Coccygectomy for refractory coccygodynia: a systematic review and meta-analysis

Advances in Coccygectomy: A Comprehensive Review Evaluating Surgical Techniques for Coccygodynia

BACKGROUND

Coccygodynia presents significant challenges in diagnosis and treatment. While coccygectomy has emerged as a crucial intervention for refractory cases, significant heterogeneity exists in surgical techniques. Traditional approaches are increasingly complemented by novel methods, necessitating a comprehensive review of current surgical options.

METHODS

A comprehensive literature review was conducted using Ovid MEDLINE, Cochrane Library and Embase databases from inception to present. Search terms included "coccygectomy", "coccydynia", "coccygodynia", "coccyx pain" and "tailbone pain". We analyzed peer-reviewed studies focusing on surgical techniques, outcomes and complications of coccygectomy. Studies were excluded if non-peer-reviewed, non-English without translation, or not directly addressing surgical management.

RESULTS

Traditional midline approaches, while common, demonstrate increased wound complications compared to paramedian techniques. Minimally invasive methods, including coccygeoplasty and endoscopic coccygectomy, show promising early outcomes with reduced recovery times. Both partial and complete resections provide significant pain relief, with complete resection potentially offering superior results in severe cases. Wound closure technique significantly impacts surgical success.

CONCLUSIONS

Optimal outcomes in coccygectomy require individualized surgical approaches incorporating modern techniques like paramedian incision and advanced wound closure. Emerging minimally invasive procedures may further reduce complications and enhance recovery. Treatment success depends on careful patient selection and surgical technique optimization.

Mind the gap: paramedian approach for coccygectomy

BACKGROUND CONTEXT

Coccydynia is pain in the coccyx that typically occurs idiopathically or from trauma. Most forms are self-limiting. However, if symptoms persist, nonsurgical treatment options can include offloading, NSAIDs, physical therapy, and steroid injections. If all treatment options fail, a growing body of evidence supports a coccygectomy for symptomatic relief. The standard approach for a coccygectomy involves a midline incision cephalad to the anus along the gluteal cleft. Historically, this method has had high rates of infection.

PURPOSE

To improve healing and decrease infection rate, we propose the paramedian approach to a coccygectomy. This approach has the benefit of distancing the surgical site from the anus, diminishing the crevice effect of the incision, and increasing the dermal and subdermal thickness for improved surgical closure.

STUDY DESIGN/SETTING

We present a case series study of 41 patients who underwent the paramedian approach coccygectomy using a 4 to 6 cm incision, approximately 0.5 to 1.5 cm lateral to the midline, for coccyx removal. These patients were evaluated postoperatively to determine infection rate and various outcome measures.

PATIENT SAMPLE

Forty-one patients suffering from refractory coccydynia had a coccygectomy via the paramedian approach between 2011 and 2022 by the senior author.

OUTCOME MEASURES

Outcome measures included self-reported measures (Oswestry Disability Index (ODI), Visual Analogue Scale (VAS) pain scale and satisfaction with procedure), physiologic measures (presence of infection and treatment provided) and functional measures (return to vocation/avocation).

METHODS

Data was compiled and transferred to Microsoft Excel and analyzed. Two-tailed T-tests were used to compare the patient improvement in VAS and ODI as appropriate for statistical analysis.

RESULTS

The patients' average age was 45.8 years. Patients' average body mass index was 27.9, with 71% of patients overweight or obese. A total of 68% of patients were female. Trauma was the most common precipitating factor (75.6%). Five patients presented with postoperative complications (12.1%), one requiring an incision and drainage, and four others were treated with antibiotics for wound erythema. Postoperative evaluations showed continual improvement, with the most significant improvement reported greater than 1-year postoperatively. The Visual Analogue Scale for pain dropped from 7.5 to 2.3 (p<.001), and the Oswestry Disability Index improved from 30.1 to 9.6 (p<.001). A total of 86.7% of patients reported either a good or excellent result.

CONCLUSION

Coccygectomies via the midline approach have a variable infection rate, likely due to proximity of the incision to the anus and due to the crevice effect of the gluteal cleft in terms of aeration. These contributing factors are overcome in the paramedian approach, making it an effective option for treating refractory coccydynia that is nonresponsive to conservative management.

Evaluation and management of chronic anorectal and pelvic pain syndromes: Italian Society of Colorectal Surgery (SICCR) position statement

Chronic pelvic pain is a hidden issue which needs to involve many different usually uncoordinated specialists. For this reason there is a risk that treatments, in the absence of well-defined pathways, common goals, and terminology, may be poorly effective. The aim of the present paper is to summarize the evidence on anorectal pelvic pain, offering useful evidence-based practice parameters for colorectal surgeons' daily activity. Analysis of chronic anorectal and pelvic pain syndromes, the diagnostic and clinical optimal needs for evaluation, and the innumerable low evidence treatments and therapeutic options currently available suggests that a multimodal individualized management of pain may be the most promising approach. The limited availability of dedicated centers still negatively affects the applicability of these principles.

Imaging findings and treatment in coccydynia - update of the recent study findings

BACKGROUND

Coccydynia is one of the most overlooked symptoms in clinical practice. The diagnosis and radiologic findings of traumatic coccyx can be more easily detected unless it is delayed and postponed. For idiopathic coccydynia, which accounts for one third of cases, patients present with long-standing pain and multiple physician visits.

METHOD

The keywords coccyx, coccydynia, coccygodynia were searched in PubMed, Embase, Scopus databases in the last 5 years. Research articles, reviews and case reports were analyzed. The studies conducted in the last 5 years were presented under the headings of etiology, radiologic assessment, interventional and surgical treatments.

RESULTS AND CONCLUSION

The first step is dynamic X-ray of the coccyx in standing and sitting position. In this way, morphologic parameters and hypermobility causing idiopathic coccydynia can be evaluated. Morphologic and morphometric features of the coccyx described in previous CT and MR studies have explained the relationship with coccydynia. The key features are as follows: Type II coccyx morphology, subluxation of the intercoccygeal joint, presence of bony spicules. Knowledge of these definitions as well as the differential diagnosis in this anatomical region will help in reaching the correct diagnosis. The treatment of coccydynia is stepwise like the diagnosis. Conservative treatments are initiated first. Manipulations, ganglion impar block, injections, radiofrequency and shock treatments and finally coccygectomy are treatment methods reported. Radiologists should not overlook this region and should be familiar with the coccyx's morphologic appearance and the sacrococcygeal region's differential diagnosis.

KEY POINTS

· The etiology of coccydynia usually includes trauma, obesity and female sex, special coccyx morphology, and coccygeal hypermobility.. · Coccyx fractures are defined into three groups as flexion type 1, compression type 2, and extension type 3.. · When evaluating coccydynia, the first step is a dynamic X-ray examination of the coccyx in standing and sitting position.. · Hypermobility is defined as more than 25 % posterior subluxation while sitting or more than 25° flexion while sitting.. · More than 35° posterior subluxation is considered significant hypermobility..

CITATION FORMAT

· Sukun A, Cankurtaran T, Agildere M et al. Imaging findings and treatment in coccydynia - update of the recent study findings. Fortschr Röntgenstr 2024; 196: 560 - 572.

Ultrasound-Guided Coccygeal Nerve Radiofrequency Ablation and Steroid Injection: Combination Therapy for Coccydynia

OBJECTIVES

Coccydynia is characterized by pain in tailbone region, which affects the quality of life. Various interventional procedures are performed for coccydynia that is unresponsive to conservative treatment. This study aimed to evaluate the efficacy of ultrasound (US)-guided radiofrequency ablation (RFA) and steroid injection of the coccygeal nerve in patients with idiopathic and traumatic coccydynia.

METHODS

In this prospective study, 32 patients with coccydynia unresponsive to conservative treatments underwent US-guided RFA of the coccygeal nerve. Coccygeal nerves were visualized at the level of the coccygeal cornua with US, 1 mL lidocaine 2% was injected into both areas and radiofrequency ablation was performed at 90°C for 60 seconds. After RFA, 2 mL dexamethasone and 2 mL bupivacaine 0.5% were injected. Visual Analog Scale (VAS) and Paris scales were used to evaluate the effect of treatment on pain and functionality before and at 1, 4, and 12 weeks after treatment.

RESULTS

We found that 54% of the patients had a >50% reduction in VAS score and 66% of the patients had a >50% reduction in Paris scores measured between baseline and week 12. Additionally, the main effect of time on the VAS and Paris scores was statistically significant (P < .001) in all measurements. Baseline P and VAS scores were higher than the post-treatment measurements (P < .001).

CONCLUSIONS

Our study showed that US-guided steroid injection and RFA of the coccygeal nerve for chronic coccydynia significantly improved pain and function scores at weeks 1, 4, and 12. RFA also results in a lower rate of adverse events. This study is the first clinical trial of ultrasound-guided coccygeal nerve RFA in patients with coccydynia. We believe that this new less invasive method may be an alternative to other interventional treatments.

Traumatic coccydynia patients benefit from coccygectomy more than patients undergoing coccygectomy for non-traumatic causes

PURPOSE

Conservative treatment is the first step in the management of coccydynia. However, surgical treatment is required in cases where conservative treatment fails. The aim of this study was to compare the effect of traumatic and atraumatic etiologies on functional outcomes in patients who underwent coccygectomy for chronic coccydynia.

METHODS

Ninety-seven patients who underwent partial coccygectomy between October 2010 and December 2018 for the diagnosis of chronic coccygodynia were evaluated retrospectively. The patients were divided into two groups according to etiologies as atraumatic (group AT) and traumatic (group T). Concomitant disorders of the patients were recorded as psychiatric and musculoskeletal diseases. Visual Analog Scale (VAS) for low back pain, the Oswestry Disability Index (ODI) scale, Short Form-36 Physical Component Summary and Short Form-36 Mental Component Summary were used to evaluate the clinical outcomes pre- and postoperative at the last follow-up.

RESULTS

The mean follow-up time was 67.3 ± 13.9 (range; 44-115) months. Group AT and group T included 48 (mean age 37.1 ± 11.3 and 36 (75%) female) and 49 patients (mean age 36 ± 11 and 35 (71.4%) female), respectively. The groups were statistically similar in terms of age (p = 0.614), gender (p = 0.691), body mass index (p = 0.885), tobacco usage (p = 0.603) and duration of pain (p = 0.073). However, the rate of musculoskeletal and total concomitant disorders was higher in the Group AT than in Group T (p < 0.05). The average preoperative SF-36 MCS and SF-36 PCS scores improved at the last follow-up from 43.3 ± 6.2 and 35.6 ± 4.9 to 72 ± 14.1 and 58.3 ± 10.9, respectively. The preoperative VAS and ODI decreased from 8 ± 1.4 and 39.8 ± 8.5 to 2.6 ± 1.8 and 13.4 ± 8.9 at the last follow-up, respectively.

CONCLUSION

Successful results were obtained with surgical treatment in chronic coccygodynia. In addition, functional outcomes in patients with traumatic etiology are better than in atraumatic ones. Levels of evidence Level III; Retrospective Comparative Study.

Management of Persistent Coccygodynia and Health Behavior: A Survey Study on Patients with Coccygodynia of Age 41 to 69 years

Objectives: Coccygodynia, with trauma as a common etiologic factor, is a clinical condition of pain around the coccygeal region. This research aimed at investigating the level of satisfaction in surgical and non- surgical treatment of coccygodynia among Turkish patients and their health behavior. Methods: There is no dearth of studies on coccygodynia; however, a clear gap in research exists of studying coccygodynia patient satisfaction of specific age groups. Turkish patients aged 41 to 69 years and suffering from coccygodynia in different public sector clinics were the respondents in this research. The major criteria of sampling were Turkish patients of coccygodynia, aged 41 to 69 years, satisfied with both surgical and non-surgical methods of treatment, and varying in the nature of the infection. Results: The study found out that coccygodynia patients had a higher probability to receive timely, successful treatment; and that there exists a positive relationship between coccygodynia patients' health behavior and coccygodynia treatment satisfaction.Conclusion: This research is a significant contribution understanding the patients with coccygodynia, and whether they improved their health in a better way with surgical or non-surgical method of treatment.

Evaluating the Optimal Management of Inoperable Giant Cell Tumors of the Spine: A Systematic Review and Meta-Analysis

Simple Summary

Spine giant cell tumors (SGCTs) are intermediate malignant bone tumors, sometimes aggressive and responsible for debilitating axial pain and sensorimotor impairments. Non-surgical therapies, including denosumab, radiotherapy, and selective arterial embolization (SAE), have shown promising results in the treatment of patients with inoperable SGCTs. In this systematic review, we aimed to comprehensively analyze the current literature on denosumab, radiotherapy, and SAE for inoperable SGCTs, comparing treatment outcomes and complications using a random-effect model meta-analysis. We found that all three treatments were equally effective in providing symptom improvement and radiological tumor response, also showing low and comparable rates of treatment-related complications. Patients treated with denosumab showed lower rates of local recurrences and distant metastases.

Abstract

Background: Surgical resection remains the preferred treatment in spine giant cell tumors (SGCTs), but it is not always feasible. Conservative strategies have been studied for inoperable cases. We systematically reviewed the literature on inoperable SGCTs treated with denosumab, radiotherapy or selective arterial embolization (SAE). Methods: PubMed, Scopus, Web-of-Science, Ovid-EMBASE, and Cochrane were searched following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to include studies of inoperable SGCTs treated with denosumab, radiotherapy or SAE. Treatment outcomes were analyzed and compared with a random-effect model meta-analysis. Results: Among the 17 studies included, 128 patients received denosumab, 59 radiotherapy, and 43 SAE. No significant differences in baseline patient characteristics were found between the three groups. All strategies were equally effective in providing symptom improvement (p = 0.187, I² = 0%) and reduction in tumor volume (p = 0.738, I² = 56.8%). Rates of treatment-related complications were low (denosumab: 12.5%; radiotherapy: 8.5%; SAE: 18.6%) and comparable (p = 0.311, I² = 0%). Patients receiving denosumab had significantly lower rates of local tumor recurrence (10.9%) and distant metastases (0%) compared to patients receiving radiotherapy (30.5%; 8.5%) or SAE (35.6%; 7%) (p = 0.003, I² = 32%; p = 0.002, I² = 47%). Denosumab was also correlated with significantly higher overall survival rates at 18 months (99.2%) and 24 months (99.2%) compared to radiotherapy (91.5%; 89.6%) and SAE (92.5%; 89.4%) (p = 0.019, I² = 8%; p = 0.004, I² = 23%). Mortality was higher in patients receiving SAE (20.9%) or radiotherapy (13.6%) compared to denosumab (0.8%) (p < 0.001), but deaths mostly occurred for unrelated diseases. Conclusions: Denosumab, radiotherapy, and SAE are safe and effective for inoperable SGCTs. Clinical and radiological outcomes are mostly comparable, but denosumab may provide superior tumor control.

Posterior epidural intervertebral disc migration and sequestration: A systematic review

Posterior epidural intervertebral disc migration and sequestration (PEIMS) is a rare and debilitating complication of degenerative disc disease. Radiological differential diagnosis is often challenging, complicating the accurate planning of appropriate treatment strategies. We systematically reviewed the literature on PEIMS, focusing on clinical-radiological features and available treatments. PubMed, Scopus, Web of Science, and Cochrane were searched to include studies reporting clinical data of patients with PEIMS. Clinical characteristics, treatment strategies, and functional outcomes were analyzed. We included 82 studies comprising 157 patients. Median age was 54 years (range, 19-91). PEIMSs occurred spontaneously (49.7%) or acutely in patients with underlying progressive degenerative disc disease (50.3%). The most common symptoms were lower-back pain (77.1%) and radiculopathy (66.2%), mainly involving the L5 nerve root (43.8%). PEIMSs were mostly detected at MRI (93%) and/or CT (7%), frequently located in the lumbar spine (81.5%). Median maximum PEIMS diameter was 2.4 cm (range, 1.2-5.0). Surgical debulking was completed in 150 patients (95.5%), sometimes coupled with decompressive laminectomy (65%) or hemilaminectomy (19.1%). Median follow-up time was 3 months (range, 0.5-36.0). Post-treatment symptomatic improvement was reported in 153 patients (97.5%), with total recovery in 118 (75.2%). All 7 patients (4.5%) who received conservative non-surgical management had total clinical recovery at ≤ 3 months follow-ups. PEIMS is a challenging entity that may severely quality-of-life in patients with degenerative disc disease. Surgical removal represents the gold standard to improve patient's functional status. Spine fusion and conservative strategies proved to be effective in some cases.