1386
Tail
piece
conspicuous feature of so many in man shrunk to a vestigial and mammals, has invisible organ of between 3 and 5 bones. Despite its size and location, the human tail has been granted an imaginative title (coccyx) by the anonymous anatomist who likened it to the cuckoo’s beak. The term coccygodynia, often contracted to coccydynia, was introduced by Simpson in 18591 to describe the symptom of pain in this region, a complaint long granted the status of a "heartsink condition" by patient and doctor alike. By 1896, Bremer2 held the view, so often adopted by doctors when faced with an intractable and inexplicable symptom, that it was a manifestation of neurosis or even hysteria, especially since coccydynia is five times as common in women as in men. More recently coccydynia has been regarded as a symptom of depression.3 The aetiology in many cases remains obscure, but trauma, avascular neurosis,and various rare tumours (eg, chondroma,55 giant cell tumour,66 intradural schwannoma,66 perineural cyst,’ and introsseous lipoma8) have sometimes been implicated. The glomus body, which is almost certainly a normal structure lying anterior to the coccyx,9 is widely believed to be a pathological lesion.1o,11 Proctologists have taken an interest in coccydynia for many years, and the condition has been associated with several anal disorders.5 Where such abnomalities could not be found, a disturbance of the ligaments and muscles attached to the coccyx was proposed.12 Another suggesion was that the pain might be referred from an invertebral disc prolapse or other abnormality in the lumbar spine.13 Clinicians have evolved numerous therapies for coccydynia, many of doubtful value. At last, 132 years after the first description of coccydynia, and 265 years after the first coccygectomy, a clinical trial has been mounted in Leicester 15 whose results offer us a rational treatment protocol for the condition. Wray et al first conducted a pilot study of 50 patients with coccydynia; these patients underwent a The tail,
a
thorough investigation, including rectal examination, radiography, bone scan, computed tomography, and full psychiatric assessment. A hierarchy of treatments was then instigated-first 2 weeks of ultrasound and 2 weeks of shortwave diathermy (16% success). 42 patients proceeded to the next stage-local injection of methylprednisolone and bupivicaine, which was repeated, if necessary, 4 weeks later (38% success). The remaining 28 patients were treated with manipulation under anaesthesia, in which the surgeon grasped the coccyx by placing his index finger in the patient’s rectum and his thumb behind and then repeatedly flexed and extended the bones for a minute. After 6 weeks all but 8 were cured, and they proceeded coccygectomy. The entire cohort was followed for at least 12 months. Of the 50 patients, 3 were thought to have abnormal personality traits; 2 came to surgery, with 1 cure. 48% of the pilot study patients had
to
computed tomographic abnormalities of the lumbar spine, which were felt to be irrelevant in view of the success
of local treatments
generally
high
to
frequency
the coccyx and the of symptomless
abnormalities in the lumbar spine. Wray et al then proceeded to a randomised trial. They compared the efficacy of injection alone against manipulation under anaesthesia and injection. 120 patients were recruited. The aetiology was a fall in 30 and childbirth in 14; 15 had had repetitive strain on their bottoms (eg, from a rowing machine or bicycling); and 6 dated their symptoms from a surgical procedure (3 in the lithotomy position). 60% responded to injection alone, and 85% to manipulation and injection. On completion of the trial, 23 patients came to coccygectomy and all but 2 had a good result. Thus, the Leicester workers have swept away many of the ill-conceived notions surrounding this complaint, and have shown that 80% of patients with coccydynia can be treated conservatively. The curious perception of many surgeons that coccygectomy is a mad or bad operation is belied both by this and by other reports.5,16-21 Patients with coccydynia deserve more than a look of incredulity from their doctor and the offer of a ring cushion. 1.
Simpson JY. Coccygodynia and diseases and deformities of the coccyx.
Med Times Gazette 1859; 861: 1. 2. Bremer L. The knife for coccygodynia. Med Rec B. Spontaneous and evoked Dis Colon Rectum 1988; 31: 210-15.
3. Maroy
(NY) 1896; 1: 154-55. coccygeal pain in depression.
Young S. Avascular necrosis of the coccyx: a cause for coccydynia? Case report and histological findings in sixteen patients. Br J Clin Pract 1985; 39: 247-48. 5. Hodge J. Clinical management of coccydynia. Med Trial Tech 1979; 25:
4. Lourie J,
277-84. 6. Kinnett JG, Root L. An obscure cause of coccygodynia. 1979; 61-A: 299.
J Bone Jt Surg
Ziegler DK, Batnitzky S. Coccygodynia caused by perineural cyst. Neurology 1984; 34: 829-30. 8. Hanelin LG, Sclamberg EL, Bardsley JL. Intraosseous lipoma of the coccyx. Radiology 1975; 114: 343-44. 9. Bell RS, Goodman SB, Fornasier VL. Coccygeal glomus tumors: a case of mistaken identity? J Bone Jt Surg 1982; 64-A: 595-97. 10. Ho K-L, Pak MSY. Glomus tumor of the coccygeal region. Case report. J Bone Jt Surg 1980; 62-A: 141-42. 11. Duncan L, Halverson J, DeShryver-Kecskemeti K. Glomus tumor of the coccyx: a curable cause of coccygodynia. Arch Pathol Lab Med 1991; 7.
115: 78-80. 12. Thiele GH. Coccygodynia. Dis Colon Rectum 1963; 6: 422-36. 13. Dittrich RJ. Coccygodynia as referred pain. J Bone Jt Surg 1951; 33-A: 715-18.
JL. A treatise of the diseases of the bones, translated from the French. London: T Woodward, 1726. 15. Wray CC, Easom S, Hoskinson J. Coccydynia: aetiology and treatment. J Bone Jt Surg 1991; 73-B: 335-38. 16. Key JA. Operative treatment of coccygodynia. J Bone Jt Surg 1937; 19:
14. Petit
759-64.
Orthop Rel Res 1959; 14: 145-61. 18. Borgia CA. Coccydynia: its diagnosis and treatment. Milit Med 1964; 17. Howarth B. The painful coccyx. Clin
129: 335-38. 19. Porter KM, Khan MAA, Piggott H. Coccydynia: J Bone Jt Surg 1981; 63-B: 635-36.
a
retrospective review.
Wray AR, Templeton J. Coccygectomy: a review of 37 cases. Ulster Med J 1982; 51: 121-24. 21. Postacchini F, Massobrio M. Idiopathic coccygodynia. J Bone Jt Surg 1983; 65-A: 1116-24.
20.
Tail
piece
conspicuous feature of so many in man shrunk to a vestigial and mammals, has invisible organ of between 3 and 5 bones. Despite its size and location, the human tail has been granted an imaginative title (coccyx) by the anonymous anatomist who likened it to the cuckoo’s beak. The term coccygodynia, often contracted to coccydynia, was introduced by Simpson in 18591 to describe the symptom of pain in this region, a complaint long granted the status of a "heartsink condition" by patient and doctor alike. By 1896, Bremer2 held the view, so often adopted by doctors when faced with an intractable and inexplicable symptom, that it was a manifestation of neurosis or even hysteria, especially since coccydynia is five times as common in women as in men. More recently coccydynia has been regarded as a symptom of depression.3 The aetiology in many cases remains obscure, but trauma, avascular neurosis,and various rare tumours (eg, chondroma,55 giant cell tumour,66 intradural schwannoma,66 perineural cyst,’ and introsseous lipoma8) have sometimes been implicated. The glomus body, which is almost certainly a normal structure lying anterior to the coccyx,9 is widely believed to be a pathological lesion.1o,11 Proctologists have taken an interest in coccydynia for many years, and the condition has been associated with several anal disorders.5 Where such abnomalities could not be found, a disturbance of the ligaments and muscles attached to the coccyx was proposed.12 Another suggesion was that the pain might be referred from an invertebral disc prolapse or other abnormality in the lumbar spine.13 Clinicians have evolved numerous therapies for coccydynia, many of doubtful value. At last, 132 years after the first description of coccydynia, and 265 years after the first coccygectomy, a clinical trial has been mounted in Leicester 15 whose results offer us a rational treatment protocol for the condition. Wray et al first conducted a pilot study of 50 patients with coccydynia; these patients underwent a The tail,
a
thorough investigation, including rectal examination, radiography, bone scan, computed tomography, and full psychiatric assessment. A hierarchy of treatments was then instigated-first 2 weeks of ultrasound and 2 weeks of shortwave diathermy (16% success). 42 patients proceeded to the next stage-local injection of methylprednisolone and bupivicaine, which was repeated, if necessary, 4 weeks later (38% success). The remaining 28 patients were treated with manipulation under anaesthesia, in which the surgeon grasped the coccyx by placing his index finger in the patient’s rectum and his thumb behind and then repeatedly flexed and extended the bones for a minute. After 6 weeks all but 8 were cured, and they proceeded coccygectomy. The entire cohort was followed for at least 12 months. Of the 50 patients, 3 were thought to have abnormal personality traits; 2 came to surgery, with 1 cure. 48% of the pilot study patients had
to
computed tomographic abnormalities of the lumbar spine, which were felt to be irrelevant in view of the success
of local treatments
generally
high
to
frequency
the coccyx and the of symptomless
abnormalities in the lumbar spine. Wray et al then proceeded to a randomised trial. They compared the efficacy of injection alone against manipulation under anaesthesia and injection. 120 patients were recruited. The aetiology was a fall in 30 and childbirth in 14; 15 had had repetitive strain on their bottoms (eg, from a rowing machine or bicycling); and 6 dated their symptoms from a surgical procedure (3 in the lithotomy position). 60% responded to injection alone, and 85% to manipulation and injection. On completion of the trial, 23 patients came to coccygectomy and all but 2 had a good result. Thus, the Leicester workers have swept away many of the ill-conceived notions surrounding this complaint, and have shown that 80% of patients with coccydynia can be treated conservatively. The curious perception of many surgeons that coccygectomy is a mad or bad operation is belied both by this and by other reports.5,16-21 Patients with coccydynia deserve more than a look of incredulity from their doctor and the offer of a ring cushion. 1.
Simpson JY. Coccygodynia and diseases and deformities of the coccyx.
Med Times Gazette 1859; 861: 1. 2. Bremer L. The knife for coccygodynia. Med Rec B. Spontaneous and evoked Dis Colon Rectum 1988; 31: 210-15.
3. Maroy
(NY) 1896; 1: 154-55. coccygeal pain in depression.
Young S. Avascular necrosis of the coccyx: a cause for coccydynia? Case report and histological findings in sixteen patients. Br J Clin Pract 1985; 39: 247-48. 5. Hodge J. Clinical management of coccydynia. Med Trial Tech 1979; 25:
4. Lourie J,
277-84. 6. Kinnett JG, Root L. An obscure cause of coccygodynia. 1979; 61-A: 299.
J Bone Jt Surg
Ziegler DK, Batnitzky S. Coccygodynia caused by perineural cyst. Neurology 1984; 34: 829-30. 8. Hanelin LG, Sclamberg EL, Bardsley JL. Intraosseous lipoma of the coccyx. Radiology 1975; 114: 343-44. 9. Bell RS, Goodman SB, Fornasier VL. Coccygeal glomus tumors: a case of mistaken identity? J Bone Jt Surg 1982; 64-A: 595-97. 10. Ho K-L, Pak MSY. Glomus tumor of the coccygeal region. Case report. J Bone Jt Surg 1980; 62-A: 141-42. 11. Duncan L, Halverson J, DeShryver-Kecskemeti K. Glomus tumor of the coccyx: a curable cause of coccygodynia. Arch Pathol Lab Med 1991; 7.
115: 78-80. 12. Thiele GH. Coccygodynia. Dis Colon Rectum 1963; 6: 422-36. 13. Dittrich RJ. Coccygodynia as referred pain. J Bone Jt Surg 1951; 33-A: 715-18.
JL. A treatise of the diseases of the bones, translated from the French. London: T Woodward, 1726. 15. Wray CC, Easom S, Hoskinson J. Coccydynia: aetiology and treatment. J Bone Jt Surg 1991; 73-B: 335-38. 16. Key JA. Operative treatment of coccygodynia. J Bone Jt Surg 1937; 19:
14. Petit
759-64.
Orthop Rel Res 1959; 14: 145-61. 18. Borgia CA. Coccydynia: its diagnosis and treatment. Milit Med 1964; 17. Howarth B. The painful coccyx. Clin
129: 335-38. 19. Porter KM, Khan MAA, Piggott H. Coccydynia: J Bone Jt Surg 1981; 63-B: 635-36.
a
retrospective review.
Wray AR, Templeton J. Coccygectomy: a review of 37 cases. Ulster Med J 1982; 51: 121-24. 21. Postacchini F, Massobrio M. Idiopathic coccygodynia. J Bone Jt Surg 1983; 65-A: 1116-24.
20.
