Background

Coccygectomy is a surgical procedure aimed at the removal of the coccyx, the tiny triangle bone at the spine base, also known as the tailbone. This procedure is typically considered when conservative treatments have failed to alleviate severe and persistent coccyx-related pain or discomfort.

The coccyx plays a role in supporting body weight when sitting and acts as a site of attachment for tendons, ligaments & muscle in pelvic area. However, injuries, trauma, or conditions such as coccydynia (pain in the coccyx) due to falls, childbirth, tumors, or infections can lead to chronic pain and functional impairment in this area. 

Indications

Coccydynia: Persistent and severe pain in the coccyx area that hasn’t responded to non-surgical treatments such as physical therapy, medications, or injections. 

Trauma or injury: Severe damage or trauma to the coccyx caused by incidents like falls, childbirth, or accidents, leading to ongoing discomfort and restricted movement. 

Recurrent infections or tumors: Rarely, recurrent infections, tumors, or cysts in the coccygeal region may necessitate surgical removal. 

Chronic instability or dislocation: Rare cases where the coccyx may be dislocated or unstable, leading to persistent discomfort or pain that doesn’t respond to conservative treatments. 

Functional impairment: Pain or discomfort in the coccyx region that significantly impairs a person’s ability to perform daily activities, sit comfortably, or participate in regular exercise. 

Contraindications

Lack of significant symptoms: Surgery might not be recommended if the symptoms related to coccyx pain are not severe or if they can be managed effectively through non-surgical treatments. 

Infection or inflammation: Active infections or inflammation in the area around the coccyx can increase the risk of complications after surgery. It’s essential to address these issues before considering coccygectomy. 

Outcomes

Equipment

Scalpel 

Retractors 

Surgical scissors and forceps 

Electrocautery device: 

Surgical drill or osteotomes 

Suction device 

Surgical sutures and staplers 

Patient Position

Patients undergoing coccygectomy usually lie face down (prone position) on the operating table. This position allows the surgical team access to the coccyx region and provides a clear view of the area to perform the procedure effectively. 

TECHNIQUE

 Excision of Coccyx 

Step-1: Surgeons have detailed two distinct methods for performing coccygectomy; certain practitioners Favour a central lengthwise cut that begins above the sacrococcygeal joint and extends towards the coccyx. 

It’s important to exercise caution when extending the cut close to the perianal skin. Proceed by deepening the incision through the gluteus muscles & fascia till it reaches the bone. Using gentle dissection, locate the tip of the coccyx. 

Step-2: The intervertebral disc between the coccyx & the sacrum is removed with a scalpel once the posterior surface of the bone has been made visible. The coccygeal vessels are cauterized or ligated on both sides. 

The procedure involves cutting the anococcygeal ligament and raising the tip of the coccyx. The ileococcygeus muscles & coccygeus are carefully dissected, ensuring the protection of the rectum. Every part of the coccyx, along with its layers and periosteum, is removed during the excision process. 

Step-3: 

Few surgeons opt to employ sharp dissection to create a subperiosteal plane on both ends of the tip, while intentionally preserving the muscular attachments & ligamentous alongside the periosteum. 

Preserving and closing the periosteum has demonstrated a minimal likelihood of infection after surgery. 

Step-4: Due to the coccyx proximity to the rectum, caution is necessary when removal is done. 

Gardener provided a method for activating the dense fascia deep in the sacrococcygeal joint, as well as the rectum. 

This approach offers benefits such as safeguarding the rectum, lowering the chances of infection, and promoting faster healing. 

Step-5: Following the excision of the coccyx, the sacrum’s distal prominent end is bevelled. 

The elimination of dead space involves aligning the severed aponeurotic tissues in the center and using 2-4 absorbable sutures to create mattress stitches. 

The closure typically involves layering the skin & subcutaneous tissues. In instances where dead space remains, a small drain may be inserted and a minor dressing is then applied. 

Laboratory Tests

Imaging Studies: X-rays, MRI (Magnetic Resonance Imaging) scans may be done to visualize the coccyx and surrounding structures. These imaging tests help identify abnormalities, fractures, tumors, or other issues related to the coccyx. 

Blood Tests: Blood tests could be conducted to detect potential underlying health issues. or assess general health before surgery, such as complete blood count (CBC), coagulation studies, or basic metabolic panels. 

Complications

Infection: As with any surgery, there’s a risk of infection at the surgical site. Proper post-operative care and antibiotics can help prevent and treat infections. 

Bleeding: Excessive bleeding during or after surgery is a potential complication. Surgeons take measures to control bleeding during the procedure, but post-operative bleeding may require medical attention. 

Nerve damage: The proximity of nerves in the lower spine means there’s a risk of nerve damage during surgery. In the affected area, this may result in tingling, numbness, or even loss of sensation. 

Pain and discomfort: After a coccygectomy, patients may experience pain or discomfort in the surgical area during the healing process. This discomfort can persist for some time as the tissues heal. 

References

Coccygodynia and Coccygectomy – PMC (nih.gov) 

References

Coccygodynia and Coccygectomy – PMC (nih.gov)