Reconsidering the role of coccygectomy in well-selected patients with coccygodynia

We read with great interest the systematic review by Mazzoleni et al. on the management of coccygodynia (1). The authors provide a valuable synthesis of recent clinical trials and clearly highlight the heterogeneity, small sample sizes, and methodological limitations that hinder guideline development. We would like to expand on a single point that has important implications for clinical decision-making: the interpretation and positioning of surgical evidence in well-selected coccygodynia patients. The authors appropriately note that prior systematic reviews and meta-analyses have consistently reported favourable outcomes after coccygectomy (1). They also correctly explain that their own review, focused exclusively on clinical trials, could incorporate only one prospective surgical series. This restriction is methodologically transparent. However, this narrow evidence base may inadvertently underrepresent the overall strength, consistency, and clinical utility of the existing surgical literature, particularly in patients with structural pathology such as posterior coccygeal dislocation or marked hypermobility. A large body of modern evidence demonstrates that the success of coccygectomy is fundamentally driven by patient selection, rather than by the procedure itself. The most robust compilation of surgical evidence remains the meta-analysis by Sagoo et al., which included 21 studies and 793 patients (2). Across these cohorts, coccygectomy resulted in substantial reductions in pain—often exceeding minimal clinically important difference thresholds—paired with high satisfaction rates, frequently around 80–90%. Wound complication rates averaged 10–13%, but complications were generally minor and did not typically compromise final functional outcomes (2). This meta-analysis provides a much broader, more representative view of surgical results than can be obtained from clinical trials alone. The relevance of meticulous patient selection is further underscored by contemporary observational research. In a 36-month prospective cohort of 115 adults, Charrière et al. reported that despite structured conservative care, more than half of patients remained significantly symptomatic at long-term follow-up (3). Crucially, patients with posterior coccygeal dislocation demonstrated poorer outcomes, leading the authors to conclude that coccygectomy “may be considered rapidly” in this subgroup rather than after prolonged non-operative treatment (3). This prospective evidence directly supports a phenotype-specific approach to management. Several well-constructed modern surgical cohorts reinforce this pattern. Izci and Keskin reported favourable outcomes in the majority of patients undergoing coccygectomy, with substantial pain reduction and high satisfaction (4). Kara et al. demonstrated that surgical outcomes were significantly better in patients with traumatic coccygodynia compared to idiopathic cases, again highlighting the prognostic value of identifying structural instability (5). Hochgatterer et al. provided long-term follow-up data up to 29 years, confirming durable pain relief and high satisfaction in a large series with extended postoperative surveillance (6). These studies further validate coccygectomy as a reliable intervention in well-selected patients. The single prospective surgical study included in the review by Mazzoleni et al.—the 98-patient cohort reported by Hanley et al.—showed that coccygectomy for chronic, refractory coccygodynia led to clinically meaningful improvement in the majority of cases (7). Although non-randomised, this study offers strong practice-oriented evidence, demonstrating substantial benefit in patients with severe, long-standing symptoms and radiographic abnormalities. Taken together, this growing body of literature supports the view that coccygectomy is not merely a last-line “salvage” procedure with moderate success but rather a validated, high-yield intervention for a clearly defined subgroup:

• Traumatic onset;
• Posterior coccygeal dislocation or pronounced hypermobility on dynamic imaging;
• Reproducible coccygeal tenderness; and
• Failure of appropriately structured conservative and interventional treatment.

For such patients, delaying surgical evaluation may result in prolonged suffering with limited benefit from repeated injections or extended physical therapy. The natural history data provided by Charrière et al. (3) particularly illustrate that reliance on conservative measures alone may not serve this subgroup well. We agree with Mazzoleni et al. that randomised controlled trials comparing operative and non-operative strategies are lacking and unlikely to be feasible in a rare condition with a distinct structural phenotype. In this context, it may be helpful for readers if the review’s discussion more explicitly distinguishes between (I) the limited availability of surgical clinical trials, and (II) the strong, consistent evidence from observational cohorts and meta-analyses, many of which are cited by the authors themselves. Such clarification would ensure that clinicians do not underestimate the role of surgery in patients who stand to benefit most. In summary, the systematic review by Mazzoleni et al. makes a valuable contribution to the field. Clarifying the interpretation of surgical evidence—particularly recognizing the robust outcomes documented in well-selected patients—may further enhance its clinical usefulness and help guide phenotype-specific management strategies.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was a standard submission to the journal. The article did not undergo external peer review.

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://aoj.amegroups.com/article/view/10.21037/aoj-2025-1-84/coif). The authors have no conflicts of interest to declare.

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References

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