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 Contemporary
Spine Surgery
VOLUME 16 NUMBER 4 APRIL 2015

Coccygectomy: Current Views and

Controversies
Christoph P. Hofstetter, MD, PhD, Craig Brecker, BS, and Michael Y. Wang, MD

LEARNING OBJECTIVES: After participat-
ing in this CME activity, the spine surgeon
should be better able to:
1. Identify common presenting features and
radiographic findings in patients with coc-
cygodynia.
2. Assess the indications for coccygectomy.
3. Describe coccygectomy with regard to
techniques, outcomes, and adverse events.
Key Words: Coccygodynia, Coccygectomy,
Pain, Trauma
the caudal 3 to 5 segments of the spinal col-
umn. The term coccyx derives from the Greek
word kokkoux, or cuckoo, as it resembles the
shape of the cuckoos peak. Coccygodynia is
a rare condition and accounts for less than
1% of back pain conditions.2,3 However,
spine surgeons frequently see patients with
symptoms of coccygodynia in the outpatient
setting. Coccygodynia has been described as
intense focal pain ranging from deep ache
around the coccyx to sitting on a knife or
being impaled on a garden cane.4 The pain
is usually elicited or exacerbated by pro-
longed sitting or cycling and aggravated
most commonly affected between their late
20s and early 50s.8,9 Causes of coccygo-
dynia include direct trauma (59.1%); idiopath-
ic causes (30.9%); childbirth (8.1%); or recent
rectal surgery, lumbar surgery, or epidural
injections (1.9%).8 Trauma secondary to falls
or childbirth within the month before the
onset of symptoms has been shown to be
associated with coccygeal hypermobility.5
Maigne and colleagues5 proposed that
body mass index greater than 27.4 kg/m2
in women and 29.4 kg/m2 in men increas-
es the risk for development of idiopathic
or posttraumatic coccygodynia. This is

C
occygodynia was first reported by
Simpson1 in the medical literature
in 1859 and is defined as pain/dis-
comfort located at and around the tailbone.
The tailbone is a triangular bone formed by
Dr. Hofstetter is Assistant Professor, Department
of Neurological Surgery, University of Washington,
Seattle, Washington; Mr. Brecker is Research
Assistant; and Dr. Wang is Professor, Depart-
ments of Neurosurgery and Rehabilitation
Medicine, University of Miami Miller School of
Medicine, 1917 NE 118 Rd, North Miami, FL
33181; E-mail: mwang2@med.miami.edu.
All faculty and staff in a position to control the
content of this CME activity and their spouses/
life partners (if any) have disclosed that they
have no financial relationships with, or finan-
cial interests in, any commercial organizations
related to this CME activity.
when rising from the sitting position. The
underlying pathophysiologic mechanisms
are diverse and often obscure. However, the
most common cause ascribed by the patient
is a fall or chronic trauma resulting in direct
injury to the sacrococcygeal synchondrosis.
Coccygodynia is more common in women.5
ETIOLOGY
Coccygodynia is more common in
women, with a female-to-male ratio of
approximately 5:1.6-9 Slender women typi-
cally have little subcutaneous fat, and the
coccyx is unpadded. Moreover, women have
a greater interischial tuberosity distance
compared with men, which increases the
risk of trauma and also allows for greater
pressure onto the coccyx.6,7 Patients are
due to the diminished pelvic rotation in
obese patients. The coccyx juts out more
posteriorly while sitting,5 which increases
the exposure to pressure and increases
the risk for coccygeal subluxation. In
some cases, coccygodynia can be related
to tumors such as chordoma, giant cell
tumor, intradural schwannoma, perineu-
ral cyst, and intraosseous lipoma.10-12
DIAGNOSIS
On examination, the typical patient
will report local pain elicited by mechani-
cal pressure on the tip of the coccyx.
Abnormal movement of the coccyx can
also be noted upon palpation, which can
be performed externally or with an exam-
ining digit placed within the rectum.

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quiz questions correctly. This activity expires on March 30, 2016.
Contemporary Spine Surgery VOLUME 16 NUMBER 4

Preoperative workup typically includes Hypermobility of the coccyx, defined

Editor-in-Chief lateral x-rays, dynamic x-rays comparing as flexion of the coccyx in relation to the
Kern Singh, MD
Associate Professor, Department of
standing and sitting radiographs, and MRI sacrum of more than 25 degrees upon sit-
Orthopedic Surgery (Figure 1).5,13,14 According to Postacchini ting, is seen in 27.4% of patients.5 It is
Rush University Medical Center and Massobrio,15 the sacrum can be clas- thought that hypermobility is attributable
Chicago, IL sified as 1 of 4 types by use of dynamic to previous trauma and incomplete bony
Contributing Editor lateral radiographs. Types I through III or ligamentous healing.14
Alpesh A. Patel, MD
indicate increasing anterior angulation of A small bony excrescence on the
Chicago, IL the coccyx, and type IV describes subluxa- dorsal aspect of the tip of the coccyx,
tion of the sacrococcygeal joint. However, termed spicule, is documented in 14.4% of
Editorial Board this classification is of limited clinical patients.5 These symptomatic spicules are
Howard S. An, MD value, because neither coccygodynia nor frequently seen in lean patients with
Chicago, IL
positive treatment response has been immobile coccyges. In these patients, the
Jonathan N. Grauer, MD associated with the various grades.8 To onset of symptoms is not related to trau-
New Haven, CT
date, 3 radiographic lesions have been ma, and symptoms are due to irritation on
Wellington K. Hsu, MD linked to coccygodynia. They are found in sitting. On examination, 80% of these
Chicago, IL
approximately 70% of patients and include patients have a pit in the overlying skin,
Yu-Po Lee, MD luxation, hypermobility, and spicule.5 with symptoms evoked precisely by pres-
San Diego, CA
Luxation is defined as coccyx slip- sure on the spicule. Chronic bursitis has
John OToole, MD page of more than 50% of the sacrococ- been proposed as the cause of symptoms,
Chicago, IL
cygeal joint diameter while sitting.13 and pain is alleviated by local anesthesia.
Frank M. Phillips, MD Approximately one quarter of patients All patients with coccygodynia should
Chicago, IL
with coccygodynia are diagnosed with undergo lumbosacral MRI with and with-
Sheeraz Qureshi, MD, MBA luxation of the coccyx. Anterior luxation out contrast to rule out less common
New York, NY is rare and occurs in leaner patients. causes of coccygodynia such as infection,
Alex R. Vaccaro, MD, PhD Posterior luxation is 4 times more com- precoccygeal cysts, or neoplasms.
Philadelphia, PA mon than anterior luxation and is linked
Michael Y. Wang, MD to obesity. In obese patients, the pelvis CONSERVATIVE TREATMENT
Miami, FL displays less sagittal rotation, so the The treatment goal for coccygodynia
Founding Editor coccyx protrudes posteriorly when the is to eliminate or diminish local pain and to
Gunnar B.J. Andersson, MD, PhD patient is sitting or falls onto his or her allow the patient to resume a premorbid
Chairman, Department of Orthopedic Surgery buttocks. Increased exposure to pres- lifestyle. Conservative treatments are effec-
Rush-PresbyterianSt. Lukes Medical Center sure leads to an increased risk of tive in approximately 75% of patients with
Chicago, IL luxation. coccygodynia.16-18 As a first-line treatment,
all patients with acute coccygodynia should
This continuing education activity is intended for orthopaedic and neurologic surgeons and other physicians receive nonsteroidal anti-inflammatory
with an interest in spine surgery. drugs (NSAIDs) for 8 weeks.19 Patients are
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PAID SUBSCRIBERS: Current issue and archives are available FREE online at www.cssnewsletter.com. involves blocking the ganglion impar,
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vertebral sympathetic chain (Figure 2).22 A
counsel should be sought for specific situations. small prospective case series by Reig and

2
APRIL 2015 Contemporary Spine Surgery

Fig. 1 A patient with severe coccydynia and Ehlers-Danlos syndrome. A, Lateral x-ray. B, CT scan showing a fracture of the coccyx.

colleagues23 included 4 patients with coccygodynia who under- laterally using adhesive tape. The perianal area is excluded from
went thermocoagulation of the ganglion impar. These 4 patients the operative field by adhesive drapes, and the coccygeal region
experienced an improvement of their visual analog scale (VAS) is prepared with iodine or chlorhexidine. The sacrococcygeal junc-
scores for pain from 8.8 preoperatively to 3.8 after the procedure. tion is localized using lateral fluoroscopic images. After infiltra-
However, improvement lasted for only 2.2 months. tion of the skin with a lidocaine-epinephrine mix, a longitudinal
Coccyx manipulation, combined with local injection, is
another nonoperative therapy for patients with coccygodynia.
Manipulation is performed with the patient in the lateral decu-
bitus position, using the index finger per rectum and the thumb
overlying the coccyx. The coccyx is then repeatedly flexed and
extended for approximately 1 minute. If this treatment regimen
is used as a first-line treatment, an 85% successful response
has been reported.7 Its therapeutic usefulness has been con-
firmed6,24 and is thought to be attributable to stretching of the
ligaments, which allows painless normal movements.25

SURGERY
Coccygectomy
In patients with coccygodynia unresponsive to conserva-
tive treatment, coccygectomy constitutes a more definitive,
albeit controversial, treatment modality.21,26 Before surgery, it is
recommended that the patient undergo a bowel preparation and
consume a low-residue diet. Frequently, a fleet enema is also
given the day before surgery. All of these efforts aim to prevent
contamination of the wound during the procedure. The risk of
wound infection is further reduced by the use of perioperative,
typically broad-spectrum, antibiotics.
After induction of general anesthesia, the patient is posi- Fig. 2 Fluoroscopic image of a ganglion impar block to treat
tioned prone on a Wilson frame. The buttock cheeks are retracted refractory coccydynia.

3
Contemporary Spine Surgery
Fig. 3 Coccyx tip resected en bloc using Keys technique.
incision is made from the sacrum to the tip of the coccyx. The
periosteum of the coccyx is opened midline, and subperiosteal
dissection is performed bilaterally. Utilizing Keys technique,27
the sacrococcygeal disc space is incised and dissected (Figure 3).
The coccyx bone is then elevated and dissected from the sur-
rounding tissues in a rostrocaudal circumferential fashion in a
subperiosteal plane with a dissector or low-power monopolar
electrocautery. Keys technique suggests dissection from rostral
to caudal, which reduces the risk of rectal injury, particularly in
a patient with an anteverted coccyx. If a posteriorly subluxated
coccyx is removed, the resection may be performed from caudal
to rostral. This technique has been proposed by Gardner.28
However, because the surgeon works blindly, there may be an
increased risk of rectal injury.
Treatment failures associated with coccygectomy may be
avoided by performing en bloc resection of the bone. The first
coccygeal segment is identified by the cornua at the articulation
with the most caudal sacral segment. Initial resection of the
cornua using Kerrison rongeurs may facilitate the mobilization
of the first coccygeal segment. If the first coccygeal segment is
solidly fused to the sacrum, it may be left in place, and the
resection may be performed distal to the first mobile segment.
In thinner patients, it is preferred to perform a sacrococcygeal
osteotomy, because the first coccygeal segment may form a
symptomatic bony prominence if it is left in place.
Once the coccyx is removed en bloc, all remaining sharp
prominences on the caudal sacrum are smoothed using a com-
bination of rongeurs and a high-speed drill to prevent any palpa-
ble bony prominences or spicules. Before closure, completeness
of the resection may be confirmed by examining the specimen
on an intraoperative lateral fluoroscopic image. Complete
removal of the coccyx is important, as partial resection has been
associated with treatment failure.17,29-33 Hemostatic agents
other than electrocautery are used to prevent rectal injury.
The use of a wound drain is controversial. Proponents
claim that a wound drain decreases void space that could com-
promise wound healing.2,20,34 Opponents think its proximity to
the rectum may be a cause for increased infection rates.9,29,35
4
VOLUME 16 NUMBER 4
However, 2 recent systematic reviews could not confirm a direct
correlation between use of wound drains and rate of infection.8,9
For closure, the periosteum, fascia, and skin are closed in lay-
ers. Application of a topical skin adhesive has been proposed to
decrease the rate of perioperative wound infection.36 Patients
are positioned lateral or supine after the surgery to avoid pres-
sure to the surgical wound. Broad-spectrum antibiotics are
given for 48 to 72 hours postoperatively.
Outcomes
Karadimas and colleagues8 recently reported a summary of
reported clinical outcomes after coccygectomy for coccygo-
dynia. The authors identified a total of 24 articles with 671
patients diagnosed with coccygodynia and treated with coccy-
gectomy as definitive pain management. Mean patient age in
the analyzed studies ranged from 26.4 to 52.8 years, and the
male-to-female ratio was 1:4.4. Etiology included trauma, idio-
pathic causes, childbirth, and recent rectal or lumbar surgery or
epidural injection. Before coccygectomy, most patients under-
went nonoperative therapies for 3 to 6 months. In the vast
majority of cases, Keys technique was used, and patients were
followed-up for a minimum of 2 years. Of a total of 596 patients
with reported clinical outcomes after coccygectomy, 504 patients
had an excellent or good outcome (mild occasional discomfort,
84.6%); 46 patients had a fair outcome (decreased residual
pain, 7.7%); and 46 patients had a poor outcome (persistent or
worsening symptoms, 7.7%).8
Patient self-reported pain VASs after coccygectomy have
been reported in 4 studies including a total of 78 patients.9,16,21,32
On average patients who undergo coccygectomy had a preopera-
tive VAS of 8.7. All 4 studies report significant improvements of
the postoperative VAS compared with preoperative values.
Thus, 41 months after the procedure, the average VAS was 3.6.
Perkins et al21 utilized the Oswestry Disability Index (ODI) a
scale in a study that found a significant decrease in the ODI from
55 preoperatively to 36 at a mean follow-up time of 43 months.
Adverse Effects
Wound infection is the most common complication after
coccygectomy, and it occurs at a rate of approximately 10%.8,9
The most frequently reported bacteria are Escherichia coli and
Staphylococcus aureus. Most infections resolve with antibiotic
treatment and/or surgical debridement.
Several measures have been proposed to decrease the risk
of wound infection.36 Perioperative prophylactic broad-spectrum
antibiotics should be administered during a period of 48 hours.
Wound closure should be performed in layers, and the skin
should be sealed with a topical skin adhesive. Postoperatively,
the dressing should be kept clean and changed every second day
during the first week after surgery, and patients should be
instructed with regard to careful local hygiene, which often
involves the help of a caregiver.
Wound dehiscence (0.9%) and wound hematomas (0.9%)
are less-frequent adverse effects.8,9 Infrequently, patients must
return to the operating room for excision of remnant coccyx.
There are case reports of rectal hernia or rectal injury during
APRIL 2015
coccygectomy.37,38 Because of the attachment of the anal
sphincter muscles to the tip of the coccyx, patients should also
be counseled regarding the possibility of decreased sphincter
tone after coccygectomy.
CONCLUSION
Coccygectomy is a valid treatment modality for patients
who fail to respond to conservative therapy for coccygodynia.
Long-lasting pain relief is achieved in the vast majority of
patients (approximately 85%), but these benefits are seen only
in carefully selected patients. High surgical wound infection
rates after coccygectomy demand preoperative bowel prepara-
tion, antibiotic prophylaxis, and impeccable surgical technique.
REFERENCES
1. Simpson JY. Coccygodynia and diseases and deformities of the coccyx.
Med Times Gaz. 1859;40:1-7.
2. Pennekamp PH, Kraft CN, Stutz A, et al. Coccygectomy for coccygo-
dynia: does pathogenesis matter? J Trauma. 2005;59(6):1414-1419.
3. Thiele GH. Coccygodynia: cause and treatment. Dis Colon Rectum.
1963;6:422-436.
4. Miles J. Symptoms of coccydynia. Coccyx pain website. http://www.coccyx.
org/whatisit/symptoms.htm. Published 2002. Accessed February 4, 2014.
5. Maigne JY, Doursounian L, Chatellier G. Causes and mechanisms of
common coccydynia: role of body mass index and coccygeal trauma.
Spine. 2000;25(23):3072-3079.
6. Duncan GA. Painful coccyx. Arch Surg. 1937;34(6):1088-1104.
7. Wray CC, Easom S, Hoskinson J. Coccydynia. Aetiology and treatment.
J Bone Joint Surg Br. 1991;73(2):335-338.
8. Karadimas EJ, Trypsiannis G, Giannoudis PV. Surgical treatment of
coccygodynia: an analytic review of the literature. Eur Spine J. 2011;
20(5):698-705.
9. Kwon HD, Schrot RJ, Kerr EE, et al. Coccygodynia and coccygectomy.
Korean J Spine. 2012;9(4):326-333.
10. Ziegler DK, Batnitzky S. Coccygodynia caused by perineural cyst.
Neurology. 1984;34(6):829-830.
11. Kinnett JG, Root L. An obscure cause of coccygodynia. Case report.
J Bone Joint Surg Am. 1979;61(2):299.
12. Hanelin LG, Sclamberg EL, Bardsley JL. Intraosseous lipoma of the
coccyx. Report of a case. Radiology. 1975;114(2):343-344.
13. Maigne JY, Guedj S, Straus C. Idiopathic coccygodynia. Lateral roent-
genograms in the sitting position and coccygeal discography. Spine.
1994;19(8):930-934.
14. Maigne JY, Tamalet B. Standardized radiologic protocol for the study of
common coccygodynia and characteristics of the lesions observed in
the sitting position. Clinical elements differentiating luxation, hypermo-
bility, and normal mobility. Spine. 1996;21(22):2588-2593.
15. Postacchini F, Massobrio M. Idiopathic coccygodynia. J Bone Joint Surg.
1983;65:116-124.
5
Contemporary Spine Surgery
16. Hodges SD, Eck JC, Humphreys SC. A treatment and outcomes analy-
sis of patients with coccydynia. Spine J. 2004;4(2):138-140.
17. Ramsey ML, Toohey JS, Neidre A, et al. Coccygodynia: treatment.
Orthopedics. 2003;26(4):403-405; discussion 405.
18. Wray AR, Templeton J. Coccygectomy. A review of thirty-seven cases.
Ulster Med J. 1982;51(2):121-124.
19. Fogel GR, Cunningham PY, 3rd, Esses SI. Coccygodynia: evaluation
and management. J Am Acad Orthop Surg. 2004;12(1):49-54.
20. Maigne JY, Pigeau I, Aguer N, et al. Chronic coccydynia in adolescents.
A series of 53 patients. Eur J Phys Rehabil Med. 2011;47(2):245-251.
21. Perkins R, Schofferman J, Reynolds J. Coccygectomy for severe refrac-
tory sacrococcygeal joint pain. J Spinal Disord Tech. 2003;16(1):
100-103.
22. Foye PM, Buttaci CJ, Stitik TP, et al. Successful injection for coccyx
pain. Am J Phys Med Rehabil. 2006;85(9):783-784.
23. Reig E, Abejon D, del Pozo C, et al. Thermocoagulation of the ganglion
impar or ganglion of Walther: description of a modified approach.
Preliminary results in chronic, nononcological pain. Pain Pract.
2005;5(2):103-110.
24. Stern FH. Coccygodynia among the geriatric population. J Am Geriatr
Soc. 1967;15(1):100-102.
25. Borgia CA. Coccydynia: its diagnosis and treatment. Milit Med.
1964;129:335-338.
26. 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(2):242-245.
27. Key JA. Operative treatment of coccygodynia. J Bone Joint Surg.
1937;19(3):759-764.
28. Gardner RC. An improved technic of coccygectomy. Clin Orthop Relat
Res. 1972;85:143-145.
29. Grosso NP, van Dam BE. Total coccygectomy for the relief of coccygo-
dynia: a retrospective review. J Spinal Disord Techn. 1995;8(4):328-330.
30. Hellberg S, Strange-Vognsen HH. Coccygodynia treated by resection of
the coccyx. Acta Orthop Scand. 1990;61(5):463-465.
31. Karalezli K, Iltar S, Irgit K, et al. Coccygectomy in the treatment of
coccygodynia. Acta Orthop Belgica. 2004;70(6):583-585.
32. Kerr EE, Benson D, Schrot RJ. Coccygectomy for chronic refractory
coccygodynia: clinical case series and literature review. J Neurosurg
Spine. 2011;14(5):654-663.
33. Mouhsine E, Garofalo R, Chevalley F, et al. Posttraumatic coccygeal
instability. Spine J. 2006;6(5):544-549.
34. Doursounian L, Maigne JY, Faure F, et al. Coccygectomy for instability
of the coccyx. Int Orthop. 2004;28(3):176-179.
35. Balain B, Eisenstein SM, Alo GO, et al. Coccygectomy for coccydynia:
case series and review of literature. Spine. 2006;31(13):E414-E420.
36. Doursounian L, Maigne JY, Cherrier B, et al. Prevention of post-
coccygectomy infection in a series of 136 coccygectomies. Int Orthop.
2011;35(6):877-881.
37. Kumar A, Reynolds JR. Mesh repair of a coccygeal hernia via an
abdominal approach. Ann Royal Collf Surg Engl. 2000;82(2):113-115.
38. Garcia FJ, Franco JD, Marquez R, et al. Posterior hernia of the rectum
after coccygectomy. Eur J Surg. 1998;164(10):793-794.
Contemporary Spine Surgery
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1. Which one of the following describes typical presentation in
patients with coccygodynia?
A. Pain radiating down the legs
B. Pain/discomfort located at and around the tailbone and exac-
erbated by sitting
C. Shooting pain along the thoracic spine
D. Intense coughing
2. Which one of the following describes the most common reason(s)
patients develop coccygodynia?
A. Trauma, idiopathic, childbirth, rectal, or lumbar surgery
B. Diabetes mellitus and hypertension
C. Lumbar spinal spondylosis
D. Hereditary
3. Which one of the following patients is most likely to develop
coccygodynia?
A. Tall man
B. Obese woman
C. Infant
D. Elderly person
4. Which of the following imaging studies is most useful in diagnosis
of coccygodynia?
A. Positron emission tomographic scan
B. CT scan of the sacrum
C. Dynamic lateral sacral x-rays and MRI
D. Standing 36-inch films of the spine
5. Which one of the following describes positive radiographic find-
ings in 70% of patients with coccygodynia?
A. Coccyx curved forward and wide interischial tuberosity
distance
B. Pelvic tilt greater than 25 degrees and loss of lumbar lordosis
C. High coccygeal angle of incidence and straight coccyx
D. Coccygeal luxation, hypermobility, and spicule
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ally tracks AMA PRA Category 1 Credits earned from neurosurgery
activities not sponsored or joint-sponsored by the AANS. As a service to
AANS members, Lippincott CME Institute will continue to provide the
AANS a monthly listing of their participants and the CME credits they
earned so that AANS members do not have to send their individual
certificates to the AANS for tracking.
Credits related to activities on orthopaedics may be applied to
American Board of Orthopaedic Surgery Maintenance of Certification.
Please confirm credit for specific activity with the Board at www.abos.org.
6. Which one of the following strategies describes first-line treat-
ment of coccygodynia?
A. Coccygectomy
B. NSAIDs, donut-shaped cushion, and sitz baths
C. Injections
D. Spinal cord stimulation
7. Typical features of Keys technique, the most common surgical
technique for coccygectomy, include
A. resection performed from rostral to caudal, and only part of
the coccyx is removed
B. resection performed from caudal to rostral, and the coccyx is
resected en bloc
C. resection performed from rostral to caudal, and the coccyx is
resected en bloc
D. removal of only the hypermobile articulation
8. The clinical success rate of coccygectomy is approximately
A. <10%
B. 85%
C. 99%
D. 25%
9. Which one of the following is the most common adverse event
associated with coccygectomy?
A. Neurologic deficit
B. Urinary or rectal incontinence
C. Hematoma
D. Wound infection
10. Strategies to reduce the risk of wound infection include
A. ice packs to the wound and 4 weeks of bed rest
B. use of minimally invasive technique
C. wound closure in layers, skin sealed with a topical skin adhesive,
and administration of perioperative broad-spectrum antibiotics
for 48 hours
D. laser-assisted coccygeal ablation