Coccydynia, or tailbone pain or coccyx pain, is condition that can cause persistent pain at the very bottom of the spine or coccyx. It is also known as coccygodynia, coccygeal pain, coccyx pain, coccyaglia or tailbone pain.
Coccydynia is is much more common in women than men.
Coccydynia is rare, accounts for less than 1% of back pain conditions.
Anatomy of Coccyx
The coccyx is the very bottom portion of the spine and consists 3-5 vertebrae. . It represents a vestigial tail (so the term tailbone) The ventral side of the coccyx is slightly concave whereas the dorsal aspect is slightly convex. The coccyx attaches the sacrum, from the dorsal grooves with the attachment being either a symphysis or as a true synovial joint, and also to the gluteus maximus muscle, the coccygeal muscle, and the anococcygeal ligament.
There is very limited movement between the coccyx and the sacrum.
Postacchini and Massobrio described four orientations of coccyx wherein anterior angulation of the coccyx may be a normal variant.
The coccyx is curved slightly forward, with its apex pointing caudally. It is most common type and found in 15% of the people.
The coccyx is curved more markedly anteriorly, with its apex pointing straight forward. This type is found in approximately 15% of people.
The coccyx is sharply angulated forward between the first and second or the second and third segments. It occurs in 5% of the people.
The coccyx is subluxed anteriorly at the level of the sacrococcygeal joint or at the level of the first or second intercoccygeal joints. This type is found in about 10%.
Patients with a type II-IV coccyx are more prone to develop idiopathic coccygodynia than those with a type I configuration.
Causes of Coccydynia
Cocydynia occurs if there is an injury or excess pressure on the area causing the bones to move beyond their normal very limited range of motion. This results in inflammation and localized pain. Ligaments, the vestigial and bones of the coccyx can source of pain. Infection of coccyx can also lead to pain.
A fall on the coccyx causes injury to ligaments or bone. It is the most common cause of coccydynia.
During delivery, the baby’s head passes over the top of the coccyx, and the pressure created against the coccyx can sometimes result in injury to the coccyx structures.
Horse riding and sitting on hard surface for long periods of time, may cause the onset of coccyx pain.
Tumor or Infection
Rarely, coccydynia is due to a tumor or infection in the coccyx area that puts pressure on the coccyx.
It is not clearly understood which portions of the anatomy can cause coccyx pain. In many cases the exact cause of the pain is not known (called idiopathic coccydynia), and in these cases the symptoms are managed.
Symptoms of Coccydynia
Typically there is pain in lowermost part of spine that becomes worse when person sit. It worsens when any pressure is placed on it, when moving from a sitting to standing position. Activities that put pressure on the affected area are bicycling, horseback riding, and other activities such as increased sitting that put direct stress on the coccyx.
Examination would reveal local tenderness. If the coccyx is not tender to palpation, then the pain is likely to be referred from another structure
Physical rectal examination, x-rays and MRI scans can rule out various causes unrelated to the coccyx.
Injection of local anesthetic into the area should produce immediate relief if the pain is related to coccyx. If it is positive, then a dynamic (sit/stand) x-ray or MRI scan may show whether the coccyx dislocates when the patient sits.
In a typical case, all imaging studies will be negative.
Application of cold packs to the area several times a day for the first few days after the pain starts. Applying heat or a hot pack to the area after the first few days. NSAIDs , anti-depressants such as amitriptyline may help alleviate pain. Patient should avoid sitting for prolonged periods, or placing any pressure on the area, as much as possible.
A custom pillow/soft cushion helps to that keeps pressure off the coccyx.Local anesthetic agent injection and steroid injections can provide some relief lasting from 1 week up to several years. No more than 3 injections per year are recommended.
Manipulation and stretch exercises can also help to reduce pain in some patients
For people who have persistent pain that is not alleviated or well-controlled with non-surgical treatment and activity modification, surgical removal of all or a portion of the coccyx (coccygectomy) is an option.
This surgery is rarely performed but has been reported to produce 80-90% relief in proper hands of coccyx under anesthesia
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