, Introduction
Coccydynia is a painful and debilitating condition characterized by discomfort in the coccygeal region, typically exacerbated by activities like sitting, standing, defecation, and sexual intercourse. Although conservative treatments such as medication and physiotherapy are the first line of treatment, some patients failed to response to these treatments may require surgical intervention. Coccygectomy, the surgical removal of part or all of the coccyx, has proven effective for patients who do not respond to non-surgical treatments. In this report, we describe the case of a 70-year-old male who underwent a partial coccygectomy through the paramedian approach due to chronic coccydynia resulting from a slip-and-fall injury.
Case Report
A 70-year-old male presented to our outpatient clinic with chronic coccygeal pain. The pain started following a slip-and-fall injury approximately one year prior. The patient was unable to sit comfortably due to the severity of the pain and described a sensation of abnormal movement in the coccygeal region. Despite treatment with medication, physiotherapy and rest, his symptom persisted. The pain varied in intensity over time until it became so severe, reaching 8/10 on the on a numerical rating scale (NRS) and forcing him to spend most of his time standing as the pain made it impossible for him to sit.
On examination, no visible deformity was observed in the coccygeal region, but there was tenderness along the coccygeal region. Plain radiography and computed tomography (CT) imaging showed bony displacement of the first coccyx segment (Figs. 1, 2), while magnetic resonance imaging (MRI) revealed chronic instability at the sacrococcygeal joint (Fig. 3). A sacrococcygeal block temporarily relieved his pain, reducing the NRS score to 5; however, the relief lasted only about three hours. After discussing treatment options, the patient consented to undergo a partial coccygectomy.
Preoperatively, the patient underwent bowel preparation to prevent fecal contamination of the surgical site and minimize the risk of complications, such as rectal perforation. Under general anesthesia, the patient was positioned prone on a Wilson frame. Intravenous antibiotics were administered before the skin incision. The buttocks were laterally retracted using adhesive tape to expose the gluteal cleft. The coccygeal region and anus were prepared with chlorhexidine and iodine, and sterile draping was applied after skin preparation.
Fluoroscopic imaging was used to identify the sacrococcygeal junction. A vertical paramedian incision was made 2 cm lateral to the intergluteal cleft, and exposure was performed from the proximal to distal direction (Fig. 4A). Dissection was carried out tangentially to the coccyx’s midline in the subperiosteal plane (Fig. 4B). Ideally, the coccyx is circumferentially separated from the surrounding tissues in this plane to allow for an en bloc resection. However, in this case, the first and second coccyx segments were unstable and fragile, making en bloc resection difficult. Consequently, the unstable coccyx was removed piece by piece using a rongeur (Fig. 4C). After the excision, the wound was thoroughly irrigated and closed in a layer-by-layer fashion.
Postoperatively, the patient experienced complete pain relief and was able to sit comfortably; post-operative plain radiography and MRI of confirm the absence of the first and second coccygeal segments (Fig. 5). He was discharged on the fourth postoperative day. At his one-month follow-up visit, the patient remained pain-free, and the surgical wound had healed without complications (Fig. 4D).
Discussion
Coccydynia refers a condition characterized by disabling pain in the coccygeal area. The pain is usually exacerbated during activities such as sitting, standing, defecation, and sexual intercourse. This pain may coexist with lumbar pain, presumably due to the patient’s constant repositioning while sitting. Physical examination typically reveals tenderness upon palpation of the coccyx. A combination of careful history taking and physical examination, supplemented by imaging modalities, is used to establish the diagnosis.
Plain radiographs, particularly sitting-versus-standing radiographs, are useful in assessing dynamic instability. Common imaging modalities such as MRI and CT are used to identify coccyx abnormalities and exclude other potential sources of sacrococcygeal pain [1]. Several independent prognostic factors for coccydynia treatment have been recognized, including female sex, body mass index, and a history of trauma [2]. The higher prevalence of coccydynia in women is likely due to anatomical differences in the shape and angles of the female pelvis and the increased risk associated with childbirth [1].
Treatment options for coccydynia include conservative therapies including medication and physiotherapy, interventional techniques including local injections of steroids and local anesthetics, and surgical approaches including coccygectomy. Conservative treatments are the first line of management, but in cases where these conservative treatments fail, surgical intervention may be required. Increasing clinical evidence supports coccygectomy as an effective option for patients with debilitating pain who have not improved with conservative treatments [3-6]. The most common surgical method for performing coccygectomy includes the midline approach, described by Key in 1937 [7]. This approach, which still widely used today, involves a vertical incision over the sacrococcygeal joint, extending down to the coccygeal bone [8-11]. Infection and wound dehiscence are the most commonly observed postoperative complications following coccygectomy, with reported rates from 0% to 30% [3]. The most frequently identified pathogen is Staphylococcus aureus [12].
The incisional site within the intergluteal cleft serves as a potential site for infection, due to its proximity to perineal region. In addition, the natural shape of crevice formed by the intergluteal cleft creates a warm and moist environment and the location of the wound makes it more vulnerable to friction and pressure while sitting, leading to delayed healing and a higher risk of infection and wound dehiscence [13]. There are several methods reducing post-surgical infection. Preserving and closing the periosteum during operation reduces a risk of infection; the infection rates are reported at 0% when the periosteum is preserved, compared to 36% when it is not [14].
The paramedian approach offers an alternative method for reducing post-surgical infection and wound dehiscence. This method allows to create a deeper skin flap and keeps the incisional site away from the intergluteal cleft. By avoiding the natural crevice formed by the intergluteal cleft, known for a high-risk zone, this method helps keep the wound dry and minimize the risk of exposure to fecal flora, thereby promoting better wound closure [13]. In addition, it reduces friction and pressure to the wound while sitting, further supporting the healing process. The paramedian approach does not appear to increase surgery time. In one study, the average procedure duration of a the paramedian approach was 40.6 minutes [13], approximately 10 minutes shorter than the time reported for the conventional approach [15]. However, studies on the paramedian approach remain limited and further research is needed for to establish its long-term benefits and optimal techniques for coccygectomy in managing chronic coccydynia.
The decision between performing a complete or partial coccygectomy is ultimately determined by the surgeon during the procedure. This decision should also consider the specific anatomical and musculoskeletal causes of the tailbone pain. A study comparing partial and total coccygectomy for traumatic coccydynia found that both methods produced similar outcomes, with low complication rates and high patient satisfaction [15]. In this case report, the patient only experienced localized pain on coccygeal area and the primary source of pain was chronic instability at the sacrococcygeal joint. Therefore, the removal of the unstable portions of the upper coccygeal bones resulted in favorable outcomes.
Conclusion
This case emphasizes the importance of careful patient selection and surgical planning when considering coccygectomy for chronic coccydynia. As demonstrated in this case, the paramedian approach presents a promising alternative to the traditional midline approach, potentially lowering the risk of infection and promoting better wound healing. The patient’s complete resolution of pain and absence of postoperative complications underscore the effectiveness of partial coccygectomy using the paramedian approach for treating chronic coccygeal instability. Further studies are needed to establish the long-term benefits and refine the optimal techniques for managing chronic coccydynia.
PDF Links
PubReader
ePub Link
XML Download
Full text via DOI
Download Citation
Print
