There are many different types of injections that pain management physicians like myself can provide for patients.
Often, an important first step is deciding whether any given patient needs an injection at all, and if so which specific type of injection they may benefit from.
What is an epidural steroid injection?
An epidural injection is an injection that places medication into the epidural space.
The epidural space is located within the spinal canal.
Placing steroids into the epidural space may help decrease inflammation at that specific site.
For example, if someone has a disc herniation in their lower back causing irritation and inflammation of the disc and epidural space and spinal nerves at that level, they may benefit from injecting an anti-inflammatory steroid into the epidural space at that level.
Epidurals can be done at various levels of the spine, including the cervical spine, thoracic spine, and lumbosacral spine.
The physician performing the injection can place the needle tip into the epidural space using different approaches or pathways for the needle.
Three different approaches include:
Transforaminal epidural
Interlaminar epidural
Caudal epidural
However, note that NONE of the approaches above place anti-inflammatory medication at the coccyx.
Why don’t epidural injections help decrease tailbone pain?
I have read hundreds of medical articles on tailbone pain, but I do not know of even one single article that has shown epidural steroid injections to be helpful at decreasing tailbone pain.
I have also seen *many* patients who have come to see me reporting that they have undergone epidural steroid injections in hopes of getting relief of their tailbone pain, only to receive zero benefit.
This is not surprising. As noted above, the epidural space is located within the spinal canal and the spinal canal does not go as low down as the tailbone.
There is a spinal canal within the cervical spine, thoracic spine, lumbar spine, and sacrum, but there is NO spinal canal or epidural space within the coccyx.
So, if the doctor is injecting a treatment into the epidural space then he or she is not injecting the medication at the tailbone.
Why do doctors do epidural injections for tailbone pain if they do not help?
I believe that almost all doctors are trying to do their best to help their patients.
Most doctors know very little about coccydynia (coccyx pain, or tailbone pain).
Even doctors who specialize in treating painful musculoskeletal conditions often know very little about the causes of tailbone pain, the best of diagnostic tests for tailbone pain, or the best and most current treatments for tailbone pain.
So, the doctors provide the treatments that they know how to do.
They do epidural injections for tailbone pain because, simply, they know how to do epidural injections.
They hope that maybe the injections will help the patient with tailbone pain, the way that they often see these injections help patients with other kinds of spine pain.
Out of all of the different epidural injections, the one that is closest to the coccyx is the “caudal” epidural injection. So maybe the doctor will “try” a caudal epidural steroid injection for a patient with tailbone pain.
But when the epidural injections fail to provide relief, the doctor may not understand why were they may not know what else to do or recommend.
Which injections *are* most helpful for tailbone pain?
Sometimes a patient with tailbone pain (coccyx pain) or their employer will ask for my official medical opinion on sitting tolerance, ability to work, etc.
In those situations I typically provide information about the difficulties that patients with tailbone pain have with prolonged sitting.
Some useful approaches can include sit-stand workstations. For example, you can arrange to have a computer workstation that raises and lowers throughout the day, so that you can stand at the workstation when your tailbone is sore from sitting and you can sit down at the workstation when your legs and back are tired from standing.
Another modification is simply allowing the person to alternate between sitting/standing at will throughout the workday.
For some jobs these modifications are not really possible though.
For example, an airline pilot can’t stand up while flying the plane, nor can a taxi driver or bus driver stand up at random.
Even typical office jobs can be difficult to modify. For example, it may be socially awkward to stand up throughout an entire business meeting while all of the representatives from other companies are sitting down at the table.
Another difficulty with these modifications is that many people are physically unable to stand throughout most of the workday.
For example, if you have arthritis or other sources of pain in your feet, knees, hips, or lower back, it may be very difficult to stand throughout the bulk of the work day.
If a patient responds very well to treatment, they may be able to sit normally throughout the workday.
However, during flareups (exacerbations) of the tailbone pain, the person might not be able to sit at all or might have pain so severe that it mentally distracts them from being able to reasonably concentrate on work tasks.
Every person is unique in their sources of tailbone pain, severity of tailbone pain, response to treatments, frequency and severity of exacerbations, work duty requirements, etc.
So, an individualized approach makes the most sense.
Since publishing my book Tailbone Pain Relief Now! I have been very grateful for the positive feedback that I have received from around the world.
Readers have sent me emails and Facebook posts from Europe, Scandinavia, Asia, Australia, and the United States and Canada.
The most intriguing e-mail I received was from Puerto Rico…
Overall, I have been extremely impressed with Amazon and my book warehouse for their prompt and efficient shipping of my book to people with tailbone pain (coccyx pain) all of the world.
But I received one e-mail from Puerto Rico asking why two weeks after ordering the book he still had not received it.
Why did this book go missing???
So we tracked the book shipment through the United States Postal Service.
We saw that he had ordered the book on September 24, 2015.
The book warehouse in Indiana shipped it out that very same day, and it was then tracked by the United States Postal Service.
By 10 PM on September 27, the book arrived in Jacksonville, Florida.
From there, the United States Postal Service tracking system seems to reach a dead end, without any further information about the whereabouts or delivery of the book. Even now, months later, it still lists the book shipment as being “in transit”, but not yet delivered.
Tailbone Book, Delivery Tracking , before the shipwreck
I shared this shipping information with the man in Puerto Rico who had been wondering why he never received his book.
From there, he figured out the tragic next turn in the story…
Two days after my book arrived in Jacksonville, Florida, it would have been aboard the cargo ship El Faro, on what turned out to be its final and fatal voyage.
Per Wikipedia: “On September 30, 2015, at 2:00 a.m., El Faro left Jacksonville, Florida for San Juan, Puerto Rico, carrying a cargo of 391 shipping containers, about 294 trailers and cars, and a crew of 33 people”.
By the following morning, Tropical Storm Joaquin had become more severe and was now a category three hurricane. The cargo ship was near the eye of the storm, amid large waves 20 to 40 feet tall (6 to 12 meters) and winds exceeding 90 miles per hour (150 km/h). The captain reported that the ship had taken on water and soon thereafter all communications with the ship or lost.
Extensive search and rescue operations found debris from the ship, but tragically they did not find the ship or any survivors.
The United States Navy searched the ocean floor and found the ship almost one month after it had gone under. It was found on October 31, at a depth of approximately 3 miles below the surface (15,000 feet, or 4600 meters).
Underwater image confirms shipwreck El Faro on ocean floor
The ship, its cargo, and any crew still within the vessel remain entombed 3 miles under water. My heart goes out to crew members’ families, who have lost their loved ones.
It is unfortunately common that patients tell me that the prior physician treating their tailbone pain never actually examined their tailbone.
It is crazy to that a doctor would be providing medical care for a specific musculoskeletal location and yet not have the time or skills to perform a basic physical exam of the painful site.
Any physician who is treating the tailbone should, at a minimum, be able to perform a physical exam where they palpate (press upon) the tailbone, at least externally, to confirm whether that site is tender and whether that tenderness matches the symptoms that you are seeing them for.
Most physicians should also be able to perform a visual exam (inspection) of the anal/perianal area, and potentially an internal/rectal/digital exam.
If it is a musculoskeletal/pain physician that prefers not to perform the anal portion of the exam, then typically it would be a matter of seeing a primary care physician or a gastroenterologist. There are times when things like an internal thrombosed hemorrhoid or an anal fissure can be the cause of anal pain (which is very close to the lower tip of the coccyx).
Essentially all surgery results in some scar tissue at the surgical site.
Not all scar tissue needs to be treated. If the scar tissue is not causing any symptoms or problems, sometimes it’s best to just ignore it.
However, scar tissue can sometimes be painful or cause irritation of nerves, muscles, and tendons in the area.
Also, scar tissue may restrict movement of muscles, tendons, ligaments, or joints. In the pelvis, this may cause problems throughout the pelvic floor.
Massaging the area of scar can help to loosen up any fibrotic tissues that are getting stuck and clump together.
However, this can be painful. So it’s important to work closely with your treating physician to obtain good relief of pain since this may help you to tolerate working on the scar tissue.
External approaches include massaging the scar tissue from OUTSIDE the skin.
Internal approaches include massaging the scar tissue from inside. This typically would involve wearing a medical glove and placing one or two fingers inside the rectum.
It can be extremely valuable to find a physical therapist with specific training and expertise in treating problems of the pelvic floor.
I am frequently asked which injections will help most for tailbone pain (coccyx pain). Or doctors contact me to ask some specifics of the details on how to perform certain injections at the tailbone.
But frequently there is an initial step that has been overlooked.
BEFORE having or performing any tailbone injection, the treating physician should try to find what is CAUSING the tailbone pain.
This evaluation involves…
carefully listening to the patient’s symptoms (taking a detailed medical history),
performing a careful physical exam,
as well as properly ordering and inspecting appropriate imaging studies
(which can include x-rays done while seated, MRI, CT scan, etc.).
Knowing the cause of the tailbone pain can help the physician and patient figure out which treatment is most likely to be helpful.
For some conditions, injections are not the answer. For example, if the tailbone pain is being caused by a cancer (malignancy), then injections, if done at all, would only be appropriate as part of a larger treatment of the malignancy itself.
So, before asking what injection to do, it’s good to make sure that a thoughtful and thorough evaluation has been performed by a physician with experience in evaluating and treating coccyx pain.
In general, the term “nerve ablation” refers to the intentional destruction of nerves.
In patients with tailbone pain or other types of pain, nerve ablation is one way of stopping the pain.
Basically, even if the patient continues to have the underlying musculoskeletal abnormality (such as joint arthritis, joint dislocation, bone spur, etc.) the idea is that if you can stop the nerves from carrying pain signals up to the brain then the person the longer suffers from the pain.
When the person is no longer suffering in pain then their quality of life improves.
Types of nerve ablation
Chemical ablation: as the name implies, chemicals are used to deaden/kill the nerves. Typical chemicals used to kill the nerves include alcohol and phenol.
Radiofrequency ablation (RFA): this uses radiofrequency waves to deaden/kill the nerves. the energy from RFA essentially heats up the nerves (essentially cooking them so that they no longer work to carry pain signals).
Cryoablation: this uses cold to deaden/kill the nerves. Basically, freezing the nerves kills them.
Preferred type of ablation for tailbone pain: Typically if I’m doing nerve ablation to treat tailbone pain I perform chemical ablation using a concentrated form of alcohol (the first option on this list).
“Endoscopic” ablation (Rarely ever done)
Let me start by saying that endoscopy is definitely NOT the usual way that ablation injections are done at the coccyx. They are almost never done this way!
Endoscopy means that the doctor performing the procedure inserts an endoscope, which is a medical device used to look inside of a patient.
Basically this is inserting a thin tube/cable into the patient with a camera on the tip, so the doctor can look inside.
Although endoscopy is very commonly used in the other parts of the body (such as an endoscopy to look down the back of the throat and down into the stomach of someone who is suffering from stomach ulcers), endoscopy is rarely (if ever) needed for ablation at the tailbone.
Because the tailbone is close to the skin, endoscopy typically should not be needed for looking at the tailbone.
Fluoroscopy typically provides a very good look at the tailbone during tailbone injections (including ablation), making endoscopy unnecessary for these procedures.
Fluoroscopy almost always makes endoscopy unnecessary for tailbone injections.
Compared with a typical coccyx injection, endoscopy requires much more medical equipment and cost, without medical justification for such equipment and cost.
Compared with a typical coccyx injection, endoscopy also requires making a much larger hole in the patient’s skin.
The reason is that the endoscope for endoscopy is much much thicker/broader than the size of the very thin needle that would normally be used for a tailbone injection.
This can result in more tissue trauma to the patient with endoscopy.
Also, having a larger hole in the skin (due to endoscopy) can result in increased risk of infection at the procedure site.
Sometimes people with tailbone pain (coccyx pain, coccydynia) will ALSO have nerve pain that shoots down one or both legs.
Nerve pain shooting down into the legs is sometimes called “sciatica.”
About the sciatic nerve
The sciatic nerve is the largest nerve that travels down into the leg.
It starts in the lower back and buttocks region and travels down the back of the thigh and divides into the tibial nerve and peroneal nerve.
From there, the nerve fibers travel all the way down into the foot.
Nerve fibers from the sciatic nerve innervate various muscles, which can become weak if the nerve is compromised.
Nerve fibers from the sciatic nerve also innervate various sensory areas on the skin, which can become partially non-if the nerve is compromised.
There are multiple locations where the sciatic nerve can be compressed or irritated.
Irritation of the sciatic nerve can cause pain that shoots down into the legs. For example, irritation of the right sciatic nerve would cause pain down into the right leg, whereas involvement of the left sciatic nerve would cause pain down into the left leg.
Pain traveling down into the legs is commonly referred to as “sciatica.”
However, not ALL pain that travels down into the legs (“sciatica”) is actually caused by irritation of the sciatic nerve.
Causes of “sciatica” in people with tailbone pain:
Sciatic nerve irritation in the lower buttocks or upper thigh.
People with tailbone pain often sit leaning forwards to avoid putting pressure on to the tailbone. This can put additional pressure on to the sciatic nerve at the lower buttock or upper thigh.
People with tailbone pain often sit with their buttocks scooted forward on the chair, again to avoid putting pressure on the tailbone. This can mean that the front edge of the chair is pressing directly into the area where the upper thigh meets the lower buttocks. This can irritate the sciatica nerve.
Sciatica nerve irritation at the piriformis muscle.
The sciatica nerve passes directly underneath the piriformis muscle within each of the buttocks.
Sometimes the sciatica nerve actually passes *through* the piriformis muscle.
Muscle tightness or muscle “spasm” within the piriformis muscle can cause irritation of the sciatic nerve at that region.
Nerve root irritation in the lower back.
Where the spinal nerve leaves the spine in the lower back, nerve irritation is common. Medically, this is called “radiculopathy.”
Many patients and even some physicians still refer to this as “sciatica” even though in actuality the nerve irritation here is up at the nerve root rather than actually involving the sciatic nerve.
Finding the cause of sciatica in people with tailbone pain:
History: The treating physician should listen carefully to the patient’s symptoms.
Physical exam: The treating physician should perform a careful, thorough, and thoughtful physical examination.
Usually, the patient’s symptoms and physical examination findings will reveal the cause of the sciatica symptoms.
Diagnostic tests: Sometimes, additional testing may be helpful.
MRI of the lumbosacral spine can help to evaluate whether the pain down the leg is being caused by nerve root irritation at the lumbar spine (such as from a herniated disc your attending the exiting nerve root).
MRI of the piriformis muscle may be able to reveal an abnormality of the sciatica nerve as it passes under or through the piriformis muscle. Higher-quality MRI machines may be necessary to see the nerve clearly (such as using a MRI machine with a stronger magnets, such as a 3-Tesla magnet strength, rather than the typical 1-Tesla magnet strength).
Electrodiagnostic testing: electromyography (EMG) and nerve conduction studies may help the physician to tell the difference between nerve irritation of the sciatic nerve versus nerve irritation up at the lumbar spine nerve roots.
