Coccygeal Dermal Sinus: Treatment Recommendations
Primary Treatment Recommendation
All coccygeal dermal sinuses with a history of infection or abscess require complete surgical excision of the entire sinus tract combined with prolonged antibiotic therapy to prevent catastrophic complications including meningitis, epidural abscess, and intramedullary spinal cord abscess. 1, 2, 3
Clinical Decision Algorithm
Step 1: Assess for High-Risk Features Requiring Immediate Intervention
Examine for these specific findings that mandate urgent surgical referral:
- Neurological symptoms (weakness, sensory changes, bladder/bowel dysfunction) indicating possible intraspinal extension 1, 2, 3
- Systemic infection signs (fever >38.5°C, tachycardia >100 bpm, leukocytosis >12,000 cells/µL) 4
- Active abscess or purulent drainage from the sinus opening 4, 1
- Additional cutaneous markers beyond simple hair (subcutaneous mass, skin discoloration, hemangioma) suggesting intraspinal connection 5
Step 2: Determine Surgical Urgency
Emergent surgery (within 24 hours) is required for:
- Any neurological deficits or decline 1, 2, 3
- Signs of meningitis or sepsis 1, 6
- Imaging-confirmed intraspinal abscess 1, 2, 3
Urgent elective surgery (within 1-2 weeks) is required for:
- History of previous infection/abscess even if currently asymptomatic 1, 5, 6
- Recurrent local infections 5, 6
Step 3: Preoperative Imaging
MRI of the entire spine with and without contrast is mandatory before surgery to identify:
- Intraspinal extension of the sinus tract 1, 2
- Intramedullary or epidural abscess 1, 2, 3, 6
- Associated dermoid cysts or tumors 3, 6
- Extent of spinal cord involvement 1, 2, 3
Surgical Management
The definitive procedure requires:
- Complete excision of the entire dermal sinus tract from skin to its deepest extent, as incomplete removal leads to recurrence and persistent infection risk 1, 2, 3, 6
- Drainage of any intraspinal or intramedullary abscess if present 1, 2, 3, 6
- Removal of associated dermoid cysts or tumors 3, 6
- Thorough irrigation of all infected spaces 6
Critical surgical pitfall: Do not expect to find gross pus when exploring intramedullary abscesses—the infected material may appear as necrotic tissue rather than frank purulence 2
Antibiotic Therapy
For Active Infection or Abscess
Initiate broad-spectrum intravenous antibiotics immediately:
- Start empiric coverage for Gram-positive (including Staphylococcus aureus), Gram-negative, and anaerobic organisms 4
- Continue IV antibiotics for 6-8 weeks post-operatively for intraspinal involvement 2, 3, 6
- Adjust based on intraoperative cultures 4
For Simple Coccygeal Sinus Without Current Infection
Prophylactic antibiotics are NOT indicated for elective excision of an uninfected sinus 4
Post-Operative Management
Long-term multidisciplinary follow-up is essential:
- Serial neurological examinations for at least 1 year 2, 3
- Surveillance MRI at 3-6 months to assess for recurrence 2
- Bladder function monitoring (intermittent catheterization may be needed for persistent sphincter dyssynergia) 3
- Physical therapy and rehabilitation for any residual deficits 3
Critical Distinction: Simple Coccygeal Pits vs. True Dermal Sinuses
Simple intergluteal dimples or pits WITHOUT other markers do NOT require intervention if:
- Located entirely within the gluteal cleft 5
- No other cutaneous stigmata present 5
- No history of infection 5
- No neurological symptoms 5
However, any history of infection converts even a "simple" pit into a high-risk lesion requiring complete surgical excision 1, 5, 6
Prognosis
Excellent neurological recovery is possible even after severe complications (including tetraplegia) when:
- Surgical intervention occurs promptly after symptom onset 2, 3
- Complete sinus excision is achieved 2, 3
- Prolonged antibiotic therapy (6-8 weeks) is administered 2, 3, 6
- Comprehensive rehabilitation is provided 3
Poor outcomes result from: