;12(1):123-9.
  4. ↑ 4.0 4.1 Daily, Drayton, et al. "Coccydynia: A Review of Anatomy, Causes, Diagnosis, and Treatment." JBJS reviews 12.5 (2024): e24.
  5. ↑ 5.0 5.1 Pennekamp PH, Kraft CN, St ¨ utz A, Wallny T, Schmitt O, Diedrich O. Coccygectomy for coccygodynia: does pathogenesis matter? J Trauma. 2005;59(6):1414-9.
  6. ↑ Mulpuri N, Reddy N, Larsen K, Patel A, Diebo BG, Passias P, Tappen L, Gill K, Vira S. Clinical outcomes of coccygectomy for coccydynia: a single institution series with mean 5-year follow- up. Int J Spine Surg. 2022;16(1):11-9.
  7. ↑ Lirette LS, Chaiban G, Tolba R, Eissa H. Coccydynia: an overview of the anatomy, etiology, andtreatment of coccyx pain. Ochsner J. 2014;14(1):84-7.
  8. ↑ Woon JTK, Perumal V, Maigne JY, Stringer MD. CT morphology and morphometry of the normal adult coccyx. Eur Spine J. 2013;22(4): 863-70.
  9. ↑ Shams A, Gamal O, Mesregah MK. Sacrococcygeal morphologic and morphometric risk factors for idiopathic coccydynia: a magnetic resonance imaging study. Glob Spine J. 2023;13(1):140-8.
  10. ↑ 10.0 10.1 Maigne JY, Guedj S, Straus C. Idiopathic coccygodynia. Lateral roentgenograms in the sitting position and coccygeal discography. Spine (Phila Pa 1976). 1994;19(8):930–4.
  11. ↑ Maigne J, Doursounian L, Chatellier G. Causes and mechanisms of common coccydynia: role of body mass index and coccygeal trauma. Spine (Phila Pa 1976). 2000; 25(23):3072-9.
  12. ↑ Sukun, Abdullah, et al. "Imaging findings and treatment in coccydynia–update of the recent study findings." RöFo-Fortschritte auf dem Gebiet der Röntgenstrahlen und der bildgebenden Verfahren. Georg Thieme Verlag KG, 2023.
  13. ↑ Case courtesy of Rania Adel Anan, Radiopaedia.org, rID: 173757
  14. ↑ Skalski MR, Matcuk GR, Patel DB, Tomasian A, White EA, Gross JS. Imaging coccygeal trauma and coccydynia. Radiographics. 2020; 40(4):1090-106.
  15. ↑ 15.0 15.1 Hodges SD, Eck JC, Humphreys SC. A treatment and outcomes analysis of patients with coccydynia. Spine J. 2004;4(2):138-40.
  16. ↑ 16.0 16.1 Scott KM, Fisher LW, Bernstein IH, Bradley MH. The treatment of chronic coccydynia and postcoccygectomy pain with pelvic floor physical therapy. PM R. 2017;9(4):367-76.
  17. ↑ Datir A, Connell D. CT-guided injection for ganglion impar blockade: a radiological approach to the management of coccydynia. Clin Radiol. 2010;65(1):21-5.
  18. ↑ Chen Y, Huang-Lionnet JHY, Cohen SP. Radiofrequency ablation in coccydynia: a case series and comprehensive, evidence-based review. Pain Med. 2017;18(6):1111-30.
Created by:
John Kiel on 24 June 2024 16:20:07
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Last edited:
5 August 2024 16:56:05
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