We recently represented a client in a motor vehicle crash caused by a man that ran a stop sign, broadsided our client on the passenger side and pushed her into a car coming from her opposite direction, head-on. This resulted in an injury to her low back and coccyx. She was diagnosed with ‘chronic coccydynia.’ The insurers argued that it was not related to trauma. We proved them wrong, had them pay for her medical expenses and losses, and reached a successful outcome on her case. We wanted to share with you what we learned in this case about coccyx injuries and trauma.
I. Trauma and Injury to the Coccyx (Tailbone) is Called Coccydnia
The coccyx is part of the law back and is at the very bottom of the tailbone. An injury to the coccyx is usually brought on by trauma to the tailbone or the surrounding area[1], such as falling directly on it, or by traumatic injury to the surrounding structure in motor vehicle collisions. The coccyx can become injured from a hard impact to the base of the spine, such as by falling over while ice skating, or tripping over a stair, or, in many cases, to an occupant involved in a motor vehicle collision with high velocity acceleration/deceleration and rotational forced directly to the coccyx or to the surrounding structure of the tailbone.
Coccydynia is the persistent, often disabling, pain in the coccyx which is most frequently worsened or aggravated by sitting, or any activity that puts pressure on the base of the spine. The coccyx has important anatomical and physiological relations to the fifth sacral and coccygeal nerve roots, the terminal sympathetic plexus, and the pelvic floor musculature, including the piriformis muscle. Coccyx-related injury can produce local pain and tenderness as well as radiating and radicular symptoms.
According to the insurer and its attorneys in our client’s case, an injury to the coccyx can only occur from direct trauma to the tailbone, such as a fall and landing on the tailbone. This is not true. In fact, in some cases, direct trauma to the low back or the sacroiliac joint can eventually lead to chronic coccydynia.[2] In other cases, low back or sacroiliac joint dysfunction has led to the development of severe, and chronic, coccydynia that developed as late as four weeks post original trauma. Many patients with referred coccyx pain also have co-existing lumbar spine disorders, including painful discs on provocative discography, disc herniations, and sacroiliac joint disease.[3]
II. Coccydynia and Activities of Daily Living (ADLs)
Along with pain while sitting, coccydynia symptoms can also include tenderness around the tailbone area. Some people suffering from coccydynia are completely unable to sit, and require a donut pillow or frequent icing directly to the coccyx for relief. This can make driving, working and other frequent activities that involve bending or sitting virtually impossible for people suffering from chronic coccydynia. Patients with coccydynia frequently complain of also having pain while rising from a seated position, pain with bowel movements, backache, shooting pain down the legs, pain during intercourse, pain in the buttocks and hips, and increased pain with menstruation for women as well. The pain of coccydynia can range from mild to severe, and is usually worse when sitting down, particularly while leaning backwards, or moving from the sitting to the standing position. Some people can only tolerate sitting in the same position for a few minutes before needing to move to relief pain.
III. Diagnosing Chronic Coccydynia
Abnormal mobility of the coccyx, which can be seen on dynamic radiograph (lateral X-rays of the coccyx in the standing and seated position), is the most common pathological finding in patients with coccydynia (70% of patients). Coccygeal origin of the pain can be confirmed by anesthetic injection, performed by a medical specialist highly skilled and experienced in injecting this area of the spine, in the structures that can be a source of the pain (in the sacro-coccygeal or intercoccygeal segments, Walther’s ganglion, muscle attachments around the top of the coccyx, etc).[4]
IV. Treatment Options for Coccydynia
Chronic coccydynia is defined as lasting more than two months.[5] Chronic coccydynia is unlikely to clear up without a multi-tiered approach to treating it.
Initial treatment for coccydynia traditionally includes:
- Applying ice or a cold pack to the area several times a day;
- Avoiding sitting for prolonged periods, or placing any pressure on the area, as much as possible;
- Using a custom pillow to help take pressure off the coccyx when sitting. Some find a donut-shaped pillow works well, and for others it is not the right shape and still puts pressure on the coccyx. Many prefer a foam pillow that is more of a U-shape or V-shape (with the back open so nothing touches the coccyx). Any type of pillow or sitting arrangement that keeps pressure off the coccyx is ideal;
- Using stool softener and increased water and stool softeners, when the tailbone pain is caused or increased with bowel movements or constipation; and/or
- Taking non-steroidal anti-inflammatory drugs (NSAIDs). Common NSAIDs, such as ibuprofen, naproxen and COX-2 inhibitors, help reduce the inflammation around the coccyx that is usually a cause of the pain;
Non-surgical medical treatment includes:
- Injection. A local injection of a numbing agent (lidocaine) and steroid (to decrease inflammation in the area);
- Manipulation. Some patients find pain relief through manual manipulation (e.g. chiropractic treatment);
- Stretching. Gently stretching the ligaments attached to the coccyx can be helpful. A physical therapist, chiropractor, physiatrist or other appropriately trained healthcare practitioner can provide instruction on the appropriate stretches; and/or
- Ultrasound. Physical therapy with ultrasound can also be helpful for pain relief.
More invasive procedures can include:
- Injection. A local injection of a numbing agent (lidocaine) and steroid (to decrease inflammation in the area);
- Neurotomy to denervate the peripheral nerve going to the coccyx. Under fluoroscopic guidance, the peripheral nerves are burned through radiofrequency thermal lesioning;
- Partial rhizotomy, which involves drilling holes through the sacral plate lesioning of the dorsal root ganglia to the S5; and/or
- Coccygectomy. If all else fails, a surgical coccygectomy can be performed for patients whose tailbone pain failed to respond to more conservative measures. The procedure involves the surgical removal of all, or part, of the coccyx. The recovery period for the patient is quite involved, and infection is a significant concern. A 2011 University of California Medical Center clinical case series, the largest in North America, monitored 62 consecutive cases of coccygectomy for coccydynia between 1997 and 2009. 26 patients were contacted for follow-up, on average 37 months post surgery. The clinical results among the 26 patients were as follows: 13 excellent, 9 good, 2 fair and 2 poor. The overall favorable (excellent and good) outcome after coccygectomy was 84.6%. There were 3 wound infections. There were no rectal injuries. An overwhelming majority of patients were satisfied with the procedure.[6]
The attorneys at Adler ♦ Giersch ps are familiar with traumatic injuries and personal injuries ranging from common to complex as well as rare injuries. Having a knowledgeable and well informed attorney on the side of your patient when faced with insurers that deny responsibility or payment for any reason, including lesser known and complicated injuries, is critical towards fairly and reasonably resolving a personal injury claim. We are available for consultations on a complimentary basis. Simply give us a call.
[1] See Maigne, JY, Doursounian, L. Cjatellier G. Causes and mechanisms of common coccydynia: role of body mass index and coccygeal trauma. Spine. 2000; 25:3072-9.
[2] Nathan, ST, Fisher, BE, Roberts CS. Coccydynia: a review of the pathoanatomy, etiology, treatment and outcome. J. Bone Joint Surg (Br.). 2010; 92-B:1622-7.
[3] Perkins, et al (J. Spinal Disor Tech)
[4] Lijec Vjesn. 2012 Jan-Feb;134(1-2):49-55, PMID: 22519253
[5] See Kerr, et al (J. Neurosurg. Spine, 14:654-653, 2011)
[6] See Kerr, et al (J. Neurosurg. Spine, 14:654-653, 2011
