American Journal of Surgery
1938, 42: 591-594.
Associate Professor of Surgery and Associate in Proctology, University of Maryland, Baltimore, Maryland
There is no doubt that trauma plays a major part in the production of coccygodynia, but contrary to what is frequently assumed, major trauma such as fracture or dislocation is rarely encountered. Paradoxically, the degree of injury is in no way proportional to the persistence and intensity of the subsequent symptoms. In those few cases in which deformity can be positively ascribed to injury, there is often much less difficulty in management than where there has been but little obvious damage.
Massage and manipulation continue to play a deservedly prominent part in the treatment of this condition. To quote Ely, "It consists of massage of the coccyx by means of the forefinger in the vagina and the thumb on the outside, holding the bone between them. The bone is moved backward and forward and the soft parts are moved about on the bone." Needless to say, the finger in the rectum serves just as satisfactorily. Duncan emphasizes forcible extension of the coccyx at the sacro-coccygeal joint as an essential part of the technique. Thiele, who explains coccygodynia on the basis of levator, coccygeus and pyriformis spasm, requires that the finger be fully inserted within the anus and the massage applied by sweeping movements across the posterolateral aspect of the pelvic floor. Treatments of this type may be given for one or two minutes every day or every other day at first, the interval being increased in porportion to the degree of relief.
The injection of analgesic agents demands some consideration. Yeomans’ technique consists in the repeated injection of 10 to 20 minims of 70 to 80 per cent grain alcohol into the point of maximum tenderness, determined by pressure upon the parts between the finger inside and the thumb outside the rectum. An interval of one week is ahowed to elapse between each injection and as many as ten have been given, although the average is four. There is considerable pain at the time of and for several minutes after this procedure and a dull ache persists for twenty-four hours. If success is to be expected by this method in any particular case, some relief is to be looked for after the first few injections.
Operative treatment varies from the subcutaneous division of the structures attached to the coccyx, originally practiced and discarded by Simpson to removal of varying amounts of the coccyx and sacrum.
The results obtained by various observers and the methods used are given in the table below.
|Treatment||Cases||Traced||Cured||Improved||Unimproved||% Unimproved||% Cured|
|Thiele and others||Massage||80||80||48||27||5||6.3||60%|
Attention is directed to the necessity for care in the interpretation of physical signs and x-ray findings in cases of trauma of the coccyx and coccygodynia. Major trauma is uncommon. Because of the frequent failure of excision to effect a cure, conservative measures shouId be persisted with for longer periods than is generally the practice.