Approach

Coccygodynia should be managed in a stepwise fashion with increasing invasiveness.[26]​ Acute coccygodynia (symptoms <2 months) is managed differently from chronic coccygodynia (symptoms ≥2 months). Coccygectomy surgery is reserved for refractory cases. The goal of treatment is to eliminate or significantly reduce coccygeal pain and allow the patient to resume a pre-morbid lifestyle. Incidentally discovered tumours or other pathologies are referred immediately to appropriate specialists.

Patients presenting with acute or chronic coccygodynia

Most patients with acute coccygodynia (symptoms <2 months) are advised to rest and prescribed a non-steroidal anti-inflammatory drug (NSAID) as required for a period of up to 8 weeks, except in those with contra-indications to their use.[27] NSAIDs are associated with an increased risk of cardiovascular thrombotic events and gastrointestinal toxicity (bleeding, ulceration, perforation), and should be used at the lowest effective dose for the shortest effective treatment course.

A stool softener is recommended in patients who have a history of pain with defecation, also over a period of 8 weeks.

Adjustments in seating with U-shaped cushions can relieve pressure on the coccyx. Additional therapies include sitz baths, pelvic floor physiotherapy, and chiropractic manipulation.[1][28][29]​​

Initial management of patients who present with chronic coccygodynia (symptoms ≥2 months) is the same as that recommended for acute coccygodynia.

Chronic coccygodynia: conservative management

If acute management is unsuccessful, dynamic sacrococcygeal x-rays and an MRI should be obtained to rule out tumour or other pathology, before proceeding with further treatment.

First-line treatment is monthly corticosteroid plus local anaesthetic injections given on an as-required basis. They may be given alone or in combination with invasive manipulation (i.e., transrectal flexion and extension) under general anaesthesia, the latter being considered more successful.[30] The corticosteroid plus local anaesthetic should either be injected into the soft tissues around the sides and tip of the coccyx (using methylprednisolone) or the sacrococcygeal (SC) junction and dorsal periosteum of the coccyx (using triamcinolone).[31] However, percutaneous SC junction injection is sometimes recommended if local injection and/or manipulation fails, and may be accomplished fluoroscopically, or with digital rectal localisation of the SC junction.[31][32]

If corticosteroid plus local anaesthetic injections have no effect after two successive monthly injections, physiotherapy combined with corticosteroid injection is an effective second-line option. Physiotherapy measures include transrectal pelvic floor massage and coccygeal mobilisation.[30][33][34][35]

Injection of the ganglion with a local anaesthetic (e.g., lidocaine, bupivacaine) under fluoroscopic guidance has been used to successfully treat coccygodynia. One systematic review concluded that the injections have a >85% success rate for pain control. The average percent improvement score was 60% at 1 month, 55% at 3 months, and 40% at 6 months.[36] Repeat injections may be required. Ganglion impar injections should always be performed with image guidance to avoid complications from intravascular injection.[37]​​​

Chronic coccygodynia: surgery

Patients with chronic coccygodynia, in whom a 3 to 6 month period of conservative management has failed, may be referred to a spine surgeon for coccygectomy. Surgical series have reported success rates ranging from 60% to 91% after coccygectomy.[27]

Coccygectomy is more successful in cases of traumatic and post-partum coccygodynia than in idiopathic coccygodynia (75% success vs. 58% success).[14] Confining coccygectomy to patients with radiographic instability on dynamic x-rays can result in good or excellent outcomes in 92% of cases.[21] Residual coccygeal fragments or a prominent sacral edge in a thin patient may lead to poor outcomes and necessitate re-operation for redo coccygectomy, or rongeuring of the edge of the sacrum.

Wound infection is the most common complication after surgery, with rates ranging from 2% to 22%.[27] The use of a drain along with post-operative antibiotics may reduce the incidence of post-operative wound problems including infection. Antibiotics should be continued for 72 hours after surgery and must cover both aerobic and anaerobic organisms. Rectal hernia is a rare complication after coccygectomy.[38][39]

Sacral rhizotomy (sectioning the S4 and S5 nerve roots) might be considered for patients with pain strictly localised to the coccygeal region, following failed coccygectomy; however, sacral rhizotomy does not currently play a major role in treatment.[40][41]

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