Favorable But Variable Responses to Tailbone Injections for Coccyx Pain

Re: Response to coccyx injections.
Hi, Folks.

Overall, the specific type of coccyx injection varies from patient to patient, along with differences in how the injection is performed based upon an individual patient’s anatomy and an individual patient’s diagnosis.

For example, regarding anatomy, a ganglion par block would be perform differently in someone who had joint fusion between the sacrum and coccyx versus how it would be done in someone who had joint fusion between the first and second bone of the coccyx, and it would be done differently again if they had fusion of the entire coccyx.

Also, depending on the patient’s diagnosis, the ganglion Impar injection may or may not also include steroid injection (anti-inflammatory) either at the ganglion Impar, at or around an abnormal joint, or at/around a distal coccyx bone spur, etc.

While the majority of patient’s respond favorably to an appropriately selected injection, I will be the first to admit that unfortunately no treatment for coccyx pain is guaranteed to provide relief for all patients. Many patients do well with each of the different forms of treatments, such as cushions, medications by mouth, local icing, various injections, pelvic floor physical therapy, surgical removal of the coccyx (coccygectomy), etc., but unfortunately there is no single treatment that helps everyone. There are unfortunately times where the pain continues to worsen despite treatments, and even instances where a given treatment many exacerbate symptoms.

Ideally, we would be able to predict which patient would respond best to which type of injections. Several years ago, I analyzed responses to hundreds of injections in hundreds of patients, to see what factors might best predict how a given individual would respond to various types of injections. We looked at factors such as each patient’s age, gender, weight (body mass index), acute versus chronic pain (I’ve seen some patients with coccyx pain that started just hours before they were sent to me, and other patients who have had coccyx pain for almost 50 years before seeing me), diagnosis (fractures, dislocations, dynamic instability, bone spurs, etc.), previously tried treatments, etc..

The general outcome was that most patients responded well to injections regardless of any of the various factors mentioned above. Patients with the shortest duration of symptoms tended to respond most favorably and tended to obtain the most complete and long-lasting/permanent resolution of symptoms. (Meanwhile, many patients with years/decades of pain can still get relief, just that their success rates at doing so is not as great as it is for those with a shorter duration of symptoms.)

Unfortunately, for every category of patients there were unfortunately some who failed to obtain adequate relief despite all of our best efforts at providing nonsurgical care. In general, those patients become potential candidates for surgical treatment (coccygectomy) if these symptoms are severe enough to warrant that. As we know, coccygectomy comes with its own potential complications after surgery, and although the majority of appropriately-selected patients do indeed obtain partial relief of coccydynia, (and even some who get complete or nearly complete relief), unfortunately most coccydynia patients still have some degree of coccyx pain despite surgery and there are some patients who get little or no relief despite undergoing the surgery.

I guess the take-home message is that it usually makes sense to use a stepwise approach, starting with the least invasive, nonsurgical approaches first (cushions, injections, etc.). Then only progress up the treatment ladder if a given treatment fails to give adequate relief. Of course each person’s response is different, but the paragraphs above summarize the types of responses that are usually seen both in my practice and from what is published in the peer-reviewed medical literature.

Medical care is continually advancing, so hopefully in the near future we will be better able to provide more complete relief for more and more patients. I am eager to do so and I give you all my commitment that I am working towards those goals, not just for my own patients but for people worldwide who suffer with this. So, while I find it gratifying to have been able to help so many over the years, it deeply concerns me that not everyone gets adequate relief and I continue to strive to find solutions/relief for those who are still seeking it.

-Patrick Foye​, M.D.

Sit-ups and Tailbone Pain (Coccyx Pain)

I recently posted a video and blog about exercise and tailbone pain, but I forgot to mention sit-ups!

Doing traditional-style sit-ups are usually very problematic and painful for people suffering from coccydynia (coccyx pain, tailbone pain).

So here is my follow-up video specifically discussing sit-ups and tailbone pain:

 

Exercise and Tailbone Pain (Coccyx Pain)

What exercises should you avoid or modify if you have tailbone pain (coccyx pain, coccydynia)?

You may want to maintain their fitness, health, body weight, and well-being, without exacerbating (flaring up) your tailbone pain.

This video gives many tips and tricks for ways that you can exercise without making your tailbone pain worse.

The video covers tailbone pain and bicycling (cycling, spin class), rowing (canoeing, kayaking, rowing machines), weight lifting, etc.

Here’s the video:

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Click the image to see the video.

Exercise and Tailbone Pain (Coccyx Pain)

 

Tailbone Injections AFTER Coccygectomy (Surgical Removal of the Coccyx)

  • Coccygectomy is surgical removal of the coccyx.
  • Fortunately, the vast majority of patients with coccydynia (coccyx pain, tailbone pain) respond well to NON-surgical treatment and therefore do NOT require coccygectomy. Typical treatments include coccyx cushions and tailbone injections.
  • For those small percentage of patients who fail to get adequate relief despite injections, etc., it may be worth considering coccygectomy.
  • Coccygectomy can give significant relief for coccyx pain, but after this surgery unfortunately most patients will still have some degree of persistent pain  at that region.
  • So, the question becomes: can you still do injections even AFTER the coccyx has been surgically removed? The answer is YES!
Tailbone Injections AFTER Coccygectomy
  • Many of the injections done AFTER coccygectomy are similar to those done BEFORE coccygectomy.
  • See: Tailbone Injections for Coccyx Pain
  • However, there are some important differences.
    • Firstly, it is important to look for the actual CAUSE of the ongoing tailbone pain. After coccygectomy, it is especially important to consider the following:
    • Secondly, the physician during the injection  must be aware of the CURRENT anatomy.
      • Some of the typical landmarks and reference points for doing injections will now be changed or completely absent because most or all of the coccyx has been removed by the surgery.
      • So, it is especially helpful to use image guidance such as fluoroscopy for tailbone injections.
    • Scar tissue from the surgery may obstruct the flow of the injected medications, making it more difficult for them to effectively cover the target area.
    • Despite these challenges,  many patients with persistent pain after coccygectomy can obtain substantial relief through a wisely and carefully performed injection.

EDS (Ehlers Danlos Syndrome) and Tailbone Pain

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.

Sit-Stand Coccyx / Tailbone X-rays After Coccygectomy?

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).

MY RESPONSE:

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.

 

 

 

Complete Coccygectomy versus Partial Coccygectomy

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:

For N.J. Pelvic Floor Physical Therapists, Dr. Foye Gave a Lecture on Tailbone Pain (Coccyx Pain)

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.

tailbone-pain-dr-foye-and-niva-herzig-pt

Niva Herzig, PT, with Patrick Foye, MD, after his lecture on Tailbone Pain.

tailbone-pain-lecture-by-foye-at-aptanj-2

Dr. Foye with a few of the Pelvic Floor P.T.’s who attended the lecture on Tailbone Pain.

tailbone-pain-lecture-by-foye-at-aptanj

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: Fluoroscopy for Coccyx Injections

Image guidance for tailbone injections:
  1. 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?
  2. 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.
  3. 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.

Tailbone Pain Conference: Later this Week

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

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


Get the Book at www.TailbonePainBook.com