Painful coccyx

Archives of surgery

June 1937, Vol 34, No. 6 1088-1104.

Duncan G.

Norfolk, VA

Abstract

Papers by Nott (4), Simpson (5) and von Scanzoni (6) about coccygodynia resulted in a fad for coccygectomy during the 19th century, and it became a common operation. Nonoperative treatment using sitz baths and massage was then revived and used almost universally until the early 20th century. The use of coccygectomy and injections of various substances was then revived.

Roentgenograms of the pelves of 262 patients who had complained of pain in the coccygeal region were studied. Studies were also made of 100 males and 100 females who did not complain of a painful coccyx but who had had roentgenograms made because of symptoms referable to the lower part of the back. It was found that almost any variation of the coccyx except a fracture or a dislocation that is noted in a patient with a painful coccyx can be matched in a roentgenogram of the coccyx of a patient who has never complained of pain in the coccygeal region.

It has been claimed (20) that coccygodynia is generally hysterical, and psychotherapy is the best form of treatment. Such a diagnosis is always dangerous. One does not make a diagnosis of hysteria in cases of pain in the knee or ankle. Sprain of the sacrococcygeal or intercoccygeal joints does not differ from a sprain about the ankle or knee, except that the symptoms may be of longer duration. Sprained ankles or knees can be placed at rest, whereas the coccyx is almost always in motion and subject to repeated small traumas.

Contusions of the coccyx and its surrounding soft parts and sprains of the sacrococeygeal joint are probably frequent. These contusions and sprains are usually caused by direct trauma, such as a fall in the sitting position. Gross and microscopic examination of coccyges removed in this hospital for supposed fractures have failed to reveal any evidence of them.

Contraction of muscles, as in the act of sitting or rising from a sitting position, is painful. Muscles attached to the coccyx in contracting flex it and in so doing stretch the tissues affected by the original trauma.

A pilonidal cyst is the most common lesion from which a painful coccyx is to be distinguished. With a pilonidal cyst there is usually a dimpling of the skin or a discharging sinus. No pain is elicited on rectal examination if a pilonidal cyst is present, as this lesion is entirely dorsal to the sacrum.

TREATMENT

From 1924 to 1934, 278 patients were admitted to the outpatient department of the New York Orthopaedic Dispensary and Hospital with the complaint of pain in the coccyx. All of these patients were treated nonoperatively either before admission to this hospital or afterward. Nonoperative treatment consisted first of all in improving the patient's posture, having her sit erect, and pull the buttocks in under the trunk, thereby taking the super-incumbent body weight off the coccyx and causing the soft parts surrounding the coccyx to act as a natural cushion.

Local massage has proved beneficial to many of these patients. Steady but firm stretching of the coccyx posteriorly has been done on patients for several consecutive visits, with relief from pain. This is done to overcome the spasticity of the muscles having their insertion on the coccyx and to prevent the formation of adhesions and contractures in the sacrococcygeal joint and the surrounding coccygeal structures.

Injections of alcohol, procaine hydrochloride or a solution of sodium chloride were found to be ineffective or provide only temporary relief.

Of the 248 patients treated by nonoperative methods, 54 were examined by me from one to four years after the onset of their coccygeal pain.

Relief from pain was experienced within one month after the injury by 36 (67 per cent) of the 54 patients, by 11 (21 per cent) within two months and by 5 (9 per cent) within six months, and 2 (3 per cent) continued to have a painful coccyx.

These results would seem to indicate that the nonoperative form of treatment should be tried for a period of six months before operative resection of the coccyx is resorted to.

Thirty (11%) of the patients in the total group had operative resection of the coccyx. Twenty-two patients (74%) were completely relieved of coccygeal pain. Three patients (9%) had only partial relief from pain. Five patients (17%) were unimproved.

REFERENCES

1. Logie, H. B.: Standard Classified Nomenclature of Disease, Compiled by the National Conference on Nomenclature of Disease, New York, Commonwealth Fund, 1935.

2. Petit, J. L.: A Treatise of the Diseases of the Bones, translated from the French, London, T. Woodward, 1726.

3. Blundell, J.: Principles and Practice of Obstetric Medicine, revised by A. Cooper Lee and Nathaniel Rogers, London, J. Butler, 1840.

4. Nott, J. C.: Facts Illustrative of the Practical Importance of a Knowledge f the Anatomy and Physiology of the Nervous System, New Orleans M. J. 1:57, 1844.

5. Simpson, J. Y.: Coccygodynia and Diseases and Deformities of the Coccyx, M. Times & Gaz. 1:861, 1859.

6. von Scanzoni, F. W.: Lehrbuch der Krankheiten der weiblichen Sexual-organe, Vienna, W. Braumuller, 1867.

7. Yeomans, F. C.: Coccygodynia: Further Experiences with Injections of Alcohol in Its Treatment, Surg., Gynec. & Obst. 29:612, 1919.

8. Gant, S. G.: Diseases of the Rectum, Anus and Colon, Including the Ileocolic Angle, Appendix, Colon, Sigmoid Flexure, Rectum, Anus, Buttocks and Sacrococcygeal Region, Philadelphia, W. B. Saunders Company, 1923.

9. Suermondt, W. F.: Die Behandlung der Coccygodynia, Arch. f. klin. Chir. 167:671, 1931.

10. Yodice, A.: Treatment of Coccygodynia, Arch. argent. de enferm. d. ap. digest. y de la nutricion. 8:733, 1932.

11. Kleckner, M. S.: Coccygodynia: The Present Day Interpretation and Treatment, Tr. Am. Proct. Soc. 34:100, 1933.

12a. Caldwell, W. E., and Moloy, H. C.: Sexual Variations in the Pelvis, Science 76:37, 1932;

12b. Caldwell, W. E., and Moloy, H. C.: Anatomical Variations in the Female Pelvis and Their Effect in Labor, with a Suggested Classification, Am. J. Obst. & Gynec. 26:479, 1933.

13. Dieulaffe, R.: Le coccyx; etude osteologique, Arch. d'anat., d'histol. Et d'embryol. 16:41, 1933.

14. Darrah, R. E., cited by David. (16)

15. Caubert, H., cited by David. (16)

16. David, V. C.: Tuberculosis of the Os Coccygis, J. A. M. A. 82:21 (Jan. 5) 1924.

17. Blount, W. P.: Osteomyelitis of the Coccyx, J. A. M. A. 91:727 (Sept. 8) 1928.

18. Gaudier, H., and Bertein, P., cited by Blount. (17)

19. Grisel, P., cited by Blount. (17)

20. Wechsler, I. S.: A Textbook of Clinical Neurology, Philadelphia, W. B. Saunders Company, 1935.

21a. Graff, E.: Resection of Coccyx During Labor, Wien. klin. Wchnschr. 37: 1260, 1924.

21b. Heckscher, S.: Ossification of Coccyx as Obstacle to Delivery, Zentralbl. f. Gynak. 52:2886, 1928.

21c. Niedermeyer, A.: Resection of the Coccyx During Labor, Monatschr. f. Geburtsh. u. Gynak. 86:190, 1930.

22. Becker, F.: Zur unfallmedizinischen Bewertung der Frakturen und Luxationen des Steissbeins und der traumatischen Coccygodynie auf Grund klinischer und experimenteller Untersuchungen, Schweiz. Ztschr. f. Unfallmed. 25:338, 1931.

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