Coccygodynia symptoms & treatment

It is a very unpleasant condition although it is quite rare and it represents less than 1% of all back pain conditions reported to physicians.

Although the pain is very strong, the reasons behind coccygodynia are not completely understood. There are many possible theories as to what causes this painful state
 and they include:

   1. Pain from the soft tissues around the tail bone
   2. Spasm of the muscles of the pelvic floor,
   3. Referred pain from lumbar pathology,
   4. Inflammation of the lower sacral nerve roots,
   5. Local posttraumatic lesions,
   6. Somatization

Although almost any of these could be the cause of the pain, patients often mention a fall on the buttocks or a delivery before the pain started so the reasons are probably mechanical such as fracture of the coccyx or fracture dislocation of the coccygeal vertebra.

In most cases, the patients feel the pain while in the sitting position. It is 5 times more common in women than in men, probably due to the fact that it is more prominent in women. Almost one third of all cases of coccygodynia are idiopathic in nature, which means that the real cause is unknown.

Anatomy of the sacrococcygeal structure

Tailbone is the last bone of the vertebral column. It is a tiny triangular bone, which is usually made of 3 to 5 vertebrae that are fused together. There is a joint where this part is connected to the sacrum, a part of pelvis,. The movements of the coccyx are restricted to flexion and extension. Range of motion of the coccyx is measured in degrees.

Flexion larger than 25-30 degrees represents hypermobility and slipping larger than 25% represents luxation.

The levator ani muscle, the anococcygeal and sacrotuberal ligaments, the sacrospinal ligament, and the gluteus maximus muscle of the buttock all play a very important role in the movement of the coccyx.
 

Symptoms of coccygodynia

The most common symptom of coccygodynia is strong pain while sitting. Pain is often described as a burning pain in the rectal area. Beside pain, numbness could also occur in lower parts of the spine. In most cases, pain is aggravated by bowel movements, sexual intercourse or menstruation.
Diagnosis of coccygodynia

The most common method of diagnosis is definitely a radiographic imaging, which usually includes a lateral view of the coccyx. There are four radiographic types of pelvis:

   1. With the coccyx curved slightly forward
   2. Similar to type 1 with the tip almost pointing straightforward
   3. The coccyx is sharply angled on the anterior side
   4. Type with subluxation of either the sacrococcygeal joints or the coccygeal joint

Patient should avoid sitting for five to ten minutes before the X-rays examination. The problem with this method is that the patient must feel the pain in order to get the right diagnosis. If the pain is not present, no sound conclusion should be drawn.

Although CT and MRI are much more sensitive diagnostic tools, they do not add any significant information to the standard standing and sitting radiographic imaging. In more then 40% cases the coccyges are found without any radiographic abnormality.

In these cases, doctor has to think about several possibilities:

   1. The cause of pain could be intradiscal inflammation. This could be tested easily with application of intradiscal injection. If the pain disappears after it, the cause is definitely a chronic joint inflammation
   2. Chronic bursitis, inflammation of subcutaneous tissues could also be the cause. It can also be treated with subcutaneous injections.
   3. Psychogenic pain is also a very common cause of pelvic pains. Hysteria, neurotic pain or depression are the most common causes among these. This could be easily distinguished from coccygodynia because in most cases the pain is permanent and not enhanced by sitting.
   4. The sacroiliac joint or the lumbosacral area can sometimes radiate pain into this area making the diagnosis much more complicated.

Coccyx can also be palpated. This examination is performed rectally with the patient lying on their left side. This way the doctor examines how the coccyx is positioned, and whether it is movable.

Abnormality in the form of a small bony excrescence on the dorsal aspect of the tip of the coccyx is called coccygeal spicule. Good thing about it is that when it is present, it can always be easily palpated! It is considered to be a form of embryonic malformation.
 

Treatment of coccygodynia

There are many different approaches to the treatment of coccygodynia including various applicable remedies, sitting in a tub of hot water, local anesthetic creams, massage, muscle relaxants, electric stimulation devices, counseling, biofeedback and sometimes even anti-depressants. However, there are three major types of the most effective treatments:

Manual Treatments

This is a classic treatment of coccygeal disorders, which consist of manual manipulations of the coccyx or massages of the pelvic muscles.

Before the treatment, patient can gets an intraregional injection that should cause 25% increase in the rate of satisfactory results. All the manipulations of the coccyx in joint and stretching of the coccyx could be performed with the rectal finger. Although the treatment is rather unpleasant, it can relieve most of the problems related to muscles stretching.

According to some researches made in the past, results of the manual treatments are satisfactory in 25% of cases at six months, and in 24% at two years after it.

Medical Therapy

In most cases, the treatment begins with non-steroidal anti-inflammatory drugs, which are being used to reduce inflammation and pain around the joint. Patients may also use small pillows that are donut-shaped. These pillows are being used to decrease coccygeal pressure and local irritation. If this therapy fails, the physician should start thinking about steroid injections therapy. This technique is being done with the help of x-rays imaging. When the doctor chooses the adequate disc, considering radiological abnormalities or tenderness at this level he will insert a 25mm needle under aseptic conditions into the lesion.

The injection is generally effective for one week. There were many studies about this method, which claim that, in the long run, this method may actually do more damage than good.

The truth is that cortisone shots can produce short-term pain relief, but can actually result in long-term loss of function and even more chronic pain because it is proven that the steroid medications are actually inhibiting the healing process of soft tissues.

Surgical Approach

There were many talks and controversies about correct surgical approach to the problems related to chronic pelvis pain. If the pelvis pain is long lasting and unresponsive to treatment, it may result in the surgical removal of the coccyx.

Although, some authors have reported good results, many of them are strongly against this therapy method. The operation is called coccygectomy. Although it probably sounds like a big and massive operation, the actual procedure is relatively simple for any surgeon who knows the region well anatomically. The operation lasts about an hour.

For many years, only total coccygectomy was performed, but in the last couple of years, a limited coccygectomy has been proposed. This operation involves only the resection of the mobile segment of the tailbone.
 

Complications and prognosis

The most common complication of this operation is infection caused by the violation of the rectal vault. Many surgeons have also described problems with healing and scarring of the both superficial and deep wounds.
The key of a good therapy is to allow enough time for the symptoms to respond to it before the operation because pain is usually managed with conservative measures. Patients should also know that, it may take 6 months to 1 year after the operation until they are completely pain free.

Prolotherapy

Many experts claim that the safest and most effective natural medicine treatment for repairing tendon, ligament and cartilage damage is Prolotherapy. What exactly is Prolotherapy?

Prolotherapy is an attractive form of therapy whose primary role is to stimulate the body to repair painful areas itself. Doctors are inducing a mild inflammatory reaction in the weakened ligaments and cartilage. Prolotherapy is performed by frequent inserting of the needle into the joint, causing a chronic inflammatory reaction, which will eventually join the damaged ligaments!

Homeopathic remedies

Several homeopathic remedies are being used for years to relieve symptoms of tailbone pain and some studies have shown that the most of them are actually leading to alleviation of coccygodnia.

The most common are:

   1. Apis - whose role is to relieve swelling of the skin and mucosal membranes
   2. Carbo Animalis – it affects the venous system and relieves the burning sensations. It has been used by elderly people mostly.
   3. Causticum – Very potent remedy that can relieve cutting and tearing sensations  often associated with burning, rawness, or soreness
   4. Gambogia – has many positive effects on digestive system
   5. Kreosotum – has been used for many years as a painkiller. It has also been used for the relieving of the menstrual problems.
   6. Hypericum – it is indicated in coccygodynia when there is excessive pain as the guiding feature.
   7. Lathesis – used mostly in cases when the pain is strongest while rising from seated position