Here is the list
of my major publications on coccydynia.
Chronic coccydynia in adolescents. A series of 53 patients.
Maigne JY et al, 2011
Little is known about coccydynia in adolescents. The aim of this study was to explore causes, clinical and imaging features and response to treatment of chronic coccydynia in adolescents. DESIGN: This was a cohort study. SETTING: The study included patients followed up at a specialized consultation in a university hospital. METHODS: A series of 53 adolescent patients with chronic coccydynia were followed for 1-4 years. Investigations included dynamic X-ray films, with a magnetic resonance imaging scan of the coccyx in 26/53. Treatment was by coccygeal steroid injection or non-steroidal anti-inflammatory drugs (NSAIDs). Amitriptyline or coccygectomy were used as second-line treatment. Outcomes were assessed at a consultation two months after the treatment, then between one to four years later, by telephone interview, questionnaires and by a visual analogue scale (VAS). Fifty-one adult patients with coccydynia formed the control group. RESULTS: In 20 cases (37.7%) the coccydynia was subsequent to trauma. Obesity was not a risk factor. Abnormal mobility was rarer and spicules more frequent compared to adult patients (P<0.001); 11/27 MRI scans showed a hypersignal within the disc or adjacent bone and 6/27 a hypersignal surrounding the tip of the coccyx (bursitis). Initial treatment was a coccygeal steroid injection for 41 patients and NSAIDs for 12. Ten were given amitriptyline and 3 a coccygectomy. At final assessment, there was no pain or almost no pain in 32/53 (60.4%), moderate pain and functional impairment in 12/53 (22.6%) and severe pain and functional impairment in 9/53 (17%). CONCLUSION: Coccydynia in adolescents differs from coccydynia in adults. A MRI scan is helpful and should be obligatory for diagnosis. Prognosis is relatively good. Clinical rehabilitation impact. Our results should help clinicians manage this rare and debilitating condition.
Prevention of post coccygectomy infection in a series of 136 coccygectomies
Doursounian L, Maigne JY et al, 2010
Postoperative infection is a regular complication in coccygectomy. The authors propose the use of a topical skin adhesive on the postoperative wound as a contribution to the prevention of this complication. It was used on the first 56 patients in this study. The rate of infection was 3.6% compared with the 14% rate of infection in a previous study. The 80 following patients had, in addition to the skin adhesive, two prophylactic antibiotics for 48 hours (cefamandole and ornidazole), a preoperative rectal enema, and closure of the incision in two layers. The rate of infection dropped to 0.0%. Topical skin adhesive constitutes a significant contribution in the prevention of infection after coccygectomy.
Four cases of coccygeal disk calcification after cortivazol injection
Maigne JY. Joint Bone Spine. 2009;
Chronic coccydynia can be treated with a glucocorticoid injection into the pain-causing intercoccygeal disk. We report four cases of calcifications within intercoccygeal disks previously injected with cortivazol. In two patients, the calcifications probably caused additional pain. Prednisolone acetate should be preferred over cortivazol for intercoccygeal disk injections.
2008
Coccydynia
related to calcium crystal deposition
Richette
P, Maigne JY, Bardin T. Spine. 2008;33:E620-3.
STUDY DESIGN:
Study of 4 cases of severe coccydynia revealing calcium deposits in
the sacrococcygeal and intercoccygeal joints. OBJECTIVE: To
highlight calcium crystal deposition as a cause of sudden-onset coccydynia.
SUMMARY OF BACKGROUND DATA: Intervertebral disc calcification
in the cervical, thoracic, or lumbar spine is well known, but calcifications
in the sacrococcygeal or intercoccygeal joints with symptoms have never been
reported. METHODS: All 4 patients presented with severe, sudden-onset
coccydynia. Radiographs of the coccygeal area showed calcific deposits in the
sacrococcygeal or intercoccygeal joints. Patients received a short course of
oral corticosteroids or steroid injections. RESULTS: Conservative
management provided prompt relief in all but one case. In 2, the resolution
of the calcific deposits as seen on follow-up radiography was highly suggestive
of their apatite origin. CONCLUSION: Calcium crystal deposition
in the sacrococcygeal or intercoccygeal joints can cause coccydynia. Conservative
treatment is effective as a first-line approach.
2006
The
treatment of chronic coccydynia with intrarectal manipulation: a randomized
controlled study
Maigne
JY, Chatellier G, Le Faou M, Archambeau M. Spine. 2006;31:E621-7.
STUDY DESIGN:
Randomized open study. OBJECTIVE: To evaluate the efficacy
of intrarectal manual treatment of chronic coccydynia; and to determine the
factors predictive of a good outcome. SUMMARY OF BACKGROUND DATA: In
2 open uncontrolled studies, the success rate of intrarectal manipulation of
the coccyx was around 25%. METHODS: Patients were randomized
into 2 groups of 51 patients each: 1 group received three sessions of coccygeal
manipulation, and the other low-power external physiotherapy. The manual treatment
was guided by the findings on stress radiographs. Patients were assessed, at
1 month and 6 months, using a VAS and (modified) McGill Pain, Paris (functional
coccydynia impact), and (modified) Dallas Pain questionnaires. RESULTS:
At baseline, the 2 groups were similar regarding all parameters. At
1 month, all the median VAS and questionnaire values were modified by -34.7%,
-36.0%, -20.0%, and -33.8%, respectively, in the manipulation group, versus
-19.1%, -7.7%, 20.0%, and -15.7%, respectively, in the control (physiotherapy)
group (P = 0.09 [borderline], 0.03, 0.02, and 0.02, respectively). Good results
were twice as frequent in the manipulation group compared with the control group,
at 1 month (36% vs. 20%, P = 0.075) and at 6 months (22% vs. 12%, P = 0.18).
The main predictors of a good outcome were stable coccyx, shorter duration,
traumatic etiology, and lower score in the affective parts of the McGill and
Dallas questionnaires. CONCLUSIONS: We found a mild effectiveness
of intrarectal manipulation in chronic coccydynia.
2005
Le
traitement chirurgical des coccygodynies / Surgical treatment of coccydynia
Doursounian
L, Maigne JY. e-mémoires de l'Académie Nationale de Chirurgie.
2005;4(3):23-9 Full
textPDF
Résumé
La pratique systématique de radiographies fonctionnelles du coccyx chez
les patients présentant une coccygodynie a permis de mettre en évidence
des instabilités coccygiennes qui se traduisent par des subluxations
ou par des hypermobilités en position assise. Lorsque le traitement médical
de ces coccygodynies était inefficace, la chirurgie a été
proposée. Entre 1993 et 2000, 61 coccygodynies par instabilité
ont été opérées. Il y avait 49 femmes et 12 hommes,
dont l’âge moyen était de 45.3 ans (18-72). Vingt sept patients
avaient une hypermobilité, 33 une subluxation et 1 cas était mixte.
Dans tous les cas la portion instable a été retirée. Le
suivi était entre 12 et 30 mois. Le résultat a été
estimé excellent ou bon pour 53 patients, moyen pour 1 et mauvais pour
7. Il y a eu 9 cas compliqués d’infection et qui ont nécessité
une réintervention. De 2002 à 2005, 48 patients consécutifs
présentant diverses causes de coccygodynie ont été opérés
avec une nouvelle procédure de fermeture cutanée. Ces patients
sont en cours d’évaluation quant aux résultats sur la douleur,
mais parmi eux seuls deux cas d’infection postopératoire ont été
observés.
Surgical management of coccygodynia
The advent of a dynamic radiography technique for patient with chronic coccygeal
pain showed coccygeal instability. There are two patterns: posterior subluxation
of the coccyx when sitting and hyperflexion of the coccyx when sitting. Patients
who did not obtain relief from conservative management where offered surgery.
Between 1993 and 2000, 61 patients with instability-related coccygodynia where
operated on. There were 49 women and 12 men, mean age 45.3 (18-72) years. Twenty
seven patients had hypermobility of the coccyx and 33 subluxation. One case
had a mixed pattern. In all cases, the unstable portion was removed. Follow-up
was between 12 and 30 months. The outcome was rated excellent or good in 53
patients, fair in 1 and poor in 7. There were 9 patients with infection requiring
reoperation. Between 2002 and 2005, 48 others patients were operated on with
a new technique of wound closure. These patients are currently under evaluation
concerning pain relief and among them there are only 2 cases of postoperative
infection.
2004
Coccygectomy
for instability of the coccyx
Doursounian
L, Maigne JY, Faure F, Chatellier G. Int Orthop. 2004;28:176-9.
Between 1993 and
2000, 61 patients with instability-related coccygodynia were operated on by
a single surgeon using the same technique. There were 49 women and 12 men, mean
age 45.3 (18-72) years. Twenty-seven patients had hypermobility of the coccyx
and 33 subluxation. In all cases, the unstable portion was removed through a
limited incision directly over the coccyx. The outcome was assessed using a
detailed questionnaire. Follow-up was between 12 months and more than 30 months.
The outcome was rated excellent or good in 53 patients, fair in one, and poor
in seven. There were nine patients with infection requiring reoperation.
2001
Comparison
of three manual coccydynia treatments: a pilot study
Maigne
JY, Chatellier G. Spine. 2001;26:E479-83; discussion E484. Full
text
STUDY DESIGN:
A prospective pilot study with independent assessment and a 2-year follow-up period
was conducted. OBJECTIVES: To compare and assess the efficacy
of three manual coccydynia treatments, and to identify factors predictive of a
good outcome. SUMMARY OF BACKGROUND DATA: Various manual medicine
treatments have been described in the literature. In an open study, the addition
of manipulation to injection treatment produced a 25% increase in satisfactory
results. Dynamic radiographs of the coccyx allow breakdown of coccydynia into
four etiologic groups based on coccygeal mobility: luxation, hypermobility, immobility,
and normal mobility. These groups may respond differently to manual treatments.
METHODS: The patients were randomized into three groups, each
of which received three to four sessions of a different treatment: levator anus
massage, joint mobilization, or mild levator stretch. Assessment with a visual
analog scale was performed by an independent observer at 7 days, 30 days, 6 months,
and 2 years. RESULTS: The results of the manual treatments were
satisfactory for 25.7% of the cases at 6 months, and for 24.3% of the cases at
2 years. The results varied with the cause of the coccydynia. The patients with
an immobile coccyx had the poorest results, whereas those with a normally mobile
coccyx fared the best. The patients with luxation or hypermobility had results
somewhere between these two rates. Levator anus massage and stretch were more
effective than joint mobilization, which worked only for patients with a normally
mobile coccyx. Pain when patients stood up from sitting and excessive levator
tone were associated with a good outcome. However, none of the results was significant
because of the low success rate associated with manual treatment. CONCLUSIONS:
There is a need for a placebo-controlled study to establish conclusively whether
manual treatments are effective. This placebo must be an external treatment. A
sample size of 190 patients would be required for 80% confidence in detecting
a difference.
2000
Causes
and mechanisms of common coccydynia: role of body mass index and coccygeal
trauma
Maigne
JY, Doursounian L, Chatellier G. Spine. 2000 Dec 1;25(23):3072-9. Full
text
STUDY DESIGN:
A total of 208 consecutive coccydynia patients were examined with the same clinical
and radiologic protocol. OBJECTIVES: To study radiographic coccygeal
lesions in the sitting position, to elucidate the influence of body mass index
on the different lesions, and to establish the effect of coccygeal trauma. SUMMARY
OF BACKGROUND DATA: A protocol comparing standing radiographs and radiographs
subsequently taken in the painful sitting position in coccydynia patients and
in controls has shown two culprit lesions: posterior luxation and hypermobility.
Obesity and a history of trauma have been identified as risk factors for luxation.
METHODS: Dynamic radiographs were obtained. The body mass index was compared
with the coccygeal angle of incidence, sagittal rotation of the pelvis when sitting
down, and the presence and time of previous trauma. The patients with the newly
described lesions were examined after an anesthetic block under fluoroscopic guidance.
RESULTS: Two new coccygeal lesions are described (anterior luxation
and spicules). Obesity was found to be a risk factor. The body mass index determines
the way a subject sits down, and lesion patterns were different in obese, normal-weight,
and thin patients (posterior luxation: 51%, 15.2%, 3.7%; hypermobility: 26.5%,
30.3%, 14.8%; spicules: 2%, 15.9%, 29.6%; normal: 16.3%, 32.6%, 48.1%, respectively;
P < 0.0001). Trauma affected the type of lesion only if it was recent (<1
month before the onset of coccydynia), in which case the instability rate increased
from 55.6% to 77.1%. Backward-moving coccyges were at greatest risk of trauma.
CONCLUSIONS: This protocol allows identification of the culprit
lesion in 69.2% of cases. The body mass index determines the causative lesion,
as does trauma sustained within the month preceding the onset of the pain.
2000
Instability
of the coccyx in coccydynia
Maigne
JY, Lagauche D, Doursounian L. J Bone Joint Surg [Br]. 2000;82:1038-41.
Coccygectomy is a
controversial operation. Some authors have reported good results, but others advise
against the procedure. The criteria for selection are ill-defined. We describe
a study to validate an objective criterion for patient selection, namely radiological
instability of the coccyx as judged by intermittent subluxation or hypermobility
seen on lateral dynamic radiographs when sitting. We enrolled prospectively 37
patients with chronic pain because of coccygeal instability unrelieved by conservative
treatment who were not involved in litigation. The operation was performed by
the same surgeon. Patients were followed up for a minimum of two years after coccygectomy,
with independent assessment at two years. There were 23 excellent, 11 good and
three poor results. The mean time to definitive improvement was four to eight
months. Coccygectomy gave good results in this group of patients.
2000
Coccydynia
after lumbar fusion: searching for the cause
Maigne
JY et al. Congress of the International Society for the Study of the Lumbar
Spine. Adelaide 2000
PURPOSE
An abnormally high rate of coccydynia following lumbar fusion (CLF) has been reported,
but not explained. We tried to define the risk and to establish why lumbar fusion
should be followed by coccydynia. BACKGROUND DATA A protocol
for the investigation of the coccyx has been described, involving lateral films
with the patient standing and then sitting in the painful position. This investigation
showed two major causes (48.8% of cases) of coccydynia seen in the sitting position
only: posterior luxation of the coccyx (reduced when standing), and hypermobility
in flexion. These two causes were seen in different patients, as shown by a recent
series of 208 cases (Table). In the other cases, patients had normal coccygeal
mobility when sitting, with the coccyx usually flexed. This series showed that
the body mass index (BMI) was related to certain angles that reflected the way
patients were sitting down and positioning their coccyx. A high BMI was associated
with low degree of pelvic rotation when sitting down, and with a high coccygeal
angle of incidence; and vice versa. The type of lesion was a function of the angle
of incidence (Table). The risk of post-traumatic coccydynia was a function of
the degree of pelvic rotation. With a high degree of rotation, the coccyx tucks
itself in under the pelvis on sitting down, and is thus protected. With a low
degree of pelvic rotation, the coccyx remains posterior and vertical, and is thus
exposed to external trauma and to repetitive sitting stress microtrauma.
METHODS Of 380 patients with chronic coccydynia examined since 1992,
11 (2.9%) had CLF. In nine cases, the condition had appeared within 3 months after
surgery, without any associated low-back pain. In two cases, coccygodynia was
made markedly worse by fusion. The results of the patients’ radiological
examination were compared with those of a control group of 208 patients without
CLF. Statistical Analysis Proportions were compared using the
chi squared test. Comparisons of several means were performed using ANOVA or t-tests,
as appropriate. A significance level of p<0.05 was used. RESULTSFrequency According to health authority estimates, the rate of lumbar
fusions in France is 0.05% of the adult population. Thus, the relative risk of
CLF is 58 (p<0.0001). None of the CLF patients had a history of local trauma
(vs 33.6% of the controls, p=0.02). Fusion is not, therefore, associated with
a higher rate of a fall on the coccyx. Lesions Nine patients (82%) had
hypermobility; one patient (9%) had posterior luxation; and one (9%) had normal
mobility; this pattern was different from the one found in the control group,
where the respective rates were 27.6%, 21.2%, and 51.2% (p<0.0001). BMI
and angles In the CLF group, the BMI (22.8±3.5) and the coccygeal
angle of incidence (21°±25) did not differ greatly from the values
seen in the controls with the same lesions (24.4±4.4, p=0.23; and 24.8°+20,
p=0.17, respectively). However, the degree of pelvic rotation was very much lower
in the CLF group (24.4°±7.6 vs 42.6°±13.2, p=0.01), showing
that lumbopelvic rotation had been blocked by fusion. CONCLUSION
CLF patients constitute a homogeneous group with the following features: no history
of causative trauma; major limitation of sagittal pelvic rotation; and predominance
of hypermobility as the cause of coccygeal pain. Lumbar fusion increases the risk
of coccydynia, since it limits pelvic rotation on sitting down. This means that
(1) the coccyx will not tuck itself completely under the pelvis in the sitting
position, and will therefore be exposed to repetitive sitting stress microtrauma;
and (2) the stiff lumbosacral junction will transfer the sitting-down stress onto
the coccyx. The low angle of coccygeal incidence further exposes the coccyx to
hyperflexion in case of microtrauma.
1996
Standardized
radiologic protocol for the study of common coccygodynia and characteristics
of the lesions observed in the sitting position. Clinical elements differentiating
luxation, hypermobility, and normal mobility
Maigne
JY, Tamalet B. Spine. 1996;21:2588-93.
STUDY DESIGN:
Ninety-one patients with common coccygodynia and 47 control subjects prospectively
underwent dynamic radiographic imagery. OBJECTIVES: To standardize the radiologic
protocol to better define normal and abnormal mobility of the coccyx, and to study
clinical parameters useful in classifying and differentiating the lesions. SUMMARY
OF BACKGROUND DATA: In a previous study, comparison of films taken in
the sitting and standing positions allowed to individualize two distinct coccygeal
lesions: luxation and hypermobility. Measurement technique was precise and reproducible,
but the control group was not pain-free. No specific clinical features were described.
METHODS: Standing films were made first. Control subjects were
healthy volunteers. The following items were recorded: presence of an initial
traumatic event, elapsed time before investigation, body mass index, presence
of an acute pain when passing from sitting to standing, effect of intradiscal
steroid injection, and angle of the coccyx with respect to the seat. RESULTS:
Hypermobility was defined as a flexion of more than 25 degrees, luxation by displacement
of more than 25% of the coccyx. The base angle is a good predictor of the direction
in which the coccyx moves when sitting. In the "luxation" group, a history
of initial trauma, a shorter clinical course, pain when standing up, increased
body mass index, and satisfactory results with intradiscal injection were found
more frequently than in the "normal" group. The "hypermobility"
group had characteristics between these two groups. CONCLUSION:
Common coccygodynia is associated in 48.4% of patients with a luxation or hypermobility
of the coccyx. A distinct clinical presentation was found in individuals with
luxation of the coccyx.
1994
Idiopathic
coccygodynia. Lateral roentgenograms in the sitting position and coccygeal
discography
Maigne
JY, Guedj S, Straus C. Spine. 1994;19:930-4.
STUDY DESIGN.
The authors hypothesized that the source of coccygodynia was a lesion
of the coccygeal disc. OBJECTIVES. This study analyzed the motion
of the painful coccyx in the sitting position as compared with the lateral decubitus
in a patient and a control group and reported the first results of coccygeal discography
(dynamic study). SUMMARY OF BACKGROUND DATA. Coccygodynia are
usually attributed to soft tissue injuries or psychologic disturbances. No previous
study has assessed the coccygeal discs as a source of pain. METHODS. Fifty-one
patients with coccygodynia and 51 controls sustained a dynamic study. Coccygeal
mobility was documented by superimposing graph paper with a double reading. The
accuracy of the measurement was +/- 2.6 degrees intra- and interobserver variations
15.3 and 12.5%. This dynamic study was followed by coccygeal discography in the
patient group. RESULTS. An abnormal motion (luxation or hypermobility)
of the coccyx that occurred in the sitting position and spontaneously was reducible
when placed in the lateral decubitus position was found in 25 patients. Such lesions
could be responsible for the pain because no similar findings were seen in the
controls and coccygeal discography was positive in these cases. Of the 26 patients
with a normal dynamic study, coccygeal discography, using a combination of provocation
and anesthetization, was positive in 15 of 21. CONCLUSIONS. Common
coccygeal pain could come from the coccygeal disc in approximately 70% of cases.
1992
[Coccygodynia:
value of dynamic lateral x-ray films in sitting position] [Article in
French]
Maigne
JY, Guedj S, Fautrel B. Rev Rhum Mal Osteoartic. 1992;59:728-31.
In coccygodynia, pain
is most severe in the sitting position. This prompted a study comparing lateral
roentgenograms of the coccyx taken with the patient lying on the side with films
taken in the (painful) sitting position. In this prospective study, eight of 30
patients had posterior subdislocation of the coccyx which caused pain and was
visible only on the films taken in the sitting position.
Résumé
Surgical management of coccygodynia
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