International Society for the Study of the Lumbar Spine Meeting, Kyoto, Japan on 3-7 June, 2019
Jean-Yves Maigne (1), Christelle Nguyen(1), Geneviève Mahieu (2)
1 Physical Medicine, Hôpital Cochin, Paris. France
2 Physical Medicine, CHU-UCL, Namur and Hôpital Vivalia, Marche. Belgium
INTRODUCTION. The long term results of the conservative management of coccydynia are not known. We present a study with two goals: to report these results with a mean follow up of 3 years and to search predictors of a good result.
METHODS. 141 new consecutive patients with chronic coccydynia (>2 months) were enrolled in 2015. At inclusion, they were administered a VAS* (sitting position, 10cm) and two questionnaires: the Paris Questionnaire (PQ, 10 points) and a partial adapted Dallas Questionnaire (sections relevant to coccyx pain, DQ, 30 points). They were managed first with dynamic films and a steroid injection in the affected disc or at the apex (spicule). The second line treatment was a repeated injection or manual therapy or surgery if indicated. Sitting aids were systematically advised.
The follow up consisted of a telephone interview and a VAS at 6 months and 3 years. The results were categorized as follow; good: VAS=3, fair: VAS>3 and =5 and failure: VAS>5 or coccygectomy (whatever its result).
Statistics. Bivariate and multivariate analyses were carried on.
RESULTS. At baseline, they were 106 females (75.2%) and 35 males, age 43±10 yrs. A provocative event was found in 42.7% (trauma: 40, child delivery: 12 (of which 4 fractures and 5 dislocations), loss of weight: 9 (of which 7 spicules). VAS, PQ and DQ: 6.4±1.1, 7.0±2.6 and 14.3±2.1 respectively. The dynamic films showed 35 rigid coccyges (25%), of which 25 spicules, 23 with normal mobility (14%), 29 with hypermobility (29%), 50 with dislocation (37%) and 4 fractures with pseudoarthrosis. 120/141 (85.1%) had a telephone interview at 6 months and 3±0.5 years). 21/141 were lost for follow up.
At 3 years, 56 patients (46.7%) had a good result with the conservative treatment (VAS=3). According to the dynamic films, patients with spicule or hypermobile coccyx did better than those with normal mobility (i.e. no visible lesion) or dislocation (the most severe lesion). According to patients’opinion, the treatment which worked the best was injections for 33, manipulation or physio for 10, acupuncture or psychotherapy for 3 and none, with a natural recovery, for 10 (good result group). 52 patients (43.3%) had a poor result, which should be alleviated by the fact that 25/52 had a coccygectomy and 7 more declined the operation despite a correct indication, letting 20 cases with intractable pain (16.7%). 12 patients (10.0%) had a fair result.
In a bivariate analysis, the factors of good prognosis at 3 years (p<.05) were a low score at the Paris and Dallas Questionnaires, a lower pain intensity on the VAS, the lack of a provocative event, no dislocation on the dynamic films and a shorter duration of complaints at inclusion and in a multivariate analysis, the lack of a provocative event and a low score at the Dallas Questionnaire.
DISCUSSION. The results of conservative management with a long term follow up are encouraging, especially if one considers that a coccygectomy can be recommended in certain cases of the failure group.
* Visual Analogue Scale (VAS) - pain marked as a point along a 10 cm line, zero representing no pain and 10 representing extreme pain