Conservative treatment for chronic coccydynia: a 36-month prospective observational study of 115 patients.

PURPOSE: To describe long-term outcomes of conservative treatment for chronic coccydynia. METHODS: We conducted a 36-month prospective observational study. Adults with chronic coccydynia (> 2 months) were included. The first-line treatment was coccygeal corticosteroid injection. The second-line treatment was either manual therapy or coccygectomy. The primary endpoint was the mean variation from baseline of coccydynia intensity at 6 and 36 months, using a numeric rating scale (0, no pain; 10, maximal pain). Evolution was considered unfavorable when coccydynia intensity was > 3 of 10 points at 36 months or coccygectomy had been performed. We carried out bivariate and multivariate analyses to identify variables associated with an unfavorable evolution. RESULTS: We included 115 participants. Mean (SD) age was 43.5 (12.3) years, duration of coccydynia 18.4 (21.6) months and coccydynia intensity 6.5 (2.0) of 10 points. Mean variations for coccydynia intensity were - 1.5 (3.0) at 6 months and - 2.8 (3.2) at 36 months. At 36 months, 59/115 (51%) participants had an unfavorable evolution. In bivariate analysis, posterior coccyx dislocations were numerically more frequent in participants with an unfavorable evolution compared to others (29/59 (48%) versus 17/56 (30%), p = 0.057). In multivariate analysis, longer duration of coccydynia was associated with an unfavorable evolution (OR = 1.04, 95% CI from 1.01 to 1.07, p = 0.023). CONCLUSION: In adults with chronic coccydynia receiving conservative treatment, symptoms decrease overtime, but significantly persist at 36 months in more than half of them. For patients with posterior coccyx dislocation, coccygectomy may be considered rapidly.

Classification of fractures of the coccyx from a series of 104 patients.

PURPOSE: To describe a classification of fractures of the coccyx, according to their mechanism. METHODS: A series of 104 consecutive patients with a fracture of the coccyx was studied. The mechanism, level, characteristics of the fracture line and complications were recorded. RESULTS: Three mechanisms are proposed to describe these fractures: flexion, compression and extension (types 1, 2 and 3, respectively). Flexion fractures (38 cases) involved the upper coccyx in 35 cases, and in 3 cases with a perineal trauma, it was the lower coccyx; compression fractures (24 cases) involved the middle coccyx and occurred only when Co2 was square or cuneiform and Co3 was long and straight, hence a nutcracker mechanism; four patients were adolescents with a compression of the sacrum extremity and were labeled adolescent compression fracture of S5 (type 2b); extension fractures (38 cases) were obstetrical and involved the lower coccyx; their key feature was a progressive separation of the fragments with time. Flexion fractures usually healed spontaneously, but an associated intermittent luxation was possible. Nutcracker and obstetrical fractures were instable in their majority. CONCLUSIONS: For the first time, a classification of fractures of the coccyx is presented. Each type exhibits specific features. This should help the clinician in the management of these patients. These slides can be retrieved under Electronic Supplementary Material.

Coccygectomy for coccygeal spicule: a study of 33 cases.

PURPOSE: To report the results of coccygectomy for coccygeal spicule. METHODS: We report the results of a retrospective series of 33 patients who underwent coccygectomy for coccygeal spicule. There were 31 women and 2 men. The mean age was 42 ± 12 years (range 23-62). There was a pit in the skin overlying the spicule in 14 cases and the spicule was bulky in 8 cases. In three cases, weight loss had preceded the occurrence of the coccygodynia. The coccyx was rigid or had very reduced mobility (less than 5°) in 25 cases and normal mobility (between 5° and 20° of flexion) in 8 cases. All the patients had initially been managed conservatively with injections targeted on the spicule. As they did not obtain sufficient relief, they were offered surgery. Ten patients were followed up for more than 72 months, 10 patients for 48-66 months, and 13 for 30-42 months. The outcome analysis involved functional criteria only. RESULTS: Twenty-six patients (79%) had a very satisfactory outcome and 7 (21%) an unsatisfactory outcome. When asked 'Would you have the surgery again?', only one patient answered in the negative. CONCLUSIONS: Surgical treatment for coccygeal spicules that are causing coccygodynia and are resistant to conservative treatment gives satisfactory outcomes, similar to those obtained from surgery for instability of the coccyx.

CT morphology and morphometry of the normal adult coccyx.

PURPOSE: Lack of data on the in vivo morphology and morphometry of the normal adult coccyx hampers understanding of radiological abnormalities in idiopathic coccydynia. The aim of this study was to investigate normal adult sacrococcygeal morphometry. METHODS: Retrospective analysis of 112 adult CT scans (mean age 63 ± 14.6 years, 50 males) evaluated the following: number of coccygeal segments; joint fusion; coccygeal spicules, subluxation, sacralization, and scoliosis; sacrococcygeal straight and curved lengths and curvature indices; sacrococcygeal and intercoccygeal angles; and lateral deviation of the coccyx tip. RESULTS: Four coccygeal segments were present in 76 % of scans. Sacrococcygeal fusion was present in 57 % and intercoccygeal fusion was increasingly common more caudally; there was no significant association with age or gender. A bony spicule was present in 23 %. Subluxation was rare. Nine of 12 coccyges with a retroverted tip were female. Mean coccygeal curved length was 4.4 ± 0.8 cm in men and 4.0 ± 0.8 cm in women (P < 0.01). Mean angle between first and last coccygeal segments was 138° ± 25° in men and 147° ± 25° in women (P = 0.08). There was no significant correlation between coccygeal length or curvature and stature, age or BMI. CONCLUSIONS: In this first detailed study of the CT morphology and morphometry of the adult coccyx, sacrococcygeal and intercoccygeal joint fusion was common. Female coccyges were shorter, straighter, and may be more prone to retroversion, factors that may be relevant to the markedly higher prevalence of idiopathic coccydynia in women.

Magnetic resonance imaging findings in the painful adult coccyx.

OBJECTIVE: Imaging of the painful coccyx currently relies on standard and dynamic radiography. There are no literature data on MRI of the coccyx. This examination could provide information on the cause of pain. METHODS: 172 patients with severe chronic coccydynia underwent MRI and dynamic radiography of the coccyx. RESULTS: Disc abnormalities (seen in 70 patients) were related to either the presence of intradiscal liquid effusion (17/70), or abnormality of the endplates similar to Modic 1 changes (38/70), or uncertain abnormalities (15/70). Abnormalities of the tip of the coccyx (seen in 41 patients) were located in the surrounding soft tissues: venous dilatations (18/41), soft tissue inflammation (13/41) and ambiguous images (9/41). Vertebral bone oedema was observed in five cases and a benign tumour was observed once. The type of imaging feature depend broadly on the mobility of the coccyx: the 105 cases with a mobile coccyx mainly presented abnormal features mainly in a disc (63 cases vs. 4 cases for the tip), whereas the 67 patients with a rigid coccyx mainly showed abnormal features at the tip (37 cases vs. 7 for the joints, p < 0.001). CONCLUSIONS: We recommend MRI of the painful coccyx when dynamic radiography fails to reveal clearly a pathological lesion (i.e., normal or slightly increased mobility of the coccyx or a rigid coccyx lacking a spicule).

Prevention of post-coccygectomy infection in a series of 136 coccygectomies.

Postoperative infection is a regular complication in coccygectomy. The authors propose the use of a topical skin adhesive on the postoperative wound as a contribution to the prevention of this complication. It was used on the first 56 patients in this study. The rate of infection was 3.6% compared with the 14% rate of infection in a previous study. The 80 following patients had, in addition to the skin adhesive, two prophylactic antibiotics for 48 hours (cefamandole and ornidazole), a preoperative rectal enema, and closure of the incision in two layers. The rate of infection dropped to 0.0%. Topical skin adhesive constitutes a significant contribution in the prevention of infection after coccygectomy.

Osteopathic medicine for fibromyalgia: a sham-controlled randomized clinical trial.

BACKGROUND: Patients with fibromyalgia (FM) frequently resort to osteopathic or chiropractic treatment, despite very weak supporting evidence. We aimed to assess the efficacy of osteopathic manipulation in FM in a properly controlled and powered randomized clinical trial. METHODS: Patients were randomized to osteopathic or sham treatment. Treatment was administered by experienced physical medicine physicians, and consisted of six sessions per patient, over 6 weeks. Treatment credibility and expectancy were repeatedly evaluated. Patients completed standardized questionnaires at baseline, during treatment, and at 6, 12, 24, and 52 weeks after randomization. The primary outcome was pain intensity (100-mm visual analog scale) during the treatment period. Secondary outcomes included fatigue, functioning, and health-related quality of life. We performed primarily intention-to-treat analyses adjusted for credibility, using multiple imputation for missing data. RESULTS: In total, 101 patients (94% women) were included. Osteopathic treatment did not significantly decrease pain relative to sham treatment (mean difference during treatment: -2.2 mm; 95% confidence interval, -9.1 to 4.6 mm). No significant differences were observed for secondary outcomes. No serious adverse events were observed, despite a likely rebound in pain and altered functioning at week 12 in patients treated by osteopathy. Patient expectancy was predictive of pain during treatment, with a decrease of 12.9 mm (4.4-21.5 mm) per 10 points on the 0-30 scale. Treatment credibility and expectancy were also predictive of several secondary outcomes. CONCLUSION: Osteopathy conferred no benefit over sham treatment for pain, fatigue, functioning, and quality of life in patients with FM. These findings do not support the use of osteopathy to treat these patients. More attention should be paid to the expectancy of patients in FM management.

Mechanism of action of spinal manipulative therapy.

Spinal manipulative therapy (SMT) acts on the various components of the vertebral motion segment. SMT distracts the facet joints, with faster separation when a cracking sound is heard. Intradiscal pressure may decrease briefly. Forceful stretching of the paraspinal muscles occurs, which induces relaxation via mechanisms that remain to be fully elucidated. Finally, SMT probably has an inherent analgesic effect independent from effects on the spinal lesion. These changes induced by SMT are beneficial in the treatment of spinal pain but short-lived. To explain a long-term therapeutic effect, one must postulate a reflex mechanism, for instance the disruption of a pain-spasm-pain cycle or improvement of a specific manipulation-sensitive lesion, whose existence has not been established to date.

Extra vertebrae in Ingres' La Grande Odalisque.

"La Grande Odalisque," a painting by Jean-Auguste Ingres (1780-1867), was throughout the 19th century notorious for its anatomical inaccuracy; in particular, the woman was said to have three lumbar vertebrae too many. This view was accepted by all art critics, but never tested and proven. We measured the length of the back and of the pelvis in human models, expressed the mean values in terms of head height, and transferred them to the painting. The deformation was found to be greater than originally assumed (five, rather than three, extra lumbar vertebrae), and to involve both the back and the pelvis. Ingres' paintings skilfully combine realism and symbolism. We suggest that the deformation may have been introduced for psychological reasons. By placing the harem woman's head further away from her pelvis the artist may have been marking the gulf between her thoughts (expressed by her aloof, resigned look) and her social role (symbolized by her deliberately lengthened pelvis).

Systematic review of manual therapies for nonspecific neck pain.

OBJECTIVE: To evaluate the effectiveness of manual therapies in the treatment of nonspecific neck pain. MATERIALS AND METHODS: Medline and the Cochrane Library were searched for randomized controlled trials of manual therapy or mobilization, used alone or with exercises to treat pain and functional impairment related to nonspecific neck pain. Cochrane Back Review Group criteria were used to assess the quality of the trials and the level of evidence (unclear, limited, moderate, or high) for short-, medium-, and long-term effects. RESULTS: Of 27 identified trials, 18 were of high quality. In acute neck pain, effective treatments were thoracic manipulation combined with electrothermal therapy in the short term and cervical manipulation in the long term. In chronic neck pain and neck pain of variable duration, both pain and function improved consistently at all follow-up time points. None of the manual therapies used alone or in combination was superior over the others. In the long term, exercises alone or combined with manual therapies were superior over manual therapies used alone. CONCLUSION: Manual therapies contribute usefully to the management of nonspecific neck pain. The level of evidence is moderate for short-term effects of upper thoracic manipulation in acute neck pain, limited for long-term effects of neck manipulation, and limited for all techniques and follow-up durations in chronic neck pain.

Magnetic resonance imaging morphology and morphometry of the coccyx in coccydynia.

STUDY DESIGN: Retrospective case-control study. OBJECTIVE: To determine if differences exists between the bony anatomy of the coccyx in patients with coccydynia and that in subjects with no known coccygeal pathology. SUMMARY OF BACKGROUND DATA: Numerous bony characteristics of the coccyx have been described in patients with coccydynia but their significance is uncertain. This study aimed to evaluate these in patients with coccydynia and compare them with normal coccyges. METHODS: Magnetic resonance scans of the coccyx from 107 adults (mean age, 43 ± 12 yr; 84 females) with clinically diagnosed coccydynia were retrospectively analyzed and compared with 112 computed tomographic scans from sex-matched adults with normal coccyges. The following were assessed: coccygeal segmentation; sacrococcygeal and intercoccygeal joint fusion, angles, and curvature; bony spicule formation; and subluxation. RESULTS: Compared with normal, females with coccydynia had a more ventrally curved coccyx (curvature index, 85 ± 7 vs. 90 ± 5; P< 0.01), a lower prevalence of sacrococcygeal joint fusion (27% vs. 58%, P< 0.01), and a higher frequency of bony spicule formation (44% vs. 19%, P< 0.01). Males with coccydynia showed a trend toward a more ventrally curved coccyx (curvature index: 86 ± 6 vs. 89 ± 5, P< 0.08), and a lower prevalence of sacrococcygeal (27% vs. 60%, P< 0.02) and intercoccygeal (0% vs. 22%, P< 0.02) joint fusion. Combining statistically significant coccygeal parameters in a logistic regression model yielded sensitivity, specificity, and positive predictive values of 72%, 71%, and 73%, respectively in females and 52%, 92%, and 73%, respectively in males. CONCLUSION: This is the most detailed comparison of coccygeal morphology and morphometry in adults with and without coccydynia investigated using cross-sectional imaging. Anatomical differences in joint fusion and coccygeal curvature may either predispose to the development of coccydynia or arise as a result of this condition.

Xiphodynia and prominence of the xyphoid process. Value of xiphosternal angle measurement: three case reports.

We describe three cases of xiphodynia in patients with prominence of the xyphoid process under the skin. The xiphosternal angle was 105°, 135°, and 120° in these three patients, respectively, compared to a mean of 172 ± 15° in 60 individuals without xiphodynia evaluated by computed tomography for another reason. The prominence of the xyphoid process caused discomfort and local irritation and was the source of the pain in all three patients. This abnormality should be looked for routinely in patients reporting xiphodynia.

Four cases of coccygeal disk calcification after cortivazol injection.

Chronic coccydynia can be treated with a glucocorticoid injection into the pain-causing intercoccygeal disk. We report four cases of calcifications within intercoccygeal disks previously injected with cortivazol. In two patients, the calcifications probably caused additional pain. Prednisolone acetate should be preferred over cortivazol for intercoccygeal disk injections.

Coccydynia related to calcium crystal deposition.

STUDY DESIGN: Study of 4 cases of severe coccydynia revealing calcium deposits in the sacrococcygeal and intercoccygeal joints. OBJECTIVE: To highlight calcium crystal deposition as a cause of sudden-onset coccydynia. SUMMARY OF BACKGROUND DATA: Intervertebral disc calcification in the cervical, thoracic, or lumbar spine is well known, but calcifications in the sacrococcygeal or intercoccygeal joints with symptoms have never been reported. METHODS: All 4 patients presented with severe, sudden-onset coccydynia. Radiographs of the coccygeal area showed calcific deposits in the sacrococcygeal or intercoccygeal joints. Patients received a short course of oral corticosteroids or steroid injections. RESULTS: Conservative management provided prompt relief in all but one case. In 2, the resolution of the calcific deposits as seen on follow-up radiography was highly suggestive of their apatite origin. CONCLUSION: Calcium crystal deposition in the sacrococcygeal or intercoccygeal joints can cause coccydynia. Conservative treatment is effective as a first-line approach.

The treatment of chronic coccydynia with intrarectal manipulation: a randomized controlled study.

STUDY DESIGN: Randomized open study. OBJECTIVE: To evaluate the efficacy of intrarectal manual treatment of chronic coccydynia; and to determine the factors predictive of a good outcome. SUMMARY OF BACKGROUND DATA: In 2 open uncontrolled studies, the success rate of intrarectal manipulation of the coccyx was around 25%. METHODS: Patients were randomized into 2 groups of 51 patients each: 1 group received three sessions of coccygeal manipulation, and the other low-power external physiotherapy. The manual treatment was guided by the findings on stress radiographs. Patients were assessed, at 1 month and 6 months, using a VAS and (modified) McGill Pain, Paris (functional coccydynia impact), and (modified) Dallas Pain questionnaires. RESULTS: At baseline, the 2 groups were similar regarding all parameters. At 1 month, all the median VAS and questionnaire values were modified by -34.7%, -36.0%, -20.0%, and -33.8%, respectively, in the manipulation group, versus -19.1%, -7.7%, 20.0%, and -15.7%, respectively, in the control (physiotherapy) group (P = 0.09 [borderline], 0.03, 0.02, and 0.02, respectively). Good results were twice as frequent in the manipulation group compared with the control group, at 1 month (36% vs. 20%, P = 0.075) and at 6 months (22% vs. 12%, P = 0.18). The main predictors of a good outcome were stable coccyx, shorter duration, traumatic etiology, and lower score in the affective parts of the McGill and Dallas questionnaires. CONCLUSIONS: We found a mild effectiveness of intrarectal manipulation in chronic coccydynia.

Acute torticollis in an adolescent: case report and MRI study.

STUDY DESIGN: A case report is presented. OBJECTIVES: To describe a typical case of acute adolescent torticollis in which a disc lesion was detected with magnetic resonance imaging. SUMMARY OF BACKGROUND DATA: Acute torticollis is attributed to atlantoaxial rotary fixation of unknown etiology. The current view is that the lesion is caused by synovial fold entrapment in the C1-C2 interspace. METHODS: In a 15-year-old male adolescent, magnetic resonance imaging was performed a few hours after the onset of torticollis, and 3 weeks after resolution of symptoms.RESULTS Increased signal intensity compatible with a fluid collection was seen in the right uncovertebral region at C2-C3. This lesion was probably linked to a sudden disruption of the disc collagen fibers, and had caused excessive lateral pressure, pushing C2 toward the left. Magnetic resonance imaging at 3 weeks was unremarkable. CONCLUSIONS: The authors think that the observed disruption was a sudden and abnormal instance of a normal and, usually, very slow process of cleft formation with extension into the fibrocartilaginous core in the uncovertebral region. It is felt that this lesion may be a frequent cause of torticollis in adolescents.

Coccygectomy for instability of the coccyx.

Between 1993 and 2000, 61 patients with instability-related coccygodynia were operated on by a single surgeon using the same technique. There were 49 women and 12 men, mean age 45.3 (18-72) years. Twenty-seven patients had hypermobility of the coccyx and 33 subluxation. In all cases, the unstable portion was removed through a limited incision directly over the coccyx. The outcome was assessed using a detailed questionnaire. Follow-up was between 12 months and more than 30 months. The outcome was rated excellent or good in 53 patients, fair in one, and poor in seven. There were nine patients with infection requiring reoperation.

Pain immediately upon sitting down and relieved by standing up is often associated with radiologic lumbar instability or marked anterior loss of disc space.

STUDY DESIGN: Comparison of functional radiographs in consecutive patients with low back pain with or without pain on sitting down and relieved by standing up. OBJECTIVES: To detect radiologic signs possibly associated with a clinical symptom. SUMMARY OF BACKGROUND DATA: No link has been established between increased vertebral mobility and a specific pain pattern or a clinical symptom. METHODS: Forty-two patients seen consecutively with low back pain occurring immediately on sitting down and relieved on standing up were compared with 32 controls whose low back pain did not show this pattern. Dynamic radiographs were taken in extension, erect, flexion, and sitting in the painful position. The segments thought to be responsible for the pain were identified by comparing clinical, radiographic, and magnetic resonance data. Endplate angles, rotation, and translation were measured. The radiographs were read twice each by two independent observers. RESULTS: Eighty-six percent (95% confidence interval, 72-99%) of the patients with the symptom were female. The segments identified as the source of pain were as follows: L4-L5 in 20 cases and L1-L2 to L3-L4 in 22 cases. Mean rotation of these segments was 13.9 +/- 4.5 degrees in the patient group versus 7.5 +/- 4.3 degrees in the control group (P < 0.001). In 14% of the patients (vs. 3% of controls), it exceeded 20 degrees (P = 0.13). Anterior or posterior translation >10% was seen in 31% of the patients (vs. 0% of controls; P < 0.001). In flexion, the endplate angle was -5.2 +/- 3.6 degrees (patients) versus 1.2 +/- 5.7 degrees (controls) (P < 0.01) and <-5 degrees in 55% of patients versus 12.5% of controls (P < 0.001). This value of <-5 degrees was associated with marked anterior loss of disc space. CONCLUSION: Low back pain occurring immediately on sitting down and relieved on standing up was statistically associated with instability (specificity 100%, sensitivity 31%) or marked anterior loss of disc space in flexion (specificity 87%, sensitivity 55%).