Coccygodynia: surgical treatment

Cocciogodinia: tratamento cirúrgico

Coccygodynia: Surgical treatment

Cocciogodinia: Tratamento cirúrgico

Alceu Gomes Chueire^I; Guaracy Carvalho Filho^II; Luciano Barboza de Souza^III

^IPhD Professor and Departament Head

^IIPhD Professor and Discipline Head

^IIIResident

^{Address for correspondence}

SUMMARY

The coccygodinya is a clinical condition that is caracterized by tumescence and by ache in the coccyx area. It can be related with trauma or with anatomic conformation of this area. The coccygodynia occurs more frequently in women. We report that in the medical treatment it must use conservative strategies and only when those strategies fail it is indicated the surgical treatment which gives good results. The aim of this study is to evoluate the sirurgical treatment by coccygectomy with 12 pacients being evuluated showing good results in 10 cases, regular in 2 cases and no bad result.

Key words: Coccygodinya; coccygectomy.

RESUMO

Coccigodinia constitui uma condição clínica caracterizada por edema e dor na região coccígea, podendo estar associada com trauma ou à conformação anatômica deste segmento, sendo mais freqüente no gênero feminino. O tratamento deve ser iniciado por meios conservadores e, na falha destes, o tratamento cirúrgico pode ser indicado com bons resultados. Objetivo deste estudo é avaliar o tratamento cirúrgico pela coccigectomia, sendo avaliados 12 pacientes com obtenção de bons resultado em 10 casos, 2 casos com avaliação regular e nenhum mau resultado.

Descritores: Coccigodinia; coccigectomia.

INTRODUCTION

Coccyx is a rudimental bone of the tail from inferior animals. It is the distal portion of the spine, with a conical format, in number of four and sometimes five segments. These bones are mobile by birth time, and trend to fuse, distal ones in childhood and the proximal ones in the beginning of adult life. Sacrum-coccygeal joint has little movement, and its fusion is rare. Primary posterior divisions of coccygeal nerves provide coccyx innervation; each coccygeal nerve receives a communicant branch from the posterior division of the lower sacral nerve.

Due to its muscle insertions, coccyx is very dynamical. Its daily movement is present at defecation and when a person is seated, in this last situation acting as a shock absorber, displacing towards anterior.

Pain is coccyx occurs due to local factors, or referred from other regions. The most common causes are:

• Traumatic — distension of sacrum-cocygeal segments, fracture, dislocation;

• Congenital — absence of anterior curve;

• Degenerative arthritis of sacrum-coccygeal joint;

• Tumors (mostly cordoma).

The referred distant causes are:

• Lumbo-sacral injuries;

• Epysacral lipoma.

In this study will only be considered patients with local coccygodynia.

Treatment of coccygodynia should always be initiated conservative, by means of orientation, special pillows, physiotherapy for analgesia, non-steroidal anti-inflammatories (NSAIDs) and even local infiltration. From the moment conservative measures are ineffective, it is indicated a surgical treatment. Thus, this is infrequent.

The aim of this study is to demonstrate the indications and results of the surgical technique of resection of coccyx (coccygectomy) in the treatment of coccygodynia.

MATERIAL AND METHOD

This study was performed at Departamento de Ortopedia e Traumatologia da Faculdade de Medicina de São José do Rio Preto — São Paulo, Brazil — FAMERP.

Twelve patients with coccygodynia underwent surgical treatment (Table 1). From these, five were operated at Santa Casa de Misericórdia de São José do Rio Preto, and seven at Hospital de Base de São José do Rio Preto.

The age of the patients ranged from 3 to 54 years, average 19 years. Regarding gender, five patients (42%) were female and seven patients (58%) male.

For diagnosis, besides the clinical picture, were requested radiographs of sacrum-coccygeal spine, anterior-posterior and lateral views, and through that was established coccyx deviation for fracture-dislocation or by congenital abnormality in its angle.

The patients underwent surgery only when conservative approach failed to obtain relief.

The surgical procedure is performed under rachidial anesthesia. Patients are placed in horizontal prone position over three pillows. These pillows are placed: one transversal to the body axis, under iliac spines and the other two parallel to each other and to the smaller body axis, under anterior thoracic wall. Two large adhesive bands are placed in each gluteal part in order to lower and expose the intergluteal cleft, making coccyx more salient. After this, asepsis and anti-sepsis are performed, and the area delimited by draping.

Skin incision was in average of 6 cm long, longitudinal and median over intergluteal cleft. After dissected by layers, coccyx and sacrum-coccygeal joint are exposed. After this, the coccyx was removed and the remaining sacral surface was regularized for avoiding tenderness due to irregular post-operative support, when seated. Suture by layers was careful for fat tissue to constitute an adequate pillow.

It was not used drainage, since it was performed rigorous haemostasia. After complete suture, simple dressing was placed.

All patients were discharged from the hospital in the first post-operative day, after dressing was changed. Were instructed not to seat on hard surfaces up to the third post-operative week. Returned to removal of stitches by the tenth post-operative day.

All patients underwent prophylactic antibiotics with cephalosporin and also received NSAIDs up to the fifth post-operative day.

In post-operative outpatient follow-up, pain was evaluated by means of the Mc Evoy & Bradford (1985) method:

I. No pain

II. Light pain: occasional use of narcotic medication, no significant interference in daily life activities.

III. Mild pain: occasional use of narcotics and some interference in daily life activities.

IV. Severe pain: frequent use of narcotic analgesics in important pain.

The results were considered as "Good" in absence of pain (Mc Evoy & Bradford I); "Regular" when patients had light pain (Mc Evoy & Bradford II) and without problems for seating and/or perform daily life activities; "Bad", when patients had mild and/or severe pain (Mc Evoy & Bradford III and IV), had difficulties for seating and daily life activities limitation.

RESULTS

Twelve patients were evaluated, with a mean follow-up of 24.1 months (range from 10 months to 36 months). An intermediate evaluation was performed 2 months after the surgery.

In the analysis per protocol, ten patients had "Good" results, and two patients "Regular" results. No "Bad" result was observed by the evaluation at 60^th postoperative day. In this occasion two patients had residual pain (chronic fracture-dislocation), being applied two infiltrations of xylocaine plus steroid in a 15 days interval, resulting in resolution of the painful condition. After the 6^th post-operative month all patients had results rated as "Good", maintained to the last evaluation performed.

We would like to stress that it was observed in this series no post-operative complication.

DISCUSSION

Even though some authors as GROSSO & VAN DAM⁽¹⁾ and ZAIER⁽⁶⁾ report coccygodynia is more frequent in women, in this study it was found an equivalency between the genders. The age displays a clear preference for young individuals, and the trauma is related to daily life activities, supported by other authors^(1,6). None of our patients had coccygodynia related to parturition, nevertheless this is less frequent, however present in literature, according to JONES et alli ⁽³⁾.

Radiographs displayed a normal angle or a lateral deviation of the coccyx, however the increased angle or deviation are not related to pain intensity, according to MAZA⁽⁵⁾ and MAIGNE⁽⁴⁾ (Figure 1).

The initial treatment should be always conservative (non-steroidal anti-inflammatories, analgesic physiotherapy, orientation for avoiding to seat in hard surfaces, and sometimes local infiltration). When these procedures fail, after a follow-up from two to eight months, it should be chosen a surgical treatment^(1,2,6).

In patients with coccygeal congenital abnormalities, there were cul de sac fistulae that were always removed. Another observation is that the surgical piece was always larger and with a more evidently posterior angled than suggested by radiographs. This is due to the cartilaginous formation of the coccyx not demonstrated by radiographs, however clinically palpable (Figure 2). It is also worthy to stress that these patients had an evident post-operative improvement, and this is poorly divulged in literature.

No complication was registered in our series, even though the small number of cases. Special attention should be drawn to the risk of infection, common in this region. This did not happen due to very careful dressings and good orientation to patients.

CONCLUSION

Coccygectomy is a good treatment method for chronic coccygodynia when patients are well selected and, mostly in congenital cases who had significant improvement already in immediate post-operative period.

Trabalho recebido em 13/05/2002. Aprovado em 26/07/2002

Work performed at the Departamento de Ortopedia e Traumatologia da Faculdade de

Medicina de São José do Rio Preto - SP - FAMERP

• 1. Grosso, N.P., Van Dam, B.E.: Total coccygectomy for relief of coccygodynia: a retrospective review. J Spinal Disord. 1995 Aug; 8(4): 328-30.
• 2. Hellberg, S., Strnage-Vognsen, H.: Coccygodynia treated by resection of the coccyx. Acta Orthop Scand 1990; 61: 463-465.
• 3. Jones, M.E., Shoaib, A., Bircher, M.D.: A case of coccygodynia due to coccygeal fracture secondary to parturition. Injury.1997 Oct; 28(8): 549-50.
• 4. Maigne, J.Y., Tamalet, B.: Standartized radiologic protocol for the study of common coccygodynia and caracteristics of the lesions observes in the sitting position. Spine.1996 Nov 15; 21(22): 2588-93.
• 5. Maza, C.G.: RX lateral de cóccix em sedentación en el diagnóstico de coccigodinia. Rev Mex Ortop Traum. 1998; 12(6): Nov.-Dec: 572-577.
• 6. Zaier, M.: Coccygodynia. Ulster Med J. 1996 May; 65(1): 58-60.

Publication Dates

• Publication in this collection
  25 Feb 2003
• Date of issue
  Dec 2002

History

• Received
  13 May 2002
• Accepted
  26 July 2002