Coccydynia Evaluation & Managementfiles.academyofosteopathy.org/convo/2019/... · DDX: Chordoma • Primary bone tumor along the spine • Most commonly in the cervical or sacral

CoccydyniaEvaluation & Management

Bobby Nourani, DO

Disclosures

None

Coccydynia● Coccyalgia, coccygodynia, tailbone pain ● Localized pain of the coccyx ● Unreported incidence ● Many causes ○Trauma ○Non-traumatic

● Clinical diagnosis ● Large differential diagnoses

Causes• Fall

• Child delivery

• Local trauma

• Idiopathic

• Bone spur

• Arthritis

• Fracture

• Cancer

• Infection

DDX: Chordoma• Primary bone tumor along the spine

• Most commonly in the cervical or sacral regions

• Slow growing sarcomas

• Account for 3% of bone tumors and 20% of all spinal tumors

• 1:1,000,000

• Metastesis in 30%-40%

• Most often diagnosed in 50s and 60swww.chordomafoundation.org

Seated Devices

• Roho cushion

• Donut

Persistent Coccydynia

! 10% will not respond to conservative management

! Persistent cases are debilitating ! Coccyx as pelvic floor insertion site ! Soft tissue continuity with spinal and

cranial structures ! Reports of anatomically-related pain

following injury

Treatment Options for Persistent Coccydynia

●Limited ●Many non-invasive therapies being evaluated ●Pelvic floor PT ●Insufficient evidence to conclude superior interventions ●Coccygectomy as a “Last Resort” ●Absence of Safe, Effective Therapies

Indications for OMT• Tenderness to palpation reproducing the patient’s pain

• Local pain to palpation out of proportion to patient’s or physician’s expectations with asymmetry or restricted range of motion

• Autonomic findings: emotionally labile, outbursts, crying, unusual anger, fidgety, fast talking, constipation, headaches associated with back or tailbone pain

• Traumatic injury – fall, skiing, snowboarding, horseback riding, kick to the tailbone, painful or traumatic birth

• Physician palpates the following bony and soft tissue structures evaluating for tenderness, asymmetry, restrictions, and tissue texture changes:

• Lateral surface of the sacrum and coccyx. Attachments Levator ani muscle, sacrotuberous and sacrospinous ligaments: Thumb pads contact the soft tissue immediately lateral to sacrum and coccyx. Apply pressure from lateral to medial until appreciating firm bony resistance. Evaluate for rotation and sidebending at the sacrococcygeal junction or coccygeal segments.

• Midline sacrum from superior to inferior. Palpate for tenderness and/or joint laxity of the sacrococcygeal junction. Continue careful palpation down each segment of the coccyx inferiorly until the inferior surface of the coccyx is reached. Note tenderness or displacement in the coronal, sagittal, or vertical axis.

• Sacrococcygeal junction: Evaluate right and left sides simultaneously using thumb pads • Inferior sacrum between sacral ala and superior coccyx • Horizontal axis of sacrococcygeal junction • Lateral surface of 1st coccygeal segment • Inferior surface of 1st coccygeal segment

Evaluation

Evaluation

Case Reports: Purpose●Describe two patients’ experiences with persistent coccydynia

● Illustrate the need for evaluation of coccydynia

●Report the effect of transrectal osteopathic manipulation therapy (OMT) for persistent coccydyna

●Report the effect of prolotherapy for persistent coccydynia

Methods

!Retrospective chart review of two patients

!In-person and phone interviews

!Consents obtained

Case #1 Results●Before treatment: Coccydynia 9/10; 2-3

headaches per week

●Immediate improvement

●Short-term improvement at 1 week

●Lasting improving at 21 months: Coccydynia 0/10; 0-1 headaches per week

●Post-traumatic coccydynia unevaluated and untreated

●4 years of low back and hip work-up, unresolved coccydynia

●Refractory pain eventually involved other areas ●Impacted QOL ●Coccyx should be considered in work-up for

potentially-related pain

Case #1 Discussion & Conclusion

Anatomy!Coccygeal - Sacrum connections:

○Anterior and posterior sacrococcygeal ligaments

!Sacrococcygeal ligaments progress proximally

○Anterior and posterior longitudinal ligaments

○Attach to the occipital bone

Thank you

Bill Kuchera, DO

Bill Kuchera, DO

Bobby Nourani, DO

•Chaperone

•Informed consent

•Discussion with patient describing detailed procedure: setup, patient assistance, expected duration, goals of therapy, and endpoint

•Gloves

•Lubricant

•Gauze

•Waste basket

Treatment Preparation

• Patient position, Part 1: Prone. Chest and head resting against the table

• Physician position: To the side of patient, facing the patient’s head. Physician’s dominant hand should be closest to the patient

Treatment, Part 1

Tx Part 1, Local Soft Tissue• With internal index finger and external thumb contacting the

soft tissue structures, evaluate for tenderness or restrictions of the following: • Annococcygeal ligament • Levator Ani

• Pubococcygeus muscle • Iliococcygeus muscle • Ischiococcygeus muscle

• Par Superficialis • Treat if there is tenderness or restricted range of motion • Soft tissue structures are more commonly treated with indirect

methods, such as myofascial release, balance ligamentous tension, ligamentous articular strain, facilitated positional release, exaggerated method, or functional technique

Tx Part 2, Bone & Dura

Transition from part 1 to part 2 of treatment is seamless with physician’s finger remaining intrarectal

Patient position: Prone-propped, aka Sphinx position Prone, lumbar hyperextension, resting on elbows

Tx Part 2, Bone & Dura• Physician’s internal index finger and external thumb contact the inferior

tip of the coccyx. Evaluate for tenderness or restrictions of the following: • Distal coccygeal tip • Each coccygeal segment including attachments at the transverse

processes of the first coccygeal segment • Sacrococcygeal junction • Lateral sacrococcygeal ligaments • Inferior sacrum • Anterior and Posterior longitudinal sacrococcygeal ligaments

• Treat if there is tenderness or restricted range of motion • Patient actively assists in treatment by moving their head and neck

slowly towards and away from the barrier in all three planes of motion - flexion/extension, sidebending, and rotation. Physician maintains balanced tension until improvement in sacrococcygeal somatic dysfunction is appreciated.

Tx Part 3, Soft Tissue• Patient in prone position. Chest and head resting against the

table • Physician’s internal index finger and external thumb contact the

following soft tissue structures and evaluate for tenderness or restrictions: • Mid-substance and pelvic attachments of sacrotuberous and

sacrospinous ligaments • Levator Ani muscle • Annococcygeal ligament

• Treat if there is tenderness or restricted range of motion • Soft tissue structures are more commonly treated with indirect

methods, such as myofascial release, balance ligamentous tension, ligamentous articular strain, facilitated positional release, exaggerated method, or functional technique

Post Tx Evaluation• Reassess findings from earlier evaluation

• Compare for tissue texture changes, asymmetry, restrictions, and tenderness

Case #2 Results●Before treatment: Coccydynia 7/10

●Immediate improvement

●Short-term improvement: one week following treatment

●Lasting improvement, four months following treatment: Coccydynia 0/10

Case #2 Discussion & Conclusion

●Hip, low back, buttock, and tailbone pain

●OMT alone did not work

●Prolotherapy shows promise for refractory coccyalgia

●Indication for further research

Intradiscal Injections• Best responders: Luxation or hypermobility patients

• Results within one week

• 2-4 months of relief in 60%-70%

• 12 months of relief in 30%

Injections

• Ganglion Impar block for sympathetically maintained pain

• Steroid injections targeting bone spurs or hyper mobile segments

• Diagnostic lidocaine blocks

Complete Anatomy 2018

Coccygectomy

• Results are dependent on the surgeon, “learning curve”

• 93% success rate for luxation and hypermobility greater than 25 degrees

• 4-10 month recovery

ImagingStanding vs seated lateral x-rays

1. Standing:15 min

2. Seated • Sitting on hard stool • Back slightly extended • Posture in position where pain is most

pronounced • Wait for pain

Pathologic if more than 25 degrees variability Jean-Yves Maigne: Treatment strategies for coccydynia. 1998

Subluxation

Jean-Yves Maigne: Treatment strategies for coccydynia. 1998

Subluxation

Courtesy of Dr Jean-Yves Maigne, Paris, France

Subluxation

Courtesy of Dr Jean-Yves Maigne, Paris, France

Subluxation

Courtesy of Dr Jean-Yves Maigne, Paris, France

Subluxation

Courtesy of Dr Jean-Yves Maigne, Paris, France

Hypermobility

Jean-Yves Maigne: Treatment strategies for coccydynia. 1998

Pain often associated with more ventrally curved coccyx and lack of fusion of sacrococcygeal joint

Hypermobility

Courtesy of Dr Jean-Yves Maigne, Paris, France

Bone Spur

Jean-Yves Maigne: Treatment strategies for coccydynia. 1998

• Account for 15% of cases • Seen on x-ray • Best visualized with CT or MRI • Coccyx is rigid

Maigne. MRI findings in the painful adult coccyx. 2012 Eur Spine J

Bone Spur

Quality Improvement Study Novel Transrectal OMT

• University of Wisconsin outpatient clinics

• Case series

• Brief pre, post, and follow-up questionnaire

• IRB exempt

Evaluation Form

Informed Consent

1.Patient’s role in the decision making process

2.Clinical issue

3.Suggested treatment

4.Option for no treatment, alternatives

Informed Consent

5.Potential risks and benefits

6.Related uncertainties

7.Patient’s understanding

8.Patient’s preferences and consent

Additional Communication

• Detailed review of procedure and goals

• Verbal vs. written consent

MinorsRefer to individual state laws on informed consent

• Communication

• Documentation

• Legal Guardian

• Chaperone

Physician Documentation• Informed consent obtained

• Review of intrarectal procedure

• Goals of therapy

• Alternatives

• Potential risks and benefits

Physician Documentation• Medical necessity

• Subjective supports indications for exam and treatment

• Objective supports treatments

• Complications

Chaperone Documentation

1.Witnessed informed consent by the patient

2.Chaperoned the entire duration of the transrectal procedure

References• Gray’s Anatomy - 36th, 39th, 40th, & 41st editions

• Complete Anatomy 2019

• Jean-Yvez Maigne, MD

• Patrick M. Foye, MD

• ChordomaFoundation.org

• William Kuchera, DO

• Susan Standring, PhD

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