Coccygodynia
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Coccygodynia (also referred to as coccydynia, coccalgia, coccygalgia, or coccygeal pain) is a painful syndrome affecting the tailbone (coccygeal) region. [1] The word coccyx is derived from the Greek word kokkyx (“cuckoo”), on the basis of this structure’s resemblance to the shape of a cuckoo’s beak (see the image below).
Coccygodynia is a rare condition but can be highly unpleasant when it does occur. Patients’ chief complaint is pain, which typically is triggered by or occurs while sitting on hard surfaces. The pain often varies and sometimes is aggravated by arising from the sitting position.
For most patients with coccygodynia, conservative therapy (eg, massage, injection, and ganglion impar block) appears to play a vital role in management. [2] For those with intractable pain that does not respond to conservative therapy, coccygectomy is typically effective. However, optimal specific therapy for each specific type of coccyx in coccygodynia is still a matter of debate, and no final consensus has yet been reached.
For patient education resources, see Tailbone (Coccyx) Injury and Low Back Pain.
The coccyx consists of three to five rudimentary vertebral units that are fused, except for the first coccygeal segment, which in turn articulates with the sacral cornu of the inferior sacral apex at S5 (see the image below). The sacrococcygeal articulation is either a symphysis or a true synovial joint.
Postacchini and Massobrio [3] classified coccygeal configurations into four types (see the image below).
The majority of cases of coccygodynia occur in conjunction with either a subluxated or a hypermobile coccyx (often referred to as a culprit lesion). It has been proposed that the pathologic instability may give rise to chronic inflammatory changes and pain. [4] However, the study by Postacchini and Massobrio showed that there was no statistical difference between asymptomatic patients and those with coccygodynia in terms of the numbers of coccygeal segments or the incidence of fusions between the segments. [3]
Several possible causes of coccygodynia have been described. The most common of these is a single axial trauma, such as occurs with a fall directly onto the coccyx or during childbirth. However, Maigne et al suggested that only a traumatic event that occurs within 1 month of onset is significant in increasing the risk of instability and subsequent coccygodynia. [5]
Obesity is another possible cause of coccygodynia. A body mass index (BMI) higher than 27.4 in women or 29.4 in men is a risk factor for the development of both idiopathic and posttraumatic coccygodynia. [5] As high-BMI individuals attempt to sit down, the coccyx tends to jut out posteriorly as a result of inadequate sagittal pelvic rotation. This results in increased exposure to the intrapelvic pressure that occurs with sitting, ultimately causing subluxation of the coccyx.
The coccygeal configuration (see Pathophysiology) also appears to influence the cause of pain. Types II, III, and IV are more painful than type I. [3]
Coccygodynia may also occur in individuals with a normal coccyx. In such cases, the pain may derive from secondary causes, such as tumor, infection, bursitis, or posttraumatic arthritis.
Coccygodynia accounts for fewer than 1% of all back pain conditions. [6, 7, 8] It is five times more prevalent in women than in men, [9] presumably because the bone is more prominent in women than in men. [10] Although coccygodynia can occur over a wide age range, the mean age of onset is around 40 years. [9]
Several studies have reported good-to-excellent outcomes in patients undergoing coccygectomy. [11, 12, 13]
In an analytic review of 671 patients with coccygodynia who underwent coccygectomy for failed conservative management, Karadimas et al found that the procedure provided pain relief in as many as 85% of cases. [14] The overall complication rate was 11%, including superficial as well as deep infections, delayed wound healing, infection, hematoma, and wound dehiscence.
In a study evaluating the results of 26 coccygectomies at a median follow-up of 37 months (range, 2-133 months), Kerr et al reported excellent clinical results in 13 patients, good results in nine, fair results in two, and poor results in two. [15] The overall favorable outcome rate was 84.6%, with a complication rate of 11.5% (mainly attributable to infection).
Ramieri et al reported the results of 28 consecutive coccygectomies for acute traumatic instability of the coccyx, of which 21 were total and seven were partial. [16] Of the 25 patients assessed at a mean follow-up of 33 months, 19 experienced complete pain relief, two experienced incomplete relief, and four experienced no relief. Partial coccygectomies were associated with poor results.
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Deepak Gautam, MBBS, MS Wellcome Trust DBT/India Alliance Fellow, Department of Orthopedics, All India Institute of Medical Sciences, India
Deepak Gautam, MBBS, MS is a member of the following medical societies: Indian Orthopedic Association, International Society of Orthopaedic Surgery and Traumatology, Spine Society Delhi Chapter
Disclosure: Received research grant from: Wellcome Trust/DBT India Alliance.
Rajesh Malhotra, MBBS, MS Professor and Head, Department of Orthopedics, All India Institute of Medical Sciences; Chief, JPN Apex Trauma Centre, India
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
William O Shaffer, MD Orthopedic Spine Surgeon, Northwest Iowa Bone, Joint, and Sports Surgeons
William O Shaffer, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, Kentucky Medical Association, North American Spine Society, Kentucky Orthopaedic Society, International Society for the Study of the Lumbar Spine, Southern Medical Association, Southern Orthopaedic Association
Disclosure: Received royalty from DePuySpine 1997-2007 (not presently) for consulting; Received grant/research funds from DePuySpine 2002-2007 (closed) for sacropelvic instrumentation biomechanical study; Received grant/research funds from DePuyBiologics 2005-2008 (closed) for healos study just closed; Received consulting fee from DePuySpine 2009 for design of offset modification of expedium.
Jeffrey A Goldstein, MD Clinical Professor of Orthopedic Surgery, New York University School of Medicine; Director of Spine Service, Director of Spine Fellowship, Department of Orthopedic Surgery, NYU Hospital for Joint Diseases, NYU Langone Medical Center
Jeffrey A Goldstein, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Association, AOSpine, Cervical Spine Research Society, International Society for the Advancement of Spine Surgery, International Society for the Study of the Lumbar Spine, Lumbar Spine Research Society, North American Spine Society, Scoliosis Research Society, Society of Lateral Access Surgery
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Medtronic, Nuvasive, NLT Spine, RTI, Magellan Health<br/>Received consulting fee from Medtronic for consulting; Received consulting fee from NuVasive for consulting; Received royalty from Nuvasive for consulting; Received consulting fee from K2M for consulting; Received ownership interest from NuVasive for none.
Coccygodynia
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