Coccydynia: The painful tale of the tail!

Coccydynia is a painful condition of the human tail bone which is the lower-most bone in our vertebral column (backbone). Patients present with variable intensity of the pain while sitting and the pain is exactly over the lower tip of the back bone. This is a classical presentation of this condition which can be due to many causes.

2009091004healthlogoIt can happen after a fall on the buttocks, direct injury, bone tumour, cancer of any organ nearby or childbirth.  So if we look carefully at the causes, they can be sub-divided into mechanical or non-mechanical causes. It is important to know whether the cause is due to a mechanical injury or due to a non-mechanical cause. 

A sudden onset of this pain can usually be attributed to a recent mechanical injury to the tail bone like a fall on the buttocks or childbirth. Patients complain of pain on sitting exactly over the lower tip of the backbone, between the buttocks, and the intensity of the pain is severe enough to prevent patients from sitting. Some patients complain of pain while lying flat and also during sexual intercourse (in women).

It is important to distinguish this pain from pain around the slit given at child birth. Coccydynia after childbirth can be severe enough to hinder mother and baby bonding.   The gradual onset of the pain is suggestive of non-mechanical causes like a tumour or a bone abnormality. In these cases patients complain of an increasing severity of pain. Pain in Coccydynia originates from inflammation around the coccyx and the spasm of the muscles attached to it. It can also have a psychological component in long-standing cases.  Coccydynia is one of the most common causes of chronic pain and can be debilitating, especially for people in professions requiring long hours of sitting. But the good part of this tale (tail) is that treatment is possible by following a standard treatment protocol.

A fair number of patients complain that physicians dismiss, minimize or belittle the problem, and this is one of the main causes for the prolongation of the pain associated with the condition. A fair understanding of the condition is required by the physician to treat it in otherwise neglected patients.

Investigations are required for confirming and planning the management of, but not to diagnose Coccydynia. A dynamic X-ray of the coccyx can be taken both standing and in the painful sitting position. This will show the exact position of the fracture/dislocation/spicule or tumour of the coccyx. Sometimes a CT scan is required to diagnose the problem.

A strict adherence to the treatment protocol is the key to recovery.  Rest is the best and first treatment of Coccydynia. By rest I mean rest to the coccyx.  Sitting devices such as doughnut cushions, which have a circular hole in the middle, or wedge cushions, which have a triangular wedge cut out at the back, are very helpful in taking the pressure off the coccyx and relieving pain while sitting. Continuous indoor and outdoor usage of the cushion for at least 6 weeks is required for a fresh injury to heal. Besides these devices, a few medications may be started, to decrease the swelling and cut down the pain, such as anti-inflammatory drugs.

Not all the patients get relief from the pain with this conservative management and a few go into a chronic phase of this condition. The next step in the management, would be manipulation like external and internal massage of the muscles and the coccyx.

These manipulations are done under general anaesthesia and have proved to be quite an effective treatment. Another modality is to give local anaesthestic blocks to the coccyx with the help of an injection. These blocks can be done under X-ray guidance to relieve pain in most of the patients even those with long-standing Coccydynia.

Surgical treatment is the last step, and includes excision of the coccyx in a special subset of patients with coccyx instability. But surgery will relieve the pain after 4-6 months and the doctor would prescribe some pain medication until then.

To conclude, any pain is a warning sign and a careful examination is required to exclude serious underlying problems. Common Coccydy-nia is related to coccygeal instability in almost half of the cases and is treatable if the physician has a fair understanding of the condition and its management.

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