Imaging Coccygeal Trauma and Coccydynia.

The coccygeal region has complex anatomy, much of which may contribute to or be the cause of coccyx region pain (coccydynia). This anatomy is well depicted at imaging, and management is often dictated by what structures are involved. Coccydynia is a common condition that is known to be difficult to evaluate and treat. However, imaging can aid in determining potential causes of pain to help guide management. Commonly, coccydynia (coccygodynia) occurs after trauma and appears with normal imaging features at static neutral radiography, but dynamic imaging with standing and seated lateral radiography may reveal pathologic coccygeal motion that is predictive of pain. In addition, several findings seen at cross-sectional imaging in patients with coccydynia can point to a source of pain that may be subtle and easily overlooked. Radiology can also offer a role in management of coccygeal region pain with image-guided pain management procedures such as ganglion impar block. In addition to mechanical coccyx pain, a host of other conditions involving the sacrococcygeal region may cause coccydynia, which are well depicted at imaging. These include neoplasm, infection, crystal deposition, and cystic formations such as pilonidal cyst. The authors review a variety of coccydynia causes, their respective imaging features, and common management strategies.©RSNA, 2020.

Activated spinal astrocytes are involved in the maintenance of chronic widespread mechanical hyperalgesia after cast immobilization.

BACKGROUND: In the present study, we examined spinal glial cell activation as a central nervous system mechanism of widespread mechanical hyperalgesia in rats that experienced chronic post-cast pain (CPCP) 2 weeks after cast immobilization. Activated spinal microglia and astrocytes were investigated immunohistologically in lumbar and coccygeal spinal cord segments 1 day, 5 weeks, and 13 weeks following cast removal. RESULTS: In the lumbar cord, astrocytes were activated after microglia. Astrocytes also were activated after microglia in the coccygeal cord, but with a delay that was longer than that observed in the lumbar cord. This activation pattern paralleled the observation that mechanical hyperalgesia occurred in the hindleg or the hindpaw before the tail. The activating transcription factor 3 (ATF3) immune response in dorsal root ganglia (DRG) on the last day of cast immobilization suggested that nerve damage might not occur in CPCP rats. The neural activation assessed by the phosphorylated extracellular signal-regulated kinase (pERK) immune response in DRG arose 1 day after cast removal. In addition, L-α-aminoadipate (L-α-AA), an inhibitor of astrocyte activation administered intrathecally 5 weeks after cast removal, inhibited mechanical hyperalgesia in several body parts including the lower leg skin and muscles bilaterally, hindpaws, and tail. CONCLUSIONS: These findings suggest that activation of lumbar cord astrocytes is an important factor in widespread mechanical hyperalgesia in CPCP.

A retrospective study on the pathologies in patients with coccydynia-lumbosacralgia and their treatment.

BACKGROUND: The aim of this study was to arrange the treatment according to the etiology following the differential diagnosis in patients who had presented to the Orthopedics and Traumatology and General Surgery outpatient departments, and to emphasize the post-treatment success. METHOD: The charts of 156 patients who had presented to the Orthopedics and Traumatology, General Surgery Departments of the Kafkas University Faculty of Medicine between July 2012 and June 2021 were retrospectively reviewed after permission was obtained from the ethics committee in this study. The demographic findings and Visual Analogue Scale (VAS) results for those with a symptom of pain as detected during the physical examination were recorded from the patient charts. RESULTS: A total of 156 patients who had presented with traumatic and non-traumatic conditions to the Orthopedics Clinic complaining of pain, burning, sensitivity, discharge and hyperemia at the coccyx region were included in the study. The reason for the lumbosacralgia was found to be traumatic as in heavy lifting or working physically difficult jobs in 62 of the 95 patients (65.26%) who presented with lumbosacralgia and pain referred to the coccyx. The mean VAS was 7.37 before treatment and 2.32 following conservative treatment. There was a history of falling on the coccyx region in 8 of the 14 patients with traumatic isolated coccydynia. The pre-treatment mean VAS was 8.64 in the patients with a diagnosis of coccydynia while the post-treatment mean VAS was 0 in 8 patients with full recovery, 4.33 in 3 patients with partial recovery, and 9.66 in 3 patients with no recovery. The pre-treatment mean VAS was 7.58 in the 29 patients with thrombosed hemorrhoids, decreasing to 0 after treatment. The pre-treatment mean VAS was 4.16 in the 18 patients with a pilonidal sinus, again decreasing to 0 after treatment. CONCLUSION: Possible underlying etiological factors should be taken into account when making a diagnosis in patients with coccydynia and the treatment should be determined in a multidisciplinary manner.

Cryoablation of recurrent sacrococcygeal tumors.

PURPOSE: To review the safety and efficacy of cryoablation of recurrent sacrococcygeal tumors. MATERIALS AND METHODS: The radiology departmental ablation database was retrospectively searched for cases of cryoablation performed to treat recurrences of sacrococcygeal tumors between January 1, 2010, and August 1, 2011. Patient demographics, procedure technical parameters, and patient outcomes were reviewed. RESULTS: Five cases of recurrent chordoma and one recurrent myxopapillary ependymoma were treated with cryoablation in six patients whose ages ranged from 31 to 80 years. The tumors measured 14-39 mm in maximal dimension. Cryoablation was performed with the use of computed tomography guidance (n = 5) or a combination of ultrasound and magnetic resonance imaging guidance (n = 1). Sterile fluid was instilled to displace adjacent bowel and/or vagina in four cases, and electromyography monitoring was performed in two cases with adjacent nerve roots. Two patients with recurrent chordoma were treated for palliation of pain, with complete pain relief in one patient (pain recurred after 6 wk) and immediate reduction in pain from a score of six to a score of two on a 10-point scale in the other (pain recurred after 7 mo). Four tumors were treated for local control, with no evidence of recurrence on follow-up imaging at 3, 6, 12, and 15 months. No serious complication occurred. CONCLUSIONS: Limited results suggest cryoablation to be a safe and relatively effective means of treating recurrent sacrococcygeal neoplasms for local control or palliation of pain in this small series with short-term follow-up.

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).

Does this patient have an infection of a chronic wound?

CONTEXT: Chronic wounds (those that have not undergone orderly healing) are commonly encountered, but determining whether wounds are infected is often difficult. The current reference standard for the diagnosis of infection of a chronic wound is a deep tissue biopsy culture, which is an invasive procedure. OBJECTIVES: To determine the accuracy of clinical symptoms and signs to diagnose infection in chronic wounds and to determine whether there is a preferred noninvasive method for culturing chronic wounds. DATA SOURCES: We searched multiple databases from inception through November 18, 2011, to identify studies focusing on diagnosis of infection in a chronic wound. STUDY SELECTION: Original studies were selected if they had extractable data describing historical features, symptoms, signs, or laboratory markers or were radiologic studies compared with a reference standard for diagnosing infection in patients with chronic wounds. Of 341 studies initially retrieved, 15 form the basis of this review. These studies include 985 participants with a total of 1056 chronic wounds. The summary prevalence of wound infection was 53%. DATA EXTRACTION: Three authors independently assigned each study a quality grade, using previously published criteria. One author abstracted operating characteristic data. DATA SYNTHESIS: An increase in the level of pain (likelihood ratio range, 11-20) made infection more likely, but its absence (negative likelihood ratio range, 0.64-0.88) did not rule out infection. Other items in the history and physical examination, in isolation or in combination, appeared to have limited utility when infection was diagnosed in chronic wounds. Routine laboratory studies had uncertain value in predicting infection of a chronic wound. CONCLUSIONS: The presence of increasing pain may make infection of a chronic wound more likely. Further evidence is required to determine which, if any, type of quantitative swab culture is most diagnostic.

Novel approach for pericapsular radiofrequency ablation of sacrococcygeal junction for patients with coccydynia.

INTRODUCTION: Coccydynia is a multifactorial complex clinical challenge. A multimodal approach with both conservative measures and procedural interventions is often recommended. We described a novel approach of radiofrequency (RF) ablation for the management of coccydynia. METHODS: Three patients with known history of coccydynia refractory to conservative therapy were referred to our clinic. All received different types of RF ablation before: one with anterior bipolar lesion with no analgesia benefit, one with posterior stripped lesion with good benefit but only after 8 weeks of pain flare and one received anterior monopolar lesion with 50% pain reduction for 2-3 months. All subjects underwent a novel RF ablation to the anterior surface of the sacrococcygeal and intercoccygeal joints with two bipolar lesions using multi-tined needles under fluoroscopy guidance. One bipolar lesion was between two needles: one in the sacrococcygeal and another in the intercoccygeal (between first and second coccyx) joints. Another bipolar lesion was between needles on both side of the sacrococcygeal joint. RESULTS: All experienced at least 65% pain relief for 6 months. The sitting endurance increased from less than 5 min to an average of 70 min. No adverse effect was observed in two and in the patient who used to have pain flare after lesioning, the pain flare lasted only for 2 weeks. DISCUSSION: The configuration of the two bipolar lesions with multi-tined needles in this case series stimulates the thinking of new approach for the ablation technique for pain from coccyx. Further prospective large case cohort study is needed.

Immunophenotypic analysis of glomus coccygeum associated with coccygodynia.

OBJECTIVE: Glomus coccygeum is a glomus body which is found in the pericoccygeal soft tissue. This specialised arteriovenous anastomosis is a non-pathological vestigial structure usually larger than its equivalent in the distal extremities. Its prevalence is uncertain. Glomus coccygeum has been associated with coccygodynia and can cause diagnostic problems to pathologists unfamiliar with this entity. MATERIALS AND METHODS: The presence of a glomus coccygeum was sought in 40 coccygectomy specimens and correlated with clinical, radiological and histological findings. RESULTS: A glomus coccygeum was identified in 13 samples (35%). Glomus cells expressed smooth muscle actin (SMA) and were negative for desmin, S100, cytokeratin and a wide range of vascular markers. Proliferative activity was low. Pre-operative MRI did not identify these tiny lesions, and most patients with coccygodynia did not have a glomus coccygeum. CONCLUSION: Glomus coccygeum is a common microanatomical structure which can be distinguished from glomus and other tumours by its small size, SMA expression and low proliferative activity.

Asymptomatic isolated coccygeal metastasis in low rectal carcinoma.

As well as being relatively rare, osseous metastases from colorectal cancer are frequently asymptomatic and represent a late manifestation of disease. We report a case of an unidentified, asymptomatic coccygeal metastasis discovered on histological processing of the resection specimen from a patient with locally advanced rectal cancer treated with neoadjuvant chemoradiotherapy followed by radical abdomino-perineal resection with coccygectomy. The anatomical explanation for this finding may involve passage of tumour cells via the vertebral venous plexus.

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.

Extrarenal teratoid Wilms' tumor: two cases in unusual locations, one associated with elevated serum AFP.

Teratoid Wilms' tumor is an unusual morphological entity characterized by a classic triphasic malignancy with predominantly heterologous tissue. The authors describe two cases of teratoid Wilms' tumor with an extrarenal site: one in a 13-year-old girl with vaginal spotting (patient 1) and another in a 1-day-old girl with a sacrococcygeal mass (patient 2). The tumors were located in the vagina and coccyx, respectively. Under the initial clinical diagnosis of sarcoma botryoides in patient 1 and teratoma in patient 2, the masses were removed. Microscopically, both tumors were composed of typical triphasic Wilms' tumor tissue with primitive cartilage and skeletal muscle, and squamous and columnar mucinous epithelia. The patient with sacrococcygeal mass (patient 2) had an elevated serum AFP level. The patients were given chemotherapy and have now remained disease free for 7 years 1 month, and 2 years 5 months after surgery, respectively. Familiarity with this rare variant of Wilms' tumor might be important in arriving at a correct diagnosis.

Osteochondroma of the coccyx: a case report.

Osteochondroma is the most common benign bone tumor. Majority of solitary osteochondromas are asymptomatic however, may give functional impairment due to pain from pressure or mass effect. Osteochondromas occur most often about the knee and picked incidentally, coccygeal osteochondroma however; is a rare occurrence. On a plain radiography, it typically appears as a bony projection with a clear cortex and medulla related to the coccyx. Here we present the case of a 7-year-old child with coccygeal osteochondroma.

14. Coccygodynia.

Coccygodynia is painful condition localized in the region of the coccyx. In most cases a traumatic etiology is present. In the idiopathic form other causes such as infections and tumor have to be excluded. Coccygodynia can also be the result of pain referred from visceral structures due to conditions such as disorders of the rectum, the colon sigmoideum, and the urogenital system. In case of a traumatic etiology the diagnosis is made based on the typical medical history whereby the pain is provoked by prolonged sitting and cycling. Lateral images of the coccyx are always indicated. The same is true for manual examination of the coccyx. In case of absence of provocation of the coccygeal pain by prolonged sitting and manual examination neurological causes such as lumbar disc hernias are a possible reason for the coccygodynia. In the acute phase the first choice of treatment are NSAIDs. Treatment for patients with severe pain in the chronic phase consists of manual therapy and/or a local injection of local anesthetic and corticosteroid into the painful segment (2 C+). Other interventional treatments such as intradiscal injections, ganglion impar block, radiofrequency treatment and caudal block are advised only under study conditions (0). Coccygectomy is not recommended because of long-term moderate results and the chance of major complications.

Sacrococcygeal teratoma with intraspinal extension: A case series and review of literature.

BACKGROUND: Sacrococcygeal teratoma (SCT) is the most common teratoma in neonates and arises from the coccyx. SCT with intraspinal invasion is extremely rare and only reported in a few cases. METHODS: 37 patients with SCT were identified at our institution between 2000 and 2018. Three of these patients had SCT with intraspinal extension. A literature review for intraspinal extension associated with SCT, including mode of diagnosis, presentation, surgical approach and neurological sequelae, between 1993 and 2018 was also conducted. RESULTS: The authors report three cases of infants who were antenatally and/or postnatally diagnosed with a sacrococcygeal teratoma extending into the spinal canal. We illustrate the challenges of accurate diagnosis and therapeutic management. Postnatal magnet resonance imaging (MRI) was the best method to define spinal anatomy and extension of the tumors prior to surgery. Management with a multidisciplinary team approach including neuroradiology, neurosurgery and general surgery was used in our two most recent patients. The literature review yielded 6 cases of SCT with intraspinal extension. CONCLUSION: Intraspinal extension in SCT is rare but should be excluded at birth before attempting any resection. In case of positive spinal invasion on Ultrasonography (US), MRI is essential to plan for surgery and possible laminectomy to be able to perform a radical resection of this congenital tumor. We recommend this multidisciplinary approach. LEVEL OF EVIDENCE: Level IV.

Epidermal growth factor receptor (EGFR) status in chordoma.

Chordoma is a rare tumour arising from the embryonal remnants of a notochord occurring most commonly in the sacrococcygeal as well as head and neck locations. Current treatment includes surgery and/or proton beam radiotherapy. In several cases especially in the head and neck location, surgery is not advised. Proton beam therapy is not always effective enough to eradicate the tumour. Additional modes of therapy are needed. One of the current therapeutic approaches in various tumours is targeted therapy and one of the targets is EGFR. The aim of this study was to evaluate EGFR expression and EGFR gene status of chordoma. Twenty-one cases of chordoma were retrieved from the in-house and consultation files of the Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology in Warsaw. Immunohistochemistry with an anti-EGFR antibody and FISH was performed on slides obtained from representative archival paraffin blocks. In our study 81% of cases of chordoma showed low to high EGFR expression in immunohistochemistry. In six cases (26.6%) the FISH results for EGFR were classified as positive (an average EGFR copy number > or = 4 per cell). There was one case of chromosome 7 aneuploidy reported.

Coccydynia relieved by a tarsal tunnel block: a case series.

BACKGROUND: This case series describes, for the first time, to the author's knowledge, a novel treatment for coccydynia. Tarsal tunnel block with lignocaine only brought relief of chronic coccydynia lasting more than 6 months in three patients. The author adopts the theory that the myelin sheath of the posterior tibial nerve will convey the lipid-soluble lignocaine upward toward the dorsal root ganglia and the nerve roots of the lumbar spine through the uninterrupted myelin sheath, which is itself mainly formed of lipids. The author thinks that most coccyx pain is actually a radiating pain from the lumbar spine, which is not always apparent on magnetic resonance imaging of the lumbar spine. Certainly, the author acknowledges that large-scale studies need to be done to prove the efficacy of this new technique and to prove that the myelin sheath can convey the lignocaine chemical upward. CASE PRESENTATION: Three Arab patients presented with chronic coccydynia of more than 6 months' duration in whom conservative management had failed to control their symptoms. They had no past medical history of significance and no history of trauma. The results of physical examination of all of the patients were normal apart from tenderness on palpation of the coccyx. They all received local coccyx injection with steroids on two occasions, which failed to relieve their pain. One patient underwent manipulation under anesthesia, and one underwent coccygectomy with no pain relief. Magnetic resonance imaging results were reported to be normal in two of them, whereas the other one had a prolapsed disc at the L4/L5 level. The three patients described pain relief 30 minutes after tarsal tunnel block with lignocaine only lasting more than 6 months. All patients had heel anesthesia 15 minutes after the tarsal tunnel injection, which lasted only 1 hour. CONCLUSIONS: Tarsal tunnel block with lignocaine can relieve coccyx pain for a long time. Tarsal tunnel block can be done to achieve heel anesthesia before injection of lignocaine into the plantar fascia in patients with plantar fasciitis.

Pressure redistributing in-seat movement activities by persons with spinal cord injury over multiple epochs.

Pressure ulcers, by definition, are caused by external forces on the tissues, often in the regions of bony prominences. Wheelchair users are at risk to develop sitting-acquired pressure ulcers, which occur in the regions of the ischial tuberosities, sacrum/coccyx or greater trochanters. As a means to prevent pressure ulcers, instruction on performing pressure reliefs or weight shifts are a part of the rehabilitation process. The objective of this study was to monitor the weight shift activity of full-time wheelchair users with acute spinal cord injury over multiple epochs of time in order to determine consistency or routine within and across epochs. A second objective was to evaluate the accuracy of self-reported pressure relief frequency within each measurement epoch. A wheelchair in-seat activity monitor was used to measure weight shifts and other in-seat movement. The data was classified into multiple in-seat activity metrics using machine learning. Seventeen full-time wheelchair users with spinal cord injury were measured within multiple epochs, each lasting more than 1 week. Across all in-seat activity metrics, no consistent pattern of activity changes emerged. None of the in-seat activity metric changed in any one direction across a majority of subjects. Subjects tended to over-estimate their frequency of performing pressure reliefs. Self-reported pressure relief behaviors are not reliable, and therefore, cannot be used to evaluate preventative behaviors either clinically or within research. This study had the capability of fully investigating in-seat movements of wheelchair users. The results indicated that in-seat movement does not reflect a routine, either in pressure reliefs, weight shifts or other functional in-seat movements. This study has illustrated the complexity of assigning causation of pressure ulcer occurrence to seated behaviors of wheelchair users and identifies the need for improved clinical techniques designed to develop routine behaviors to prevent pressure ulcers.