Yesterday, I really enjoyed teaching medical students about my field: Physical Medicine and Rehabilitation (PM&R).
Throughout the year I teach medical students where I work, at Rutgers New Jersey Medical School.
But this once-a-year “Medical Student Fair” brings in medical students from many different medical schools from around the country.
The students learn about PM&R and they rotate through stations to learn about different areas of practice within the specialty. My station was the fluoroscopy suite, where they learned about evaluating and treating patients in pain, including the use of fluoroscopically-guided spinal injections for back pain, coccyx pain (tailbone pain), etc.
It is great to teach these students, since they will be our next generation of physicians. They were a terrific bunch.
Patrick Foye MD (center) teaches about PM&R, Spinal Injections, and Fluoroscopy
Patrick Foye MD teaches Medical Students about PM&R and Fluoroscopy
Group Photo, Medical Students learn about PM&R. Awesome group!
Dr. Foye recently attended the Pain Medicine Symposium 2017, which is a medical conference for pain management physicians.
The conference was run by the New York Society of Interventional Pain Physicians (NYSIPP) and the New Jersey Society of Interventional Pain Physicians (NJSIPP).
There were physician experts speaking and attending from around the world. Modern treatments were covered, including regenerative medicine (Platelet Rich Plasma [PRP] injections, stem cell injections, etc.), neuromodulation procedures, nerve ablation, injections and other procedures done under fluoroscopic guidance, injections and other procedures done under ultrasound guidance, etc.
It was a terrific conference and a great chance to network and reconnect with other physicians who also specialize within the field of pain management.
Conference, NJSIPP, NYSIPP, New York Society of Interventional Pain Physicians and New Jersey Society of Interventional Pain Physicians, 2017
Patrick Foye MD at NYSIPP NJSIPP New Jersey Society of Interventional Pain Physicians, NYC skyline
Patrick Foye MD, Fluoroscopy Lab at NYSIPP NJSIPP New Jersey Society of Interventional Pain Physicians, Conference 2017
Patients sometimes ask me whether the “spinal cord” is located at their coccyx.
It’s a reasonable question, since the spinal cord does extend through most of the human spine.
What is the Spinal Cord?
The spinal cord is a dense, relatively tightly packed collection of nerves.
The spinal cord is almost like a big, thick electrical cable, with lots of electrical wires (nerves) going through it.
But it’s more complicated because there is also a complex system of connections that work like relay switches (synapses), where electrical signals get turned on and off.
Where is the Spinal Cord and the Spinal Canal?
In general, the “spinal cord” itself goes from the base of the brain down to the upper lumbar region.
Usually the lowest part of the spinal cord is at about the level of the 1st or 2nd lumbar vertebral bone, which, for reference, would be a few inches ABOVE your belt line or waistband.
So, the spinal cord is relatively far away from the tailbone in the vast majority of patients.
(A small percentage of patients may have a spinal cord that is “tethered” down, sometimes seen in people with spina bifida, for example, but even then it would not be so far down that it would be expected to be down at the level of the coccyx).
However, the spinal CANAL extends downward through the sacrum.
The coccyx does NOT have a spinal cord within it, and the coccyx does NOT have a spinal canal within it.
The “Meninges” are “Lining” for the Spinal Canal
The walls on the inside of the spinal canal are mostly made of spinal bones.
But there is a lining inside the bones. It’s sort of like the way that there is a plastic lining inside of the walls of a swimming pool. This lining keeps the spinal fluid from leaking out.
The lining of the spinal canal is called the “Meninges” or meningeal lining or meningeal layers. It includes the dura mater, arachnoid mater, and pia mater .
The meningeal lining is almost like Saran wrap or whatever you call plastic wrap in your part of the world
Although the coccyx does not have any spinal canal within it (unlike the rest of the human spine)… BUT… some of the meningeal fibers that line the spinal canal do extend down through the sacrum and a few of those fibers attach at the top of the coccyx. This is probably not clinically significant in the vast majority of patients, but it rare cases patients may have tension or tugging or tightness of those fibers, where movements or tightness at other levels of the spine may cause tension/tugging on the coccyx, and vice versa. It’s uncommon, but possible.
OTHER Nerves at the Coccyx
Since there is no spinal cord at the coccyx, does that mean that there are no at the coccyx region???? …… No! Definitely not!
There are lots of other nerves at the coccyx.
Examples include normal somatic nerve fibers that carry pain and other sensation from the coccyx and surrounding tissues.
The skin over the coccyx is innervated by nerves.
Importantly, the ganglion Impar is located at the level of the upper coccyx.
In summary, the spinal cord itself is NOT located at the coccyx. But other nerves ARE located at the coccyx.
There are many reasons why doctors choose to specialize in a given area of medicine.
The video below was done by the American Academy of Physical Medicine and Rehabilitation (AAPM&R) regarding why doctors choose to specialize in Physical Medicine and Rehabilitation (PM&R). It features Patrick Foye, M.D., and other PM&R physicians.
The word “Doctor” comes from the Latin word docēre [dɔˈkeːrɛ] ‘to teach‘.
So, a Doctor is a Teacher.
Doctors teach patients about the health and about their medical conditions and treatment options. A patient who is well-informed about their condition can make better decisions about their healthcare.
There are many ways to teach people about their health.
The most traditional approach is for a physician to spend time with each individual patient, informing one patient at a time regarding his or her specific diagnosis.
But physicians also have some responsibility to society overall, beyond just the individual patients who come for in-person medical care.
Public and private physician groups regularly issue public statements regarding matters of public health.
Examples include medical professional groups such as pediatricians recommending childhood immunization programs, or a national cancer society recommending certain protocols for cancer screening programs.
Modern methods of communication such as the Internet allow physicians to provide information online for free use by the public.
This can include blogging, YouTube videos, social media posts on Facebook, Twitter, etc.
Physicians are increasingly using the Internet to provide helpful information to society at large, providing benefit even to those who may never meet the physician in person.
In general, when people find medical information online, they should discuss this with their in-person treating physician, who can advise the person as to whether the information is correct and whether it is relevant to this individual person.
In the Link below, there is a video encouraging physicians to provide medical information online via Social Media.
The video is from Medscape.com, which is a well-regarded medical information site.
The speaker is Dr. Arthur L. Caplan, PhD. He is a Professor of Bioethics, in the Department of Population Health, at NYU (New York University) School of Medicine.
Source: Medscape, which is described as follows: “Medscape is the leading online global destination for physicians and healthcare professionals worldwide, offering the latest medical news and expert perspectives”
Tailbone Injections and Repeat Injections are Common and Reasonable for Coccyx Pain
There are multiple different types of tailbone injections that are done in the treatment of coccyx pain.
Common examples include: local coccyx steroid injection, ganglion Impar sympathetic nerve block with local anesthetic, nerve ablation at the coccyx to deaden/kill the nerve fibers that are carrying the pain, etc.
Coccyx injections can be very helpful in many patients.
The amount of relief provided by a given injection can vary from patient to patient.
In some patients, it may make sense to REPEAT a coccyx injection. Let’s go into further details on this…
REPEAT Tailbone Injections for Coccyx Pain
The best reason to repeat a tailbone injection is when the same injection has previously provided excellent relief for a substantial duration of time.
For example, if an specific injection gave 100% relief but then a year later the pain starts coming back, then repeating the injection often makes sense.
Second dose: In some patients, the initial injection may fail to give adequate relief, but it still may make sense to REPEAT the injection.
This is sometimes referred to as the “2nd dose” effect.
Headache comparison: Imagine that you have a headache, and you take 2 tablets of Tylenol. After 4 or 5 hours, if you do not have complete relief of your headache, then it may be reasonable to take a “second dose”. The same treatment is given, but this may be dramatically more effective than the initial treatment was.
At the coccyx, imagine that you had a coccyx injection, and received only partial relief, or perhaps even no relief at all. Then, depending on your specific details, it may make sense to REPEAT the same injection, in order to obtain the “Second dose” effect and thereby receive relief. It is often very dramatic to see patients where a single injection has given little or no relief, and yet a repeat injection (second dose) has given complete relief and terrific improvement in quality of life.
The decision regarding whether to undergo or repeat a coccyx injection in any given patient should be a consideration and discussion between the individual patient and their in-person treating physician (ideally a physician with experience in evaluating and treating patients with coccydynia [coccyx pain, tailbone pain]).
2017 Appreciation Award Given to Dr. Patrick Foye, M.D.
At this year’s graduation ceremonies for graduating residents physicians and fellows, the Department of Physical Medicine and Rehabilitation at Rutgers New Jersey Medical School presented the Department’s “Appreciation Award” to Dr. Foye, in honor of his almost-five-years serving as Interim Chair of the Department.
