Should Coccygectomy be done for a Tailgut Cyst (Retrorectal Hamartoma)?

Many patients come to see me for coccydynia (coccyx pain, tailbone pain).

Occasionally we discover that their pain seems to be coming from a mass, tumor, abscess, or similar problem. (We see these types of things in ~ less than 5% of our patients with coccyx pain.)

One such mass is called a Tailgut Cyst (Retrorectal Hamartoma).

Tailgut Cysts are Located Near the Coccyx 
  • This mass is typically located just in front of the coccyx or just below the coccyx, or sometimes in front of the lower sacrum.
Note: a ‘Tailgut’ Cyst is very different from a ‘Tarlov’ Cyst.
MRI is better than X-rays to see a Tailgut Cyst
  • Note that Tailgut Cysts fail to show up on plain x-rays, which is why advanced imaging studies such as MRI are often helpful and necessary in cases where coccyx pain is persisting or failing to improve with standard non-surgical treatments. (But the MRI needs to be done correctly! See: Link)
Excellent recent article on Tailgut Cysts
  • There was a recent (2019) research study and review article on this topic which was excellent. I recommend that you use the link below to read the full article, for free, at the Journal’s website. The journal is called: the Annals of Coloproctology.
  • Below are my summary points from the article (highlighting important points or quotes from the article, as part of Fair Use commentary):
Surgery is recommended for Tailgut Cysts, for a few reasons:
  • 1) to confirm the diagnosis,
  • 2) to make sure the mass is not a cancer,
  • 3) to avoid complications that can occur if left in place, such as infection or the mass turning into a cancer.
  • Important quote from the article:

“Surgical treatment is always required because of complications including malignant transformation, infection, and perianal fistula formation.”

Should Coccygectomy be done for a Tailgut Cyst (Retrorectal Hamartoma)?

On the topic of whether the surgery for a tailgut cyst should also include coccygectomy (surgical removal/amputation of the coccyx), this seems to be up for debate:

Debate persists about whether the coccyx should be removed with the cyst. Several studies advocate coccygectomy since it improves surgical exposure and decreases risk of recurrence assuming that the coccyx may harbor a nidus of totipotential cellular remnants that may cause recurrence [4, 26]. However, the concern that the coccyx will increase risk of recurrence has not been demonstrated in other studies, especially for cysts not adherent to the coccyx and that can be removed entirely without coccygectomy; hence, coccyx removal is not required [27]. Removal of coccyx was based on the cyst itself and not the coccyx harboring aberrant remnants of the postanal gut leading to cyst formation. Recent trials report preserving the coccyx unless en bloc resection is required for malignancy or cysts densely adhere to the coccyx. Based on our findings, we removed the coccyx for 4 patients: 3 due to the cyst adhering to the coccyx and 1 for a large cyst requiring a combined coccygectomy and lower sacrectomy; the latter cyst was malignant.”

Source:

  • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6863012/pdf/ac-2018-12-18.pdf
  • Ann Coloproctol. 2019 Oct;35(5):268-274. doi: 10.3393/ac.2018.12.18. Epub 2019 Oct 31.
  • Single-center Experience of 24 Cases of Tailgut Cyst.
  • Sakr A1,2, Kim HS1, Han YD1, Cho MS1, Hur H1, Min BS1, Lee KY1, Kim NK1.
  • Author information: 1:  Division of Colorectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
  • Author information: 2:  Colorectal Surgery Unit, Department of General Surgery, Mansoura Faculty of Medicine, Mansoura University Hospitals, Mansoura, Egypt.
  • Journal article on 24 Cases of Tailgut Cysts, 2019, Annals of Coloproctology
      Journal article on 24 Cases of Tailgut Cysts, 2019, Annals of Coloproctology

COME FOR RELIEF: For more information on coccyx pain, or to be evaluated in-person at Dr. Foye’s Tailbone Pain Center in the United States, go to: www.TailboneDoctor.com

- Patrick Foye, M.D., Director of the Coccyx Pain Center, New Jersey, United States.

Tarlov Cyst Surgery May Relieve Coccyx Pain

Below is one research publication from Japan reporting on 9 patients.

They found that surgical treatment of Tarlov cysts may help relieve coccyx pain in some of the patients who had Tarlov cyst surgery.


Here is the link to the article at the Journal’s website: https://www.sciencedirect.com/science/article/abs/pii/S187887501933195X?via%3Dihub


Below is the abstract: (Presented here as part of “Fair Use” for discussion, commentary, etc.)

World Neurosurg. 2020 Jan 10. pii: S1878-8750(19)33195-X. doi: 10.1016/j.wneu.2019.12.163. [Epub ahead of print]

Myelographic CT, a check-valve mechanism, and microsurgical treatment of sacral perineural Tarlov cysts.
Kikuchi M, Takai K, Isoo A, Taniguchi M.
Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital, 2-6-1, Musashidai, Fuchu, Tokyo, Japan.
Abstract
“OBJECTIVE:

There is currently no consensus regarding surgical indications for symptomatic sacral perineural cysts.

METHODS:

Nine patients with symptomatic sacral perineural cysts underwent microsurgery. All patients fulfilled the following criteria: (1) cyst sizes are larger than 15 mm; (2) cysts show the “delayed inflow” and/or “delayed outflow” of contrast on myelographic CT, and (3) neurological symptoms correlate with the primary cyst.

RESULTS:

On myelographic CT, all primary cysts showed the “delayed inflow” of contrast; the average cyst/thecal sac Hounsfield units (HU) ratio was 0.17. In 7 patients, the primary cyst showed “delayed outflow”; the average cyst/thecal sac HU ratio increased to 3.12 on images obtained 24 hours after contrast injection. Regarding modified Rankin Scale, 67% of patients reported that their overall symptoms improved to normal activities after surgery. The most improved symptom was coccydynia (75% improvement, p=0.017), followed by leg radiation pain (67% improvement, p=0.027) and buttock pain (50% improvement, p=0.068). Bowel/bladder dysfunction improved in 100% of patients, but newly developed in 1 patient (p=0.32). Perineal pain only decreased in 33% (p=0.41).

CONCLUSIONS:

To the best of our knowledge, this is the first study to have performed a quantitative analysis of the dynamics of CSF in sacral perineural cysts using myelographic CT. Sixty-seven percent of patients benefited from surgery; however, our criteria may not be a necessary and sufficient condition for patient selection because 33% did not respond to surgery despite the successful elimination of the check-valve.”



  • - Patrick Foye, M.D., Director of the Coccyx Pain Center, New Jersey, United States.

Looking Below the Sacrococcygeal Joint in Patients with Coccyx Pain, Tailbone Pain

Today I was informed that my latest publication on coccyx pain has just been published by the Indian Journal of Orthopaedics.

The title is:

Looking Below the Sacrococcygeal Joint in Patients with Coccydynia (Coccyx Pain)
Our 3 main points:
  • When treating patients with tailbone pain (coccyx pain, coccydynia), unfortunately doctors often limit themselves to the sacrococcygeal joint (SCJ) and they fail to look lower than that.
  • Doctors often fail to consider the lower coccyx on imaging studies, or during physical exam, or  when providing treatments.
  • This oversight is a problem since the sacrococcygeal joint is usually NOT the site that is causing the tailbone pain. Instead, more often the source of tailbone pain is one of the other joints within the coccyx, or a distal coccyx bone spur .

Due to copyright, I don’t know if I can post the full publication here on my website, so here is the Journal’s Link to the article online: https://rdcu.be/b0jak

Below are the screenshots from the congratulations/announcement of the publication, as well as the publication header and citation.

Looking Below the Sacrococcygeal Joint, by Foye, Header of Publication

Looking Below the Sacrococcygeal Joint, by Foye, Header of Publication

Looking Below the Sacrococcygeal Joint (SCJ), email to Foye, announcing publication

Looking Below the Sacrococcygeal Joint (SCJ), email to Foye, announcing publication

Indian Journal of Orthopaedics, Journal Cover

Indian Journal of Orthopaedics, Journal Cover

Looking Below the Sacrococcygeal Joint, by Foye, Citation for Publication

Looking Below the Sacrococcygeal Joint, by Foye, Citation for Publication


COME FOR RELIEF: For more information on coccyx pain, or to be evaluated in-person at Dr. Foye’s Tailbone Pain Center in the United States, go to: www.TailboneDoctor.com

- Patrick Foye, M.D., Director of the Coccyx Pain Center, New Jersey, United States.

Podcast Interview by Dr. Betsy Greenleaf, Asking Dr. Patrick Foye about Coccyx Pain, Tailbone Pain, Coccydynia

Dr. Foye was Interviewed about Tailbone Pain, on a Podcast called “Some of Your Parts”
  • Thank you to Dr. Betsy Greenleaf, for helping me spread the word about coccydynia (coccyx pain, tailbone pain).
  • It is a shame that so many patients suffer from tailbone problems, yet most doctors have little or no training in the best tests and treatments.
  • I hope that this podcast will help educate both patients and doctors.
Here are the links to the podcast:
Here is the VIDEO version for this Podcast:

YouTube link:

Podcast pic, Some of Your Parts, Interviewing Dr Foye about Coccyx Pain, Tailbone Pain, Coccydynia

Podcast pic, Some of Your Parts, Interviewing Dr Foye about Coccyx Pain, Tailbone Pain, Coccydynia

Podcast, Some of Your Parts, Interviewing Dr Foye about Coccyx Pain, Tailbone Pain, Coccydynia

Podcast, Some of Your Parts, Interviewing Dr Foye about Coccyx Pain, Tailbone Pain, Coccydynia


COME FOR RELIEF: For more information on coccyx pain, or to be evaluated in-person at Dr. Foye’s Tailbone Pain Center in the United States, go to: www.TailboneDoctor.com

- Patrick Foye, M.D., Director of the Coccyx Pain Center, New Jersey, United States.

Free Book on Tailbone Pain, Coccyx Pain, New Year's Day 2020

Free Book on Tailbone Pain, Coccyx Pain, New Year’s Day 2020
  • Start the New Year with a Free Book on Coccyx Pain (Tailbone Pain, Coccydynia).
  • Go to Amazon’s website in your country, using the links shown at the bottom of this page.
  • The electronic version of the book (e-book, Kindle book) will be completely FREE all day, on New Year’s Day, Pacific Time zone.
  • If the Amazon website initially shows you the paperback version, click the line that says “show all formats” and then it will show you the e-book version, which will be free on this day.
  • The images below show where you need to click to get the book for free.
  • Near the bottom of this page there is a list of website links to Amazon’s website in different countries that provide this book.

Free Book on Tailbone Pain, Coccyx Pain, on Amazon, 1-1-20

Free Book on Tailbone Pain, Coccyx Pain, on Amazon, 1-1-20

FREE Book, Select it on Amazon, for Tailbone Pain Awareness Day

FREE Book, Select it on Amazon

Free e-book, Tailbone Pain Relief Now, by Patrick Foye MD

Free e-book, Tailbone Pain Relief Now, by Patrick Foye MD


COME FOR RELIEF: For more information on coccyx pain, or to be evaluated in-person at Dr. Foye’s Tailbone Pain Center in the United States, go to: www.TailboneDoctor.com

- Patrick Foye, M.D., Director of the Coccyx Pain Center, New Jersey, United States.

Podcast Interview Consultant360 for Tailbone Pain Awareness Day 2019

For Tailbone Pain Awareness Day 2019… Patrick Foye, M.D., was interviewed by the healthcare podcast Consultant360.

Dr.  Foye is Director of the Tailbone Pain Center at Rutgers New Jersey Medical School.

Dr. Foye discussed tailbone pain—an often misunderstood, underdiagnosed, & undertreated condition.

Here is the Link to the Podcast: http://bit.ly/FoyeTailbone360

(Or you can use the longer Link here: https://www.consultant360.com/podcast/consultant360/pain-management/patrick-foye-md-diagnosing-and-treating-coccyx-pain ).

Consultant360 Podcast Interview by Patrick Foye, MD, for Tailbone Pain Awareness Day 2019

Consultant360 Podcast Interview of Patrick Foye, MD, for Tailbone Pain Awareness Day 2019


 

GET THE BOOK: To get your copy of the book “Tailbone Pain Relief Now!” go to: www.TailboneBook.com  or go to Amazon.

COME FOR RELIEF: For more information on coccyx pain, or to be evaluated in-person at Dr. Foye’s Tailbone Pain Center in the United States, go to: www.TailboneDoctor.com

- Patrick Foye, M.D., Director of the Coccyx Pain Center, New Jersey, United States.

VIDEO: Facebook Live Questions-Answers about Coccyx Pain, on Tailbone Pain Awareness Day

On Tailbone Pain Awareness Day, November 15, 2019, Dr. Foye answered live questions about coccyx pain from people worldwide.

The event was held on the Facebook page for the Tailbone Pain Center, which is located at: https://www.facebook.com/TailbonePainCenter/

Here is the video from the Question and Answer session:

Or you can watch the video on YouTube using this Link: https://www.youtube.com/watch?v=MwyrqMtcfts

Screenshot from the video:

Facebook Live, Tailbone Pain Awareness Day, Dr Foye

Facebook Live, Tailbone Pain Awareness Day, Dr Foye


GET THE BOOK: To get your copy of the book “Tailbone Pain Relief Now!” go to: www.TailboneBook.com  or go to Amazon.

COME FOR RELIEF: For more information on coccyx pain, or to be evaluated in-person at Dr. Foye’s Tailbone Pain Center in the United States, go to: www.TailboneDoctor.com

- Patrick Foye, M.D., Director of the Coccyx Pain Center, New Jersey, United States.

Tailbone Pain Awareness Day: November 15, 2019

Last year, 2018, was the first Tailbone Pain Awareness Day.
This year, 2019, is the second annual Tailbone Pain Awareness Day.

COME FOR RELIEF: For more information on coccyx pain, or to be evaluated in-person at Dr. Foye’s Tailbone Pain Center in the United States, go to: www.TailboneDoctor.com

- Patrick Foye, M.D., Director of the Coccyx Pain Center, New Jersey, United States.

Honoring James Oleske, MD, Pioneer in the Care of Pediatric AIDS

This evening it was a pleasure to join with others at Rutgers New Jersey Medical School in honoring James Oleske, MD, as he leaves @Rutgers_NJMS after 43 years.

He was the first US physician to diagnose #AIDS in children, in the early 1980’s.

Pediatric Infectious Disease specialist.

Well known as a wonderful doctor, a great role model, and a terrific advocate for patients on a global scale.

A movie called “The Littlest Victims” was made about @DrJimOleske‘s pioneering work, where he was played by @Tim_Matheson

Patrick Foye MD and James Oleske MD, at Dr Oleske's retirement from Rutgers New Jersey Medical School

Patrick Foye MD and James Oleske MD, at Dr Oleske’s retirement from Rutgers New Jersey Medical School

Trough, Folding Cushion for Tailbone Pain, Pelvic Pain, Genital Pain

Most patients with coccyx pain (tailbone pain) find that sitting is painful, but that it is somewhat less painful if they use the right cushion. For most people with tailbone pain, the best cushion has a cut-out located just at the back of the cushion (under the coccyx, so that the coccyx does not hit the chair when sitting).

But some patients have pain that is not limited to only the back area of the pelvic floor (at the coccyx). They may ALSO have pain at the front area of the pelvic floor (e.g. at the area of the external genitalia, such as the scrotum in men, or at the vulva and vaginal area in women).

When patients have sitting pain that is located at both the FRONT and ALSO at the BACK of the pelvis , they may benefit from a cushion that has a cut-out area extending from back -to-front. (Unlike people who have pain only at the coccyx and usually use a cushion where the cut-out is only at the back part of the cushion.)

The extended area of cut-out is basically like a trough, or trench, or channel, that extends from front-to-back down the middle of the cushion.

Most of these are adjustable, so that the trench (trough, channel) down the middle can be made to be either wider or narrower, depending on your body size and what gives you the most relief.

I do not endorse specific brands, but I will show a few here so that you can see what I am talking about.

Twin Cheeks coccyx pudendal cushion, from cushionyourassets.com

Twin Cheeks coccyx pudendal cushion, from cushionyourassets.com

Twin Cheeks coccyx pudendal cushion,  on a chair, from cushionyourassets.com

Twin Cheeks coccyx pudendal cushion, on a chair, from cushionyourassets.com

Twin Cheeks coccyx pudendal cushion,  on a chair, Folded-up for Carrying, from cushionyourassets.com

Twin Cheeks coccyx pudendal cushion, on a chair, Folded-up for Carrying, from cushionyourassets.com

Link: https://cushionyourassets.com/Twin-Cheeks-Folding-Cushion-TWC101.htm


 

Pelvic Pain, coccyx cushion, trough cushion,  orange color, from pelvicpainsolutions.com

Pelvic Pain, coccyx cushion, trough cushion, orange color, from pelvicpainsolutions.com

Link: https://pelvicpainsolutions.com/collections/capps-seat-cushions/products/capps-travel-foldable-seat-cushion


Pelvic Pain, coccyx cushion, Pink color, from Pinterest

Pelvic Pain, coccyx cushion, Pink color, from Pinterest

Link: https://i.pinimg.com/originals/5e/bc/88/5ebc88dc7e31e359cbeb57cfb5787444.jpg

Also Link: https://www.pinterest.com/pin/469500329896839646/


 

Pelvic Pain, Channel coccyx cushion, from Pelican Manufacturing

Pelvic Pain, Channel coccyx cushion, from Pelican Manufacturing

Link: https://www.pelicanmanufacturing.com.au/products/pudendal-channel-cushion/


GET THE BOOK: To get your copy of the book “Tailbone Pain Relief Now!” go to: www.TailboneBook.com  or go to Amazon.

COME FOR RELIEF: For more information on coccyx pain, or to be evaluated in-person at Dr. Foye’s Tailbone Pain Center in the United States, go to: www.TailboneDoctor.com

- Patrick Foye, M.D., Director of the Coccyx Pain Center, New Jersey, United States.

Book Now Available! Click on the book to get it now:


Get the Book at www.TailbonePainBook.com