|
 
 |
| ORIGINAL ARTICLES |
|
| Year : 2022 | Volume
: 5
| Issue : 1 | Page : 99-105 |
|
Tailbone: Is partial coccygectomy the way to go?
Subir Nipunbhai Jhaveri1, Arth Patel1, Sachin R Patel1, Sharan Subir Jhaveri2, Jignasu Yagnik3
1 Dr. Subir Jhaveri’s Spine Hospital, Ahmedabad, India
2 Smt. NHL Municipal Medical College, Ahmedabad, India
3 Indukaka Ipcowala Institute of Management (I2IM), Anand, Gujarat, India
| Date of Submission | 20-Apr-2021 |
| Date of Decision | 06-Oct-2021 |
| Date of Acceptance | 06-Oct-2021 |
| Date of Web Publication | 02-Feb-2022 |
Correspondence Address:
Subir Nipunbhai Jhaveri
Dr. Subir Jhaveri’s Spine Hospital, First Floor, Jyoti Plaza, Shyamal Cross Roads, 132 Feet Ring Road, Satellite, Ahmedabad 380015, Gujarat.
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ISJ.ISJ_34_21
Background: Complete coccygectomy has proved to be a successful operation, with a success ratio of 70%–85%. Wound infection and dehiscence following coccygectomy ranges between 15% and 30%. The purpose of this article was to present improved outcomes following partial coccygectomy and to suggest modifications to mitigate wound complications. Methods: Seventeen patients (13 women and 4 men) underwent partial coccygectomy using a curved paramedian incision after failing nonoperative care for minimum of 6 months over the last 8 years. Twelve of these were posttraumatic, whereas five were of idiopathic origin. Patients were barred from sitting or sleeping supine for 2 weeks following the surgery. The use of water for cleaning post-defecation was also prohibited. Visual analog scale (VAS), Oswestry Disability Index (ODI), along with a novel Coccyx Disability Questionnaire (CDQ) as well as a truncated ODI (Coccyx Disability Index – CDI) were administered preoperatively, at 6 months and then at last follow-up. Wilcoxon signed rank tests were used as variables were nonparametric. Results: Fifteen patients completed questionnaires at a mean follow-up period of 68 months. Fourteen (93.33%) patients had good-to-excellent outcomes. VAS sitting improved from 9.27 to 0.79 (P = 0.001) and ODI improved from 68.89 to 8.27 (P = 0.001) postoperatively. Novel CDQ scores improved from 7.33 to 1.12 (P = 0.001) and CDI scores improved from 84.56 to 6.44 (P = 0.001). We compared outcomes of our partial coccygectomy cohort with those of complete or partial coccygectomy in literature, and found equivalent or superior results. Three (20%) of our patients developed wound infections, with only one (6.67%) requiring revision surgery, while the other two recovered with dressings. Conclusion: Partial coccygectomy provides equivalent or superior outcomes, compared to complete coccygectomy. Postoperative modifications for 2 weeks help mitigate wound complications. The proposed novel CDQ can be used by surgeons across the globe, once validated. Keywords: Coccyx disability index, coccyx disability questionnaire, outcomes of coccygectomy, partial coccygectomy, wound complications following coccygectomy
How to cite this article:
Jhaveri SN, Patel A, Patel SR, Jhaveri SS, Yagnik J. Tailbone: Is partial coccygectomy the way to go?. Indian Spine J 2022;5:99-105 |
| Background | |  |
Coccygectomy for chronic coccygodynia has been performed for more than three-quarters of a century.[1],[2] Most authors have reported successful outcomes following coccygectomy, with a success ratio of approximately, 70%–85%.[3],[4] Majority of authors perform complete coccygectomy, whereas a few authors have claimed equivalent results even with partial coccygectomy.[5],[6],[7] The incidence of wound-related complications, especially wound dehiscence, and need for a second procedure is high with this surgery.[3] Kulkarni et al.[8] have recently shown a Z-plasty to reduce the incision and wound-related problems associated with this surgery. However, this requires a skilled plastic surgeon to perform the incision as well as closure, which increases the manpower required to undertake an otherwise simple surgery. Barring a few articles, coccygectomy is rarely reported in large numbers. The authors present their experience over the last two decades and suggest methods to mitigate complications arising from this surgery.
Level of evidence
Retrospective case series. Level IV.
| Materials and Methods | | |
Seventeen patients (13 women and 4 men) underwent partial coccygectomy over a period of 8 years (2010–2018) with only one case being undertaken before two decades (1999). Twelve patients had a history of fall at some point, following which, they developed persistent painful coccygodynia, whereas five patients had developed the problem in an idiopathic manner. We did not encounter any patient having post-partum coccygodynia, or secondary to another cause. We classified the radiographs of our patients according to the method of Postacchini and Masobrio.[5] We had four cases of type II, five cases of type III, and eight cases of type IV variety. There was no case with a type I configuration. Acute management involved providing a soft doughnut cushion, local ice application, and pain medications, followed by low-frequency ultrasonic waves and cold laser therapy. Cases that did not respond to these measures were subjected to a local injection of methylprednisolone with diluted bupivacaine (0.25%) in the painful coccygeal area. Impar Ganglion Block was given in only two cases.[9] All cases that responded to these nonoperative measures were excluded from the study, and only those who did not respond for a period of 6 months or more were considered for a surgical excision. Psychological causes as well as lumbar disc pathologies as a potential cause of this problem formed an important differential diagnosis in these cases. Any case that showed either of these conditions was also excluded from the study. Patients with type IV coccyx showed persistent posterior subluxation between two coccygeal segments on dynamic supine and sitting X-rays [Figure 1] and [Figure 2]. Sacrococcygeal angles were not measured as they did not have any impact on decision-making as well as outcomes of treatment. No sacrococcygeal junctional pathology was detected. Local anorectal pathologies were excluded by a general surgeon well versed in the practice of anorectal disorders. MRI of the sacrococcygeal region was done only in cases where an infection was suspected. A thorough preoperative counselling was undertaken with each of these patients regarding the outcomes of this surgery, along with the need to use the doughnut cushion for 6–12 weeks postoperatively, with the coccygodynia taking almost 4 months to subside following the surgery.  | Figure 2: Lateral X-ray of same patient (as in Figure 1) in sitting position demonstrates posterior subluxation of the coccyx on dynamic loading. Postacchini classification Type IV. Only the hyper-mobile unstable segment of the coccyx was removed at surgery
Click here to view |
Surgical technique
Patients were operated under spinal anesthesia in prone position after taking full aseptic precautions. A semi-circular, curved incision was made with the subluxated coccygeal segment forming the apex of the curvature [Figure 3]. Sharp dissection was undertaken in the para-median subcutaneous plane to raise a thick flap of skin and subcutaneous tissue. Midline was then accessed, and ligamentous attachments on the dorsal aspect of the coccygeal segments were sub-periosteally erased using electrocautery. The subluxating segments were then identified, and the disc between the intact and subluxating segment was incised. Using a towel clip, the subluxating segment was then held and gently separated from the underlying tissue, using the cautery, at low strength. The technique that was followed was a combination of that described by Key and Gardner; however, we undertook only a partial coccygectomy with the Co1 segment being retained in all cases.[1],[10] After dissecting the inter-coccygeal disc, dissection was carried out from cranial to caudal, in front of the coccyx. Then, we used a caudocranial approach to elevate the tip, and thus, meet the dissection halfway, to clear the undersurface of the coccygeal segment from the retro-rectal tissues. The most distal part of the rectum lies directly in front of the coccyx, and is at risk of perforation, if a sub-periosteal plane is not maintained.[11] After completing the partial coccygectomy, any sharp bony edges were removed with a bone nibbler. The muscular and ligamentous attachments were then approximated with an absorbable suture, and skin closure was done with non-absorbable 2-0 nylon. Antibiotics (IV Cefazolin) were given for 48 h postoperatively till patients were discharged from the hospital. | Figure 3: Semi-circular incision used in all our cases. The central dot, shown by the arrow, is the location of the most tender portion of the coccyx. It forms the centre of the arc, along which the incision was made
Click here to view |
Postoperatively, all patients were made to lie in a lateral decubitus position, for a period of 2 weeks till the sutures were removed. Also, all patients were barred from sitting, except while using toilet facilities for a period of 2 weeks, akin to Hanley et al.[4] Meals were preferably taken in the lateral decubitus or in the standing position. Standing and walking were encouraged from Day 2 of the procedure. All patients were advised to completely avoid the use of water for cleaning after defecation, as is otherwise, the norm in this part of the world. After complete wound healing, usually 2 weeks in most cases, all restrictions were removed, and the patients were allowed routine activities of daily living, with just the use of the doughnut pillow.
The patients were followed up at 6 weeks, 3 months, 6 months, and then annually. Visual analog scales (VAS) for pain on standing and sitting along with Oswestry Disability Index (ODI) scores were noted preoperatively and then again at 6 months and at last follow-up.
We used a novel Coccyx Disability Questionnaire (CDQ), based on the Activities of Daily Living (ADL) of majority of active middle-aged adults, and gave “1” mark if the activity was painful or produced discomfort [Table 1]. A total of nine questions were asked, and each patient was asked to respond to these questions, pre-operatively as well as post-operatively. The greater the disability, greater was the number, out of a total of nine. We also calculated the Coccyx Disability Index (CDI) based on Kleimeyer’s suggestion, to use questions 1, 5, 8, and 9 of the ODI to assess the coccyx-related disability.[3] Patients were interviewed in person, or on telephone by individuals not involved in the day-to-day care of these patients at intervals mentioned previously.
Nonparametric Wilcoxon Signed Rank Test was applied, as none of the variables were distributed normally. R statistical software (version 3.5.0) was used to arrive at the statistical analysis.
| Results | | |
Complete follow-up data was available in 15 patients, as two patients had relocated to a foreign country, and could not be traced. Mean duration from diagnosis to surgery was 20.70 (12–32) months. Three patients had additional backache, with two patients having prolapsed lumbosacral disc. However, their radicular pain had subsided prior to embarking upon the coccygeal surgery. One patient had complaints of dyspareunia, which was resolved after surgery.
MacNab’s criteria were used to assess overall satisfaction of the procedure. Eight out of 15 (53.33%) had an excellent outcome, 6 (40%) had a good outcome and 1 (6.7%) had a poor outcome. Overall, 93.3% of patients had a good to excellent outcome following partial coccygectomy [Figure 4] and [Figure 5]. | Figure 4: Preoperative X-ray of patient with instability at multiple levels, between first and second, second and third, as well as between third and fourth. Unclassifiable type of injury
Click here to view |
 | Figure 5: Same patient as in [Figure 3]. Six years postoperative X-rays following removal of distal three coccygeal segments. Co1 segment intact with virtually no complaints
Click here to view |
Surgical results and outcomes were scored according to VAS and ODI scores noted pre as well as postoperatively [Table 2]. Marked improvement was noticed in all parameters measured. All scores were found to be statistically significant (P = < 0.05).
Regarding outcome scores using the novel CDQ, as well as the CDI, a statistically significant improvement in the patients’ post-operative responses, was noted in both the outcome methods [Table 3].
Regarding the response of our patients to anecdotal questions, 11 (73.3%) out of 15 patients were not willing to undergo the surgery again, but an equal number (11/15, 73.3%) were willing to recommend the surgery to a friend having the same problem. This was a different response than what was expected.
Three (20%) patients had a complication, in terms of wound infection, with one (6.67%) of them having a wound dehiscence, requiring a secondary procedure. Repeated dressings over 2 weeks healed the wounds of the other two patients. Two patients had recurrence of pain, after 8 months in the first patient, and after 2 years in the other; which subsided with anti-inflammatory medication, local ice application, and doughnut cushion support for 2–4 weeks. No patient developed any rectal perforation, or any other complication.
| Discussion | | |
Despite coccygectomy being performed for more than three-quarters of a century, wound-related complications have continued to remain an enigma..[1] Most authors have reported good to excellent outcomes following coccygectomy as far as pain relief is concerned, but have reported wound-related complications, to the tune of 14%–30%.[3],[4],[6],[8],[11] Kulkarni et al.[8] published their experience with a Z-plasty, where they enlisted the services of a plastic surgeon to close the wound. They did show a 0% skin infection, but their series is too small with only 10 patients enrolled in it, and hence cannot be used as a benchmark.
From our perspective, we can cite three reasons for the wound-related issue. Firstly, the lack of subcutaneous fat and associated vascularity in the skin of the median raphe leads to a breakdown of the epidermis and dermis. Secondly, the stretch on the skin while sitting, or sleeping supine, leads to an increased chance of separation of the dermis and thus results in wound dehiscence. Lastly, the proximity of the entire area to the anal region may potentially contaminate the wound and cause its breakdown.
All our cases were operated by a semi-circular incision, keeping the sub-luxating segment of the coccyx at the apex of the curvature. The para-coccygeal area has thick subcutaneous fat and is richly supplied by blood vessels, which is not the case with the median coccygeal raphe. Also, the skin over the midline is very thin, and prone to breakdown. This paramedian curvilinear incision avoids the midline avascular raphe, and has greater potential to heal without any problem. Also, it avoids the need to undergo closure with a complex Z-plasty by a plastic surgeon, as shown by Kulkarni et al.[8]
Our cases were predominantly female, as has been documented in the literature.[12] Ours was a 1:5 ratio of male versus female as compared to Sarmast et al.’s[6] ratio of 1:3. The probable reason for the female preponderance is the particular anatomy of the female sacrum, which is more prominent making it vulnerable to traumatic insults, more so, than the male sacrum.[13]
Many women during and after menopause, develop obesity, along with increased visceral adipose tissue as well as total body fat.[14] On sitting or lying in a supine position, the gluteal fat pads are pushed laterally and a lot of stretch is generated in the midline cleft area. In order to reduce this stretch, we barred our patients from sitting or lying supine for 2 weeks post-operatively. Only the lateral decubitus was preferred for sleeping, and except toilet seats, sitting was completely avoided. Meals were consumed either in the lateral decubitus or in the standing position. Walking and standing was encouraged post-operatively, from the next day itself. This post-operative posturing avoided any direct pressure onto the wound, and also reduced the stretch on the stitches.
Ours is an ethnic Indian population, where toilet habits involve the use of water to clean the anal region following defecation. Urban households are now equipped with jet-based systems. However, the use of water, directly or by a jet-based system, can potentially contaminate the wound, and lead to a wound breakdown. All patients were instructed to completely avoid the use of water and instead use tissue rolls or wet wipes for cleaning up after defecation, till wound healing was complete.
Adopting these measures in the post-operative regimen has allowed us to have a significantly reduced postoperative wound complication rate. Although 3 patients (20%) from our cohort of 15 had wound problems, only one patient required to undergo wound revision surgery (6.67%). The other two were managed by wound dressings only. Doursounian had suggested the use of cyanoacrylate glue over the skin sutures to have a water-tight skin closure and achieve a 0% wound complication rate.[15] This can be incorporated into routine practice to further mitigate wound complications.
We undertook only partial coccygectomy, and never removed the Co1 vertebrae. Most literature claims excellent results with complete coccygectomy, and not so good results with partial coccygectomy. However, our results matched the results of various series published in the literature, be it for partial or complete coccygectomy [Table 4] and [Table 5]. Even the VAS scores as well as ODI scores fared equal or were better than in most other series.
Overall, we had a good to excellent outcome in 14 out of 15 patients (93.7%), with only one patient having persistent pain following the surgery. Of interest, is the fact that when the patients were asked whether they would recommend the same surgery to a friend having a similar problem, 11 patients (73.33%) replied in the affirmative, but an equal percentage of patients responded in the negative if they were to undergo the same procedure again. This implies, that despite the high degree of success from an “outcomes” perspective, the experience of the patient was such, that they were not willing to undergo the same procedure again. This was not in concordance with published literature by Kwon and Sarmast, whose patients (85% and 87%) were willing to undergo repeat surgery, even at an earlier date, and were also willing to recommend the same to a friend.[6],[16]
The study is limited in the fact that we have small numbers, although the mean follow-up period is almost 6 years. The focus of the study was clinical outcomes, so detailed radiological angles pre and postoperatively were not documented. Moreover, only after patients had exhausted all nonoperative options for 6 months or more were they provided with an option to undergo surgical excision of the unstable segment of the coccyx. We have used a novel CDQ, which is as yet to be validated, but, as none exists specifically for the coccyx, it might serve as a base upon which further coccyx disability questionnaires can be developed. We did not have our own non-operative treatment cohort to compare outcomes of operative treatment versus non-operative protocols. However, we had a strict protocol of operating only those patients who showed failure of conservative measures for at least 6 months or more.
| Conclusion | | |
Partial coccygectomy gives excellent results, equivalent or superior to those provided by complete coccygectomy. Modification of the activities of daily living helps improve outcomes and mitigate wound complications. Coccyx-specific outcomes can be evaluated by surgeons across the globe, once the proposed novel coccyx disability questionnaire is validated.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Ethical policy and institutional review board statement
Ethics approval was obtained from IRB/Research Ethics Committee prior to data collection.
| References | | |
| 1. | Key JA Operative treatment of coccygodynia. J Bone Joint Surg Am 1937;19:759-64.  |
| 2. | Powers JA Coccygectomy. South Med J 1957;50:675-8. |
| 3. | Kleimeyer JP, Wood KB, Lønne G, Herzog T, Ju K, Beyer L, et al. Surgery for refractory coccygodynia: Operative versus nonoperative treatment. Spine (Phila Pa 1976) 2017;42:1214-9. |
| 4. | Hanley EN, Ode G, Jackson JB III, Seymour R Coccygectomy for patients with chronic coccydynia. A prospective, observational study of 98 patients. Bone and Joint J 2016;98-B:526-33. |
| 5. | Postacchini F, Massobrio M Idiopathic coccygodynia. Analysis of fifty-one operative cases and a radiographic study of the normal coccyx. J Bone Joint Surg Am 1983;65:1116-24. |
| 6. | Sarmast AH, Kirmani AR, Bhat AR Coccygectomy for coccygodynia: A single centre experience over 5 years. Asian J 0f Neurosurgery 2018;13:277-82. |
| 7. | Ogur HU, Seyfettinoğlu F, Tuhanioğlu Ü, Cicek H, Zohre S An evaluation of two different methods of coccygectomy in patients with traumatic coccydynia. J Pain Res 2017;10: 881-6. |
| 8. | Kulkarni AG, Tapashetti S, Tambwekar VS Outcomes of coccygectomy using the “Z” plasty technique of wound closure. Global Spine J 2019;9:802-6. |
| 9. | Munir MA, Zhang J, Ahmad M A modified needle-inside-needle technique for the ganglion impar block. Can J Anaesth 2004;51:915-7. |
| 10. | Gardner RC An improved technique of coccygectomy. Clin Orthop 1972;85:143-5. |
| 11. | Karadimas EJ, Trypsiannis G, Giannoudis PV Surgical treatment of coccygodynia: An analytic review of the literature. Eur Spine J 2011;20:698-705. |
| 12. | Maigne JY, Doursounian L, Chatellier G Causes and mechanisms of common coccydynia: Role of body mass index and coccygeal trauma. Spine (Phila Pa 1976) 2000;25:3072-9. |
| 13. | Wray CC, Easom S, Hoskinson J Coccydynia. Aetiology and treatment. J Bone Joint Surg Br 1991;73:335-8. |
| 14. | Polotsky HN, Polotsky AJ Metabolic implications of menopause. Semin Reprod Med 2010;28:426-34. |
| 15. | Doursounian L, Maigne JY, Cherrier B, Pacanowski J Prevention of post-coccygectomy infection in a series of 136 coccygectomies. Int Orthop 2011;35:877-81. |
| 16. | Kwon HD, Schrot RJ, Kerr EE, Kim KD Coccygodynia and coccygectomy. Korean J Spine 2012;9:326-33. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
|
Search Pubmed for