Transrectal osteopathic manipulation treatment for chronic coccydynia: feasibility, acceptability and patient-oriented outcomes in a quality improvement project

CONTEXT

Pain of the coccyx, coccydynia, is a common condition with a substantial impact on the quality of life. Although most cases resolve with conservative care, 10 % become chronic and are more debilitating. Treatment for chronic coccydynia is limited; surgery is not definitive. Osteopathic manipulative treatment (OMT) is the application of manually guided forces to areas of somatic dysfunction to improve physiologic function and support homeostasis including for coccydynia, but its use as a transrectal procedure for coccydynia in a primary care clinic setting is not well documented.

OBJECTIVES

We aimed to conduct a quality improvement (QI) study to explore the feasibility, acceptability, and clinical effects of transrectal OMT for chronic coccydynia in a primary care setting.

METHODS

This QI project prospectively treated and assessed 16 patients with chronic coccydynia in a primary care outpatient clinic. The intervention was transrectal OMT as typically practiced in our clinic, and included myofascial release and balanced ligamentous tension in combination with active patient movement of the head and neck. The outcome measures included: acceptance, as assessed by the response rate (yes/no) to utilize OMT for coccydynia; acceptability, as assessed by satisfaction with treatment; and coccygeal pain, as assessed by self-report on a 0-10 numerical rating scale (NRS) for coccydynia while lying down, seated, standing, and walking.

RESULTS

Sixteen consecutive patients with coccydynia were offered and accepted OMT; six patients also received other procedural care. Ten patients (two males, eight females) received only OMT intervention for their coccydynia and were included in the per-protocol analysis. Posttreatment scores immediately after one procedure (acute model) and in follow-up were significantly improved compared with pretreatment scores. Follow-up pain scores provided by five of the 10 patients demonstrated significant improvement. The study supports transrectal OMT as a feasible and acceptable treatment option for coccydynia. Patients were satisfied with the procedure and reported improvement. There were no side effects or adverse events.

CONCLUSIONS

These data suggest that the use of transrectal OMT for chronic coccydynia is feasible and acceptable; self-reported improvement suggests utility in this clinic setting. Further evaluation in controlled studies is warranted.

Case Report: Labor induced coccydynia associated with Modic I changes successfully treated with platelet-rich plasma

Imaging can aid in determining potential causes of coccygeal pain and therefore guide clinicians to carry out individualized treatment. We represent a case of postpartum coccydynia treated by platelet-rich plasma (PRP) which was assessed and followed by MRI. A primipara with uncomplicated labor developed coccygeal pain after delivery that significantly limited her postpartum recovery. On the first MR scan, recorded 6 months after delivery, there were edematous changes of the vertebral endplates of Co1-4 level (Modic type I) with the presence of pronounced precoccygeal venous drainage. Degenerative changes with signs of edema in the area of the pubic symphysis were recorded. The sacroiliac joints had regular morphological features. Since the patient was breastfeeding, PRP therapy was applied with a total of three injections in the area of the coccyx subcutaneously, once every 3 months. The subjective feeling of pain reduction after each injection was about 30%, with the complete withdrawal of pain after one year and still pain-free at the two-year follow-up. One year after the initial MR imaging, a follow-up MR examination was performed, where almost complete resolution of edematous changes in the previously present zones was observed, with residual minor edema of the vertebral endplates at the Co2-3 level. Edema of the pubic bones in the area of the pubic symphysis also subsided. A case of labor-induced coccydynia that was represented as Modic type I changes without neither fracture or luxation was successfully treated with PRP with complete resolution of symptoms.

Pelvic pain in women after childbirth and physiotherapy

OBJECTIVE

There are many types of pelvic pain. Pelvic plexus pain, coccyx pain, pain from episiotomy scars, and vulvodynia are frequently seen in postpartum women. The aim of this study was to conduct a systematic review of studies on pelvic pain in postpartum women to assess the effect of physiotherapy interventions on each type of pain.

METHODS

A comprehensive literature review was conducted by searching on PubMed, Ovid Embase and Scopus Web of Science using the key words - pelvic pain, women after childbirth, pelvic girdle pain, coccygodynia, episiotomy, vulvodynia, and physiotherapy. The author reviewed all the identified articles and selected articles for inclusion according to relevance to the topic.

CONCLUSION

Based on the analysis of the above studies, it can be concluded that a comprehensive physiotherapy designed for postpartum women that includes manual techniques, behavioral techniques, relaxation of hypo-tonic and shortened muscles and strengthening of hypotonic muscles can positively affect a wide range of pain and associated dysfunctions of the pelvic floor and trunk muscles.

Coccydynia-The Efficacy of Available Treatment Options: A Systematic Review

STUDY DESIGN

Systematic Review.

OBJECTIVE

To evaluate the efficacy of available treatment options for patients with persistent coccydynia through a systematic review.

METHODS

Original peer-reviewed publications on treatment for coccydynia were identified using Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines by performing a literature search of relevant databases, from their inception to January 17, 2020, combined with other sources. Data on extracted treatment outcome was pooled based on treatment categories to allow for meta-analysis. All outcomes relevant to the treatment efficacy of coccydynia were extracted. No single measure of outcome was consistently present among the included studies. Numeric Rating Scale, (NRS, 0-10) for pain was used as the primary outcome measure. Studies with treatment outcome on adult patients with chronic primary coccydynia were considered eligible.

RESULTS

A total of 1980 patients across 64 studies were identified: five randomized controlled trials, one experimental study, one quasi-experimental study, 11 prospective observational studies, 45 retrospective studies and unpublished data from the DaneSpine registry. The greatest improvement in pain was achieved by patients who underwent radiofrequency therapy (RFT, mean Visual Analog Scale (VAS) decreased by 5.11 cm). A similar mean improvement was achieved from Extracorporeal Shockwave Therapy (ESWT, 5.06), Coccygectomy (4.86) and Injection (4.22). Although improved, the mean change was less for those who received Ganglion block (2.98), Stretching/Manipulation (2.19) and Conservative/Usual Care (1.69).

CONCLUSION

This study highlights the progressive nature of treatment for coccydynia, starting with noninvasive methods before considering coccygectomy. Non-surgical management provides pain relief for many patients. Coccygectomy is by far the most thoroughly investigated treatment option and may be beneficial for refractory cases. Future randomized controlled trials should be conducted with an aim to compare the efficacy of interventional therapies amongst each other and to coccygectomy.

Clinical Outcomes of Coccygectomy for Coccydynia: A Single Institution Series With Mean 5-Year Follow-Up

BACKGROUND

Prior studies of coccygectomy consist of small patient groups, heterogeneous techniques, and high wound complication rates (up to 22%). This study investigates our institution's experience with coccygectomy using a novel "off-center" wound closure technique and analyzes prognostic factors for long-term successful clinical outcomes.

METHODS

Retrospective review of all patients who underwent coccygectomy from 2006 to 2019 at a single center. Demographics, mechanism of injury, conservative management, morphology (Postacchini and Massobrio), and postoperative complications were collected. Preoperative and postoperative Oswestry Disability Index (ODI), visual analog scale (VAS), Patient-Reported Outcomes Measurement Information System-29 (PROMIS-29), and EuroQol-5D (EQ-5D) were compared. Risk factors for failing to meet minimum clinically importance difference for ODI and PROMIS-physical function/pain interference were identified. Risk factors for remaining disabled after surgery (ODI <20) and factors associated with VAS and EQ-5D improvement were investigated using stepwise logistic regression.

RESULTS

A total of 173 patients (77% women, mean age = 46.56 years, mean follow-up 5.58 ± 3.95 years). The most common etiologies of coccydynia were spontaneous/unknown (42.2%) and trauma/accident (41%). ODI, VAS, and several PROMIS-29 domains improved postoperatively. Older age predicted continued postoperative disability (ODI <20) and history of prior spine surgery, trauma etiology, and women had inferior outcomes. No history of spine surgery (cervical, thoracic, or lumbar) prior to coccygectomy was found to predict improved postoperative VAS back scores. No outcome differences were demonstrated among the coccyx morphologies. Sixteen patients (9.25%) were noted to have postoperative infections of the incision site with no difference in long-term outcomes (all P <0.05).

CONCLUSIONS

This is the largest series of coccygectomy patients demonstrating improvement in long-term outcomes. Compared to previous studies, our cohort had a lower wound infection rate, which we attribute to an "off-center" closure.

CLINICAL RELEVANCE

Patients should be counseled that their surgical history, along with age, gender, and etiology of pain can influence success following coccygectomy. These data can help surgeons set realistic expectations following surgery.

LEVEL OF EVIDENCE

3.

Morphological Features of the Coccyx in the Turkish Population and Interrelationships Among the Parameters: A Computerized Tomography-Based Analysis

Introduction

The coccyx is well-known to be a highly variable structure considering its morphology. To our knowledge, the relationship between the coccygeal types and other morphological features has not been studied yet. In addition to the interrelations among morphological parameters, this study investigated the morphology and morphometry of coccyx more extensively in the adult Turkish population using computerized tomography images.

Methods

Five hundred subjects who underwent pelvic computerized tomography were included in this study. In addition to coccyx type and the counts of coccygeal vertebrae and segments, the presence of coccygeal deviation, sacrococcygeal joint (SCJ) fusion, SCJ subluxation, intercoccygeal joint (ICJ) fusion, and coccygeal spicule were evaluated. The coccygeal length, sacrococcygeal angle, and intercoccygeal angle were measured on the digital workstation. The findings were subjected to statistical analyses.

Results

The coccygeal vertebra count ranged between three to five, with an average of 4.04 ± 0.48. The range of coccygeal segment count was between one and five, with an average of 2.53 ± 1.02. ICJ fusion in any segment, SCJ fusion, and SCJ subluxation were identified in 397 subjects (79.4%), 343 subjects (68.6%), and 17 subjects (3.4%), respectively. The coccyx types from the most common to the least common were as follows: type 2, type 1, type 3, type 4, and type 5. Coccygeal deviation to the left side was observed in 71 subjects (14.2%), while coccygeal deviation to the right side was observed in 61 subjects (12.2%). A coccygeal spicule was identified in 73 subjects (14.6%). The subjects’ mean age demonstrated no significant difference considering the ICJ fusion (p=0.271), SCJ subluxation (p=0.51), coccygeal spicule (p=0.337), features of coccygeal deviation (p=0.83), and coccyx types (p=0.11). The subjects with SCJ fusion (50.7 ± 18.3 years) were significantly older than the subjects without SCJ fusion (46.5 ± 18.5 years) (p=0.016). The differences between the coccyx types considering the rate of SCJ fusion (p=0.002), ICJ fusion (p=0.04), and spicule presence (p<0.001) as well as the coccygeal vertebra count (p<0.001) were significant.

Conclusion

The presence of coccygeal spicule, a risk factor for coccydynia, is reported to be 14.6% in this study group that represents the Turkish population. This study indicates an association between the coccyx types and the frequency of SCJ fusion, ICJ fusion, and spicule presence and consequently suggests the significance of the coccyx type among the morphological features to cause susceptibility to coccydynia. Due to the multiplicity of the pain generators in the coccygeal region that is established by previous reports, the comparisons of different human populations and the knowledge on the interrelations between the morphologic parameters might facilitate the comprehension of the etiology of coccydynia. The clarification of interrelationship existence among the coccygeal morphological parameters requires further investigations.

The efficacy of coccygectomy in patients with persistent coccydynia

AIMS

The aim of this study was to investigate the efficacy of coccygectomy in patients with persistent coccydynia and coccygeal instability.

METHODS

The Danish National Spine Registry, DaneSpine, was used to identify 134 consecutive patients who underwent surgery, performed by a single surgeon between 2011 and 2019. Routine demographic data, surgical variables, and patient-reported outcomes, including a visual analogue scale (VAS) (0 to 100) for pain, Oswestry Disability Index (ODI), EuroQol five-dimension questionnaire (EQ-5D), and the Physical Component Score (PCS) and Mental Component Score (MCS) of the 36-Item Short-Form Health Survey questionnaire (SF-36) were collected at baseline and one-year postoperatively.

RESULTS

A total of 112 (84%) patients with a minimum follow-up of one year had data available for analysis. Their mean age was 41.9 years, and 15 (13%) were males. At 12 months postoperatively, there were statistically significant improvements (p < 0.001) from baseline for the mean VAS for pain (70.99 to 35.34), EQ-5D (0.52 to 0.75), ODI (31.84 to 18.00), and SF-36 PCS (38.17 to 44.74). A total of 78 patients (70%) were satisfied with the outcome of treatment.

CONCLUSION

Patients with persistent coccydynia and coccygeal instability resistant to nonoperative treatment may benefit from coccygectomy. Cite this article: Bone Joint J 2021;103-B(3):542-546.

Effects of Multilayer Silicone Foam Dressings for the Prevention of Pressure Ulcers in High-Risk Patients: A Randomized Clinical Trial

Objective: To determine whether multilayer silicone foam dressings can prevent pressure ulcers arising in the sacrum and coccyx of patients with persistent severe diarrhea and/or fragile skin. Approach: This randomized, 14-day controlled trial included 600 hospitalized patients with persistent severe diarrhea and/or fragile skin who were at high risk of developing pressure ulcers. All participants were enrolled from three Japanese institutions. Participants meeting all inclusion and exclusion criteria were randomized using the Excel program to receive standard care (control; n = 300) recommended by Japanese guidelines or multilayer silicone foam dressings applied to the sacrum and coccyx (intervention; n = 300). Results: Significantly more participants in the control than the intervention group developed pressure ulcers (22 vs. 5, p = 0.001). Innovation: The incidence of pressure ulcers remains high in hospitalized patients at high risk of developing pressure ulcers. The present findings might contribute to novel preventive strategies for patients at high risk of developing pressure ulcers. Conclusion: Multilayer silicone foam dressings can prevent pressure ulcers of the sacrum and coccyx in patients with persistent severe diarrhea and/or fragile skin.

Coccygeal Polypoid Eccrine Nevus Presenting as a Skin Tag: Case Report and Review of the Literature

Coccygeal polypoid eccrine nevi (CPEN) are rare, benign, cutaneous polypoid lesions localized to the coccyx region that are characterized by areas of hyperplastic eccrine ducts without hyperhidrosis. We present the case of an asymptomatic 16-month-old female with a congenital lesion in the lower sacral area and review the literature and the differential diagnosis for CPEN.

Tailbone Pain from Coccyx Injuries on Water Slides: A Case Series

BACKGROUND

Water slides and rides are increasingly popular attractions at amusement parks. There has been some documentation of various patterns of injury associated with these rides, most notably vaginal injuries caused by water jets. But we find no previous medical publications reporting the association between water slides/rides with coccydynia (coccyx pain) and tailbone injuries.

CASE REPORT

Our purpose in this case report was to assess for an association between water slides/rides with injuries to the coccyx causing coccyx pain. We conducted a retrospective chart review in a coccyx pain clinic on a medical school campus at a level I trauma center. The retrospective chart review took place over a 2-year period and encompassed 217 new patients. Four patients presenting to our coccyx pain clinic had either onset or exacerbation of symptoms with temporal relationship to water slide or ride activities. Three of 4 patients had abnormal dynamic instability on radiologic dynamic imaging, including standing versus seated radiographs and magnetic resonance imaging. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Recreational water slides/rides are a newly reported cause of coccygeal dynamic instability with resultant tailbone pain. Dynamic imaging studies (sitting vs. standing) of the coccyx should be considered in patients with coccyx pain after injuries on a water slide or ride. Many of these patients may initially seek care from emergency physicians.

Magnetic Resonance Measurements of Sacrococcygeal and Intercoccygeal Angles in Normal Participants and those with Idiopathic Coccydynia

BACKGROUND

In the past, few studies have been done to objectively measure the sacrococcygeal (SC) and intercoccygeal (IC) angles in the population and in patients with coccydynia. Coccydynia is an age-old disorder, the exact incidence of which has not been determined. It is reported to be more common in females and the obese. The magnetic resonance imaging (MRI) studies done in the past have calculated the curvature indices. In this study, we used MRI to objectively measure the angles in the normal participants as well as those with idiopathic coccydynia.

MATERIALS AND METHODS

Two groups of patients were identified. Group A was "control group" of 106 normal participants and Group B comprised "study group" of ten patients suffering from idiopathic coccydynia. In all these patients, midsagittal T1-weighted MRI image acquired in supine position was used to calculate SC and IC angles. Data were analyzed, and angles were compared between the study and control groups. Statistical analysis was done with Chi-square test.

RESULTS

In the control group, the average SC and IC angles in the control group were 126.8° and 33.5°, respectively. In the study group, the average SC angle and the average IC angle turned out to be 127.1° and 43.2°, respectively. The difference between the SC angles in the control and study groups was not significant (P = 0.7), whereas the difference between the IC angles in the two groups was significant (P = 0.002).

CONCLUSIONS

From our study, we observed that the IC angle shows a decreasing trend with increasing age. In addition, increased IC angle was identified as a possible cause of idiopathic coccydynia.

Concurrent lumbosacral and sacrococcygeal fusion: a rare aetiology of low back pain and coccygodynia?

Sacrum is a triangular bone placed in the base of the spine and formed by the synostosis of five sacral vertebrae (S1-S5). Its upper part is connected with the inferior surface of the body of L5 vertebra forming the lumbosacral joint, while its lower part is connected with the base of the coccyx forming the sacrococcygeal symphysis, an amphiarthrodial joint. The existence of four pairs of sacral fora-mina in both anterior and posterior surface of the sacrum is the most common anatomy. Nevertheless, supernumerary sacral foramina are possible to be created by the synostosis of lumbosacral joint or sacrococcygeal symphysis. We present a case of an osseous cadaveric specimen of the sacrum belonging to a 79-year-old Caucasian woman. A rare variation of the anatomy of the sacrum is reported; in which, the simultaneous fusion of the sacrum with both the L5 vertebra and the coccyx has created six pairs of sacral foramina. This variation should be taken into serious consideration, especially in the domain of radiology, neurosurgery, orthopaedics and spine surgery, because low back pain, coccygodynia and other neurological symptoms may emerge due to mechanical compression. (Folia Morphol 2018; 77, 2: 397-399).

An evaluation of two different methods of coccygectomy in patients with traumatic coccydynia

Purpose

The aim of this study was to evaluate the results of partial and total coccyx excisions in patients with traumatic coccydynia resistant to conservative treatment.

Patients and methods

The study included 22 patients (from a total of 27) who underwent partial or total coccygectomy because of persistent coccydynia between December 2007 and January 2014. There were 15 females and 7 males with a mean age of 33.6 years (range 23–46 years). Partial coccygectomy was performed in 14 patients and total coccygectomy in 8. They were evaluated according to their pre- and postoperative visual analog scale (VAS) scores. The mean follow-up period was 28 months (range 16–48 months).

Results

The mean VAS scores in the total excision group were 8.88±0.64 preoperatively and 2.5±2.67 at the final postoperative follow-up examination. In the partial excision group, these values were 8.79±0.89 preoperatively and 2.5±2.85 postoperatively. No statistically significant difference was determined between the two groups with respect to the mean scores (p>0.05). No rectum injury was seen in any patient. When the VAS scores of the patients were evaluated as a whole, excellent and good results were obtained in 78%. Patient satisfaction with the operation was 90%.

Conclusion

Coccyx excision is a successful treatment method in patients with long-term coccydynia who are resistant to conservative treatment. Two different surgical methods can be applied in the treatment and both of them have low complication rates and high patient satisfaction.

High incidence of persistence of sacral and coccygeal intervertebral discs in South Indians - a cadaveric study

The sacrum, by virtue of its anatomic location plays a key role in providing stability and strength to the pelvis. Presence of intervertebral discs in sacrum and coccyx is rare. Knowledge of its variations is of utmost importance to surgeons and radiologists. The current study focused on the presence of intervertebral discs between the sacral and coccygeal vertebrae in south Indian cadaveric pelvises. We observed 56 adult pelvises of which, 34 (61%) pelvises showed the presence of intervertebral discs between the sacral vertebrae and between the coccygeal vertebrae, while 22 (39%) pelvises did not have the intervertebral discs either in the sacrum or the coccyx. We also found that most of the specimens had discs between S1 and S2 vertebrae (39%), followed by, between S4 and S5 (18%), between S2-S3 (14%) and least being between S3-S4 (13%). In the coccyx it was found that 7% of pelvises had disc between Co1-Co2, 4% of them had between Co2-Co3 and 4% had between Co3-Co4. Knowledge regarding such anatomic variations in the sacro-coccygeal region is important to note because they require alterations in various instrumentation procedures involving the sacrum.

Clinical decision making for the evaluation and management of coccydynia: 2 case reports

STUDY DESIGN

Case report.

BACKGROUND

Coccydynia is a painful condition of the sacrococcygeal region, with symptoms associated with sitting and rising from a seated position. There is no gold standard for diagnosis of this condition; however, coccyx mobility assessment, pain provocation testing, and imaging have been proposed as reasonable diagnostic approaches. Once correctly diagnosed, treatment options for coccydynia include conservative management and surgical excision. The purpose of this report is to describe the different but successful clinical management strategies of 2 patients with coccydynia.

CASE DESCRIPTION

Two women, 26 and 31 years of age, presented to physical therapy with persistent coccygeal pain that increased with prolonged sitting and intensified when transitioning from sit to stand. One patient had a traumatic onset of symptoms, in contrast to the other patient, for whom prolonged sitting was the precipitating factor. Both individuals were considered to have hypomobility of the sacrococcygeal joint, as assessed through intrarectal mobility testing, which also reproduced their symptoms. In both patients, examination of the lumbar spine was negative for alleviation or reproduction of symptoms. The patient with a traumatic onset of symptoms was referred to physical therapy at the onset of her symptoms, whereas the patient with a nontraumatic onset of symptoms was initially treated with a cortisone injection and, when symptoms returned 1 year later, was referred to physical therapy. Both individuals underwent manual therapy to the sacrococcygeal joint over 3 treatment sessions.

OUTCOMES

The patient with traumatic onset of symptoms had almost complete resolution of symptoms, whereas the patient with a nontraumatic onset only had temporary relief. This patient required further diagnostic examination and surgical excision.

DISCUSSION

Although the mechanisms of injury were different, both patients presented with similar clinical symptoms, and both were considered to have coccydynia through coccyx mobility assessment and pain provocation testing. Successful clinical outcomes were achieved in both cases; however, the interventions were significantly different. Level of Evidence Therapy, level 4.