Coccydynia

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Initial posting by: Jonathan Stone
Coccydynia is a medical term meaning pain in the ~~coccyx[[or tailbone area, usually brought on by sitting.

Contents

Synonyms

Coccydynia is also known as coccygodynia, coccygeal pain, coccyx pain, coccaglia or (in layperson's terms) simply tailbone pain or buttache.

Etiologies

Common etiologies include:

1. Local trauma (may be associated with fracture or dislocation)
25% have a history of fall
12% have repetitive trauma (rowing machine, bicycle riding)
12% started with parturition
5% started following surgical procedure
2. Idiopathic
3. Neoplasms
Chordoma
Giant cell tumor
Intradural schwannoma
Perineural cyst
Intra-osseous lipoma
Pelvic metastases

Controversial etiologies

1. Local pressure over coccyx
2. Referred pain from herniated lumbosacral disc, cauda equina syndrome, arachnoiditis, pelvic inflammatory disease, perirectal abscess
3. Inflammation of various ligaments attached to coccyx

Evaluation

Typically the discomfort is experienced on sitting or rising from a sitting position. This entity is more common in females, possibly due to a more prominent coccyx. A number of different conditions can cause pain in the general area of the coccyx, but not all involve the coccyx and the muscles attached to it. The first task of diagnosis is to determine whether the pain is related to the coccyx. Physical examination, high resolution x-rays and MRI scans can rule out various causes unrelated to the coccyx, such as Tarlov cysts and pain referred from higher up the spine. Note that, contrary to most anatomical text books, most coccyxes consist of several segments: 'fractured coccyx' is often diagnosed when the coccyx is in fact normal or just dislocated at an intercoccygeal joint.1,2 A simple test to determine whether the coccyx is involved is injection of local anesthetic into the area. If the pain relates to the coccyx, this should produce immediate relief.3 If the anesthetic test proves positive, then a dynamic (sit/stand) x-ray or MRI scan may show whether the coccyx dislocates when the patient sits.4 Use of dynamic x-rays on 208 patients who gave positive results with the anesthetic test showed:

22% Posterior luxation (partial dislocation of the coccyx backwards when sitting)
5% Anterior luxation (partial dislocation of the coccyx forwards when sitting)
27% Hypermobility (excessive flexing of the coccyx forwards and upwards when sitting)
14% Spicule (bony spur) on the coccyx
31% Not possible to identify the cause of pain

This study found that the pattern of lesions was different depending on the obesity of the patients: obese patients were most likely to have posterior luxation of the coccyx, while thin patients were most likely to have coccygeal spicules.

Natural History

In many cases the exact cause is not known. Most cases resolve within 3 months of conservative management consisting of NSAIDs, mild analgesics, and measures to reduce pressure on the coccyx. Recurrence occurs in approximately 20% of conservatively treated cases, usually within the first year. Repeat therapy is often successful in providing permanent relief. More aggressive treatment may be considered for refractory cases.

Clinical Features

Activities that put pressure on the affected area are bicycling, horseback riding, and other activities such as increased sitting that put direct stress on the coccyx. The medical condition is often characterized by pain that worsens with constipation and may be relieved with bowel movement. Rarely, sexual intercourse can even aggravate symptoms.

Non-Surgical Treatment

Since sitting on the affected area may aggravate the condition, a cushion with a cutout at the back under the coccyx is recommended (the donut cushion traditionally recommended by doctors is generally useless for this condition). If there is tailbone pain with bowel movements, then stool softeners and increased fiber in the diet may help. For prolonged cases, anti-inflammatory or pain-relieving drugs may be prescribed. The use of anti-depressants such as Elavil (amiltriptyline) may help alleviate constant pain. Local nerve blocks are often beneficial. Manipulation of coccyx under general anesthesia, caudal epidural steroid injection, and neurolytic techniques directed at S4, S5, and coccygeal nerves can also be used to provide pain relief.

Surgical Treatment

In rare cases, surgery to remove the coccyx (coccygectomy) may be required.

External links

References

  1. Idiopathic coccygodynia. Analysis of fifty-one operative cases and a radiographic study of the normal coccyx. The Journal of bone and joint surgery. American volume. 1983 Oct; 65(8): 1116-1124. Postacchini F, Massobrio M
  2. Clinical and radiological differences between traumatic and idiopathic coccygodynia. Yonsei Medical Journal, 1999 Jun, 40:3, 215-20. Kim NH; Suk KS
  3. Coccydynia/Levator Syndrome, A Therapeutic Test. Techniques In Coloproctology, Volume 4 - No.1 - 1996. Fred A. Marx
  4. Causes and Mechanisms of Common Coccydynia: Role of Body Mass Index and Coccygeal Trauma. Spine, volume 25, number 23, 2000, 3072-3079. Maigne, J-Y, Doursounian, L, and Chatellier, G.
  5. Foye P, Buttaci C, Stitik T, Yonclas P (2006). "Successful injection for coccyx pain.". Am J Phys Med Rehabil 85 (9): 783-4. PMID 16924191.
  6. Foye 2006
7. Handbook of Neurosurgery seventh edition Mark S. Greenberg p 516-517.
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