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Coccydnia

Coccydynia, commonly called tailbone pain or coccyx pain, is a fairly rare and relatively poorly understood condition that can cause persistent pain at the very bottom of the spine. This part of the spine is the coccyx, or tailbone. Coccydynia is felt as a localized pain and will generally feel worse when sitting or with any activity that puts pressure on the bottom area of the spine.

The condition is much more common in women than men. It is usually caused by local trauma (e.g. a fall) or giving birth. On rare occasions, an infection or tumor can also cause pain in the coccyx.

Coccydynia Terminology

Coccydynia may be referred to in various terms, such as:

• Coccygodynia
• Coccygeal pain
• Coccyx pain
• Coccyaglia
• Tailbone pain

The various terms are all used to describe a set of symptoms in the tailbone that can be caused by various injuries or conditions. Treatment may vary depending on the underlying cause of the symptoms and the severity and duration of the symptoms.

Coccydynia Symptoms and Treatments

Coccydynia symptoms may consist of one or all of the following:

• Pain that is markedly worse when sitting
   
• Local pain in the tailbone area that is worse when touched or when any pressure is placed on it
   
• Pain that is worse when moving from a sitting to standing position
   
• Pain that is worse with constipation and feels better after a bowel movement.

A combination of treatments to reduce the pain and activity modification to keep pressure off the tailbone usually suffices to control or alleviate the pain. In very rare cases, surgery to remove the coccyx may be recommended, but the surgery (a coccygectomy) will typically only be considered if the pain is severe and at least several months of non-surgical treatment and activity modification has not been effective in relieving the pain.

History of Coccyx Pain

Coccydynia has a long history of being poorly understood. In the early 1900s, coccydynia was a popular diagnosis for all types of lower back pain. A fairly extreme treatment, the surgical removal of the coccyx (coccygectomy), was commonly undertaken to treat low back pain. At best, this operation had variable results.

Then the pendulum swung the other way, and the general opinion was that since the condition was mostly in women it was in some way related to "neurosis". The corollary was that if the operation did not work, it was because the pain was in the individual’s head; therefore the operation fell into disrepute and was no longer commonly performed. Subsequently, little research on the subject has been done.

Both extremes of opinion have long since fallen by the wayside, and it is now known that coccydynia does exist as a medical condition. However, it is fairly uncommon.

Why Do More Coccyx Injuries Occur in Women Than Men?

The majority of coccyx injuries occur in women because:

• The women’s coccyx is rotated, leaving it more exposed to injury
• Women have a broader pelvis, which means that sitting places pressure on their coccyx (male anatomy causes them to sit without much pressure on the coccyx)
• Childbirth is a common cause of the condition

It is not clearly understood which portions of the anatomy can cause coccyx pain. In many cases the exact cause of the pain is not known (called idiopathic coccydynia), and in these cases the symptoms are managed.

Possible Underlying Causes of Coccydynia

In general, pain can by caused in the coccyx if an injury or some type of excess pressure on the area causes the bones to move beyond their normal very limited range of motion, resulting in inflammation and localized pain. An injury to either the ligaments or the vestigial disc may be a cause of pain. Rarely, the bones of the coccyx can fracture and cause pain. Also, in rare cases a tumor or infection in the coccyx can be a primary cause of tailbone pain.

• Local trauma. A fall on the tailbone can inflame the ligaments or injure the coccyx or the coccygeal attachment to the sacrum. This is probably the most common cause of coccydynia.
   
• Childbirth. During delivery, the baby's head passes over the top of the coccyx, and the pressure created against the coccyx can sometimes result in injury to the coccyx structures (the disc, ligaments and bones). While uncommon, the pressure can also cause a fracture in the coccyx.
   
• Pressure. Certain activities that put prolonged pressure on the tailbone, such as horseback riding and sitting on hard surface for long periods of time, may cause the onset of coccyx pain. Tailbone pain due to these causes usually is not permanent, but if the inflammation and symptoms are not managed, the pain may become chronic.
   
• Tumor or infection. Rarely, coccydynia is due to a tumor or infection in the coccyx area that puts pressure on the coccyx.

Diagnosis Of Coccydynia

A health professional diagnoses coccydynia by taking a thorough medical history from the patient and completing a physical examination. Diagnostic tests, such as x-ray or MRI, are also commonly performed in order to rule out other potential causes of the pain.

Physical Examination

A thorough physical examination for coccyx pain should include:

• Pelvic and rectal exam to check for a mass or tumor that could be a cause of the pain
• Palpation to check for local tenderness.

The most striking finding on examination is usually the local tenderness upon palpation of the coccyx. If the coccyx is not tender to palpation, then the pain in the region is referred from another structure, such as a lumbosacral disc herniation or degenerative disc disease.

Preferable Diagnostic Tests for Coccydynia

Diagnostic studies that should be done include:

• X-rays of the sacrum and coccyx to rule out the unlikely event that either an obvious fracture or a large tumor is the cause of the discomfort
• An MRI scan to rule out infection or tumor as a cause of pain.

Bone scans and CT scans add very little information and are generally not done. Typically, all imaging studies will be negative.

Treatments for Coccydynia

Treatments for coccydynia are usually noninvasive and local. The first line of treatment typically includes:

• Non-steroidal anti-inflammatory drugs (NSAIDs). Common NSAIDs, such as ibuprofen, naproxen and COX-2 inhibitors, help reduce the inflammation around the coccyx that is usually a cause of the pain.
• Applying ice or a cold pack to the area several times a day for the first few days after the pain starts.
• Applying heat or a hot pack to the area after the first few days.
• Avoiding sitting for prolonged periods, or placing any pressure on the area, as much as possible.
• A custom pillow to help take pressure off the coccyx when sitting. Some find a donut-shaped pillow works well, and for others it is not the right shape and still puts pressure on the coccyx. Many prefer a foam pillow that is more of a U-shape or V-shape (with the back open so nothing touches the coccyx). Any type of pillow or sitting arrangement that keeps pressure off the coccyx is ideal.
• If the tailbone pain is caused or increased with bowel movements or constipation, then stool softeners and increased fiber and water intake is recommended.

Additional Non-Surgical Treatments

• Injection. A local injection of a numbing agent (lidocaine) and steroid (to decrease inflammation in the area) can provide some relief. Fluoroscopic guidance is recommended. Relief can last from 1 week up to several years. No more than 3 injections per year are recommended.
• Manipulation. Some patients find pain relief through manual manipulation (e.g. chiropractic treatment).
• Stretching. Gently stretching the ligaments attached to the coccyx can be helpful. A physical therapist, chiropractor, physiatrist or other appropriately trained healthcare practitioner can provide instruction on the appropriate stretches.
• Ultrasound. Physical therapy with ultrasound can also be helpful for pain relief.

Provided that infection and tumor has been ruled out as a cause of pain (through exam, x-ray and MRI scan), then prolonged non-surgical treatment for pain relief and activity modification is a reasonable option.

After attaining sufficient pain relief so that movement is not too painful, daily low-impact aerobic activity is beneficial, as the increased blood flow brings healing nutrients to the area and encourages the body’s natural healing abilities. The additional benefit of aerobic activity is the release of endorphins, the body’s inherent pain relieving process.

Coccygectomy Surgery for Pain

For people who have persistent pain that is not alleviated or well-controlled with non-surgical treatment and activity modification, surgical removal of all or a portion of the coccyx (coccygectomy) is an option.

This surgery is rarely performed, and the procedure is not even included in most spine surgery textbooks. While the surgery itself is a relatively straight-forward operation, recovery from the surgery is a long and uncomfortable process for the patient.
 

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