Wrong-Minded Denials of Coccyx X-rays by the UK Radiology Directorate, NHS Foundation Trust

Apparently, in the United Kingdom, the National Health Service (NHS) has radiology protocols that explicitly deny the usefulness of tailbone x-rays (coccyx radiographs, xrays) for patients suffering with tailbone pain (coccyx pain, coccydynia).

A person in the UK who suffers from tailbone pain sent me the following link: (As of Feb-11-2018, this PDF can be downloaded using the Google Chrome browser, but not with the Firefox browser.)

Here are the relevant parts of the 220-page protocol, (the ALL-CAPS parts are theirs!) which specifically address coccyx pain:



Page 14 of 220:

Coccyx [x-rays]
Not routinely indicated. Normal appearances often misleading and findings do not alter management. (RCR guidelines 1998)

Page 41 of 220:

Pain with suspected tumour or infection
AP 15 (Cranial)
Trauma to Coccyx – X-rays not indicated as it will not alter patient management.

 Dr. Foye’s response:
  • I think that their protocol is severely misguided and shows a lack of understanding of coccyx pain and a lack of compassion for those who suffer from it.
  • The radiology protocols also suggest that clinicians in the UK would not know how to make useful decisions and treatment plans based on the x-ray results. The protocol is essentially implying that in the UK their medical doctors, chiropractors, physical therapists, etc., are too ignorant of how to use the x-ray results, so let’s ban the x-rays from being done in the first place. By contrast, I believe and I know that there are indeed clinicians in the UK who are well aware of how to make important treatment decisions based on the x-ray results.
  • In 2016, I (Dr. Foye) previously addressed a similar nihilist attitude that a radiology journal had published against the use of coccyx x-rays in hospital Emergency Departments.
  • To their credit, the journal published my response (here is that Link: https://www.ajronline.org/doi/abs/10.2214/AJR.16.16542), where I offered the following critiques. The point that I raised, shown below, also apply to the NHS radiology protocols:
    • “Did they include sacrococcygeal collimation (i.e., coned-down views to obtain clearer bony definition), which is especially important for the small coccygeal bones?
    • Did their sacrococcygeal imaging include sitting-versus-standing lateral radiographs, without which the researchers would be unable to diagnose coccygeal dynamic instability, which is one of the most common causes of coccyx pain?
    • Instead of eliminating sacrococcygeal radiographs for patients in the emergency department, perhaps we should focus on improving sacrococcygeal radiography.”
    • “Meanwhile, the authors suggest that the imaging results do not affect treatment. However, their own study shows that patients without positive imaging studies receive fewer analgesic medications.”
    • “Unaddressed issues included patients’ emotional distress from not knowing the cause of their pain or feelings of whether the treating physicians were dismissive or unbelieving of the patients’ injuries.”
    • “Furthermore, accurate diagnosis creates individualized treatment options, such as fluoroscopically guided injections targeting the specific site of injury or nasal calcitonin treatment of acute fracture of a coccygeal vertebral body.”
    • “In summary, rather than eliminating sacrococcygeal radiography, we believe clinicians should focus on improving how these studies are performed, interpreted, and acted on.”

Screen-capture from Dr. Foye’s 2016 publication on the usefulness of coccyx x-rays in patients with tailbone pain:

X-rays ARE useful for coccyx pain, tailbone pain, explained by Dr Foye, 2016 AJR

X-rays ARE useful for coccyx pain, tailbone pain, explained by Dr Foye, 2016 AJR

Screen-captures from the UK’s Radiology Protocol document (from the publicly-available PDF that was downloaded from the link above) are below:

NHS Cover Page, Radiology Guidelines

NHS Cover Page, Radiology Guidelines

NHS, Radiology HEADING

NHS, Radiology HEADING

NHS, Radiology Protocol Advised AGAINST Coccyx Xrays

NHS, Radiology Protocol Advised AGAINST Coccyx X-rays

NHS, Sacrum Radiology Protocol Advised AGAINST Coccyx Xrays

NHS, Sacrum Radiology Protocol Advised AGAINST Coccyx X-rays

Patrick Foye, M.D.
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1 comment to Wrong-Minded Denials of Coccyx X-rays by the UK Radiology Directorate, NHS Foundation Trust

  • Jacqui Hodges

    Thank you for writing this article on the links I sent. I think it explains perfectly how the protocol on coccyx X-rays is ‘’misguided’’ here in the UK.
    No wonder it is such an uphill battle for many of us here to get diagnosis and correct treatment. It takes its toll physically and mentally, and is so upsetting to be told ‘’ there is no point x-raying as treatment will be the same’’ (ie. not specifically tailored to treat what is wrong!)
    I found it very hard to get my specialist to even refer me for coccyx x-rays (I was sent for X-ray AFTER 2 blind injections with MUA) – I was so upset when radiology flatly refuse to do them .
    And yes, definitely yes, the quality of X-rays needs improving by using better techniques. My coccyx could not even be seen (at all) on the one I had done several years ago. Hopefully with expert opinions like yours, and an article out there about this, things might change here. I am wondering if I could start a petition to get these rules looked at and hopefully changed.

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