Management of coccygodynia: talking points from a systematic review of recent clinical trials

Introduction

Coccygodynia, or coccygodynia or coccygeal neuralgia, manifests as pain within the coccyx and surrounding tissues, often exacerbated by sitting, standing, or defecation, impairing quality of life and daily activities (1-12). The coccyx, a triangular bone at the lowermost end of the spine, comprises a variable number of rudimentary vertebrae, typically ranging from three to five due following segmental fusion (9,10,13-28), and serves as the attachment site for various pelvic structures. It harbours an extensive nerve supply, including the S4, S5, and coccygeal nerves forming the coccygeal plexus, responsible for sensory and pain innervation of the anterior and posterior aspects of the coccyx (3,29-32).

Coccygodynia is relatively uncommon, with a prevalence estimated at 1–3% among all back pain disorders, occurring more frequently in adult females and obese individuals (25,33-36). Prolonged sitting exacerbates symptoms, with triggers including standing up, defecation, and sexual intercourse (37-41). While the aetiology of coccygodynia remains elusive, traumatic injury, particularly backward falls, is frequently implicated (13,37,42-46). Fractional dislocation of the sacrococcygeal synchondrosis resulting from excessive sitting may induce abnormal coccygeal movement, leading to persistent pain attributed to ligament and muscle inflammation (15,47-49). The less common non-traumatic coccygodynia may arise from various sources, including sacrococcygeal hypo- or hypermobility, degenerative joint or disc disease, morphological variants of the coccyx, childbirth, obesity, rapid weight loss, and infectious aetiologies (25,33,37,50-53).

Diagnostic evaluation typically involves a medical history and physical examination supplemented by radiographic imaging to assess sacrococcygeal region abnormalities (42,54-56). While acute coccygodynia often resolves spontaneously within weeks to months without treatment, refractory cases necessitate intervention primarily to alleviate symptoms. Conservative management, including rest, anti-inflammatory medications, seating aids, stretching, physiotherapy, manipulative therapy, physical therapy, and heat therapy, has demonstrated efficacy in approximately 90% of cases (25,57).

When chronic symptoms persist and significantly affect daily quality of life, interventional treatment options may be considered (58,59). Radial extracorporeal shockwave therapy (rESWT) is a non-invasive alternative for symptom alleviation, leveraging biological responses mediated by mechanotransduction (2,60-63). Steroid and anaesthetic injections have also been proposed as viable alternatives for patients unresponsive to non-invasive therapies; however, there exists controversy regarding the optimal injection site (13,64). Another more invasive treatment is the ganglion-impaired block, involving the injection of local anaesthetic and alcohol through the sacrococcygeal disc into the retroperitoneal space, with guidance provided by fluoroscopy or ultrasound (54,65-74). Another strategy for denervation procedures is ultrasound-guided coccygeal nerve radiofrequency ablation (UGCN-RFA) (45,75-77). By applying thermal energy to coccygeal nerve branches, an accessible target given its superficial course between the coccyx and subcutaneous tissue, it offers good therapeutic potential (78). Radiofrequency ablation selectively destroys nerve fibres, transmitting pain signals from the coccyx to the brain and minimising collateral damage to adjacent structures. Surgical intervention, including partial and complete resection of the coccyx, has been proposed as a salvage treatment in coccygodynia refractory to other therapeutic options (4,49,79-85). Although outcomes of surgical interventions generally yield favourable results, the proximity of the surgical site to the anal canal poses challenges for subsequent wound care and necessitates meticulous postoperative management (1,79,86-93).

Based on the high-level evidence, no standardised clinical guidelines for managing coccygodynia are currently available. This study aims to address this gap by formulating good clinical practice recommendations based on a systematic analysis of the most relevant data available in the literature. Given the wide range of interventions described, this review aims to summarise and critically appraise the existing body of evidence, providing physicians with updated, evidence-based guidance for the optimal management of patients with coccydynia. The present systematic review is conducted in accordance with the PRISMA reporting checklist (94) (available at https://aoj.amegroups.com/article/view/10.21037/aoj-24-40/rc).

Methods

Eligibility criteria

All the clinical studies investigating the management of coccygodynia were accessed. Studies included in this review were limited to those published in peer-reviewed journals. Articles written in English, German, Italian, French, and Spanish were considered eligible, reflecting the language proficiency of the authors. Research meeting levels I to IV evidence criteria, as defined by the 2020 Oxford Centre for Evidence-Based Medicine, was also eligible for inclusion (95). Reviews, opinions, letters, unpublished data, editorials and studies without full-text availability were excluded. Animals, in vitro, biomechanics, computational, and cadaveric studies were not eligible.

Search strategy

The following algorithm was used for the literature search:

• Problem: coccygodynia;
• Intervention: conservative and surgical management;
• Design: clinical trial.

In December 2024, searches were conducted in PubMed, Web of Science, and Embase without applying additional filters or restricting the time frame. The Medical Subject Headings (MeSH) terms utilized for the database search are detailed in the Appendix 1.

Selection and data collection

The database search was conducted independently by two authors (F.M. and T.B.). All retrieved titles were manually reviewed, and abstracts were examined when deemed relevant. Full texts were accessed for abstracts aligning with the topic of interest. Articles were excluded if their full text was unavailable or inaccessible. Additionally, the reference lists of the full-text articles were cross-checked to identify further eligible studies for inclusion. A third senior author (N.M.) made the final decision in case of the authors’ disagreements.

Data items

Data extraction was carried out by two authors (F.M. and M.G.M.). The baseline data collected included the author, year of publication, journal, follow-up duration, number of patients, along with their mean age and body mass index (BMI). All data were organized using Microsoft Office Excel version 16.0 (Microsoft Corporation, Redmond, USA).

Assessment of the risk of bias

The risk of bias in the included studies was assessed according to the Cochrane Handbook for Systematic Reviews of Interventions (96). Two authors (F.M. and T.B.) independently evaluated the risk of bias. For randomized controlled trials (RCTs), the revised risk of bias assessment tool (RoB2) (97,98) was utilized, following the Cochrane methodology (99). The evaluation included the following domains: bias arising from the randomization process, deviations from intended interventions, missing outcome data, measurement of the outcome, and selection of the reported result. Non-randomized controlled trials (non-RCTs) were assessed using the Risk of Bias in Nonrandomized Studies of Interventions (ROBINS-I) tool (100). Seven domains of potential bias in non-RCTs were evaluated. Two of these domains focus on potential confounding factors and the method of patient selection prior to the commencement of the comparative intervention. Another domain assesses bias in the classification of interventions during the study. The remaining four domains address methodological quality after the intervention comparison, including biases related to deviations from intended interventions, incomplete data, inaccurate outcome measurements, and selective reporting of outcomes. The results from the ROBINS-I assessment were visualized using the Robvis Software (Risk-of-bias Visualization, Riskofbias.info, Bristol, UK) (101).

Synthesis method and statistical analysis

The main author (F.M.) performed the statistical analyses following the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions (96). Descriptive statistics were performed using IBM SPSS software version 25. Continuous data were summarized using the arithmetic mean and standard deviation, while dichotomous variables were reported as frequencies (events/observations).

Results

Study selection

The systematic literature search yielded 407 articles related to the topic of interest. Of these, 203 were excluded as duplicates. The remaining 204 studies were then screened for eligibility. After reviewing the abstracts, 161 articles were excluded because they did not meet the eligibility criteria. The specific reasons for exclusion were as follows: study type and design (n=47), not investigating the management of coccygodynia (n=66), full-text not available (n=46), and language limitations (n=2). Of the remaining 43 articles, another 27 were excluded after accessing the full text. In conclusion, 16 studies were selected in the present systematic review. The results of the literature search are shown in Figure 1.

Figure 1 PRISMA flow chart of the literature search.

Risk of bias assessment

In 63% (10 out of 16) of the studies included in this systematic review, the Cochrane RoB2 for RCTs was applied. Five of the included studies demonstrated good comparability between intervention groups at baseline, leading to a low risk of bias from the randomisation process. The remaining four studies raised concerns regarding the randomisation process, resulting in a high risk of bias in this domain. Bias related to deviations from the intended intervention, missing outcome data, and the selection of reported outcomes was occasionally noted, with varying levels of concern, leading to an overall risk of bias ranging from low to high in these domains. In five studies, the absence of assessor blinding resulted in a moderate to high risk of bias in outcome measurement, while the remaining studies exhibited a low to moderate risk in this domain. In conclusion, five studies were assessed as having a low or moderate risk of bias, whereas the remaining five RCTs were rated as having a high risk of bias (Figure 2).

Figure 2 Cochrane risk of bias 2.0 tool (RoB2 tool). RoB2, risk of bias assessment tool.

The risk of bias for non-RCTs was evaluated using the ROBINS-I tool for 38% (6 of 16) of the included studies, which were non-RCTs. Of these, two were rated as having a severe or critical risk of bias in at least one domain, but no study exhibited a critical risk of bias across all domains. The risk of bias from confounding was moderate in all included studies. The risk of bias in participant selection was low in five studies, while one study had a critical risk in this domain. The risk of bias in intervention classification was predominantly low. Concerns were identified in some studies regarding the measurement of outcomes in post-intervention domains. However, no concerns were raised about the selection of reported results. Overall, the risk of bias was moderate in 67% (4 of 6) of the studies and serious to critical in 33% (2 of 6), suggesting generally acceptable methodological quality (Figure 3).

Figure 3 The ROBINS-I of non-RCTs. RCT, randomised controlled trial; ROBINS-I, Risk of Bias in nonrandomized Studies of Interventions.

Study characteristics and results of individual studies

Data from 858 patients were retrieved. Of them, 77% (660 of 858 patients) were women. The mean length of follow-up was 10.6±12.0 months. The mean age was 42.9±4.5 years, and the mean BMI was 26.6±3.1 kg/m². The generalities of the included studies are shown in Table 1.

Discussion

Coccygodynia poses a considerable challenge in clinical practice, particularly given its low incidence and uncertain etiopathogenesis, which often complicates diagnostic and treatment algorithms for clinicians (37). While the existing literature emphasizes initial conservative measures such as rest and sitting aids, persistent or chronic pain remains a primary concern (55,58,59,102,110).

One critical issue in understanding coccygodynia lies in determining the pain’s primary origin: whether it stems from trauma, is secondary to other pathologies, or is idiopathic. This delineation represents a significant patient selection bias affecting the existing literature. Based on many pooled patients, previous systematic reviews and meta-analyses have highlighted coccygectomy as the most prevalent treatment modality with the highest success rates. Despite the rigorous research strategy focusing solely on the available evidence, the limited number of RCTs, small sample sizes, variable follow-up durations, heterogeneity among study designs, and heterogeneous treatment modalities preclude formulating a robust pooled strategy. Moreover, limitations of the present investigation, attributable to study design, the number of RCTs included and the overall small sample size, precluded the examination of patient subgroups, such as those with traumatic or idiopathic aetiology, which may significantly impact treatment outcomes. Nevertheless, the present investigation aims to provide clinicians with the best evidence-based recommendations from peer-reviewed clinical trials, emphasizing interventional non-surgical treatments for patients suffering from persistent coccyx pain.

Four RCTs evaluated manual and physiotherapeutic approaches. Notably, one high-quality RCT involving 60 obese patients demonstrated favourable outcomes with an exercise program supplemented with kinesiotaping, indicating improvements in pain, range of motion, and disability at 1-month follow-up (103). However, other than the small sample size, the primary concern of this study is the patient population selected by the definition of coccygodynia induced by obesity, which does not correctly consider the nature of the condition. Other RCTs suggest benefits from piriformis and iliopsoas stretching to correct lumbopelvic posture and alleviate abnormal sacral loading and intrarectal manipulation, albeit with mild effectiveness primarily observed in post-traumatic cases (38,50,109). Conversely, pelvic biofeedback and muscle exercises showed no significant improvement in chronic pain at short to mid-term follow-up. These observations are subject to substantial methodological biases, particularly in randomisation and missing outcome data.

Physical therapy-based interventional treatments emerged as the most extensively studied approach for coccygodynia. Notably, with a low risk of bias, three weekly sessions of rESWT demonstrated superior and longer-lasting efficacy compared to non-image-guided steroid injections at the tip of the coccyx, providing sustained pain relief even at 6 months (107). Furthermore, a pain-adapted rESWT protocol, tailored to individual patient pain tolerance, showed the potential to improve long-term success and recurrence rates, albeit with a moderate risk of bias from clinical management reproducibility and outcome measurement concerns (61). With some concern of bias from the randomisation, rESWT has also proven to be superior in short-term results when compared to focused ESWT and heat muscle relief through local application of shortwave diathermy (SWD) (27.12 MHz frequency) combined with deep electrical stimulation interferential current (IFC) protocols (40 minutes 3 times a week).

Concerning the infiltrative approach, corticosteroid injections at the point of maximum tenderness were efficient for up to 24 weeks, showing no differences when administrated with or without ultrasound guide in recurrent chronic coccygodynia after a first-line treatment through physical and oral therapy (2). Based on the burgeoning body of research surrounding ganglion-impaired (Walther ganglion) blockade, the present investigation underscores a mounting interest in addressing symptomatic treatment by targeting the sympathetic system located in the retroperitoneal space adjacent to the sacrococcygeal joint. Trans-sacrococcygeal and trans-coccygeal fluoroscopic-guided approaches to ganglion-impaired block yielded safe and effective outcomes, with excellent patient satisfaction immediately post-procedure. At the same time, the administration technique showed questionable better results and ease of administration through the first intra-coccygeal joint (105); adding steroids (40 mg of methylprednisolone) to local anaesthetic was crucial for the prolonged efficacy of the block (106), with various combinations utilized across studies. The most commonly used local anaesthetic was 3 to 8 mL of 0.5% bupivacaine (54,105,106), while one non-randomized study used 1% lidocaine followed by 5 mL of 99% absolute alcohol (67).

Since the critical risk of bias emerged from the assessment of the only study proposing coccygeal nerve radiofrequency ablation, caution is warranted concerning this approach (104).

Steroid blocks are generally not administered without prior unsuccessful attempts at conservative treatment, mirroring the approach whereby surgical intervention is reserved for patients unresponsive to prior interventional treatment strategies. Notably, all the conservative treatments proposed in the studies examined in the present systematic review excluded patients with radiographic evidence of sacrococcygeal dislocation, in whom surgical intervention should be considered. However, one notable exception is the observational study by Charrière et al. (102), which revealed a long-term unfavourable outcome in patients treated conservatively for posterior coccyx dislocations despite the severe risk of bias.

A prior systematic review (110) discussed surgery as the best-validated outcome, but the present study focuses solely on clinical trials. This decision was rooted in the recognition that the validity of any analysis hinges on the quantity and quality of the included evidence, which can vary significantly among studies. The sole study focusing on surgical coccygectomy (79) included in the present systematic review was a non-randomised prospective observational study characterised by a moderate risk of bias. This study involved the complete removal of the entire coccyx as the last-line treatment in 94 patients suffering from chronic (lasting more than 1 year) and severe symptoms resistant to conservative treatments such as nonsteroidal anti-inflammatory drugs (NSAIDs) or at least one sacrococcygeal injection. These patients also met the inclusion criteria by presenting radiographic evidence of coccygeal abnormalities, as outlined by Maigne et al. (33,49,111). Despite the absence of a control group, preventing the comparison of improvement with continued non-operative care, coccygectomy demonstrated a moderate success rate, with 70.4% of patients meeting the designated minimal clinically important difference (MCID) threshold. However, this intervention carried substantial risks of wound healing complications, albeit without significantly impacting the overall outcome. On the other hand, surgical failure was linked to pre-existing psychiatric conditions, lower quality of life, higher pain levels, and the use of opioids. This highlights the significance of careful patient selection and thorough pre-operative assessment in predicting the likelihood of successful treatment outcomes.

Conclusions

A multidisciplinary approach is advocated for coccygodynia management, with conservative measures as initial strategies. Physical therapy-based interventions and interventional treatments, such as corticosteroid injections and ganglion impair blockade, offer viable options for refractory cases. Surgical intervention should be considered judiciously, weighing risks and benefits based on patient-specific factors and treatment response. Further research and high-quality RCTs are needed to establish standardised guidelines and management protocols for coccygodynia management based on high-quality evidence.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the PRISMA reporting checklist. Available at https://aoj.amegroups.com/article/view/10.21037/aoj-24-40/rc

Peer Review File: Available at https://aoj.amegroups.com/article/view/10.21037/aoj-24-40/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://aoj.amegroups.com/article/view/10.21037/aoj-24-40/coif). F.M. serves as an unpaid editorial board member of Annals of Joint from August 2024 to December 2026. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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