Coccydynia from fall

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#3

First of all, fx or no fx? Osteoporotic? acute or chronic?

fx: rest, time, ?nasal calcitonin if osteo

no fx: OMT, TPIs, guided local/steroid inj's, pelvic floor ther., stretch those hammies
 
As far as injections go, I have seen the most success with just injecting steroid/lido right over the most tender area on the coccyx (assuming no fx). Often that can be done in the office if they are not obese. If that is not helpful, try a caudal.
 
Caudal ESI and a little injected into the SC junction. If that doesn't work I RF.
 
Don't forget to r/o pudendal neuralgia when working up this issue. They can present similarly with history but physical exam is key on this.
 
epidural man said:
Needle in the caudal space (tip at S3 ish), lateral side - pulsed RF. Both sides.
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That's interesting, first time that I've heard of this one, actually sticking the RF probe in through the sacral hiatus? How do you bill this?
 
Jitter Bug said:
How would you differentiate these two? I've never seen pudendal neuralgia. Or maybe I have, and thought it was coccygodynia 😉
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Well obviously, one has a sclerodermal pattern c/w pudendal neuropathy while the other has a sclerodermal pattern c/w coccydynia. :scared:
 
impar block for coccydynia.

? pulsed RF ? caudal? wtf?

donut cushion and pelvic floor PT is the best long-term
 
clearly a diagnosis is needed.... i have seen all kinds of missed diagnoses including subluxed fractures, etc...

i wouldn't stick a needle until I had adequate imaging...

i have even had in older patients normal bone scans and then a CT scan that actually shows the fracture...
 
I posted the coccygeal nerve RF pictures before somewhere. I can never remember the link.

The nerves run just inside the walls of the sacral hiatus. I lay a cannula on either side parallel to the floor of the canal with the tip about 1 cm in from the entrance of the hiatus and burn.

BTW donut cushions are horrible. I always recommend a Tush Cush. These are expensive but there are cheap knockoffs on eBay. Basically a wedge shaped pillow with a notch cut out at the back for the coccyx. The donuts will compress or splay the ischia and play hell with the coccyx.
 
Mister Mxyzptlk said:
Caudal ESI and a little injected into the SC junction.
Click to expand...

Yes, caudal esi with tip of needle between S4 and S3 (a shallow caudal) and then inject sacrococcygeal joint. Also agree with MM on the superiority of the tush cush over the donut.
 
brori said:
Yes, caudal esi with tip of needle between S4 and S3 (a shallow caudal) and then inject sacrococcygeal joint. Also agree with MM on the superiority of the tush cush over the donut.
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Is there a real joint down there? We call it that, but does it really exist?
 
PMR 4 MSK said:
Is there a real joint down there? We call it that, but does it really exist?
Click to expand...

rudimentary disc? vestigial disc? trying to think of another big word.

lots of times these patients with coccydynia are new moms, so i tell them to sit on their boppie. for those of you who dont know what a boppie is: any chance you'd like to switch lives with me?
 
Mister Mxyzptlk said:
I posted the coccygeal nerve RF pictures before somewhere. I can never remember the link.

The nerves run just inside the walls of the sacral hiatus. I lay a cannula on either side parallel to the floor of the canal with the tip about 1 cm in from the entrance of the hiatus and burn.

BTW donut cushions are horrible. I always recommend a Tush Cush. These are expensive but there are cheap knockoffs on eBay. Basically a wedge shaped pillow with a notch cut out at the back for the coccyx. The donuts will compress or splay the ischia and play hell with the coccyx.
Click to expand...

Not completely picturing this. Are you placing the needle APish on the medial side of the Cornu, or coming in steep caudad and parallel to a caphalocaudad nerve?
 
SSdoc33 said:
rudimentary disc? vestigial disc? trying to think of another big word.

lots of times these patients with coccydynia are new moms, so i tell them to sit on their boppie. for those of you who dont know what a boppie is: any chance you'd like to switch lives with me?
Click to expand...

Right before we had our first kid, my wife tells me: "we have to buy a boppie". My response: "what the F is a boppie?". They are also a great solution for your less savvy young moms with neck and upper back pain, they really help the ergonomics. I remember hauling that F_ing boppie everywhere we went for years (3 kids in 5 years later). I finally bought 3 or 4 and just left them where we visited frequently.
 
Does anyone get sitting and standing sacrococcygeal xrays to look for mov't in their w/u for coccydynia? I was taught to do this at one point but it always comes back normal. Am I wasting my time and exposing the patient to unnecessary radiation?
 
clubdeac said:
Does anyone get sitting and standing sacrococcygeal xrays to look for mov't in their w/u for coccydynia? I was taught to do this at one point but it always comes back normal. Am I wasting my time and exposing the patient to unnecessary radiation?
Click to expand...

Yes. Yes.

If it doesn't change treatment it is not needed.
 
If a fracture is present, how long would you wait prior to injection? Is 6 weeks enough? I have another patient with an acute fall who's 90yo. I'd like to inject as so far I've had really good results with ganglion impar blocks. I started meds and am first sending her out for x ray to r/o fracture. If not present, I plan to inject. I'd rather not put her through a CT scan. Even if a fracture does come back on CT, will it really change the course of treatment?
 
Pain Applicant1 said:
Which yields the best results?

1. Caudal ESI
2. Ganglion Impar Block
3. Something else
Click to expand...

Bone scan or STIR MRI showing fx = time, activity mods, meds.

Bone scan or STIR MRI showing no fx = never get better no matter what.
 
101N said:
Bone scan or STIR MRI showing fx = time, activity mods, meds.

Bone scan or STIR MRI showing no fx = never get better no matter what.
Click to expand...

time... just keep in mind she's 90 years old
 
I have done Gang Impar RF with a curved tip needle directly thorough the sacro-coccygeal ligament/ disc (m/b rudimentory disc), with good results! but I am willing to try that coccygeal nerve approach given in above posts. Thanks MM for the pix!!

But nothing (Gang Impar, Caudal ESI, TPI) have worked so far in fx/ subluxated patients! any new idea?😕
 
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