SPINAL CONDITIONS
Coccyx Pain - Coccydynia
What is coccydynia?
The coccyx is the tip of your spine right down by your bottom. It is often referred to as the ‘tail bone’. The coccyx can become inflamed and potentially even mis-shaped. Coccyx pain is more common in women than in men. A painful coccyx can be caused by trauma, inflamed tendons, childbirth, poor pelvic floor function, poor posture, abnormal movement of the coccyx, and age-related degenerative change. Very rarely coccyx pain can be caused by infection or cancer.
If you a getting pain from your coccyx then this will typically affect you when you are sitting down, as well as when getting up after sitting. We refer to a painful coccyx as having ‘coccydynia’.
If you have coccydynia then the potential management options are:
- Using a cushion when sitting to keep the load off your coccyx. If you search ‘coccyx cushion’ on a search engine, then it will give you a number of options of differing prices. The idea with a cushion is that by keeping your weight off the coccyx hopefully your symptoms will settle down.
- Physiotherapy can also be helpful, though it is often best to see a pelvic floor specialist physiotherapist rather than a general physiotherapist. If your symptoms are not settling down with conservative management, then we will arrange for you to have an MRI scan of your coccyx.
- Injection: This is an injection of a mixture of local anaesthetic and hydrocortisone (steroid) around the coccyx. The injection is a potent anti-inflammatory, and it is hoped that this will help to break the inflammatory cycle. Following an injection, you should continue with your cushion for at least six weeks, even if your symptoms are feeling better.
- Surgery: If you have an on-going problem with coccydynia then you may be a candidate for having your coccyx removed. This is called a ‘coccygectomy’.
SPINAL CONDITIONS
Coccyx injection
Coccyx injections are carried out as a day case procedure in an operating theatre. To minimise discomfort the injection is performed under sedation, which is administered by an anaesthetist. Prior to receiving sedation, we will examine your coccyx to determine where you are most tender. After the injection we will attempt to manipulate your coccyx as this can also be helpful in breaking the inflammatory cycle if your coccyx has become stiff.
The injection needle is inserted into the correct position using X-ray guidance.
What are the risks?
Infection
There is a risk of infection at the injection site, but this is rare due to the use of sterile techniques.
Bleeding
The risk of bleeding is very small following a coccyx injection.
If you are on any medication that has the potential to thin your blood such as aspirin, clopidogrel, warfarin, rivaroxaban or any other blood thinning medication then we do need to know about this prior to the date of your injection as this will usually need to be stopped prior to your injection.
Injection site discomfort
Following the injection you may have some localised soreness at the injection site, for which you can take some simple painkillers and it should settle over a few days.
Side effects from the injected steroid
There are very few side effects when steroids are administered this way. Occasionally patients may notice some facial flushing, nausea, or mild abdominal cramps for a few days following the injection. There can also be a temporary disturbance to the menstrual cycle. Diabetics may find that the steroid alters their blood sugar control for a few days, so should monitor it closely.
Allergic reaction
An allergic reaction to injected steroid and local anaesthetic is incredibly rare. However, you must inform us of any know allergies before-hand.
What can I expect following the injection?
After you have had the injection you will be spend a few minutes being monitored in the recovery room before being taken back to the ward. Once back on the ward, most patients will feel like having a short sleep. When you are ready to get up, you must call for one of the nursing team and only get up when they are with you as sometimes patients feel a little bit unsteady when they first get up following an injection. This will quickly pass. You will normally be able to leave hospital once you have had something to eat and drink, you are safely mobile, and you have passed urine. This is normally one and a half to two hours following your injection. As you will have had sedation you will be unable to drive for 24 hours following the injection and will need to arrange for someone to collect you from hospital.
After the injection we normally we use a spray on dressing that requires no removal or special care. You should keep the injection site dry for six hours. Beyond this, there are no special wound care instructions. If a small dressing is used, then this can be removed after six hours.
We would advise that you have a restful day the day after your injection but can return to normal activities the following day. There are no other restrictions following the injection. It is important that you continue with your cushion for at least six weeks following your injection. It can take up to two weeks for you to experience improvement in your symptoms following an injection.
What next?
You will be seen back in the clinic a few weeks after your injection. Your on-going treatment will be guided by your response to the injection.
SPINAL CONDITIONS
Coccygectomy
A coccygectomy is the surgical removal of your coccyx. This maybe indicated when someone has responded well to injections, but the benefit has only been short-lasting. The other indication is when you have a mis-shapen or previously damaged coccyx.
If your coccyx is causing you problems, then removing it would seem to be a logical step forward. The difficulty with coccyx surgery is the location of the wound, and the biggest risk is that of wound break down or infection. If this occurs, then it can take several weeks for the wound to heal and can leave you with on-going pain.
A coccygectomy is carried out in the operating theatre under a general anaesthetic. The operation involves making a small incision over your coccyx and removing the coccyx. At the end of the procedure the wound will be closed with a dissolvable stitch and covered with a skin glue dressing.
You will normally be in hospital for 24-hours.
What are the risks of having a coccygectomy?
Wound problems / Infection
The risk of wound problems / infection is 5-10%. If there is a problem with your wound, then it will likely take several weeks to address. It may require you to have further surgery or have a special dressing applied designed to bring the edges of your wound together. If you have a wound problem, then it is likely that you will have on-going pain / discomfort from the wound.
Bleeding
Blood loss is usually minimal with a coccygectomy.
If you are on any medication that has the potential to thin your blood such as aspirin, clopidogrel, warfarin, rivaroxaban or any other blood thinning medication then we do need to know about this prior to the date of your operation as this will usually need to be stopped prior to your operation.
If you take anti-inflammatory tablets, then you must stop taking them seven days before your operation as these drugs can also affect blood clotting.
DVT
Developing blood clots in the legs (deep vein thrombosis – DVT) is a risk of any surgery. We worry about DVTs as bits can break off a travel around your body. This is called an embolus. An embolus can affect your breathing, cause you to have a stroke, and could potentially be fatal. DVTs occur in approximately one in 200 patients having back surgery. An embolus is a much less common occurrence. We minimize the risk of DVT by asking patients to wear hospital stockings following their surgery (TEDS), and mechanical pumps during and immediately after surgery. These pumps squeeze your lower legs, helping the blood to circulate. They are put on when you go to sleep and stay on until you start to mobilize. We encourage early mobilisation as this also helps to prevent DVTs. If a patient is considered to be high risk for a DVT then we will prescribe blood thinning medication for a couple of weeks after your surgery.
Rectal injury
The rectum lies just anterior to your coccyx. There is a 1% of damaging your rectum with coccyx surgery. If this occurs then you may require surgery on your rectum to address this, potentially requiring a stoma to rest your rectum and allow it to recover. A stoma is when your bowel is bought out through your abdominal wall with your faeces being collected in a bag.
Scar tissue
Scar tissue can form at the surgical site. It is possible that you replace a painful coccyx for a painful scar.
Risks associated with having an operation lying on your front
When getting you ready for surgery, care is taken to ensure that everything is protected. The does however remain a small risk of pressure damage. This can cause some temporary skin damage to areas such as the tip of your nose and chin as well as to your torso. This would be expected to recover within two to three weeks. There is a very small risk of some damage to your vision. Visual damage is reported as occurring in 1 in 10,000 cases.
Medical complications
Prior to being admitted to hospital you will go through a pre-operative assessment process. This is to ensure that you are as fit as possible for your operation. If you have a chronic condition that is found to be poorly controlled or if a new condition is identified by the pre-operative assessment, then your operation may need to be delayed in order for your medical condition to be optimised. General anaesthesia for elective surgery is very safe. Occasionally unexpected medical events can occur under general anaesthetic. Fortunately, the risk of death under anaesthesia is very rare. Death as a direct result of general anaesthesia is reported as occurring in 1 in 100,000 cases.
Following any operation there is a small risk of post-operative medical complications, such as chest infections or urine infections.
What can I expect following my surgery?
When you wake up following your surgery you will feel bruised at the site of the operation. We try and minimize this by injecting local anaesthetic around the wound. The wound will be closed with a dissolvable suture and covered with a skin glue, so there will be no stitches that need to be taken out. You will be in hospital for one night. Before you go home the nurses will explain how you need to look after your wound. You will need to keep you wound completely dry for four weeks.
For the first two weeks you will need to avoid sitting. For the next four weeks after this sitting needs to be kept to an absolute minimum. This is to allow the wound to heal without putting any undue tension on the wound.
Many patients can get back to work within a couple of weeks from surgery, although often with some restriction of activity.
Driving – There is no restriction with the DVLA, though there will be with your insurance company. You will need to be able to undertake an emergency stop and be in complete control of your car at all times without being distracted by pain. If this is not the case, then your insurance will NOT be valid. As driving requires you to be sitting, driving should be kept to a minimum for the first six weeks.
Flying – You should not fly for two weeks following your surgery. You should not undertake any long-haul flights for six weeks. If traveling on a long-haul flight within six months of your operation then you should wear your hospital stockings when flying.
Follow-up
You will be seen back in the clinic two weeks after your surgery. An appointment will be made for you before you are discharged.
More information can be found in the booklets section of the patient’s area on the British Association of Spine Surgeons website (www.spinesurgeons.ac.uk)
