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.
Suffering with pain day after day, week after week, month after month is incredibly frustrating.
Life can start to revolve around the pain and how to avoid it:
Where can I sit?
What seats or couches do I need to avoid?
Oh no, I forgot or lost my cushion… how am I going to make it through the day?
What social activities can I attend?
When is my next dose of the pain medications?
where can I sit, what activities can I attend, when is my next dose of pain medication, etc.).
Doctors sometimes say thoughtless things:
Unfortunately, sometimes doctors are dismissive of patients with tailbone pain.
Doctors may not understand what is causing your pain or how badly your suffering and how badly this condition can impair your quality of life.
Sometimes the doctor may make an inappropriate offhand comment or joke. Perhaps he/she was trying to use humor to ease the stress of the situation, or maybe they were just being inappropriate, unprofessional, or just lacking good interpersonal skills.
In general, when I train medical students and resident physicians here, I tell them that the safest bet is to follow the patient’s lead. Specifically, if the patient is not joking around about their pain or situation then it is definitely better if the healthcare clinicians don’t start joking around about it. This sounds simple but unfortunately many doctors say thoughtless things that harm patient care.
If you are suffering with tailbone pain, hang in there.
In addition to the medical treatment for the pain itself, you may want to consider seeing a professional counselor for expert guidance on how to deal with the emotional stressors that understandably occur for people suffering from chronic daily pain.
Seek out the best medical care you can. Finding an accurate diagnosis is often a terrific source of emotional relief. Also, an accurate diagnosis lays the foundation for the optimal medical treatment plan, individualized just for you.
Know that there is hope. Medical care constantly advances, with new treatments always on the horizon. Hang in there!
Tailbone pain (also called coccyx pain, or coccydynia) sometimes requires surgical treatment. Surgery to remove the coccyx is called coccygectomy.
Fortunately, the vast majority of people with tailbone pain respond well to non-surgical treatment, such as the use of cushions, medications by mouth, and coccyx injections.
For those uncommon cases where the tailbone needs to be surgically removed, patients sometimes ask whether the surgeon can give them their tailbone after it is taken out.
In the United States, typically if a portion of the body like this is surgically removed the surgeon will send it to the pathology department where a pathologist will take a look at it just to make sure there is no evidence of cancer, etc..
The assessment by the pathologist may be unnecessary the majority of the time, but just becomes one of those standard protocol things.
For those who do have a surgeon willing to give them their tailbone, initially it looks pretty gross if you are not used to seeing surgical specimens and such.
Then you would need to clean off all the muscle/tendon/etc. attachments.
Depending on whether you had a dislocation or bony fracture you might just be left with a few separated pieces (the individual bones of the coccyx).
Conversely, if your coccyx were entirely fused or the ligaments were still intact around the joints, you might have a solid specimen, which would make quite the conversation piece.
Some patients have even said that they would like to hang it from a necklace!
How do you know if your pain is coming from something OTHER than the tailbone (coccyx)?
Or, if you do have tailbone pain (coccyx pain), how do you know if you ALSO have pain coming from other causes?
In general, each person needs to work closely with their treating physicians to try to determine where the pain is coming from.
This involves a combination of looking at
how localized to the symptoms are,
how focal the physical exam findings/tenderness are,
how focal any imaging abnormalities are,
how you have responded to treatments given at the tailbone versus how well you have responded to treatments at other sites
etc.
Consults: You may need to consult with specialists (e.g., seeing a gastroenterologist for a colonoscopy if there is concerned that the pain in the coccyx region is coming from colon cancer or anal fissure).
Test injection: Sometimes it can be helpful if the treating pain management physician does a test injection (“diagnostic injection”) to place a small amount of local anesthetic focally at one specific spot to see if that substantially relieves the symptoms (if a tiny, focal dose of local anesthetic at one specific body location provides excellent relief of the vast majority of your pain, this helps to confirm that your pain was indeed coming from that specific part of your body).
Some common sites of pain in the lower back and buttock region can include:
Lumbar or lumbosacral disc herniation
Lumbar or lumbosacral facet joint pain
Lumbar or lumbosacral radiculopathy
Sacroiliac joint pain
Piriformis muscle pain
Rectal pain
Anal pain
Tailbone pain
Pelvic floor pain
Various cancers in the pelvic and low back region
You should work closely with your treating physicians to determine the specific location of your pain as well as the specific cause of pain at that location.
Chapter 15 of my book (Tailbone Pain Relief Now!) talks a lot about different sources of back and buttock pain OTHER than the coccyx.
I am honored and excited to be part of the first ever medical conference dedicated solely to problems of the coccyx (tailbone), such as coccyx pain (tailbone pain, coccydynia).
If an MRI shows that there is a lumbar disc herniation, could this be the cause of your tailbone pain?
Usually not.
Lumbar disc “abnormalities”
“Abnormalities” in the lumbar discs are very very commonly seen on MRI studies.
Sometimes these abnormal-looking discs may cause symptoms such as low back pain or nerve pain that travels down your leg.
Perhaps even more commonly, those abnormal-looking discs might not be causing you any symptoms at all!
It is important for the treating physician to carefully evaluate each individual patient in order to see how any such MRI findings may or may not match up with the patient’s symptoms and physical exam findings.
Lumbar vs. Tailbone
If the patient has symptoms that are very well localized to the tailbone (coccyx), then it is very unlikely that those tailbone symptoms are coming from the lumbar spine.
It is vastly more common that tailbone pain is actually coming from the tailbone itself.
Let’s think about this the reverse way for a moment to see how crazy this approach is.
In someone with lumbar symptoms (in the “small of the lower back”) it would not be automatically assumed that those lumbar symptoms are due to referred pain from the tailbone.
Similarly, in someone with tailbone symptoms it should not be assumed that those tailbone symptoms are due to referred pain from the lumbar spine.
Problems caused by focusing only on the lumbar spine
Unfortunately, over the years, I have seen MANY patients who saw their doctors due to tailbone pain, but the following has occurred:
The doctor incorrectly lumps “tailbone pain” in with general “low back pain” (essentially LUMBAR pain), often without even examining the tailbone area where the patient is reporting her pain.
The doctor orders a “LUMBAR” MRI done (which does not even include the tailbone).
The lumbar MRI shows some “abnormal” looking findings. (In reality, the lumbar MRI findings such as a lumbar disc herniation might not be causing the patient any symptoms at all.)
Based on the lumbar MRI “abnormalities”, the patient is subjected to various lumbar treatments, which can include:
lumbar epidural steroid injections
lumbar facet joint injections
lumbar surgery
Not surprisingly, treating the lumbar spine for problems in a totally different part of the spine (the coccyx) usually fails to give any relief at all.
Meanwhile, the patient continues suffering while the doctor has failed to ever even examined the area of pain (the tailbone) and the doctor has failed to order the appropriate diagnostic tests for the area of pain (the tailbone).
Because the patient has not gotten any better despite extensive treatment (at the wrong body region!), the doctor assumes that the patient’s case is hopeless or that the patient is “”crazy” or that the pain is just “all in her head”.
Take home message:
If your symptoms are mainly localized to the tailbone area, then most likely they are being caused by a medical condition localized to the tailbone area.
Before jumping to conclusions that the tailbone symptoms are coming from MRI “abnormalities” in the lumbar spine, be sure to see a physician who will perform a careful and thoughtful evaluation specifically at the tailbone region.
You may be wondering… “If I have tailbone pain, why not just have it surgically removed? Why bother trying non-surgical approaches?”
Why not just remove the tailbone right off the bat for people having tailbone pain?
My answer would be that the vast majority of patients do well with milder and easier treatments.
The milder treatments generally have a faster recovery time and less side effects.
For patients who are still having pain despite oral medications, cushions, etc., then I typically use a stepwise approach regarding injections.
For example, I often start with a local steroid injection, or sometimes a local steroid injection combined with a ganglion Impar injection (which is a type of sympathetic nerve block).
Most patients do well with those injections, obtaining very good relief of their tailbone pain.
For those patients who do not get enough relief, then I consider nerve ablation, which deadens or destroys the nerves that are carying the pain.
For the limited number of patients who are still not getting enough relief, then I consider surgical consult for possible coccygectomy.
The majority of people respond well to one of the simple more-introductory type of injections, so it makes sense to start with those simplest things first and only climb the treatment ladder as far as needed in any individual person’s case.
Regarding complications and side-effects from coccygectomy (surgical removal of the tailbone), please click on the links below:
