Coccygectomy can be a option for coccydynia which is refractory to medical treatment

The aim of this study was to evaluate the clinical outcome of coccygectomy those who were refractory to conservative treatment. Twenty patients (5 males, 15 females) underwent total coccygectomy when coccygodynia did not responding to medical treatment July 2013 to September 2018. All the patients timely attended with non-traumatic (n = 12) and traumatic (n = 8) cause with mean follow-up visits of 24 months (range 18-28 months). The outcome pain intensity was evaluated by visual analogue scale (VAS) in sitting position and during daily activities. Three patients had infection which improved after antibiotic therapy. The VAS improved from 6.4 ± 0.9 to 2.1 ± 0.9 for sitting and from 5.8 ± 0.9 to 1.6 ± 0.6 for daily activities. Improvement in pain and daily activities were significant at the final follow-up. Ninety percent patients were satisfied with the operation.


Introduction
Coccygodynia was first described by Simpson in 1859. 1 Coccydynia refers to the pain in the coccygeal region.Abnormal mobility of the coccyx is present in most of the cases which causes chronic inflammatory process. 2 The coccyx is the last bone of the spinal column which is formed by 3-5 separate or fused vertebrae. 3The coccyx serves as an attachment for sacrospinous, anterior, posterior coccygeal and lateral sacrococcygeal ligaments as well as levator ani and coccygeus muscles.These structures prevent the sagging of pelvic contents. 4The coccyx may be of four types.In type 1, it is slightly curved forward, in type 2, curvature points straight forward, in type 3, it acutely angled in forward direction and in type 4, there is sacrococcygeal or intercoccygeal joint subluxation. 5The mean age of onset is usually at 40 years and the disease is more common in female because the coccyx is more prominent in female. 6The factors responsible are sacrococcygeal instability, high body mass index, trauma and childbirth.It may be primary (idiopathic, traumatic, infection, tumor, sacrococcygeal osteoarthritis, congenital, etc) or secondary (lower lumbar stenosis, neural tumors, rectal tumors and infections, urogenital system and metastases). 7e primary management of coccydynia is the conservative treatment with success rate of 90%. 8Non-operative treatment is the basis of treatment.NSAIDs are used to reduce inflammation and pain.The pressure on the coccyx can be reduced by the use of laxatives.Lifestyle modification i.e. avoiding excessive pressure on the coccyx by using soft seats and ring cushioins are the principle of conservative treatment.Therapeutic injection is also recommendded. 9The patient of primary coccydynia does not give satisfactory result by conservative treatment and hampering daily activities, the surgery is necessary.Surgery can be partial or complete coccygectomy. 10Several studies show good surgical outcome in patients with persistent pain who did not respond to conservative treatment. 11Surgical treatment of coccydynia was viewed cautiously in the past because of its high complication rates but better outcome have been shown in recent studies. 12,13 ccygectomy can be a option for coccydynia which is refractory to medical treatment Md.Anowarul Islam, Santosh Batajoo, Md.Sayeed Al Mahmud and Manish Shrestha clinical examination, all patients had marked tenderness over the coccyx.A digital examination was performed to exclude other pathology.All the patients underwent coccygectomy.

Surgical technique
Coccygectomy can be done by Powers and Gardner techniques. 14, 15The position of the patient was prone on a two parallel pillow, with hips and knees in flexion.A midline longitudinal incision was given in the back from the sacrococcygeal joint to the tip of the coccyx.The bone was dissected subperiosteally, holding the tip of the coccyx by Allis tissue forcep and sacrococcygeal joint disarticulation was performed.After that, distal part of the sacrum was beveled by bone rasp (Figure 2).Meticulous hemostasis was achieved.The wound was irrigated with normal saline.Dressing was applied.Intra-venous antibiotics was continued for 5 days followed by oral antibiotics for 2 weeks.Sutures were removed after two weeks following surgery.Patients were allowed to mobilize and sit when the pain permitted.
All patients properly attended their follow-up regularly.The mean follow-up period was 24 months.Pre-and post-operative pain were evaluated by Visual analog scale (VAS).The outcome measures included VAS, in sitting and activities of daily living (Table I).The patients were also asked if they were satisfied with the operation.Satisfaction was categorized asexcellent, good, fairly satisfactory and unsatisfactory.

Statistical analysis
Statistical analysis was done using paired t-test with significance level of p≤0.001.

Results
Excellent results were observed in 5 (sitting), 10 (activities of daily living) patients, good in 10 (sitting), 8 (activities of daily living) patients, satisfactory in 5 (sitting), 2 (activities of daily living) patients and none of our patients had poor outcome.Table II shows the results of the VAS in sitting and during activities of daily living.The result was statistically significant with the p value p<0.001.Wound infection was present in 2 (10%) cases, which resolved with antibiotics.Mean preoperative VAS was 6.3 ± 0.9 for sitting and 5.7 ± 0.9 for activities of daily living which improved to 2.1 ± 0.9 for sitting and 1.6 ± 0.6 for activities of daily living after surgery at final follow-up.No other complications were found.Worsening of pain did not occur in any patient.

Discussion
In this study, successful results in 75% (sitting) and   23 had no infection in his series of 80 patients all of whom received two prophylactic antibiotics over 48 hours and preoperative rectal enema.Ceftriaxone and flucloxa-cillin were used as prophylactic antibiotics in all the patients before surgery and same antibiotics were used in postoperative period for five days, as well as preoperative rectal enema were given.In this study, we encountered 10% cases of wound infection.The infections were controlled after treatment with antibiotics according to culture and sensitivity.Wound infection is the most common complication ranging from 2 to 22%. 24The limitation of this study is the low number of cases.

Conclusion
In our series, total coccygectomy showed good relief of pain in majority of the patients.With meticulous operative technique and correct patient selection, the outcome of coccygectomy is good in patients with coccydynia which is refractory to conservative treatment.