coccyx pain

[PinchandBurn]

I have a lady. She works. no Psych issues. Has exclusively coccyx pain. She has a sedentary job, is obese.

The coccyx is TTP. No fx over it. I have done coccyx nerve injections/ganglion impar injections. They helped transiently. Thus I did a RFA of the nerves. NO help at all.

Any thoughts? I was thinking of doing a caudal.....

She has tried PT, uses a donut to sit on. Thoughts?

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[lobelsteve]

Donut wrong.

Tushcush right.

I used to inject alcohol or phenol on ganglion and it worked well. Now just botox it and if fails pns.

 

[Doctodd]

If its due to lax ligaments or hyper mobility, you can PRP it. Or poor mans version....prolo.

 

[joshmir]

There is a guy around here who does coccyx manipulation; has anyone done this?

If so what's involved?

Any opinions on effectivenes?

 

[emd123]

I have a lady. She works. no Psych issues. Has exclusively coccyx pain. She has a sedentary job, is obese.

The coccyx is TTP. No fx over it. I have done coccyx nerve injections/ganglion impar injections. They helped transiently. Thus I did a RFA of the nerves. NO help at all.

Any thoughts? I was thinking of doing a caudal.....

She has tried PT, uses a donut to sit on. Thoughts?

I have lady similar to this, I did a caudal and it helped a lot more than I thought it would.

 

[SSdoc33]

There is a guy around here who does coccyx manipulation; has anyone done this?

QUOTE]


once. but i was young and liked to experiment.....


seriously. a good manual pelvic fllor therapist can really help out, espicially if there is concomitant pelvic floor tension myalgia. but the patient has to be open to it, because there is a lot of internal work.

 

[kstarm]

You could try injecting the joint itself with lidocaine and/or steroid. Try some dynamic xrays to see which (if any) of the joints are hypermobile (http://www.coccyx.org/investig/dynamic.htm) to put your needle in the right place under fluoro. I have a patient that this will be the next step on if she isn't improved with non-invasive treatments.

Also what was the PT like? If possible you really want a PT who specializes in pelvic floor work. We have a few around the city, and one in particular with whom we have gotten good results with.

 

[newbie04]

There is a guy around here who does coccyx manipulation; has anyone done this?

If so what's involved?

Any opinions on effectivenes?

I just worked with a colleague that does transrectal manipulation of the coccyx with good success. Most patients were (very) reluctant at first, but came back when all other treatments failed.

 

[deleted185747]

To the OP: why not phenol the ganglion of impar?

 

[PinchandBurn]

To the OP: why not phenol the ganglion of impar?

I wasnt thinking of phenol only because since I've finished fellowship I have not done phenol/alcohol for non-malignant pain.

Botox sounds interesting. Where would I put it? Would I put it just like where the ganglion of impar is? Any possibility it could relax the anal spinchtor and cause incontinence of bowels?

Steve---you mentioned PNS? Are you suggesting putting a peripheral stim lead somewhere? She's tried pelvic floor exercises,PT, TENS unit down there.

 

[deleted185747]

Benzon pg 923. Phenol 6% is recommended after the diagnosis has been confirmed with local anesthetic diagnostic blocks. Cryoablation is also an option. Reference from Benzon is below as well as the link to the article.

Swofford JB, Ratzman DM: A transarticular approach to blockade of the ganglion impar. Reg Anesth Pain Med 1998;23(Suppl 3):103.

http://test.paulchristomd.com/wp-content/themes/flowhub/pdf/PelvicPainFINAL.pdf

 

[lobelsteve]

I wasnt thinking of phenol only because since I've finished fellowship I have not done phenol/alcohol for non-malignant pain.

Botox sounds interesting. Where would I put it? Would I put it just like where the ganglion of impar is? Any possibility it could relax the anal spinchtor and cause incontinence of bowels?

Steve---you mentioned PNS? Are you suggesting putting a peripheral stim lead somewhere? She's tried pelvic floor exercises,PT, TENS unit down there.

Ive popped pns leads adjacent to the coccyx but through the ligament. 3 years was last case and still working.

 

[powermd]

Treadmill desk. Get her off her *****.

Has anyone done phenol or alcohol for this? I too have tried RF on several patients without success despite 100% temporary relief with local (either on the spot, or adjacent to the lower sacral foramina/sacral cornue.)

 

[PinchandBurn]

Ive popped pns leads adjacent to the coccyx but through the ligament. 3 years was last case and still working.

few questions:

1) what do you code this as?

2) when you say you 'popped" it through the ligament, how many electrodes are put in there? As in do you have 2 electrodes through the sacrococcygeal lig and 2 are out?

3) arent you concerned that the bowels can be perforated/burned? Are you laying these leads anterior to the sacrum sort of where the contrast spreads cephalad when you do a ganglion impar block?

 

[Mister Mxyzptlk]

I always try a caudal ESI first. IMHO a lot of coccydynia is sacral nerve root pain. Note how many people with coccydnia complain of concordant pain during a caudal injection as you inject volume ABOVE the coccyx.

Pinch&Burn how did you do the RF?

 

[Mister Mxyzptlk]

donut wrong.

Tushcush right..

+1

 

[fozzy40]

I have a lady. She works. no Psych issues. Has exclusively coccyx pain. She has a sedentary job, is obese.

The coccyx is TTP. No fx over it. I have done coccyx nerve injections/ganglion impar injections. They helped transiently. Thus I did a RFA of the nerves. NO help at all.

Any thoughts? I was thinking of doing a caudal.....

She has tried PT, uses a donut to sit on. Thoughts?

Was the PT she had specifically with a pelvic floor therapist? These can be tough patients.

 

[SSdoc33]

I always try a caudal ESI first. IMHO a lot of coccydynia is sacral nerve root pain. Note how many people with coccydnia complain of concordant pain during a caudal injection as you inject volume ABOVE the coccyx.

Pinch&Burn how did you do the RF?

why would the sacral nerve roots get compressed or become painful? its not like a disc is pushing on them.

 

[bedrock]

I don't know personally. But I've also seen several pts w coccyx pain improve after Caudals, so thats something I offer these patients.

 

[PinchandBurn]

I always try a caudal ESI first. IMHO a lot of coccydynia is sacral nerve root pain. Note how many people with coccydnia complain of concordant pain during a caudal injection as you inject volume ABOVE the coccyx.

Pinch&Burn how did you do the RF?

instead of going through the sacro coccygeal ligament, I went on both sides. I literally bipolared with 2, 18G needles up and down where the ganglon of impar typically is. then as a bonus I went lateral to the S4 neuroforamen and bipolared around both of these (didnt charge).

 

[Mister Mxyzptlk]

Try this: http://www.angelfire.com/planet/pai...ex.album/rftc-of-the-coccygeal-nerves-ap?i=23 and this http://www.angelfire.com/planet/pai...bum/rftc-of-the-coccygeal-nerves-lateral?i=24

 

[nvrsumr]

Thread jack

Gorback - could you describe your thoracic rf technique a bit more. Saw the Fluoro pic.

Thanks

 

[Mister Mxyzptlk]

Thread jack

Gorback - could you describe your thoracic rf technique a bit more. Saw the Fluoro pic.

Thanks

There is no one here named Gorback. There is only the wise and famous Mxyzptlk, whose proximity while wearing high boots causes sheep to tremble.

 

[nvrsumr]

Haha. This wise and mysterious person has the "gorbacks" name on the Fluoro pics he gave a link to....

 

[Mister Mxyzptlk]

You are confused, grasshopper. No one would describe gorback as wise. Mysterious, yes - as in, "It is a mystery to me how he ever got into medical school". If you continue to insult me I will change you into Michael Moore's underpants.

Nevertheless, since gorback is too ashamed to show his face in my illustrious presence I will try to answer the question.

Pick the target pedicle shadow. Use an entry point about 2 pedicle shadows below. This usually gives you an angle such that the axis of the cannula is parallel to the lamina. The picture shows the cannula coming across lateral to medial, but parallel to the spine works equally well. I will ask that simpleton to put up a more recent picture if he hasn't lost the password for the site, which he has.

Advance until contact is made and the tip is slightly past the upper edge of the pedicle shadow.

Check a lateral to be sure that you are on the lamina and not inside the joint. On the lateral your tip should be over the pedicle and on the inferior aspect of the lamina. If you make contact at the inferior aspect of the pedicle shadow you are more likely to enter the joint.

You can check sensory stim if you want and it might be advisable until you've become comfortable with placement. No motor stim is necessary. I don't do either for this technique.

BTW, I did another coccygeal RF a week ago. Saw him for follow up two days ago. No pain.

 

[nvrsumr]

Please thank the simpleton for me!

 

[clubdeac]

Did impar block on a guy with coccydynia a few months ago and gave him 3 mos relief. Just saw him again and RF'd and added 2cc 98% alcohol to the mix. Will keep you posted on what happens...

 

[NEA]

Hi Steve, I read about your experience with Botox. I also read up an article about using 80-100 units of Botox. Do you do trans sacroccygeal technique and then once the dye spread looks good inject Botox? What's the dilution of Botox? I have been using clonidine 75mcg along with bupi and depo for my ganglion impars and they typically last anywhere from 4-12 weeks. I am too chicken to use neurolytics for non malignant pain. someone I met, claims to use 6% lidocaine with good success but I have no experience with it.

 

[lobelsteve]

Hi Steve, I read about your experience with Botox. I also read up an article about using 80-100 units of Botox. Do you do trans sacroccygeal technique and then once the dye spread looks good inject Botox? What's the dilution of Botox? I have been using clonidine 75mcg along with bupi and depo for my ganglion impars and they typically last anywhere from 4-12 weeks. I am too chicken to use neurolytics for non malignant pain. someone I met, claims to use 6% lidocaine with good success but I have no experience with it.

Midline approach, cross through the ligament, shoot contrast, go AP to make sure I didn't walk out to the side. Squirt 0.5cc Omni240 to see my teardrop spread of contrast (and prove I'm not in the rectum). 4cc Marcaine 0.25% and 100u Botox.

 

[clubdeac]

What kind of results are you seeing with that Steve? And anything special you have to do to bill?

 

[PinchandBurn]

Midline approach, cross through the ligament, shoot contrast, go AP to make sure I didn't walk out to the side. Squirt 0.5cc Omni240 to see my teardrop spread of contrast (and prove I'm not in the rectum). 4cc Marcaine 0.25% and 100u Botox.

what is the MOA of botox helping with this? what about causing spasm of the anus/rectum..

 

[Ducttape]

what is the MOA of botox helping with this? what about causing spasm of the anus/rectum..

isnt botox is acting as a neurotoxin by blocking acetylcholine transmission in these nerves...

 

[joshmir]

Botox prevents SNAP 25 vesicle exocytosis in neurons, reducing all neurotransmitter exocytosis and thereby making it harder for nerves to talk to other nerves

Since ganglion of impar is a ganglion, there are synapses (ie its not just axons passing by)

 

[clubdeac]

Botox prevents SNAP 25 vesicle exocytosis in neurons, reducing all neurotransmitter exocytosis and thereby making it harder for nerves to talk to other nerves

Since ganglion of impar is a ganglion, there are synapses (ie its not just axons passing by)

But it synapses at the muscle nerve junction i.e. motor endplate, not a presynaptic to postsynaptic nerve synapse, no?

 

[Ducttape]

But it's synapses at the muscle nerve junction i.e. motor endplate, not a presynaptic to postsynaptic nerve synapse, no?

arent there nicotinic acetylcholine receptors in the sympathetic ganglions?

 

[nvrsumr]

just did a Mr. Mzy style thoracic RF. Looking forward to seeing what the results are.

 

[ctts]

I have not done any RF procedures for coccyx pain, but just wanted to add to this discussion.

I believe most papers describe using pulsed RF versus continous thermal RF. Also, most papers describe RF of the ganglion impar.

I came across one article that describes a different approach:
http://www.ncbi.nlm.nih.gov/pubmed/21341145
(There is free link to the whole article)
It describes pulsed RF of the coccygeal plexus, and it seems the needle placement is similar as for a caudal ESI. If this works, I imagine that it is technically a lot easier to perform than placing the needles anterior to the sacrum for the ganglion impar, which would be an important consideration especially for larger patients.

I see the suggestions above for phenol/alcohol... I have never used it before. On the one hand it is neurolytic, and on the other hand it seems safe to use according to papers and those who use it. I realize everything we do has risks, but I just can't fully reconcile this in my mind, and have been hesitant to give it a try. Sounds scary to me since you cannot fully control where the alcohol goes once you inject it, especially at larger volumes.

 

[ctts]

Mr. Mxyzptlk, when you do your RF procedure for coccyx pain as described above, are you using bipolar, or 2 separate lesions, or possibly pulsed?

 

[ctts]

Also, for those suggesting phenol, what are your thoughts on the concern that it could affect the adjacent bowel? I have read that 3-5 ml as a suggested volume. I guess I would err on the lower side and go with 3 ml.

 

[Mister Mxyzptlk]

Mr. Mxyzptlk, when you do your RF procedure for coccyx pain as described above, are you using bipolar, or 2 separate lesions, or possibly pulsed?

Just a plain old 18g cannula with 10 mm tip at each side at 80 C.

 

[thecentral09]

Also, for those suggesting phenol, what are your thoughts on the concern that it could affect the adjacent bowel? I have read that 3-5 ml as a suggested volume. I guess I would err on the lower side and go with 3 ml.

IN fellowship (recent grad) we had an attending that would put 5-9 cc of 100% alcohol for chemical neruolysis for a lot of young women with nonmalignant pain at the ganglion impar. Sometimes it was effective, sometimes not. I overall wasn't impressed, especially concerning the risks on a young person with possible limited benefit and the likely need for repeat procedure in 6-9 months. Overall, it appears it has been a difficult target to treat, as I have also experienced similar results with a caudal ESI as I saw with alcohol. I am very interested in the botox suggestion, but I would not know how to bill for reimbursement.

 

[Mister Mxyzptlk]

Alcohol neurolysis in the sacral canal? Seems like begging to be sued for incontinence.

 

[thecentral09]

Alcohol neurolysis in the sacral canal? Seems like begging to be sued for incontinence.

Not the sacral canal. At the ganglion impar

 

[bronchospasm]

Do RF Instead . You can not control speak of alcohol

 

[Ducttape]

Alcohol neurolysis in the sacral canal? Seems like begging to be sued for incontinence.

Ganglion impars is anterior to sacrum... (Not caudal of course)


Needle entry point can be through sacrococcygeal ligament or distal to coccyx.

I've dove this for rectal cancer pain, perineal cancer pain. Pretty effective.

Operative word tho in each of these is "cancer"...


Sent from my iPhone using SDN mobile

 

[Mister Mxyzptlk]

Not the sacral canal. At the ganglion impar

I think the way you wrote it it looked like you were saying you got the same results with alcohol whether caudal or ganglion impar.

For GI I use phenol. I've had good results using superior hypogastric plus GI for pelvic cancer pain but as mentioned above the key word is cancer.