59 Coccygectomy To alleviate pain from an unstable or deformed coccyx. 1. Careful patient selection is mandatory. 2. History of significant trauma (fracture or dislocation), or severe congenital deformity is preferable. 3. Pain with sitting or while arising from a seated position (may be a symptom of instability). 4. No other significant spinal problem. 5. No radiating pain. 6. Physical examination is helpful for evaluation of tenderness, motion, deformity, or masses. 7. Look for pilonidal sinus or cyst. 8. Radiographs to evaluate anatomy. 9. Dynamic stress x-rays are valuable: Standing lateral of sacrum and coccyx (Fig. 59–1A); standing lateral after at least 10 minutes (Fig. 59–1B); and sitting lateral with hips at 90 degrees. If this position does not reproduce symptoms, have the patient sit in a position that reproduces usual pain. Two unstable patterns have been identified: posterior subluxation with sitting (Fig. 59–2A), and increase in flexion greater than 25 degrees when sitting (Fig. 59–2B). 10. Magnetic resonance imaging (MRI) or computed tomography (CT) are rarely needed unless clinically indicated. 11. Lidocaine injection test can be helpful. 1. Chronic pain not responsive to conservative measures 2. Malunion of fractures or dislocations 3. Coccygeal instability with positive dynamic stress x-rays and injection test 4. Gross congenital deformities 1. Chronic pain disorders 2. Concomitant severe spinal disorders 3. Perirectal or pilonidal abscess 4. Secondary gain situations 1. Relief of pain 2. Relatively low risk Failure to relieve pain.
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