Overview
Definition:
Coccygectomy is the surgical excision of the coccyx (tailbone) or a portion thereof, indicated for persistent, refractory coccydynia
Coccydynia is chronic pain localized to the coccyx, often exacerbated by sitting.
Epidemiology:
Coccydynia affects approximately 1-2% of the adult population, with a higher prevalence in females
It is often idiopathic, but can be associated with trauma, childbirth, obesity, or prolonged sitting
Coccygectomy is a rare procedure, reserved for failures of conservative management.
Clinical Significance:
Chronic coccydynia can significantly impact a patient's quality of life, affecting daily activities, posture, and psychological well-being
Understanding the indications, surgical techniques, and potential outcomes of coccygectomy is crucial for surgeons managing these challenging pain syndromes.
Clinical Presentation
Symptoms:
Localized pain at the coccyx, typically a dull ache or sharp pain
Pain is exacerbated by direct pressure, sitting, straining during defecation, or arising from a seated position
Pain may radiate to the gluteal region or lower back
Pain duration is typically >3 months
Palpation over the coccyx elicits tenderness
Difficulty sitting for prolonged periods.
Signs:
Tenderness on palpation of the coccyx, both externally and through rectal examination
Limited range of motion in the sacrococcygeal joint may be noted
Bruising or deformity of the coccyx may be evident in cases of acute trauma
No significant neurological deficits are typically present.
Diagnostic Criteria:
Diagnosis of coccydynia is primarily clinical, based on a history of localized pain and physical examination findings
Pain exacerbated by sitting and relief upon standing or sitting on a cushion are characteristic
Imaging is used to rule out other pathologies
No formal established criteria for coccydynia exist, but prolonged pain (>3 months) with characteristic symptoms is key.
Diagnostic Approach
History Taking:
Detailed history of pain onset, character, duration, aggravating, and relieving factors is essential
Inquire about previous trauma, childbirth history, prolonged sitting habits, and occupational factors
Evaluate previous treatments attempted and their efficacy
Assess impact on daily activities and psychological status
Red flags include fever, weight loss, or neurological deficits suggestive of spinal cord pathology.
Physical Examination:
Begin with observation of posture and gait
Palpate the gluteal region and sacrococcygeal area for tenderness
Perform a bimanual rectal examination to assess coccygeal mobility and tenderness directly
Assess for pelvic floor muscle spasm
Rule out other spinal causes of buttock pain through neurological examination.
Investigations:
Plain radiographs (anteroposterior, lateral, and oblique views of the coccyx, often taken in sitting and standing positions) are crucial to assess coccygeal alignment, luxation, fracture, or osteophytes
MRI or CT scan may be used to rule out tumors, infections, or discogenic pathology if red flags are present or if plain films are equivocal
Ultrasound can assess soft tissue abnormalities.
Differential Diagnosis:
Conditions to consider include sacral insufficiency fracture, lumbar disc herniation, spinal stenosis, sacroiliitis, pilonidal sinus, anal fissure, perianal abscess, pelvic floor dysfunction, coccygeal ganglion cyst, and referred pain from hip pathology
Lumbar spine pathology and sacroiliac joint dysfunction are common differentials.
Management
Initial Management:
Conservative management is the mainstay
This includes rest, avoiding prolonged sitting, and modifying activities
Use of a donut cushion or wedge cushion to relieve direct pressure on the coccyx
Application of ice or heat to the affected area.
Medical Management:
Pharmacological treatment typically involves NSAIDs (e.g., ibuprofen 400-600mg TID, naproxen 500mg BID) for pain and inflammation
Muscle relaxants (e.g., cyclobenzaprine 5-10mg TID) may be helpful for associated muscle spasms
Opioids may be used for severe, intractable pain, but with caution due to potential for dependence
Topical analgesics may provide localized relief
Nerve blocks (e.g., local anesthetic and corticosteroid injections into the sacrococcygeal area) can be diagnostic and therapeutic, repeated up to 3-4 times annually.
Surgical Management:
Coccygectomy is indicated for chronic coccydynia that has failed to respond to at least 6 months of comprehensive conservative management, including physical therapy and judicious use of injections
Surgical options include partial or complete excision of the coccyx
Techniques involve posterior approaches, careful dissection to preserve surrounding structures, and adequate pain control post-operatively
The goal is to remove the painful segment of the coccyx.
Supportive Care:
Physical therapy is vital, focusing on stretching and strengthening of pelvic floor muscles, gluteal muscles, and lumbar spine
Biofeedback can help patients learn to relax pelvic floor muscles
Psychological support and counseling may be beneficial due to the chronic nature of the pain and its impact on quality of life.
Complications
Early Complications:
Infection at the surgical site, bleeding or hematoma formation, cerebrospinal fluid leak (rare, if dura is breached), wound dehiscence, and persistent or new-onset pain
Anal sphincter injury is a rare but serious complication from the rectal approach.
Late Complications:
Chronic pain recurrence, scar tissue formation leading to discomfort, instability of the sacrococcygeal junction if partial excision is performed and is unstable, and perineal irritation
Psychological distress can persist.
Prevention Strategies:
Meticulous surgical technique, sterile precautions, appropriate antibiotic prophylaxis, judicious use of dissection, and proper wound closure are essential to prevent infection and other surgical complications
Careful patient selection and thorough pre-operative counseling are crucial to manage expectations and prevent recurrence of pain
Post-operative pain management is key.
Prognosis
Factors Affecting Prognosis:
Successful pain relief is variable
Factors influencing outcome include the exact cause of coccydynia, extent of surgical resection, presence of comorbidities, patient expectations, and adherence to post-operative rehabilitation
Good results are reported in 50-80% of appropriately selected patients.
Outcomes:
Most patients experience significant pain relief after successful coccygectomy, with improvement in sitting tolerance and overall quality of life
Some patients may have partial relief, while a smaller percentage may experience persistent or recurrent pain
Long-term functional improvement is common.
Follow Up:
Regular follow-up is required, typically at 2 weeks, 6 weeks, 3 months, and 6 months post-operatively
This includes assessment of wound healing, pain levels, functional status, and addressing any emerging complications
Long-term follow-up may be necessary for persistent issues
Physical therapy is crucial for long-term success.
Key Points
Exam Focus:
Coccygectomy is reserved for refractory coccydynia after at least 6 months of failed conservative management
Differential diagnosis is broad and includes spinal, pelvic, and anorectal pathologies
Imaging (X-ray, MRI/CT) is essential to rule out other causes.
Clinical Pearls:
A thorough rectal examination is critical for accurate localization of tenderness and assessing coccygeal mobility
Conservative management should be maximized before considering surgery
Patient selection is paramount for successful surgical outcomes.
Common Mistakes:
Performing coccygectomy prematurely without adequate trials of conservative therapy
Inadequate investigation to rule out other differentials
Overestimation of surgical success rates and underestimation of potential complications
Neglecting comprehensive post-operative rehabilitation.