Ehlers Danlos Syndrome (EDS)
- EDS is a medical condition associated with “loose joints” (joint hyper-mobility) and other problems (loose skin, etc.).
EDS and Tailbone Pain (Coccyx Pain)
- EDS patients have joint hypermobility, as noted above. This is important, since joint hypermobility is one of the most common causes of coccydynia (even in people without EDS).
- So, especially in coccydynia (coccyx pain) patients who have EDS it makes sense to assess for hypermobility (looseness, laxity) between the bones of the coccyx.
Xrays to Diagnose Joint Hypermobility at the Coccyx
- For people with tailbone pain, making an accurate diagnosis is the first step towards treatment.
- Since tailbone pain typically happens when a person is sitting, it makes sense to do the x-rays while the person is sitting.
- The tailbone x-rays done while sitting are compared with tailbone x-rays done while standing. Then, the position of the bone can be compared.
- The overall idea of the sitting-versus-standing x-rays would be to identify whether there are one or more joints that are unstable.
- Unfortunately, very few radiology centers are familiar or experienced with performing sitting-versus-standing xrays of the coccyx.
Treatment of Tailbone pain in EDS patients
- Many of the treatments for tailbone pain are the same or similar for people, regardless of whether they have EDS.
- Cushions may help.
- Medications by mouth may help.
- Steroid injections can be done in people with EDS to help relieve acute pain/inflammation at a specific site, but caution is recommended before doing multiple repeated steroid injections in someone with EDS since people with EDS may have worsening joint laxity over time.
- Meanwhile, other injections such as local anesthetic nerve blocks and nerve ablation can be done in people with EDS, essentially the same way that they are done in people without EDS.
- Surgical removal of the coccyx (coccygectomy) is typically done only if the other treatments have been tried and have failed to give adequate relief.
I was recently asked: Do I order sitting-versus-standing coccyx x-rays for patients who have persistent pain after coccygectomy (surgical removal of the coccyx/tailbone).
1) First of all, do we know for sure whether the ENTIRE tailbone has indeed been surgically removed?
- If we know for sure that the entire tailbone has been surgically removed, then it may not be medically necessary to get x-rays done while sitting, since there is no remaining coccyx that could be hyper-mobile (essentially, there’s no possibility of coccygeal dynamic instability if there is no coccyx to begin with).
- If we do NOT know for sure whether the entire tailbone has been surgically removed (in many cases there is a partial coccygectomy performed, leaving the upper coccyx segment in place) then the remaining coccyx segment might be hyper-mobile (there might be dynamic instability of the remaining coccyx segment).
- (Click here for an explanation about complete versus partial coccygectomy)
2) Secondly, if NO imaging studies have been done since the time of coccygectomy surgery, despite pain that has persisted for longer than expected after this surgery, then it usually make sense to start with the plain set of coccyx x-rays.
- (Since it is possible that there may be a remaining coccygeal segment, you could get the sitting-versus-standing coccyx x-rays done at the same time, but if the local radiology center is not familiar with doing these then you can just start with plain x-rays specifically at the sacrum/coccyx region, including the AP [front-to-back] view and the lateral [side] view.)
3) Thirdly, aside from coccyx x-rays (radiographs), other diagnostic imaging studies of the sacrum/coccyx region in select cases might include:
- MRI ,
- CT scans,
- and sometimes triple-phase bone scans.
What is coccygectomy?
- Coccygectomy is the surgical amputation of the coccyx.
- During coccygectomy, the coccyx (tailbone) is removed.
Who needs coccygectomy?
- Coccygectomy is only medically necessary in a relatively small fraction of patients with coccydynia (tailbone pain, coccyx pain).
- Typically, coccygectomy is reserved for those patients who have failed to get adequate relief despite a full course of nonsurgical treatment (including using coccyx-wedge cushions, avoiding exacerbating factors, various coccyx injections, etc.).
Complete versus partial coccygectomy:
- Coccygectomy can be “complete” or “partial”.
- “Complete” coccygectomy involves removal of the ENTIRE tailbone.
- “Partial” coccygectomy involves removal of only part of the coccyx, leaving the upper coccyx in place.
Deciding between complete versus partial coccygectomy:
- In the small percentage of patients with tailbone pain who require coccygectomy, the decision regarding whether to do a complete versus incomplete/partial coccygectomy depends upon the surgeon during the procedure. It should also depend upon the specific anatomical/musculoskeletal cause of the tailbone pain. For example, if the pain is primarily coming from the highest joint within the coccyx (up at the sacrococcygeal joint [SCJ], where the lower part of the sacrum articulates with the upper part of the coccyx), than a partial coccygectomy would still leave the problematic source of pain still in place (which would obviously be undesirable.
- Sometimes after a complete coccygectomy the surgeon may also “shave down” the lower part of the sacrum. This may be done to “smooth out” any pointy or irregular surfaces that might cause pain when used it upon them. This may also be done in hopes that surgical involvement of the lower sacral bone may help to stimulate healing at the surgical site.
Possible complications (side effects) of coccygectomy:
On 9-24-16, Patrick Foye, M.D., Director of the Tailbone Pain Center (www.TailboneDoctor.com) gave a lecture to the APTANJ (American Physical Therapy Association of New Jersey) Women’s Health Special Interest Group (SIG) Meeting.
The lecture topic was “Coccyx pain: Overview for Pelvic Floor Physical Therapists.”
Approximately 20 pelvic floor physical therapists attended the 2-hour talk.
Niva Herzig, PT, with Patrick Foye, MD, after his lecture on Tailbone Pain.
Dr. Foye with a few of the Pelvic Floor P.T.’s who attended the lecture on Tailbone Pain.
Dr. Patrick Foye at the APTANJ (American Physical Therapy Association of New Jersey) Women’s Health Special Interest Group (SIG) Meeting.
Image guidance for tailbone injections:
- The most important first step is for the treating physician to thoroughly assess for the CAUSE of the tailbone pain. In many ways, this can be more important then which type of injection is done and whether or not image-guidance is used for the injection. It is extremely important for the treating physician to assess for whether the tailbone pain is being caused by a bone spur at the lowest tip of the coccyx versus an unstable joint up at the highest end of the coccyx. Without such an evaluation, how would the physician know where to inject?
- Depending on what country you are in, image-guidance may or may not be available for your injection. In the United States, such injections are typically done using image-guidance. For example, I am located in New Jersey and I use image-guidance for almost all of the coccyx injections that I perform.
- There are different types of radiology methods for image guidance.
- Fluoroscopy: The most common method is fluoroscopy. Fluoroscopy is like immediate x-ray images that are displayed up on a computer screen. This allows the physician to see the target (the specific joint or bone spur or other abnormality where they want to place the injection). Fluoroscopy also allows the physician to see the tip of the needle, so that they can guide it to the best specific location.
- CT scans: CT (computerized tomography) is another method of image guidance for injections. Historically, CT scans are known as a source of substantial radiation to patients. Newer methods may allow the CT scan and to be done using less radiation, but it is still an area of concern.
- MRI (magnetic resonance imaging): there are a couple of research papers that talk about using MRI-guidance for coccyx injections. But MRI is extremely expensive compared to other methods.
- Ultrasound: in the future, ultrasound-guidance may have a significant role in performing tailbone injections. One limitation is that ultrasound can really only see the back wall of the coccyx, not being able to see past that bony surface. So it is limited at this time.
- Overall: Fluoroscopy is the most common method of image guidance for coccyx injections.
I will be speaking at the first-ever international coccyx pain symposium, being held in Paris, France on July 8-9, 2016.
Upcoming Tailbone Pain (Coccyx Pain) Symposium
There are a few different ways to approach your question about an association between tailbone (coccyx) problems and bowel problems. Sometimes it is the bowel problems causing tailbone symptoms, and sometimes it is the reverse where the coccyx problems are causing difficulties with the bowels. Let’s address these 2 categories separately below.
Bowel problems can cause pain in the coccyx region.
This can include things like:
- rectal cancer (malignancy),
- non-cancer masses/tumors behind the rectum (such as a rector rectal hamartomatosis tailgut cyst, etc.)
- perianal abscess (an infection around the anus)
- thrombosed hemorrhoids
- anal fissure
- coccyx irritation while passing a large bowel movement
- coccyx irritation during colonoscopy
- constipation can cause increased pressure on the tailbone region
Coccyx problems can cause problems/symptoms in the gastrointestinal (rectum, colon) region.
This can include:
- If the coccyx is abruptly angled too far forward, it can actually indent into the rectum.
- This can cause a perpetual feeling of bowel fullness.
- Also, during a bowel movement the movement of the stool within the rectum can press against the coccyx, causing worsening of the tailbone pain.
- If the patient has undergone a coccygectomy (surgical removal of the tailbone), one potential complication is prolapse (sagging) of the pelvic floor. When the pelvic floor is sagging the position of the rectum and anus is altered, which can create difficulty with controlling or passing bowel movements.
- Pain medications taken for tailbone pain (or other conditions) can cause constipation, internal bleeding within the stomach and intestines, etc.
Last night I lectured on Tailbone Pain (Coccyx Pain) in Morris County, New Jersey.
Thank you to the Montville, New Jersey, public library for hosting the event in recognition of my recently published book: Tailbone Pain Relief Now!
There was a terrific turnout and I greatly enjoyed the question-and-answer session at the end of my talk.
Thank you to everyone who helped set up the event, and all those who came.
I will make arrangements for doing some online lectures and question/answer sessions in the near future.
Patients with tailbone pain (coccyx pain, coccydynia) sometimes ask me…
“After receiving medical radiation exposure (fluoroscopy, x-ray, etc.), how soon is it safe to get pregnant?”
How long after tailbone (coccyx) x-rays or fluoroscopy should I “wait” before getting pregnant?
- Here is information from the Health Physics Society (“a scientific organization of professionals who specialize in radiation safety.”)
“How long should I wait to conceive after x-ray exams that have exposed my ovaries
or my husband’s testes? Can I become sterile after having x rays? ANSWER:
There is no evidence that there are any effects on the ovaries or sperm at doses used in diagnostic procedures such as the one(s) you had. If there were any risk at all, it would be very small. Also, this type of radiation does not remain in your body so that does not need to be a concern either.” Source: http://hps.org/publicinformation/ate/faqs/pregnancyandradiationexposure.html
“How long should I wait to try to become pregnant after x-ray exams
that have exposed my ovaries or my husband’s testes? Can I become sterile after having x rays? ANSWER:
There is no evidence of effects on the ovaries or sperm at radiation doses used in diagnostic x-ray procedures. Radiation doses from routine medical x rays are too small to affect sterility or have an effect on a future pregnancy. Therefore, you do not need to wait after diagnostic x-ray exams before trying to become pregnant.” Source: http://www.radiationanswers.org/radiation-questions-answers/radiation-and-pregnancy.html
You are invited to attend…
Free lecture on Tailbone Pain (Coccyx Pain).
- By Patrick Foye, M.D., Director of the Tailbone Pain Center.
- When: Wednesday, May 25, 2016, at 7:00 pm
- Where: Montville N.J. Public Library
(Morris County, New Jersey, United States)
90 Horseneck Rd, Montville, NJ 07045
- For Free registration, click here.