====== Coccydynia Treatment ======

Numerous [[treatment]]s have been proposed, and some are offered here for historical purposes
((Wray CC, Easom S, Hoskinson J. Coccydynia. Etiology and Treatment. J Bone Joint Surg. 1991; 73B:335–338))
(and to dissuade casual attempts to effect a “new” cure that in reality has already been tried):

1. plaster jackets

2. hot baths (sitz baths), heating pads

3. massage therapy

4. [[XRT]]

5. psychotherapy

Most cases resolve within ≈ 3 months of conservative management consisting of [[NSAID]]s, mild analgesics, and measures to reduce pressure on the [[coccyx]] (e.g. a rubber ring (“doughnut”) sitting cushion, lumbar supports to maintain sitting lumbar lordosis to shift weight from coccyx to posterior thighs)
((Raj PP, Raj PP. Miscelleneous Pain Disorders. In: Pain Medicine: A Comprehensive Review. St. Louis: C V Mosby; 1996:492–501))


Management recommendations for refractory cases
((Wray CC, Easom S, Hoskinson J. Coccydynia. Etiology and Treatment. J Bone Joint Surg. 1991; 73B:335–338))
((Raj PP, Raj PP. Miscelleneous Pain Disorders. In: Pain Medicine: A Comprehensive Review. St. Louis: C V Mosby; 1996:492–501))

1. local injection: 60% respond to [[corticosteroid]] + local anesthetic (40 mg Depo-Medrol® in 10 cc of
0.25% bupivacaine). Recommended as initial treatment; the response should be achieved by 2
injections

2. manipulation of the coccyx: usually under general anesthesia. ≈ 85% successful when combined
with local injection

3. ± physiotherapy (diathermy & ultrasound): found to be of benefit only in ≈ 16% (maybe more
effective with the addition of gentle manipulation of the coccyx without general anesthesia
((Boeglin ER. Coccydynia. J Bone Joint Surg. 1991; 73B)))

4. [[caudal epidural injection]]

5. blockade or neurolysis (with chemicals or by cryoablation
((Loev MA, Varklet VL, Wilsey BL, et al. Cryoablation: A Novel Approach to Neurolysis of the Ganglion Impar. Anesthesiology. 1998; 88:
1391–1393)))
of the ganglion impar (AKA ganglion of Walther, the lowest ganglion of the paired paravertebral sympathetic chain, located just anterior to the sacrococcygeal junction): some success has been described with this technique (traditionally used for intractable sympathetic perineal pain of neoplastic etiology
((Plancarte R, Amescua C, Patt RB, et al. Superior
Hypogastric Plexus Block for Pelvic Cancer Pain.
Anesthesiology. 1990; 73:236–239)))

6. neurolytic techniques directed to S4, S5, and coccygeal nerves

7. coccygectomy (surgical removal of the mobile portion of the coccyx, followed by smoothening of
the residual bony prominence on the sacrum): was required in ≈ 20% of patients in one series,
((Wray CC, Easom S, Hoskinson J. Coccydynia. Etiology and Treatment. J Bone Joint Surg. 1991; 73B:335–338))
with a reported success rate of 90%. However, many practitioners do not view this as a highly effective treatment and feel that great restraint should be used in considering this form of therapy
----
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.

Coccygectomy is not recommended because of long-term moderate results and the chance of major complications
((Patijn J, Janssen M, Hayek S, Mekhail N, Van Zundert J, van Kleef M. 14.
Coccygodynia. Pain Pract. 2010 Nov-Dec;10(6):554-9. doi:
10.1111/j.1533-2500.2010.00404.x. Epub 2010 Sep 6. Review. PubMed PMID: 20825565.
))

[[Ganglion impar]] block appears to be effective in patients who have coccygodynia resistant to conservative therapy, with high success rates and prolonged duration of effect. Controlled studies are required to reveal the mechanism of this effect
((Usta B, Gozdemir M, Sert H, Muslu B, Demircioglu RI. Fluoroscopically guided
ganglion impar block by pulsed radiofrequency for relieving coccydynia. J Pain
Symptom Manage. 2010 Jun;39(6):e1-2. doi: 10.1016/j.jpainsymman.2010.02.005.
PubMed PMID: 20538176.
))
((Gunduz OH, Sencan S, Kenis-Coskun O. Pain Relief due to Transsacrococcygeal
Ganglion Impar Block in Chronic Coccygodynia: A Pilot Study. Pain Med. 2015
Jul;16(7):1278-81. doi: 10.1111/pme.12752. Epub 2015 Mar 20. PubMed PMID:
25801345.
)).

===== References =====