What is the recommended injection treatment for coccydodynia?

Recommended Injection Treatment for Coccygodynia

Local anesthetic and corticosteroid injections are the recommended first-line injection treatment for coccygodynia, particularly for patients who have failed conservative management. 1, 2

Diagnostic Considerations

• Coccygodynia is pain in the tailbone (coccyx) area that can significantly impact quality of life due to sitting intolerance 1
• Common causes include:
  • Trauma (fracture, subluxation, luxation) 1
  • Abnormal mobility (hypermobility, anterior/posterior subluxation) 1, 2
  • Disc degeneration at sacrococcygeal and intercoccygeal segments 1
  • Coccygeal spicule (bony excrescence) 1
  • Idiopathic (30% of cases) 1

Injection Treatment Algorithm

First-Line Injection Therapy

• Local anesthetic and corticosteroid injections into painful structures around the coccyx 1, 3
  • Target sites: sacrococcygeal disc, first intercoccygeal disc, Walther's ganglion, and muscle attachments around the top of the coccyx 1
  • Technique: Fluoroscopic guidance recommended for accurate placement 4, 3
  • Efficacy: Significant pain relief in majority of patients, particularly those with Postacchini Type I coccyx configuration 3

Second-Line Injection Therapy

• Ganglion impar block for patients who fail local corticosteroid injections 4, 5
  • Target: Terminal end of the pelvic sympathetic chain 4
  • Approach: Trans-sacrococcygeal joint or intra-coccygeal joint approach under fluoroscopic guidance 4
  • Efficacy: Can provide complete pain relief (NRS=0) lasting up to one year in some patients with idiopathic coccygodynia 4

Patient Selection for Injection Therapy

• Best candidates for local steroid injections:

  • Patients with Type I coccyx configuration (normal curved coccyx) 3
  • Those with idiopathic coccygodynia 1, 4
  • Patients who have failed conservative measures (rest, cushioning, physical therapy) 2, 3

• Best candidates for ganglion impar block:

  • Patients with chronic idiopathic coccygodynia unresponsive to medical management 4
  • Those who have failed local infiltration of the coccyx 4

Treatment Progression

1. Begin with conservative measures (cushioning, physical therapy, NSAIDs) for 2-3 months 1, 2
2. If unsuccessful, proceed to local anesthetic and corticosteroid injections 1, 3
3. For persistent pain, consider ganglion impar block 4, 5
4. For refractory cases with abnormal mobility or spicule formation, surgical intervention (coccygectomy) may be considered 2, 3, 5

Common Pitfalls and Considerations

• Diagnostic confirmation of coccygeal origin of pain should be established before injection therapy, as extracoccygeal disorders can mimic coccygodynia 1
• Dynamic radiographs (lateral X-rays in standing and sitting positions) should be obtained to identify abnormal mobility, which is present in 70% of patients 1
• Type II, III, and IV patients (based on Postacchini classification) may respond better to surgical intervention than injections 3
• Patients with trauma history may have less sustained response to injections 3
• Proper technique with fluoroscopic guidance is essential for accurate placement and optimal outcomes 4, 3