Radiofrequency to coccyx interdisc, pulsed radiofrequency to ganglion impar, and coccyx removal are all being used in recalcitrant cases.
I have had letters of unsatisfactory coccyx pain case and have included some more advanced measures:
Though prior studies have failed to find much MRI features, a recent study found significant findings:
Eur Spine J. 2012 Feb 22. [in press]
Magnetic resonance imaging findings in the painful adult coccyx.
Maigne JY, Pigeau I, Roger B abstract here
- 172 cases severe chronic coccydynia
- 70 cases (40%) disc abnormalities – intradisc fluid (17), Modic 1 end plate changes (38), or uncetain changes (15)
- Tip of coccyx abnormalities – 41 (24%) – 13 soft tissue inflammation, 18 venous dilatations, ambigious 13
- vertebral bone edema 5;
- benign tumor 1
- rigid coccyx cases were more likely to show coccyx tip abnormalities while mobile coccyx cases more likely a disc lesion:
“the 105 cases with a mobile coccyx mainly presented abnormal features mainly in a disc (63 cases vs. 4 cases for the tip), whereas
the 67 patients with a rigid coccyx mainly showed abnormal features at the tip (37 cases vs. 7 for the joints, p < 0.001)”.
Hence ascertaining whether coccyx mobile or not is useful.
In a disc case, they found radiofrequency ablation of the intradiscal joint followed by injection 20 mg methylprednisolone was helpful:
Pain Pract. 2011 May-Jun;11(3):278-81.
Radiofrequency ablation within the first intercoccygeal disk for coccygodynia: a case report.
Scemama P, Shaparin N, Kaufman A, Dua S. abstract here
- 44 year oold lady with 1 year history of a fall
- Confirmations included:
– localization of her pain at the disk between the 1st and 2nd coccygeal vertebrae.
– provocation with needle puncture or area
– local injection of 40 mg of methylprednisolone gave 3 weeks relief
- Radio frequency ablation (RFA) was then carried out at 70°C for 80 seconds, followed by injection of 20 mg of methylprednisolone.
- 70% relief for 6 months (initially 9/10 Pains to 3/10 after)
For a case of uncertain origin of the pain, pulsed radiofrequency to ganglion impar offered relief:
J Pain Symptom Manage. 2010 Jun;39(6):e1-2.
Fluoroscopically guided ganglion impar block by pulsed radiofrequency for relieving coccydynia.
Usta B, Gozdemir M, Sert H, Muslu B, Demircioglu RI.
- 54 years old with 5 year coccyx pain unrelieved by usual measures
- did do trial block with 3 ml 1% lidocaine through transsacrococcygeal disc and I presume it helped temporarily though they did not say.
- “SMK-10 needle (NeuroTherm 22G, UK) with an active tip of 5 mm was inserted through the sacrococcygeal disc to the anterior surface of the coccygeal disc, with the guidance
of anteroposterior and lateral fluoroscopy”
- 42 degrees centigrade for 240 seconds.
- pain initially 8/10; was 0/10 initially , the 1-2/10 thereafter
>Agri. 2011 Jan;23(1):1-6.
Pulsed radiofrequency in the treatment of coccygodynia.
Atim A, Ergin A, Bilgiç S, Deniz S, Kurt E. free article here
- 21 cases average age 40 – five times more likely in women
- pain during sitting or standing up from a chair
- sedation by 0.02 mg/kg midazolam (1.4- 2 mg)
- coccyx is innervated by anterior branches of S4 and S5 spinal nerves and anterior branch of coccygeal spinal nerve
- local to skin
- Cannula was advanced to the intervertebral region between the foramina S3-S4 with anteroposterior fluoroscopic imaging.
- Pulse radiofrequency – 180 seconds avoiding temperatures above 42°C. – in caudal space
- In the 16 cases without surgery, pain level was initially 9/10 and dropped to 1.5/10 at 3 weeks and 6 months.
- In the 5 cases with prior sugery, pain dropped from 9/10 initially to 4 /10 at 3 weeks and 5/10 at 6 months
- All together, 81% was considered successful at 6 months.
For those unresponsive to any other therapy , coccygectomy (tailbone removal) is still done:
Chin J Traumatol. 2011 Feb 1;14(1):25-8.
Coccygectomy for stubborn coccydynia.
Cheng SW, Chen QY, Lin ZQ, Wang W, Zhang W, Kou DQ, Shen Y, Ying XZ, Cheng XJ, Lü CZ, Peng L. abstract here
- followed up for 1 to 6 years (mean 3.3 years)
- 31 cases
- excellent in 20 patients (64.5%), good in 7 patients (22.6%), moderate in 3 patients (9.7%) and poor in 1 patient (3.2%)
- Getting an overall good-excellent rate of 87.1%, they felt procedure was worthwhile
- couple superficial wound infections
Given that results are generally good from surgery, particularly for prior trauma, it was suggested people not wait so much:
Injury. 2007 Oct;38(10):1183-8. Epub 2007 Apr 6.
Coccygectomy for coccygodynia: do we really have to wait?
Cebesoy O, Guclu B, Kose KC, Basarir K, Guner D, Us AK. abstract here
“coccygectomy is a reliable method of treatment with a high satisfaction and a low complication rate.”
Comment – There are a variety of treatments available:
- Good sites to look at would be :
and of course Dr. Maigne in France:
- I find the tip of tailbone is often tender (apparently more in rigid coccyx cases) and steroid to area could help –
- Where intradiscal pains are present, steroid inject into disc area, followed by rhizotomy (if temporary relief) could be valid.
- Overall, Ganglion impar injections could be useful and I have discussed this elsewhere:
Ganglion Impar Injection For Tailbone Coccydynia
- Botox injections to the ganglion may give more lasting relief:
- Now it looks like simple pulse radiofrequency to ganglion thru sacro-coccygeal joint may work as well.
- What I can’t ignore, is how a coccygectomy (tailbone removal) could work as well…
Any comments welcome…