|Year : 2019 | Volume
| Issue : 3 | Page : 44-48
Coccydynia: A lean topical review of recent updates on physical therapy and surgical treatment in the last 15 years
Ganesh Singh Dharmshaktu, Navneet Adhikari, Binit Singh
Department of Orthopedics, Government Medical College, Haldwani, Uttarakhand, India
|Date of Submission||19-Nov-2019|
|Date of Acceptance||05-Dec-2019|
|Date of Web Publication||23-Dec-2019|
Ganesh Singh Dharmshaktu
Department of Orthopedics, Government Medical College, Haldwani - 263 139, Uttarakhand
Source of Support: None, Conflict of Interest: None
Coccydynia is disabling painful condition resulting from various factors and often not given serious importance. The chronic or recurrent pain affects activities of daily living and overall quality of life. Not only it is a poorly understood disorder with newer findings related to its anatomy, radiology, and the management periodically supplementing the medical literature but also it is managed in casual manner in clinical settings. There are various treatment options in both conservative and operative methods of its treatment and knowledge of which is important for its optimal management. A relevant topical review of recent advances on its management is presented here as handy guide for busy practitioners.
Keywords: Coccygectomy, coccyx pain, conservative management, physical therapy
|How to cite this article:|
Dharmshaktu GS, Adhikari N, Singh B. Coccydynia: A lean topical review of recent updates on physical therapy and surgical treatment in the last 15 years. J Orthop Dis Traumatol 2019;2:44-8
|How to cite this URL:|
Dharmshaktu GS, Adhikari N, Singh B. Coccydynia: A lean topical review of recent updates on physical therapy and surgical treatment in the last 15 years. J Orthop Dis Traumatol [serial online] 2019 [cited 2021 Jan 16];2:44-8. Available from: https://www.jodt.org/text.asp?2019/2/3/44/273886
| Introduction|| |
Coccydynia or coccygodynia is a debilitating disorder of multifactorial origin. Various methods of treatment are described and recommended for this disorder. There is a growing body of literature suggesting newer updates on morphometry of this enigmatic and poorly understood disorder along with newer methods of treatment. A crisp and relevant topical review regarding the therapeutic advances in the last 15 years (2004 onward) is presented here.
| Conservative Management|| |
Various conservative methods have been described for the management of coccydynia. However, due to scant good quality literature support, no one particular modality can be recommended as the most effective one. In a recent and probably only systematic review of literature, comprising of articles between June 2002 and July 2012, authors found seven articles (2 randomized trials and 5 observational) and results were inconclusive with authors insisting upon further studies to know about efficacy of various modalities in order to better recommend the most effective one.
Injection or manipulation
In one report, the cause of coccydynia was identified as associated lumbar radiculopathy and somatic dysfunction of the lumbar and sacral vertebrae. Following sessions of serial epidural injection, manipulation of coccyx under anesthesia along with osteopathic mobilization of lumbosacral spine resulted in good outcome. In another study, fluoroscopically guided coccygeal injection with triamcinolone acetate and 1% lidocaine (80 mg and 2 mg, respectively) were given in a patient pool of 14 cases following which more than 50% relief of pain was seen in cases with <6 months of symptoms. Acute cases thus fared better than chronic cases. Stretching of remote muscle groups such as piriformis (P) and iliopsoas (I) has been tried for 3 weeks in a study involving 48 cases in three groups (Group 1 with stretching of P and I, Group 2 with stretching of P and I along with Maitland's rhythmic oscillatory thoracic mobilization, and Group 3 with conventional methods such as Sitz bath, cushions, and phonophoresis). In both Groups 1 and 2, significant improvement in pain pressure threshold and pain-free setting.
In a comparative study involving large number of patients (51 each group) of chronic coccydynia who underwent low-power external physiotherapy and intrarectal manipulation, found intrarectal manipulation as more effective modality of the two. This study, however, had moderate risk of bias. The study also highlighted important prognostic factors. The results were better in posttraumatic cases, recent-onset cases and those not associated with instability of coccyx or any psychosocial factors. Mobility testing can also be done to assess hypermobility of sacrococcygeal joint, and it may also serve as a provocative testing for coccydynia. In an interesting observation between two cases, one with traumatic and another nontraumatic one, who underwent manual therapy to sacrococcygeal joint resulting in complete resolution in posttraumatic case, whereas other one required further interventions. In an another comparative study between cases of transrectal manipulation combined with single steroid injection (21 cases) to those undergoing only steroid injection (23 cases) concluded that better results were found in combined therapy, and this can be viable option before surgical intervention in chronic cases. A prospective pilot study with 2-year follow-up compared three manual therapies in randomized group of levator ani massage, joint mobilization, and mild levator stretch, respectively. Patients with normal mobile coccyx fared well and levator anus massage and stretch was more effective than joint mobilization alone. The authors, however, advocated a placebo-controlled study in this regard for better evidence. Inconclusive evidence, however, for recommendation of any particular manipulation technique for the treatment of coccydynia was found in a recent evidence report.
Peripheral nerve field stimulation
Other notable therapy with promising results, not necessarily for coccydynia related to coccyx fracture, include peripheral nerve field stimulation which was also fund beneficial in one case with chronic coccydynia.
Dorsal root ganglion stimulation
Dorsal root ganglion stimulation has also been tried in one article with promising results. More literature support, however, is required on this topic that has scant advances in recent times.
Extracorporeal shockwave therapy
Extracorporeal shockwave therapy (ESWT), an effective method in various other musculoskeletal disorders was tested in chronic nontraumatic coccydynia in a quasi-interventional study involving ten individuals and was found to improve early pain intensity. In another study that was a randomized trial comparing 20 patients with ESWT and 21 with physical therapy measures, ESWT was found to be more effective than physical therapy methods such as short-wave diathermy and interferential current. Favorable outcome with majority of cases having partial relief was noted in a series when ESWT directing the most painful area was given in three sessions (one per week) and followed up for 6 months.
Ganglion impar blockade
Injections for recalcitrant pain, in an elderly female, not responsive to physical therapy measures have been tried with good results in one report. Failure of conservative methods such as use of cushion, avoidance of provocative activities, and injection of local anesthetic to ganglion impar led to 100% pain relief without recurrence.
Ganglion impar, a solitary retroperitoneal structure formed from terminal fusion of lowest paravertebral sympathetic cannels, supplies nociceptive and sympathetic supply to perianal structures. The ganglion impar is also known as “ganglion of Walther” is described to lie variably between the sacrococcygeal joint to first coccyx. It is more commonly found in upper coccygeal region.
Ganglion impar injections with corticosteroid and local anesthetic agent were found to decrease pain and disability in chronic coccydynia patients. The injection route in this study was through sacrococcygeal junction.
Other routes, however, are also advocated for this block such as transcoccygeal, intracoccygeal, or coccygeal transdiscal. The rationale for this is based on the fact that sacrococcygeal joint is fused in majority of cases and its location as stated above may be more likely in upper coccygeal area. Ganglion impar blockade under computed tomography (CT) guidance involving thin section CT-guidance for needle placement followed by injection of bupivacaine and triamcinolone in a series of eight cases showed pain relief in 75% cases. Accurate placement within ganglion impar and less risk of inadvertent injection into adjacent structures were proposed advantages of this technique. Use of magnetic resonance imaging as guidance for the percutaneous perineural ganglion impar injection is believed to provide higher soft-tissue contrast and direct, radiation-free approach.
One study involving 50 cases from India evaluating the effectiveness of fluoroscopically guided ganglion impar injection with lidocaine and triamcinolone found the technique to be effective and worth recommendation.
In another study, results of the trans-sacrococcygeal approach on ganglion impar followed by radiofrequency therapy in 41 cases, was effective and safe. The authors, however, pointed out that patient selection and experience are critical for the success of this technique.
Radiofrequency thermocoagulation (RFT) was used to destroy the ganglion impar in 10 patients with chronic coccydynia and 90% success rate was seen in midterm evaluation (6 months). Strict patient criteria and technique were advocated by authors for the good results. Radiofrequency theromocoagulation (RFT) of ganglion impar, in a retrospective study of 19 cases covering an year of follow-up, recorded effective outcome, and lower pain scores.
Twenty-one patients with, failed conservative treatment, were managed with caudal epidural pulsed radiofrequency (PRF) with most cases being posttraumatic. The method was found to be satisfactory, and authors regarded it as an alternative to surgery after failed conservative care. PRF is neuromodulative therapy useful in various chronic pain syndromes. The use of fluoroscopic guidance, through sacrococcygeal disc, in one report has been fund to make these procedures more effective. PRF of ganglion impar in a series of 20 cases, resulted in successful results in 75% cases.
Recognizing intercoccygeal disc as source of pain in coccydynia, radiofrequency ablation (RFA) through first intercoccygeal disc was attempted in one case report with 70% pain relief up to 6 months. RFA of sacrococcygeal nerves was fund a viable therapeutic option in an another series of 12 patients.
| Operative Management|| |
Most of the advances for this condition are regarding its anatomy, radiology, and conservative management, while surgical options are limited. A few researches regarding surgical procedures, however, add significantly to existing procedures to improve the outcome and reduce the complications.
An anecdotal report of novel management method in the lines of vertebroplasty or sacroplasty was reported. These procedures entail injection bone cement within the compressed bone to regain height and dramatic pain relief in vertebral body and sacrum, respectively. The author performed this procedure which they termed coccygeoplasty with good outcome reported.
Surgical excision of painful coccyx is concluded as treatment of choice in posttraumatic instability with total coccygectomy as advocated method for excellent results in a series of 31 cases of posttraumatic coccydynia.
One study based on patient-reported satisfaction scores evaluating the effect of age and body mass index (BMI) concluded that higher BMI may be associated with lower, whereas posttraumatic cases may show higher satisfaction scores indicating that BMI along with traumatic status are independent variables in overall outcome following coccygectomies.
In another study of eight traumatic and six nontraumatic coccydynia cases, coccygectomy resulted in overall excellent results with fewer complications.
Both partial and total coccygectomies were fund to have good outcome with low complication in a small study of mix cases of both types of surgery for refractory posttraumatic coccydynia. Partial coccygectomy has advantage of sorter and less invasive surgery with low complication rate.
In one interesting study comparing pain score and patient satisfaction between two groups of coccygectomy cases with or without periosteum involvement were assessed. There was no significant statistical difference between patients with coccygectomy along with periosteum resection or those with subperiosteal excision in 11 and 14 cases, respectively. The risk of infection, however, was less in periosteum preservation group.
In a study covering 28 case series covering 742 cases of coccygectomies from 1980 to 2012, 84% cases had excellent outcome following the procedure. That corresponded to 84.6% cases with excellent outcome of the author's series. Complication rates were 13.3% only with wound-related complications being the most common.
In a recent large study of 98 cases of chronic refractory coccydynia were managed by coccygectomy and showed significant improvement in patient-reported outcome at 2 years. The bad results were linked to several factors, including the presence of psychiatric illness, higher level of pain, or use of opiates. Complete coccygectomy in refractory cases, in a recent study involving 16 consecutive cases, also found the method to be simple, effective, and devoid of major complications. In a recent systematic review of English language literature during the period of 1980–2010 within Pubmed, only 2 were prospective and 22 retrospective ones. Only 5 were classified as Level 3 and rest were Level 4 studies. Direct trauma and female sex were most common associations and overall 671 cases underwent coccygectomy with 85% cases had relief of pain. There have been very few studies comparing surgical and nonsurgical modalities for coccydynia. One recent retrospective cohort study (2004–2014 with 109 cases) evaluated the long-term outcome of surgical versus nonsurgical treatment for coccydynia. All surgical cases (48 cases) had at least 2-year treatment of conservative methods and advance imaging before the surgical intervention. 79% of surgical cases improved in contrast to 43% of nonsurgical group at 2 years on various parameters such as visual analog score, EuroQol five-dimension, Coccygodynia Disability Index, and PROMIS pain interference scores. Only 11 cases had wound-related complications managed by minor interventions. The use of topical skin adhesive along with two prophylactic antibiotics (cefamandole and ornidazole) for 48 h, preoperative enema, and closure of incision in two layers were stepped remarkably decreasing the incidence of postcoccygectomy infection in a large series. A recent review published literature in PubMed during the period of August 2012 to August 2017 including 13 studies, included various modalities of treatment such as conservative, interventional, and surgical. The study concluded that large numbers of articles suggest coccygectomy as an effective method and hoped that future randomized controlled studies should strengthen the evidence base. Another article following Medline search regarding benefit of coccygectomy yielded 24 studies with a total of 702 cases of coccygectomies showing 83% excellent or good results. Coccygectomy is thus worth recommendation for intractable pain following failed conservative treatment.,,,
| Conclusion|| |
A proper education of coccyx and chronic pain is important to demystify the often underappreciated conditions that is disabling and requires proper recognition and better management. A recent survey of primary care physicians revealed lack of proper knowledge about the incidence and management of coccydynia. Most did not refer the patients to pain specialist despite chronicity of symptoms and many considered surgical intervention and absurd option. Despite the treatment various factors affect the overall outcomes such as exact pathology, neurotic personality, BMI, associated disc lesions, or coccygeal mobility.
Conservative care is mainstay of the treatment, and operative intervention is reserved for recalcitrant cases. The future should see better treatment protocols as the current literature is scant of robust, high-quality studies in good number.
This review comprises of recently published relevant articles for educative purpose. The review may, however, be not comprehensive, and many articles might have been left for want of space. The coccydynia requires high-quality research for better understanding of its morphometry, pathological variations, and treatment methods.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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