Cookie-bite coccyx: tailbone pain due to retained coccygeal fragment

American Journal of Physical Medicine and Rehabilitation

2009 Mar; 88 (3): S56

Patrick M. Foye, MD

Director, Coccyx Pain Service, Department of Physical Medicine and Rehabilitation, UMDNJ: New Jersey Medical School, 90 Bergen St., DOC-3100, Newark, NJ 07103-2499. Phone: (973)972-2802. Fax: (973)972-2825.


BACKGROUND: Coccydynia (tailbone pain) usually responds to nonsurgical treatment. But patients who fail to get adequate relief from nonsurgical care may be candidates for coccygectomy (surgical removal of the coccygeal bones).

CASE PRESENTATION: We present a case of a 27-year-old male who fell from a height of 15 feet, sustaining a fracture/dislocation of his coccyx (confirmed by MRI and CT scans). He failed to get adequate relief via physical therapy, oral medications, and local steroid injections performed without fluoroscopic guidance. He eventually underwent coccygectomy, reportedly removing the entire coccyx. Even after the surgical site finally healed multiple months later, pain and tenderness in the coccyx region persisted for years.

DIAGNOSIS: Eventually, he presented to a physiatric musculoskeletal/pain practice, where palpation during physical examination revealed a sharply-pointed bony structure immediately below the sacrum. Radiographs were obtained, revealing that about one third of the first coccygeal segment (C1) remained attached to the sacrum. Both the AP and lateral views revealed that the remaining fragment of C1 included a portion that was sharply-pointed in the downward direction, perfectly corresponding to the patient's site of persistent pain. The AP view revealed that the right C1 transverse process and right-sided portion of C1 vertebral body remained. But the left C1 transverse process and left-sided portion of the C1 vertebral body were gone/removed. The surgical lesion through C1 had a curved margin creating the appearance of a "cookie bite" into C1.

CONCLUSIONS: We propose that retained coccygeal fragments should be included in the differential diagnosis for patients who have persistent tailbone pain after coccygectomy. We suggest that there should be a low threshold for ordering imaging studies to evaluate for this in such patients.

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