Coccydynia

coccydynia

1. Coccydynia

2. COCCYDYNIA/ COCCYGODYNIA

3. COCCYDYNIA / COCCYGODYNIA Introduction: Implies pain in the region of coccyx. Term first coined by SIMPSON in 1859 Simplistic classification based on aetiology was given by NATHAN & ROBERTS Classification based on morphology of coocyx was formulated by POSTACCHINI & MASSOBRIO

4. ANATOMY OF COCCYX

5. 4 RUDIMENTARY VERTEBRAE FUSED TOGETHER. PELVIC AND DORSAL SURFACES. BASE/UPPER END HAS AN OVAL FACET ARTICULATING WITH THE SACRUM. 1 ST COCCYGEAL VERTEBRA – RUDIMENTARY TRANSVERSE PROCESS. REMAINING VERTEBRAE REPRESENTED BY NODULES OF BONE.

6. ATTACHMENTS OF COCCYX Coccygeus is attached to the lateral aspect of the pelvic aspect of the last piece of sacrum and the whole of coccyx. Levator ani is attached to the lower two segments of the coccyx. The gluteus maximus arises from the lateral margin of the lowest part of the dorsal aspect of the sacrum and that of the coccyx. Sphincter anii externus .

7. AETIOLOGY Most common : Direct axial trauma. Idiopathic. During child birth ( Labour ) Repeatitive strian (Cycling, rowing) Poor Posture (Prolonged sitting with leaning backward) Ageing Tumour – Chordoma , metastasis Infection – Pilonoidal sinus

8. CLASSIFICATION A) BASED ON AETIOLOGY: Idiopathic Traumatic. B) BASED ON PATHOLOGY: Degeneration of sacro-coccygeal and inter- coccygeal discs and joints. Morphology of Coccyx – type 2,3,4 are more prone Mobility of coccyx - Hypermobile or posterior subluxation . Referred pain – Lumbar pathology, spasm of pelvic floor muscles and inflammation of peri-coccygeal soft tissues.

9. POSTACCHINI AND MASSOBRIO MORPHOLOGIC CLASSIFICATION Type 1: Curved gently forward. Type 2: Has a marked curve with apex pointing straight forward. Type 3 : Angled forward sharply between 1 st and 2 nd or 2 nd and 3 rd coccygeal segments. Type 4: Anteriroly subluxated at the level of the sacro-coccygeal joint or between the 1 st and 2 nd intercoccygeal joint. Type 5: Coccygeal retroversion Type 6: Scoliotic deformity

10. CLINICAL FEATURES Accounts for 1% of all non traumatic complaints of the spine . M:F – 1:5 Pain and tenderness in the region of the lower sacrum, coccyx, pericoccygeal tissues. Pain proportional to the duration of time spent sitting. Disproportionate increase in pain in pre-menstrual periods. Spasm of the pelvic floor muscles ( Levator anii ) as pain is often present during defecation. At times associated with pyriformis syndrome.

11. Investigations 1) Routine Blood test: CBC, ESR, CRP, ALK Phos . (in case of infection, neoplasm and inflammation) 2) Dynamic radiographs. (Standing v/s Sitting) 3) Steroid injections with or without local anaesthetics used as diagnostic as well as therapeutic modality for coccydynia .

12. Treatment CONSERVATIVE : Successful in 95% patients. Non steroidal anti-inflammatory drugs SIETZ bath Ring shaped cushions. Ergonomic adaptations: Postural training Use of rubber ring or firm corset. Physiotherapy Manual manipulation of coccyx.

13. Treatment Procedural : Sacro-coccygeal Corticosteroid injections with or without local anaesthetics agents. Ganglion impar blocks. (Blockade of nociceptive and sympathetic fibres ) Radiofrequency theromocoagulation of ganglion impar . Trans sacral ammonium chloride injections.

14. Treatment Surgical : Coccygectomy – Complete OR Partial . Surgical removal of coccyx. Power’s technique : Gardner’s technique: Safer technique Less chance of infection No blind plane formation close to the rectum.

15. Complications : Infection Posterior rectal wall injury Loss of anal sphincter control. Chance of rectal prolapse .

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