Surgical removal of coccyx (coccygectomy)
See also personal experiences of coccygectomy
Summary: Surgery is sometimes used when other treatments have failed. Before going for surgery, be sure of two things: that you are a good candidate for surgery, and that your surgeon has plenty of experience and success with this operation. If you do that, there's an 80% chance of getting rid of the pain. The best indications of being a good candidate are an unstable coccyx or a spur on the coccyx. You can see a list of doctors and specialists recommended by other patients here.
The operation is normally carried out under general anesthetic, and lasts about an hour. The pain caused by the surgery makes it very painful to sit down for up to a month afterwards. Because of the position of the coccyx close to the anus, there is a danger of infection of the wound. Not all patients are suitable candidates for surgery (see below). The treatment may take from 3 months to a year or more to be effective.
Success rates for surgery
This operation used to have a bad reputation among some doctors, and some will still advise you that it should never be done. But clinical trials show success rates of 50-90%, rising to 80-90% in patients who are 'good candidates' for surgery, and have it performed by a surgeon with plenty of experience and success with this operation. A study published in 2001 summarised 24 separate trials of this operation. The trials covered a total of 702 patients operated on. The result was reported as 'good' or 'excellent' in 83% of cases.
There are at least three factors which could influence the likelihood of success:
- Selection of patients. Success rates appear to be much higher if patients are carefully selected to be 'good candidates' for surgery:
- Some doctors operate only on those with abnormal movement of the coccyx (see dynamic x-rays). This seems to be the most reliable indicator of success of the operation.
- Some surgeons only operate on people with a history of injury (including injury caused by childbirth) to the coccyx.
- Some will not operate unless corticosteroid injections have given some pain relief, even if it was only temporary.
- Surgical procedure. Surgeons use similar techniques, with some variations - here are some examples:
- Operative treatment of coccygodynia by Key, 1937 (PDF).
- An improved technic of coccygectomy by Gardner, 1972.
- Coccygectomy for instability of the coccyx by Doursounian, Maigne, Faure and Chatellier, 2004.
- Coccygectomy for stubborn coccydynia by Cheng, Chen, Lin, Wang, Zhang, Kou, Shen, Ying, Cheng, Lü and Peng, 2011.
- Prevention of post-coccygectomy infection in a series of 136 coccygectomies by Doursounian, Maigne, Cherrier and Pacanowski, 2011.
- A surgeon's report on one operation
- One patient wrote to me that she asked the surgeon to give her the coccyx after the operation, but he said he couldn't because he burred it out rather than cutting as one piece. His reasoning was to cause less trauma to the area, thus it should heal faster.
- Some surgeons remove only the mobile part of the coccyx, and some all of it. Here are the arguments for partial or complete coccygectomy.
- Post-operative infection can be a complication. Doursounian, Maigne, Cherrier and Pacanowski showed that use of a topical skin adhesive on the postoperative wound reduced infection rates from 14% to 3.6%. Additional use of antibiotics, a preoperative rectal enema, and closure of the incision in two layers reduced the rate of infection dropped to zero among 80 patients.
- Some sew up the internal tissues with 'dissolvable' stiches before sewing up the skin, but others say that sewing the internal tissues is unnecessary, and could cause irritation or infection. [In my own experience, 'dissolvable' stitches did not dissolve, did cause irritation, and had to be removed by a nurse.]
- A factor that could affect the the speed of recovery from the operation is pre-emptive analgesia.
- Experience and skill of the surgeon.
- Dr Maigne wrote: 'It is a difficult operation for the surgeon. The dissection of the bone has to be very careful and slow to avoid any damage which could compromise the result. With my colleague, Pr Doursounian, a Parisian orthopaedic surgeon, we have shown that there is a "learning curve" for this surgery, the results being better when the surgeon becomes more skilled and experienced.'
- Removal of the coccyx is a very rare operation for most surgeons. Like other surgical procedures, it is best if you can get it carried out by a surgeon with experience in this particular operation. An indication of the importance of experience in surgery was a report in The Lancet (volume 354, 1999 November 13, pages 1697-1698) on a study of surgery for cleft lip and palate. The study found that surgeons who carried out 3 or more of these operations a year got much better results than those that did fewer of them. It made no difference if the surgeon was a consultant or trainee - experience in that particular operation made the difference.
- Ask your surgeon how many coccygectomies he or she has carried out, and what the success rate was.
If you are considering surgery, here are some points for and against.
Recovery from surgery
Surgery may increase your pain in the short term, though your surgeon should put you on painkillers to reduce that. The time required off work varies, and depends on whether you have to sit to work. I (Jon) had 6 weeks off work, followed by a few weeks working part-time. Some people need more than that, some less.
Full recovery will probably take months, it could be a year or even more. Partly that is because you have to sit on the scar.
Infection delays healing. Here are pictures, one from an uninfected patient at 18 days after surgery, and one from a patient at week two who developed an infection.
Here are some more pictures of some patients' scars after surgery: Anonymous 1, Anonymous 2, Anonymous 3, Carol, Miriam, Kimberly, Gary.
Sally has written about trapped nerves following surgery
In some cases absorbable sutures can cause adverse reactions, stopping the wound from healing.
Relevant medical papers:
- Management of common coccygodynia. Jean-Yves Maigne
- Treatment strategies for coccydynia. Jean-Yves Maigne
- Coccydynia. Aetiology and treatment. Wray CC, Easom S, Hoskinson J
- The influence of etiology on the results of coccygectomy. Bayne O, Bateman JE, Cameron HU
- Coccygodynia. Zayer M
- Idiopathic coccygodynia. Postacchini F, Massobrio M
- Total coccygectomy for the relief of coccygodynia: a retrospective review. Grosso NP, van Dam BE
- Coccygodynia treated by resection of the coccyx. Hellberg S, Strange-Vognsen HH
- Surgical treatment of coccygodynia Shaposhnikov VI
- Tactics in management of coccygodynia. Mszwidobadze M, Alborow G
- Repair of a long-standing coccygeal hernia and open wound. Zook NL; Zook EG
- An improved technic of coccygectomy Richard C Gardner
- Coccygectomy for coccygodynia Valen B; Bringedal K
- Instability of the coccyx in coccydynia Jean-Yves Maigne, Denis Lagauche, Levon Doursounian