The Korean Journal of Pain

The Korean Pain Society (대한통증학회)
권호 표지
DOI QR코드

DOI QR Code

Coccydynia: anatomic origin and considerations regarding the effectiveness of injections for pain management

  • Shin-Hyo Lee (Department of Anatomy, Wonkwang University School of Medicine) ;
  • Miyoung Yang (Department of Anatomy, Wonkwang University School of Medicine) ;
  • Hyung-Sun Won (Department of Anatomy, Wonkwang University School of Medicine) ;
  • Yeon-Dong Kim (Jesaeng-Euise Clinical Anatomy Center, Wonkwang University School of Medicine)
  • Received : 2023.06.09
  • Accepted : 2023.06.15
  • Published : 2023.07.01
Download PDF
⟨ Previous Next ⟩

Abstract

Coccydynia is a debilitating pain disorder. However, its pathophysiology is not well understood. When approaching coccydynia, the exact underlying cause of pain must be identified to develop an appropriate treatment plan. The specific approach to coccydynia can vary depending on an individual's condition and the underlying cause. Thorough evaluation by a pain physician is essential to determine the most appropriate course of treatment. The purpose of this review is to examine the various causes contributing to coccygeal pain and specifically focus on the exact anatomical neurostructures, such as the anococcygeal nerve, perforating cutaneous nerve, and ganglion impar. We also reviewed the relevant clinical outcomes and suggested recommendations for each anatomical structure.

Keywords

Acknowledgement

This study was supported by Wonkwang University in 2023.

References

  1. Breivik H, Collett B, Ventafridda V, Cohen R, Gallacher D. Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment. Eur J Pain 2006; 10: 287-333. https://doi.org/10.1016/j.ejpain.2005.06.009
  2. Manchikanti L, Singh V, Datta S, Cohen SP, Hirsch JA; American Society of Interventional Pain Physicians. Comprehensive review of epidemiology, scope, and impact of spinal pain. Pain Physician 2009; 12: E35-70. https://doi.org/10.36076/ppj.2009/12/E35
  3. Carey TS, Garrett J, Jackman A, McLaughlin C, Fryer J, Smucker DR. The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors, and orthopedic surgeons. The North Carolina Back Pain Project. N Engl J Med 1995; 333: 913-7. https://doi.org/10.1056/NEJM199510053331406
  4. Kim YD, Moon HS. Review of medical dispute cases in the pain management in Korea: a medical malpractice liability insurance database study. Korean J Pain 2015; 28: 254-64. Erratum in: Korean J Pain 2016; 29: 62.
  5. Romanes GJ. Cunningham's textbook of anatomy. 12th ed. Oxford University Press. 1981, pp 797-806.
  6. Berry M, Standring SM, Bannister LH. Nervous system. In: Gray's anatomy. 38th ed. Edited by Williams PL. Churchill Livingstone. 1995, pp 901-1397.
  7. O'Rahilly R, Muller F, Meyer DB. The human vertebral column at the end of the embryonic period proper. 4. The sacrococcygeal region. J Anat 1990; 168: 95-111.
  8. Pearson AA, Sauter RW, Buckley TF. Further observations on the cutaneous branches of the dorsal primary rami of the spinal nerves. Am J Anat 1966; 118: 891-903. https://doi.org/10.1002/aja.1001180313
  9. Oh CS, Chung IH, Ji HJ, Yoon DM. Clinical implications of topographic anatomy on the ganglion impar. Anesthesiology 2004; 101: 249-50. https://doi.org/10.1097/00000542-200407000-00039
  10. Woon JT, Stringer MD. Clinical anatomy of the coccyx: a systematic review. Clin Anat 2012; 25: 158-67. https://doi.org/10.1002/ca.21216
  11. Sugar O. Coccyx. The bone named for a bird. Spine (Phila Pa 1976) 1995; 20: 379-83. https://doi.org/10.1097/00007632-199502000-00024
  12. Soames RW. Skeletal system. In: Gray's anatomy. 38th ed. Edited by Williams PL. Churchill Livingstone. 1995, pp 425-711.
  13. Maigne JY, Guedj S, Straus C. Idiopathic coccygodynia. Lateral roentgenograms in the sitting position and coccygeal discography. Spine (Phila Pa 1976) 1994; 19: 930-4. https://doi.org/10.1097/00007632-199404150-00011
  14. Simpson JY. Clinical lectures on the diseases of women. Lecture XVII: on coccydynia and diseases and deformities of the coccyx. Med Times Gaz 1859; 40: 1-7.
  15. Foye PM. Stigma against patients with coccyx pain. Pain Med 2010; 11: 1872.
  16. Ghormley RK. An etiologic study of back pain. Radiology 1958; 70: 649-53. https://doi.org/10.1148/70.5.649
  17. Pennekamp PH, Kraft CN, Stutz A, Wallny T, Schmitt O, Diedrich O. Coccygectomy for coccygodynia: does pathogenesis matter? J Trauma 2005; 59: 1414-9. https://doi.org/10.1097/01.ta.0000195878.50928.3c
  18. Foye PM. Coccydynia: tailbone pain. Phys Med Rehabil Clin N Am 2017; 28: 539-49. https://doi.org/10.1016/j.pmr.2017.03.006
  19. Przybylski P, Pankowicz M, Bockowska A, Czekajska-Chehab E, Staskiewicz G, Korzec M, et al. Evaluation of coccygeal bone variability, intercoccygeal and lumbo-sacral angles in asymptomatic patients in multislice computed tomography. Anat Sci Int 2013; 88: 204-11. https://doi.org/10.1007/s12565-013-0181-2
  20. Postacchini F, Massobrio M. Idiopathic coccygodynia. Analysis of fifty-one operative cases and a radiographic study of the normal coccyx. J Bone Joint Surg Am 1983; 65: 1116-24. https://doi.org/10.2106/00004623-198365080-00011
  21. Woon JT, Maigne JY, Perumal V, Stringer MD. Magnetic resonance imaging morphology and morphometry of the coccyx in coccydynia. Spine (Phila Pa 1976) 2013; 38: E1437-45. https://doi.org/10.1097/BRS.0b013e3182a45e07
  22. Doursounian L, Maigne JY, Jacquot F. Coccygectomy for coccygeal spicule: a study of 33 cases. Eur Spine J 2015; 24: 1102-8. https://doi.org/10.1007/s00586-014-3753-5
  23. Nathan ST, Fisher BE, Roberts CS. Coccydynia: a review of pathoanatomy, aetiology, treatment and outcome. J Bone Joint Surg Br 2010; 92: 1622-7. https://doi.org/10.1302/0301-620X.92B12.25486
  24. Patijn J, Janssen M, Hayek S, Mekhail N, Van Zundert J, van Kleef M. 14. Coccygodynia. Pain Pract 2010; 10: 554-9. https://doi.org/10.1111/j.1533-2500.2010.00404.x
  25. Thiele GH. Coccygodynia: cause and treatment. Dis Colon Rectum 1963; 6: 422-36. https://doi.org/10.1007/BF02633479
  26. Lirette LS, Chaiban G, Tolba R, Eissa H. Coccydynia: an overview of the anatomy, etiology, and treatment of coccyx pain. Ochsner J 2014; 14: 84-7.
  27. De Andres J, Chaves S. Coccygodynia: a proposal for an algorithm for treatment. J Pain 2003; 4: 257-66. https://doi.org/10.1016/S1526-5900(03)00620-5
  28. Won HS, Yang M, Kim YD. Facet joint injections for management of low back pain: a clinically focused review. Anesth Pain Med (Seoul) 2020; 15: 8-18. https://doi.org/10.17085/apm.2020.15.1.8
  29. Bayne O, Bateman JE, Cameron HU. The influence of etiology on the results of coccygectomy. Clin Orthop Relat Res 1984; 190: 266-72. https://doi.org/10.1097/00003086-198411000-00047
  30. Perkins R, Schofferman J, Reynolds J. Coccygectomy for severe refractory sacrococcygeal joint pain. J Spinal Disord Tech 2003; 16: 100-3. https://doi.org/10.1097/00024720-200302000-00016
  31. Balain B, Eisenstein SM, Alo GO, Darby AJ, CassarPullicino VN, Roberts SE, et al. Coccygectomy for coccydynia: case series and review of literature. Spine (Phila Pa 1976) 2006; 31: E414-20. https://doi.org/10.1097/01.brs.0000219867.07683.7a
  32. Trollegaard AM, Aarby NS, Hellberg S. Coccygectomy: an effective treatment option for chronic coccydynia: retrospective results in 41 consecutive patients. J Bone Joint Surg Br 2010; 92: 242-5. https://doi.org/10.1302/0301-620X.92B2.23030
  33. Datir A, Connell D. CT-guided injection for ganglion impar blockade: a radiological approach to the management of coccydynia. Clin Radiol 2010; 65: 21-5. https://doi.org/10.1016/j.crad.2009.08.007
  34. Foye PM, Buttaci CJ, Stitik TP, Yonclas PP. Successful injection for coccyx pain. Am J Phys Med Rehabil 2006; 85: 783-4. https://doi.org/10.1097/01.phm.0000233174.86070.63
  35. Govardhani Y, RamMohan G, Abhijith S, Savithri B. A comparative retrospective study of the efficacy of caudal epidural with manipulation versus ganglion impar block with manipulation in patients with coccydynia. Indian J Pain 2021; 35: 42-5. https://doi.org/10.4103/ijpn.ijpn_152_20
  36. Sencan S, Yolcu G, Bilim S, Kenis-Coskun O, Gunduz OH. Comparison of treatment outcomes in chronic coccygodynia patients treated with ganglion impar blockade versus caudal epidural steroid injection: a prospective randomized comparison study. Korean J Pain 2022; 35: 106-13. https://doi.org/10.3344/kjp.2022.35.1.106
  37. Yamada K, Ishihara Y, Saito T. Relief of intractable perineal pain by coccygeal nerve block in anterior sacrococcygeal ligament after surgery for rectal cancer. J Anesth 1994; 8: 52-4. https://doi.org/10.1007/BF02482755
  38. Alimehmeti RH, Schuenke MD, Dellon AL. Anococcygeal nerve and sitting pain: differential diagnosis and treatment results. Ann Plast Surg 2022; 88: 79-83. https://doi.org/10.1097/SAP.0000000000002920
  39. Lema MJ. Invasive analgesia techniques for advanced cancer pain. Surg Oncol Clin N Am 2001; 10: 127-36. https://doi.org/10.1016/S1055-3207(18)30089-9
  40. Toshniwal GR, Dureja GP, Prashanth SM. Transsacrococcygeal approach to ganglion impar block for management of chronic perineal pain: a prospective observational study. Pain Physician 2007; 10: 661-6. https://doi.org/10.36076/ppj.2007/10/661
  41. Gunduz OH, Kenis-Coskun O. Ganglion blocks as a treatment of pain: current perspectives. J Pain Res 2017; 10: 2815-26. https://doi.org/10.2147/JPR.S134775
  42. Day M. Sympathetic blocks: the evidence. Pain Pract 2008; 8: 98-109. https://doi.org/10.1111/j.1533-2500.2008.00177.x
  43. Munir MA, Zhang J, Ahmad M. A modified needle-inside-needle technique for the ganglion impar block. Can J Anaesth 2004; 51: 915-7. https://doi.org/10.1007/BF03018890
  44. Ho KY, Nagi PA, Gray L, Huh BK. An alternative approach to ganglion impar neurolysis under computed tomography guidance for recurrent vulva cancer. Anesthesiology 2006; 105: 861-2. https://doi.org/10.1097/00000542-200610000-00048
  45. Mitra R, Cheung L, Perry P. Efficacy of fluoroscopically guided steroid injections in the management of coccydynia. Pain Physician 2007; 10: 775-8. https://doi.org/10.36076/ppj.2007/10/775
  46. Wray CC, Easom S, Hoskinson J. Coccydynia. Aetiology and treatment. J Bone Joint Surg Br 1991; 73: 335-8. https://doi.org/10.1302/0301-620X.73B2.2005168