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Frolov D, Zhu K, Rusev M, Geiger K, Fuller C, Schmitz MA. Mind the gap: paramedian approach for coccygectomy. Spine J 2024:S1529-9430(24)00170-0. [PMID: 38643949 DOI: 10.1016/j.spinee.2024.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 04/08/2024] [Accepted: 04/12/2024] [Indexed: 04/23/2024]
Abstract
BACKGROUND CONTEXT Coccydynia is pain in the coccyx that typically occurs idiopathically or from trauma. Most forms are self-limiting. However, if symptoms persist, non-surgical 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 non-responsive to conservative management.
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Affiliation(s)
- David Frolov
- Washington State University, Elson S. Floyd College of Medicine 412 E Spokane Falls Blvd, Spokane, WA, USA.
| | - Kai Zhu
- Washington State University, Elson S. Floyd College of Medicine 412 E Spokane Falls Blvd, Spokane, WA, USA
| | - Maksim Rusev
- Washington State University, Elson S. Floyd College of Medicine 412 E Spokane Falls Blvd, Spokane, WA, USA
| | - Kyle Geiger
- University of Iowa Health Care, Department of Orthopedics and Rehabilitation, 200 Hawkins Drive, Iowa City, IA, USA
| | - Carson Fuller
- Harbor-UCLA Medical Center, Department of Orthopedic Surgery, 1000 W Carson St, Torrance, CA, USA
| | - Miguel A Schmitz
- Washington State University, Elson S. Floyd College of Medicine 412 E Spokane Falls Blvd, Spokane, WA, USA; Alpine Orthopaedic and Spine, P.C., 212 E Central Ave #365, Spokane, WA, USA
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Galanakos SP, Karakousis ND, Bablekos G, Fontara S. Coccygeal Disc Disease as a Possible Cause of Coccygodynia. Acta Med Acad 2023; 52:231-235. [PMID: 38095179 PMCID: PMC10945321 DOI: 10.5644/ama2006-124.418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 07/18/2023] [Indexed: 02/27/2024] Open
Abstract
OBJECTIVE The aim of the present study was to describe the causes involved in the pathophysiology of coccydynia, emerging from the coccyx or the anatomical tailbone region. CASE REPORT We present the case of a 64-year-old man with pain in the coccyx and numbness in the perianal area. After clinical examination and imaging evaluation, including plain X-rays and magnetic resonance, coccygeal disc disease was identified. Other findings, such as tumor and fracture were excluded. We decided to undertake conservative management and the pain was eventually relieved. This is the first case report of coccygodynia and perianal numbness attributed to coccygeal disc disease. CONLCUSION Although there is no standard treatment, coexisting coccygeal disc disease should be always taken into account, with clinical and imaging examinations being considered of major importance to establish both medical diagnosis and treatment.
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Affiliation(s)
- Spyridon P Galanakos
- Primary Health Care, Orthopedics and Trauma, Amarousion Health Center, Attica, Greece.
| | | | - George Bablekos
- Biomedical Sciences, Occupational Therapy and Nursing, University of West Attica, Athens, Greece
| | - Sophia Fontara
- Henry Dunant Hospital Center, Radiology Department, Athens, Greece
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Nagappa S, Alshameeri Z, Elmajee M, Hashmi Y, Bowry A, Jones M, Spilsbury J. Clinical Outcome of Coccygectomy Using a Paramedian Curvilinear Skin Incision in Adults and Children With Meta-Analysis of the Literature Focusing on Postoperative Wound Infection. Global Spine J 2023; 13:1878-1893. [PMID: 34875185 PMCID: PMC10556909 DOI: 10.1177/21925682211058155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN A single surgeon case series and meta-analysis of literature. OBJECTIVE To evaluate the clinical outcome and patient satisfaction following coccygectomy for coccygodynia in adults and children using a curvilinear paramedian skin incision and to conduct a meta-analysis of the literature to determine the associated infection rate with different surgical factors. METHODS 45 consecutive patients (40 adults and 5 children) underwent surgical coccygectomy for persistent coccygodynia symptoms using a paramedian curvilinear incision. Postoperative clinical outcome scores, patients' satisfaction and wound complications were assessed. A systematic literature search using specific MesH terms was then conducted covering the period from 1980 to 2020. Only those studies reporting infection rates post coccygectomy were included in a meta-analysis. RESULTS The average age of patients was 39 years with a mean duration of symptoms prior to surgery of 7.4 years. The mean Oswestry Disability Index improved from 29 to 7.7 (P < .001). The mean pain Visual analogue scale improved from 8 to 2 (P < .001) and the median patient satisfaction score was 8 (out of 10) suggesting good to excellent outcome. The clinical improvement was the same in children and adults. There was a total of 5 (11%) wound infections, 2 of which needed surgical debridement. Meta-analysis of the included studies showed that the use of prophylactic antibiotics for 24 hours, nonabsorbable skin sutures and glue were associated with low infection rate. CONCLUSIONS Coccygectomy using curvilinear paramedian skin incision for chronic coccygodynia is an effective procedure with similar or lower complication rates as reported in the literature.
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Affiliation(s)
- Satish Nagappa
- Department of Spine Surgery, The Royal Orthopaedic Hospital, Birmingham, UK
- Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
| | - Zeiad Alshameeri
- Department of Spine Surgery, The Royal Orthopaedic Hospital, Birmingham, UK
- University Hospitals of North Midlands, Royal Stoke University Hospita, Stoke-on-Trent, UK
| | - Mohammad Elmajee
- Department of Spine Surgery, The Royal Orthopaedic Hospital, Birmingham, UK
| | - Yousuf Hashmi
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Ajay Bowry
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Morgan Jones
- Department of Spine Surgery, The Royal Orthopaedic Hospital, Birmingham, UK
| | - Jonathan Spilsbury
- Department of Spine Surgery, The Royal Orthopaedic Hospital, Birmingham, UK
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Wessell JE, Eskandari R. Minimally Invasive Coccygectomy: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2022; 23:e121. [PMID: 35838466 DOI: 10.1227/ons.0000000000000227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 02/09/2022] [Indexed: 01/17/2023] Open
Affiliation(s)
- Jeffrey E Wessell
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
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Manfre L, Gil I, Baptista T, Calvão Pires P, de Vivo AE, Masala S, Chandra RV, D'Anna G, Hirsch JA. Coccygeoplasty: preliminary experience with this new alternative treatment of refractory coccydynia in patients with coccyx hypermobility. J Neurointerv Surg 2022; 15:82-85. [PMID: 35882554 DOI: 10.1136/neurintsurg-2021-018149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 02/09/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Coccydynia has many causes, including fracture, subluxation, and hypermobility of sacrococcygeal segments. Existing treatments are limited in their effectiveness. Coccygeoplasty (CP) is a relatively new, minimally invasive treatment that appears to address this difficult clinical challenge. OBJECTIVE To describe clinical results at the time of the procedure and at 3- and 12-months' follow-up of patients with coccydynia related to subluxation and coccyx hypermobility treated with the CP technique. Additionally, to determine if there is any correlation between the final imaging and clinical results at 3- and 12-months' follow-up. METHODS A prospectively maintained database was used, and all patients who underwent CP for chronic coccydynia between January 2005 and October 2018 were retrospectively reviewed. All the patients had painful hypermobility (greater than 25°) with anterior flexion confirmed on radiological imaging. Alternative causes of coccydynia were excluded using CT and MRI. Procedures were performed under local anesthesia with combined fluoroscopic and CT guidance. Clinical follow-up was performed at two time points: 3 and 12 months after treatment using the Visual Analogue Scale (VAS). RESULTS Twelve patients were treated in a single center. No procedural complications occurred. At 3- and 12-months' follow-up, the majority (75%) of patients had significantly lower VAS scores than at baseline, with mean changes of 3.5 and 4.9, respectively. There was no pain recurrence at 12 months and just one patient had no improvement of the pain. Follow-up CT images confirmed fixation of the sacrococcygeal bone segments in nine patients; however, no correlation was found between final imaging results and clinical outcome (p=0.1). CONCLUSIONS Patients with refractory painful coccyx subluxation and hypermobility undergoing CP have a favorable clinical response at 3- and 12-months' follow-up. Further studies are required to validate this technique and to identify predictors of treatment response. Coccygeoplasty may be considered a reasonable alternative to coccygectomy.
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Affiliation(s)
- Luigi Manfre
- Department of Radiology, IOM Mediterranean Oncology Institute, Viagrande, Italy
| | - Inês Gil
- Department of Neuroradiology, Centro Hospitalar do Algarve EPE, Faro, Portugal
| | - Tiago Baptista
- Department of Neuroradiology, Oxford University Hospitals NHS Trust, Oxford, UK.,Department of Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | - Pedro Calvão Pires
- Department of Neuroradiology, Centro Hospitalar de Lisboa Ocidental EPE, Lisboa, Portugal
| | - Aldo Eros de Vivo
- Department of Radiology, IOM Mediterranean Oncology Institute, Viagrande, Italy
| | - Salvador Masala
- Department of Diagnosis Imaging Interventional Radiology and Clinical Pathology, Ospedale San Giovanni Battista, Roma, Italy
| | - Ronil V Chandra
- Department of Interventional Neuroradiology, Monash Health, Clayton, Victoria, Australia.,Department of Image, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
| | - Gennaro D'Anna
- Department of Radiology, IRCCS Istituto Clinico Humanitas, Rozzano, Italy
| | - Joshua A Hirsch
- NeuroEndovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
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Abstract
STUDY DESIGN This is a retrospective cohort study. OBJECTIVE The aim of this article was to evaluate the results of patients operated for chronic coccydynia, and determine any factors that could affect outcomes. SUMMARY OF BACKGROUND DATA Patients with coccydynia who do not respond to conservative treatment will often profit from coccygectomy. Studies of results and complications vary considerably and often report on a limited number of patients. Methods. A total of 184 patients were operated with coccygectomy in our department and followed-up with questionnaires after a minimum of 1 year post-operatively. Treatment results were compared to their preoperative state, and any complications or reoperations were recorded and analyzed. Results. A total of 171 patients (93%) responded to final follow-up. The overall success rate was 71%, defined by patients being either completely well or much better at final follow-up. Furthermore, 89% off all patients would have consented to the operation if they had known the outcome in advance. The rate of post-operative infections was reduced from 10% to 2% by increasing the duration of prophylactic postoperative antibiotics from 24 to 48 hours (P = 0.018). CONCLUSION Coccygectomy, for patients where conservative measures have failed, seems to give acceptable levels of success and high levels of patient satisfaction. The main complication after this procedure is infection, and the risk can be somewhat reduced by using antibiotic prophylaxis for 48 hours after surgery. LEVEL OF EVIDENCE 4.
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König MA, Grifka J, Benditz A. A novel radiological classification for displaced os coccyx: the Benditz-König classification. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:10-17. [PMID: 34495391 DOI: 10.1007/s00586-021-06971-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 07/01/2021] [Accepted: 08/18/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Treatment of coccygodynia is still a challenging entity. Clear surgical selection criteria are still lacking. The aim of the investigation was to establish a novel radiological classification for surgical decision-making in coccygodynia cases. MATERIAL AND METHODS Retrospective analysis of standing and sitting X-rays of coccygodynia patients referred to a single centre from 2018 to 2020. The sacro-coccygeal angle (SCA), the intra-coccygeal angle (ICA) and the difference of the intervertebral disc height (∆IDH) were measured. All coccyges were distributed in subtypes and correlated with the patients' treatment. RESULTS In total, 138 patients (female/male: 103/35) with a mean age of 45.6 ± 15.4 years were included in the study. In total, 49 patients underwent coccygectomy. Four different subtypes of displaced coccyges were identified: Type I with a non-segmented coccyx, anterior pivot, increased SCA and ICA from standing to sitting, ∆IDH = 1.0 ± 1.5 mm. Type II with a multisegmented coccyx, anterior pivot, increased SCA and ICA standing/sitting, ∆IDH = 1.1 ± 1.6 mm. Type III showed a posterior pivoted coccyx, negative SCA and ICA, ∆IDH = 0.6 ± 1.6 mm. Type IV is characterized by an anterior-posterior dissociation of the tail bone with a positive SCA, and the ICA shifted from a posterior to an anterior orientation. ∆IDH was - 0.6 ± 1.8 mm. CONCLUSION The presented radiological classification could help to facilitate the surgical decision-making for patients with displaced os coccyx. In addition, lateral and sitting X-rays were easy to perform and did not need unnecessary ionizing radiation like in CT scans and were more cost-effective than MRI investigations. The subtypes III and especially IV were more likely leading to surgery.
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Affiliation(s)
- Matthias A König
- Department of Orthopedic Surgery, Regensburg University Medical Center, Bad Abbach, Germany.
| | - Joachim Grifka
- Department of Orthopedic Surgery, Regensburg University Medical Center, Bad Abbach, Germany
| | - Achim Benditz
- Department of Orthopedic Surgery, Regensburg University Medical Center, Bad Abbach, Germany
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Sagoo NS, Haider AS, Palmisciano P, Vannabouathong C, Gonzalez R, Chen AL, Lokesh N, Sharma N, Larsen K, Singh R, Mulpuri N, Rezzadeh K, Caldwell C, Tappen LA, Gill K, Vira S. Coccygectomy for refractory coccygodynia: a systematic review and meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 31:176-189. [PMID: 34694498 DOI: 10.1007/s00586-021-07041-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 09/11/2021] [Accepted: 10/18/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE We sought to systematically assess and summarize the available literature on outcomes following coccygectomy for refractory coccygodynia. METHODS PubMed, Scopus, and Cochrane Library databases were systematically searched in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data concerning patient demographics, validated patient reported outcome measures (PROMs) for pain relief, disability outcomes, complications, and reoperation rates were extracted and analyzed. RESULTS A total of 21 studies (18 retrospective and 3 prospective) were included in the quantitative analysis. A total of 826 patients (females = 75%) received coccygectomy (720 total and 106 partial) for refractory coccygodynia. Trauma was reported as the most common etiology of coccygodynia (56%; n = 375), followed by idiopathic causes (33%; n = 221). The pooled mean difference (MD) in pain scores from baseline on a 0-10 scale was 5.03 (95% confidence interval [CI]: 4.35 to 6.86) at a 6-12 month follow-up (FU); 5.02 (95% CI: 3.47 to 6.57) at > 12-36 months FU; and 5.41 (95% CI: 4.33 to 6.48) at > 36 months FU. The MCID threshold for pain relief was surpassed at each follow-up. Oswestry Disability Index scores significantly improved postoperatively, with a pooled MD from baseline of - 23.49 (95% CI: - 31.51 to - 15.46), surpassing the MCID threshold. The pooled incidence of complications following coccygectomy was 8% (95% CI: 5% to 12%), the most frequent of which were surgical site infections and wound dehiscence. The pooled incidence of reoperations was 3% (95% CI: 1% to 5%). CONCLUSION Coccygectomy represents a viable treatment option in patients with refractory coccygodynia.
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Affiliation(s)
- Navraj S Sagoo
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, MC 8855, USA
| | - Ali S Haider
- Deparment of Neurosurgery, MD Anderson Cancer Center, Houston, TX, USA
| | - Paolo Palmisciano
- Department of Neurosurgery, Trauma and Gamma Knife Center, Cannizzaro Hospital, Catania, Italy
| | - Christopher Vannabouathong
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, MC 8855, USA
| | - Roberto Gonzalez
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, MC 8855, USA
| | - Andrew L Chen
- Department of Orthopaedic Surgery, Texas Tech University School of Medicine, Lubbock, TX, USA
| | - Nidhish Lokesh
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, MC 8855, USA
| | - Neha Sharma
- Roseman University of Health Sciences, South Jordan, UT, USA
| | - Kylan Larsen
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, MC 8855, USA
| | - Ravinderjit Singh
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, MC 8855, USA
| | - Neha Mulpuri
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, MC 8855, USA
| | - Kevin Rezzadeh
- 6Department of Orthopaedic Surgery, Cedars-Sinai Orthopaedics, Los Angeles, CA, USA
| | - Christie Caldwell
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, MC 8855, USA
| | - Lori A Tappen
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, MC 8855, USA
| | - Kevin Gill
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, MC 8855, USA
| | - Shaleen Vira
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, MC 8855, USA.
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Govardhani Y, RamMohan G, Abhijith S, Savithri B. A comparative retrospective study of the efficacy of caudal epidural with manipulation versus ganglion impar block with manipulation in patients with coccydynia. INDIAN JOURNAL OF PAIN 2021. [DOI: 10.4103/ijpn.ijpn_152_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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10
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Coccydynia-A comprehensive review on etiology, radiological features and management options. J Clin Orthop Trauma 2021; 12:123-129. [PMID: 33716437 PMCID: PMC7920198 DOI: 10.1016/j.jcot.2020.09.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 09/10/2020] [Accepted: 09/20/2020] [Indexed: 11/20/2022] Open
Abstract
Coccydynia is a disabling condition characterized by pain in the coccyx region of the spine. The first description of the disease was given in as early as 1859. Since then a number of theories have been proposed by various researchers to explain the pathogenesis of the disease. Treatment options for coccydynia include ergonomic adaptation, manual therapy, injections and surgery. Despite being identified as a disease as early as 18th century, several uncertainties with respect to the origin of pain, predisposing factors and treatment outcomes of a wide range of treatment options persist till date. The current narrative review presents various aspects of the disease including pathoanatomy, clinical presentation, radiological features and management options for the disease.
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Finsen V, Kalstad A, Knobloch RG. The effect of injection therapy and operation of coccydynia on the schooling and physical activity of adolescent patients. Orthop Rev (Pavia) 2020; 12:8619. [PMID: 33312487 PMCID: PMC7726829 DOI: 10.4081/or.2020.8619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 06/20/2020] [Indexed: 11/22/2022] Open
Abstract
Pain while sitting is the most common complaint among patients with Coccydynia. In young patients this may seriously affect their schooling which usually involves long periods of sitting. We studied if this improved after either injection therapy or surgery. During a seven-year period 32 adolescents with a mean age of 15 (range: 11-17) years were treated in our department because of coccydynia. They were followed up with mailed questionnaires at a minimum of 12 months after treatment and 28 (88%) responded. Three were no longer attending school and were excluded. Of the remainder, 12 received only injection therapy while 13 were operated upon. Mean follow-up time was 36 (14-66) months. Eight reported absence from school during the month before treatment, but only one during the week before review (pÃ0.01). There was significant improvement in sitting during class and physical exercise at school and when engaging in general sports (pÃ0.01). We can not exclude that improvements would have occurred spontaneously, but this seems unlikely as symptoms had persisted for more than two years before treatment. We conclude that in juveniles, an additional benefit of treating coccydynia with corticosteroid injection or operative resection is that their ability to attend school and take part in sports improves significantly.
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Affiliation(s)
- Vilhjalmur Finsen
- Department of Orthopaedic Surgery, St. Olav's University Hospital, Trondheim.,Faculty of Medicine, Norwegian University of Science and Technology, NTNU, Trondheim, Norway
| | | | - Rainer G Knobloch
- Department of Orthopaedic Surgery, St. Olav's University Hospital, Trondheim
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12
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Finsen V, Kalstad A, Knobloch RG. Normal Preoperative Images Do Not Indicate a Poor Outcome of Surgery for Coccydynia. Spine (Phila Pa 1976) 2020; 45:1567-1571. [PMID: 33122606 DOI: 10.1097/brs.0000000000003642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN This is a retrospective cohort study. OBJECTIVE To evaluate the long-term outcomes after surgery for refractory coccygodynia in patients with normal imaging studies compared with patients where imaging shows an anomaly. SUMMARY OF BACKGROUND DATA Patients with coccydynia who do not respond to conservative treatment will often profit from coccygectomy. Most surgeons employ plain radiographs or magnetic resonance imaging (MRI) in their preoperative work-up. These will often show anomalies, but in some cases they do not. We investigated whether these patients do less well than those with abnormal images. METHODS We operated on 184 patients with coccydynia during a 7-year period and 171 (93%) responded to follow-up questionnaires after 37 (range: 12-85) months. Images of 33 patients were normal and 138 showed some coccygeal pathology. Surgery was considered to have been unsuccessful when respondents stated at review that they were somewhat better, unchanged, or worse. RESULTS There were no clinically or statistically significant differences in outcome between the groups. Surgery was unsuccessful in 24% of patients with normal images and in 32% among those with abnormal images. The median pain scores (0-10) during the week before review were two (interquartile range [IQR]: 0-3) and one (IQR: 1-5) in the two groups respectively. Similar proportions in the two groups stated that they would not have consented to surgery if they had known the outcome in advance. CONCLUSION Patients with severe coccydynia who have not responded to conservative treatment should not be denied surgery only because their radiographs or MRI studies look normal. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- Vilhjalmur Finsen
- Department of Orthopaedic Surgery, St. Olav's University Hospital, Trondheim, Norway
- Faculty of Medicine, Norwegian University of Science and Technology, NTNU, Trondheim, Norway
| | - Ante Kalstad
- Department of Orthopaedic Surgery, St. Olav's University Hospital, Trondheim, Norway
- Faculty of Medicine, Norwegian University of Science and Technology, NTNU, Trondheim, Norway
- Norwegian Armed Forces Joint Medical Services, Norway
| | - Rainer G Knobloch
- Department of Orthopaedic Surgery, St. Olav's University Hospital, Trondheim, Norway
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Abstract
Aims To determine if the results of treatment of adolescents with coccydynia are similar to those found in adults. Adult patients with coccydynia may benefit from injection therapy or operative treatment. There is little data evaluating treatment results in adolescents. We have treated adolescent patients similarly to adults and compared the outcomes. Methods Overall, 32 adolescents with coccydynia were treated at our institution during a seven-year period; 28 responded to final follow-up questionnaires after a minimum of one year, 14 had been treated with only injection therapy, and 14 had been operated with coccygectomy. We collected data with regards to pain while sitting, leaning forward, rising from a sitting position, during defecation, while walking or jogging, and while travelling in trains, planes, or automobiles. Pain at follow-up was registered on a numeric pain scale. Each adolescent was then matched to adult patients, and results compared in a case control fashion. The treatment was considered successful if respondents were either completely well or much better at final follow-up after one to seven years. Results Out of the 28 treated adolescents, 14 were regarded as successfully treated. Seven were somewhat better, and the remaining seven were unchanged. In the adult control group the corresponding number was 15 successfully treated, eight patients were somewhat better, and five were unchanged. Six of the 14 successfully treated adolescents had been operated. There were no significant differences between the groups in the various registered domains, or on numeric pain scale. Conclusion Treatment results in adolescent patients seem similar to those in adults. The long-term success rate of injection therapy is low. In case of injection treatment failure, operation may be considered, also in adolescents.
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Affiliation(s)
- Ante Matti Kalstad
- Department of Orthopedic Surgery, St. Olavs University Hospital, Trondheim, Norway.,Norwegian Armed Forces Joint Medical Services, Trondheim, Norway.,Faculty of Medicine, Norwegian University of Science and Technology, NTNU, Trondheim, Norway
| | | | - Vilhjalmur Finsen
- Department of Orthopedic Surgery, St. Olavs University Hospital, Trondheim, Norway.,Faculty of Medicine, Norwegian University of Science and Technology, NTNU, Trondheim, Norway
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Ranker A, Wegener B, Winkelmann A, Irnich D. [Undetected coccyx fracture in a woman with fibromyalgia]. Schmerz 2019; 33:549-554. [PMID: 31286239 DOI: 10.1007/s00482-019-0392-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
This article presents the case of a 46-year-old woman with fibromyalgia with an undetected fracture of the coccyx. The heterogeneity of the symptoms of patients suffering from fibromyalgia including chronic widespread pain, vegetative and functional disorders, mental and physical exhaustion as well as sleep disorders can cause accidentally undetected comorbidities, especially if these are rare and predominantly present with pain as the main symptom. In the present case the reason for symptoms was detected only after 14 months of ineffective therapies and diagnostic procedures. The coccygeal pain was eliminated through a coccygectomy as ultima ratio. It should be nevertheless emphasized that patients with fibromyalgia suffer from a central pain-processing disorder. Indications for operative treatment must be very carefully considered. Surgery should only be considered in consultation with the patient and after failed conservative therapy.
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Affiliation(s)
- Alexander Ranker
- Klinik und Poliklinik für Orthopädie, Physikalische Medizin und Rehabilitation, Klinikum der Universität München, LMU München, Marchioninistr. 15, 81377, München, Deutschland. .,Interdisziplinäre Schmerzambulanz, Klinikum der Universität München - Campus Innenstadt, LMU München, Pettenkoferstr. 8a, 80336, München, Deutschland.
| | - Bernd Wegener
- Klinik und Poliklinik für Orthopädie, Physikalische Medizin und Rehabilitation, Klinikum der Universität München, LMU München, Marchioninistr. 15, 81377, München, Deutschland
| | - Andreas Winkelmann
- Klinik und Poliklinik für Orthopädie, Physikalische Medizin und Rehabilitation, Klinikum der Universität München, LMU München, Marchioninistr. 15, 81377, München, Deutschland.,Interdisziplinäre Schmerzambulanz, Klinikum der Universität München - Campus Innenstadt, LMU München, Pettenkoferstr. 8a, 80336, München, Deutschland
| | - Dominik Irnich
- Interdisziplinäre Schmerzambulanz, Klinikum der Universität München - Campus Innenstadt, LMU München, Pettenkoferstr. 8a, 80336, München, Deutschland
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Seker A, Sarikaya IA, Korkmaz O, Yalcin S, Malkoc M, Bulbul AM. Management of persistent coccydynia with transrectal manipulation: results of a combined procedure. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 27:1166-1171. [PMID: 29234884 DOI: 10.1007/s00586-017-5399-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 11/14/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE We compared the results of manual therapy combined with steroid injection with single steroid injection in the treatment of persistent coccydynia. PATIENTS AND METHODS Combined therapy was performed in 21 patients (Group 1) and steroid injection in 23 patients (Group 2). We compared two groups and investigated the combined therapy group in details. Patients were classified according to the underlying cause, BMI, anatomic type of coccyx and duration of symptoms (< 6 or ≥ 6 months). RESULTS Mean age was 30.5 years at the time of procedures. Mean followup time was 27.8 months. VAS scores were decreased in both groups but combined therapy group had much more better results. Complete pain relief was achieved in 61.9% of patients in Group 1 whereas it was only 17.4% in Group 2. In 23.8% of Group 1, the VAS score was significantly decreased but the feeling of uncomfortability persisted. This was 73.9% in Group 2. We had no relapse in Group 1 but in Group 2 the relapse rate was 56.5%. Underlying cause, body mass index, anatomic type of coccyx and duration of symptoms had no effect on results. CONCLUSION Manual therapy combined with steroid injection would be an alternative method in case of persistent coccydynia. It is a safe and easy option before surgical treatment.
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Affiliation(s)
- Ali Seker
- Department of Orthopaedics and Traumatology, Istanbul Medipol University, Istanbul, Turkey
| | | | - Ozgur Korkmaz
- Department of Orthopaedics and Traumatology, Istanbul Medipol University, Istanbul, Turkey
| | - Sercan Yalcin
- Department of Orthopaedics and Traumatology, Istanbul Medipol University, Istanbul, Turkey.
| | - Melih Malkoc
- Department of Orthopaedics and Traumatology, Istanbul Medipol University, Istanbul, Turkey
| | - Ahmet Murat Bulbul
- Department of Orthopaedics and Traumatology, Istanbul Medipol University, Istanbul, Turkey
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Abstract
PURPOSE OF REVIEW Coccygodynia is pain within the coccyx area. The diagnosis is made clinically with symptoms of pain in the coccyx region and worsening pain in sitting position. The initial treatment is conservative therapy. For patients who do not respond to conservative therapies, there are further interventions available. This includes local injection of local anesthetics and steroids, neurolysis of sacral nerve roots, caudal epidural block, pulse radiofrequency (PRF), intra-rectal massage and manipulation, ganglion impar block, levator ani massage and stretching, coccyx manipulation, and coccygectomy. The purpose of this review is to evaluate the efficacies of these interventions in the treatment of coccygodynia. RECENT FINDINGS Literature search was performed with the keywords including coccygodynia, treatment, and coccygectomy, on PubMed and Google Scholar between August 2012 and August 2017. Thirteen studies with patients age 18 and over who underwent treatments for coccygodynia were selected for analysis. These treatments include conservative therapies (physical therapy and capsaicin patch), interventional techniques (local injections with steroids and local anesthetic, pulsed radiofrequency ablation of ganglion impar, extracorporeal shock wave therapy), and surgical techniques (complete and partial coccygectomies). The results from these studies demonstrated that most patients had significant pain relief with these techniques. Our literature review demonstrated various interventions including coccygectomy can be effective in the treatment of coccygodynia refractory to conservative therapies. There is a growing body of clinical evidence to support that coccygectomy is an effective treatment for patients with debilitating pain who had failed interventional therapies. Further randomized control studies should be conducted to examine duration of pain relief after coccygectomy and associated surgical complications.
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Affiliation(s)
- Yasmin Elkhashab
- Department of Anesthesiology, Jefferson Pain Center, Thomas Jefferson University Hospital, 834 Chestnut Street, Suite T-150, Philadelphia, PA, 19107, USA
| | - Andrew Ng
- Department of Anesthesiology, Jefferson Pain Center, Thomas Jefferson University Hospital, 834 Chestnut Street, Suite T-150, Philadelphia, PA, 19107, USA.
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Kleimeyer JP, Wood KB, Lønne G, Herzog T, Ju K, Beyer L, Park C. Surgery for Refractory Coccygodynia: Operative Versus Nonoperative Treatment. Spine (Phila Pa 1976) 2017; 42:1214-1219. [PMID: 28800569 DOI: 10.1097/brs.0000000000002053] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN This is a retrospective cohort study. OBJECTIVE To evaluate the long-term outcomes for patients with refractory coccygodynia treated with coccygectomy compared to a nonsurgical regimen of sitting aids, physical therapy, medications, and injections. SUMMARY OF BACKGROUND DATA The surgical treatment of coccygodynia remains controversial. To date, there has only been one small comparative study of surgical versus nonsurgical treatment. METHODS From 2004 to 2014, 109 patients presenting with coccygodynia were treated with either total coccygectomy or a nonsurgical course of sitting aids, physical therapy, anti-inflammatory medications, and injections. All had at least 2 years of symptoms before surgery. The patient principally made the treatment decision, counseled by the treating physician. Before surgery, all subjects underwent at least 2 years of conservative treatment and three-dimensional imaging (computed tomography and/or magnetic resonance imaging). Subjects completed visual analog pain scales, EuroQol five-dimension, components of the PROMIS measure, and a novel Coccygodynia Disability Index evaluation. Work status, complications, and satisfaction were recorded. RESULTS A total of 61 patients received nonsurgical care; eight declined participation and five could not be located. Forty-eight patients underwent total coccygectomy; three declined participation and five could not be located. At an average 4.8 years of follow-up (range: 2-9), the nonsurgical visual analog pain scales was 5 and the surgical 2 (P = 0.001); 79% of surgically treated patients were improved at 2 years versus 43% for the nonsurgical group. EuroQol five-dimension (P = 0.002), Coccygodynia Disability Index (0.01), and PROMIS Pain interference scores (0.02) were also significantly improved in the surgical group. Eleven surgical patients (26%) had complications, all wound related with successful resolution; seven treated with dressing changes and four with surgical debridement. CONCLUSION Total coccygectomy is a safe and effective surgical treatment of coccygodynia refractory to nonoperative care. Patient-reported outcome measures were improved after surgery compared with nonsurgical management. Postoperative wound care remains a concern. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- John P Kleimeyer
- Department of Orthopedic Surgery, Stanford University School of Medicine, Redwood City, CA
| | - Kirkham B Wood
- Department of Orthopedic Surgery, Stanford University School of Medicine, Redwood City, CA
| | - Greger Lønne
- Department of Orthopaedic Surgery, Innlandet Hospital Trust, Lillehammer, Norway
| | - Tyler Herzog
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Kevin Ju
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Lisa Beyer
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Christine Park
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Coccygodynia review: coccygectomy case series. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2017; 27:961-965. [PMID: 28386714 DOI: 10.1007/s00590-017-1947-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 04/01/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Coccygodynia is a pain of the coccyx that is typically exaggerated by pressure. Management includes anti-inflammatory medications, physiotherapy, and coccyx manipulation. Coccygectomy is the surgical approach for treating coccygodynia when the conservative management fails. Generally, coccygectomy yields good results. Its most common complication is wound infection. OBJECTIVE To determine the effectiveness of coccygectomy in patients with coccygodynia. METHODS A retrospective review of 70 patients (52 females and 18 males) with coccygodynia at King Khalid University Hospital in Riyadh was carried out, and the outcomes were studied. Twenty patients did not respond to conservative management; therefore, bimanual coccyx manipulation was done. Eleven were identified with instability and did not respond to coccygeal manipulation. Coccygectomy was performed on 8 patients while 3 declined. RESULTS All patients who underwent coccygectomy showed improvement of their symptoms. One case of superficial wound infection and delayed wound healing was encountered. CONCLUSION Coccygectomy provides effective pain relief to patients not responding to conservative therapies.
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