Symptoms and Signs

• 
  

  Moderate/Severe pain in coccyx region (coccydynia)

  
  
• 
  

  Tenderness on palpation over coccyx

  
  
• 
  

  Bruising around coccyx

  
  
• 
  

  Pain when moving/straining bowel

  
  
• 
  

  Pain in lower back

  
  
• 
  

  Radiating pain into legs

Surgical Pathology

• 
  

  Coccyx benign/malignant trauma

Diagnostic Modalities

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  Physical/Neurologic examination and patient history

  
  
• 
  

  Rectal examination

  
  
• 
  

  CT of coccyx without contrast

  
  
• 
  

  MRI of coccyx without contrast

  
  
• 
  

  X-ray of coccyx

Differential Diagnosis

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  Coccyx fracture

  
  
• 
  

  Coccyx fracture dislocation

  
  
• 
  

  Coccyx tumor (i.e., sacrococcygeal teratoma)

  
  
• 
  

  Ingrown hair cyst

  
  
• 
  

  Pelvic muscle spasms

  
  
• 
  

  Coccyx spicules (new bone growths)

  
  
• 
  

  Referred pain from adjacent structures

  
  
  
  
  • 
    

    Disk herniation(s)

    
    
  • 
    

    Spinal stenosis

    
    
  • 
    

    Episacral sarcoma

    
    
  • 
    

    Lumbosacral lesion

    
    
  • 
    

    Sacrococcygeal joint injury

Treatment Options

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  Acute pain control with medications and pain management

  
  
• 
  

  Stool softeners to prevent constipation

  
  
• 
  

  Coccygeal cushions

  
  
• 
  

  Physical/Occupational/Recreational therapy and rehabilitation

  
  
• 
  

  If symptomatic without nonsurgical improvement:

  
  
  
  
  • 
    

    Urgent surgical fracture repair/resection if deemed suitable candidate for surgery

    
    
    
    
    • 
      

      If poor surgical candidate with poor life expectancy, medical management recommended

      
      
    • 
      

      Coccygectomy (complete removal of coccyx)

      
      
    • 
      

      Removal of indicated coccygeal segments

Indications for Surgical Intervention

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  No improvement after nonoperative therapy (physical therapy, pain management, coccygeal cushion use)

  
  
• 
  

  Fracture displacement after nonoperative therapy

  
  
• 
  

  Unstable patterns of fracture

  
  
• 
  

  Neurologic dysfunction and/or instability resulting from coccyx trauma

Surgical Procedure for Posterior Coccyx (Coccygectomy)

1. 
   

   Informed consent signed, preoperative labs normal, no Aspirin/Plavix/Coumadin/NSAIDs/Advil/Celebrex/Ibuprofen/Motrin/Naprosyn/Aleve/other anticoagulants and anti-inflammatory drugs for at least 2 weeks

   
   
2. 
   

   Preoperative antibiotics are administered intravenously

   
   
3. 
   

   Appropriate intubation and sedation and lines (if necessary) as per the anesthetist

   
   
4. 
   

   Patient placed prone on operating table with pressure point padding

   
   
5. 
   

   Neuromonitoring not needed

   
   
6. 
   

   Make a 5 cm incision over the midline, 1 cm above gluteal cleft

   
   
7. 
   

   Dissect past subcutaneous tissue (no muscles are present to interrupt this dissection)

   
   
8. 
   

   Open fascia to expose the posterior coccyx (see ▶Fig. 5.1)

   

   

   
   
9. 
   

   Excise the intervertebral disk between the sacrum and coccyx using a scalpel

   
   
10. 
    

    Bilaterally ligate/cauterize coccygeal vessels

    
    
11. 
    

    Incise anococcygeal ligament and elevate tip of coccyx

    
    
12. 
    

    Dissect and incise coccygeus and iliococcygeus through muscle attachments, carefully avoiding rectal injury

    
    
13. 
    

    Before removing the entire coccyx, mobilize the rectum and dense fascia deep to the sacrococcygeal joint

    
    
14. 
    

    Remove the entire coccyx using electrocautery

    
    
15. 
    

    If tumor is present, isolate the tumor if performing en bloc coccygectomy with tumor resection or start removing tumor in piecemeal fashion

    
    
16. 
    

    Perform hemostasis

    
    
17. 
    

    If dead space remains, place small drain

    
    
18. 
    

    After appropriate hemostasis is obtained, muscle and skin incisions can then be closed in appropriate fashion