Is a patient with minimal outward displacement of the distal coccygeal segment and surrounding minimal soft tissue thickness a candidate for partial or total coccygectomy?

Management of Minimal Outward Displacement of Distal Coccygeal Segment

Coccygectomy is not indicated for minimal outward displacement of the distal coccygeal segment with minimal soft tissue thickness unless conservative treatments have failed and the patient has significant, persistent pain affecting quality of life.

Assessment of Coccygodynia

When evaluating a patient with coccygeal pain (coccygodynia) and radiological findings showing minimal outward displacement:

• Dynamic radiographic assessment is the most accurate diagnostic tool to evaluate abnormal coccygeal mobility 1
• Pain characteristics: Assess if pain is exacerbated by sitting, standing from sitting position, or direct pressure
• Duration of symptoms: Chronic coccygodynia is typically defined as pain lasting more than 2-3 months
• Previous treatments: Document response to conservative measures

Treatment Algorithm

First-Line Treatment (Conservative Management)

1. Non-steroidal anti-inflammatory medications
2. Cushioning devices to reduce pressure on the coccyx
3. Physical therapy including:
   • Coccygeal massage
   • Stretching of the levator ani muscle 1
4. Local injections of anesthetic and corticosteroid into the painful segment 1

Second-Line Treatment

If conservative management fails after 3-6 months:

• Bimanual coccyx manipulation under anesthesia to address any mobility issues 2

Surgical Consideration (Third-Line)

Surgery should only be considered when:

1. Conservative treatment has definitively failed (typically after 6+ months)
2. Pain significantly impacts quality of life
3. There is radiographic evidence of abnormal coccygeal mobility or a significant anatomical abnormality 1

Surgical Outcomes and Patient Selection

The evidence shows that coccygectomy can be effective in carefully selected patients:

• Success rates range from 70-90% in patients who failed conservative management 3, 2
• One study reported 79% of patients had very satisfactory outcomes after coccygectomy 4

However, careful patient selection is critical as certain factors predict poor outcomes:

• Pre-existing psychiatric disorders
• Pre-operative opiate use
• Multiple comorbidities (>3)
• Poor pre-operative quality of life scores 3

Surgical Complications

Potential complications of coccygectomy include:

• Wound infection (most common complication) 2, 5
• Delayed wound healing
• Persistent pain requiring reoperation in some cases 5

Conclusion

For a patient with minimal outward displacement of the distal coccygeal segment and minimal soft tissue thickness, coccygectomy should be reserved only for cases with:

1. Significant pain affecting quality of life
2. Failure of comprehensive conservative management
3. Radiographically demonstrated abnormalities of coccygeal mobility

The minimal findings described in this case suggest starting with conservative management rather than proceeding directly to surgical intervention.