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On June 3rd 2008 a 33 years old female presented at the County Hospital for a three view sacrum and coccyx study, due to mid buttocks and coccyx area pain caused by patient falling approximately a year prior. Patients’ ID was verified using three methods of authentication and a thorough history was obtained. Patient history revealed that she was currently on her menstrual cycle and no chance of pregnancy, she had experienced trauma from a fall one year prior to medical visit. The pain has been constant since accident occurred manifesting by throbbing, dull and sometimes sharp pain. On a 1 to 10 pain scale level the patients experienced a pain level of 6. The onset to patient trauma occurred by her trying to sit on a chair that wheeled itself backwards causing patient to fall on her rear. Patient pain is aggravated by extensive periods of sitting increasing pain level to a 9. No associated manifestations have been reported. Subsequent to patients history attainment she was escorted to the radiographic room which has been set up for the study. Patient was instructed to remove everything below waist line except undergarment, as well as to remove any body piercings in midriff area. Patient was then asked to change into a gown and informed of the course of study that was to be performed.
Upon patients’ understanding of the procedure she was asked to lay down supine on the radiographic table. The first image performed was an (anteroposterior) AP axial sacrum on a 10X12 cassette with 85 kilovoltage (kV) and 15 milliampers per second (mAs). Patients’ breasts were shielded with lead apron; she was supine with arms on her sides and with no rotation. X-ray tube detented at 40 inches source-to-image distance (SID), 5 degrees (°) cephalic central ray (CR) angle, centered 2 inches above symphysis pubis exposed on suspended expiration. After the image was processed the second image was obtained. AP axial coccyx was acquired on the same size cassette using 82 kV and 20 mAs, there was no adjustment to patient positioning from previous image.
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All three images were evaluated to insure diagnostic factors. Image of the AP axial sacrum demonstrates L5 vertebra, sacroiliac joints, sacral base all free of superimpositions, and sacral apex superimposed by the superior margin of symphysis pubis. Patient minimally tilted to the right, and centered slightly to the left of IR. CR part centering directed to the second sacral segment, there is evidence of collimation on all four sides however marginally unequal. Image exposure is diagnostic with good density and detail, slightly low contrast, and no distortion. Left anatomical marker evident in the left ala. Image of the AP axial coccyx demonstrates entire coccyx free of superimposition and placed too high on the IR. CR centered to the left transverse process of the coccyx, with evidence of marginally unequal four sided collimation. Image exposure is adequate with good density and detail, slightly low contrast and no distortion. Anatomical left marker is apparent on the left acetabulum. Image of the lateral sacrum/coccyx exhibits L5 vertebra, sacrum, sacral promontory, median sacral crest and coccyx in its entirety free of superimposition. Part is positioned to the center of the IR with correct CR placement and evidence acceptable four sided collimation is present. Image exposure is diagnostic there is no distortion and good detail is visible, contrast is fair however, density is too low at the top of the sacrum but adequate at the coccyx, any increase in density would have “burned out” the coccyx. Anatomical right marker is evident in the superimposed femoral heads. Upon image reviews a diagnosis of acute sacrococcygeal angle due to coccygeal injury and no visible fracture was issued (Wasserman, 2008).
Sacrum. Sacrum is a large triangular bone site of second primary curvature (Bontrager & Lampignano, 2014) that consists of 5 segments S1 through S5 that are fused together, suited at the lower part of the vertebral column and upper and lower part of the pelvic cavity. It is inserted like a wedge between the two ossa innominata (Gray, 1993). Coccyx. Coccyx is a slightly movable most rudimentary part of the vertebral column. The name coccyx derives from being compare to the shape a cuckoo’s bird beak. It comprises the 3 to 5 fused terminal vertebrae and articulates to sacrum by the sacrococcygeal joint (Gray, 1993).
Sacrococcygeal injury is a sudden forceful onset of injury to the sacrococcygeal joint causing anterior subluxation of the coccyx. Injury to the coccygeal area is one of the causes of coccydynia (Patel, Appannagari & Whang, 2008). Coccydynia, the coccy- prefix means coccyx, the suffix –dynia means pain. Thus, coccydynia also known in some literature as coccygodynia (McCarthy, 2014) is defined as pain in the area of the coccyx due to the bones of the coccyx moving beyond their range of motion which causes the ligament of the coccyx to become inflamed (Staehler, 2010). Coccydynia can vary anywhere from discomfort to acute pain and manifests differently with time and individual. It is a collection of conditions which can have different causes and need different treatments. The major causes of coccydynia are idiopathic, result from a fall and infection or pathology (Kim & Suk, 1999). Symptoms of coccydynia range from moderate to severe and include but are not limited to: pain when sitting, local pain in tail bone area that worsens when touch or pressure is applied, pain that is worst when moving from sitting to standing positions, discomfort when constipated but fades after a bowel movement, as well as pain during coitus (Coccydynia (tailbone pain), 2014).
There are a numerous array of risk factors associated with coccydynia. Being a female is one of the more prevalent risk factors. A male has a longer and more anteriorly curved coccyx that is situated in a narrower pelvis which causes the male to sit on the ischial tuberosities (Staehler, 2010) and the coccyx not to have any direct contact when sitting. Compared to a male, a female coccyx is shorter and straighter and is located in a wider pelvis (Staehler, 2010) thus placing the coccyx at the most posterior aspect of the pelvis putting it at a higher risk of acute or chronic injury from either blunt trauma to the area, child birth or direct contact to hard surfaces from prolonged sitting which applies pressure to the coccyx caused by its structural anatomy. Additional risk factors of coccydynia could derive from the conditions of having brittle bones, playing contact sports, having pathology or acquiring infections, as well as obesity (Staehler, 2010). Coccydynia complications are mostly pain associated unless hyperflextion of the coccyx is involved. This coccygeal angulation pushes the coccyx forward into the posterior rectal wall, causing the digestive issue know as constipation which in its own gives rise to separate complications such as hemorrhoids, anal fissures, fecal impaction and rectal prolapse (Mayo Clinic Staff, 2014).
Coccydynia can be best diagnosed by anesthetic coccyx injection ("Injections and needles," 2013) and palpation, also magnetic renaissance imaging (MRI) and x-ray (Staehler, 2010). If the pain subsides post anesthetic injection or during palpation pain increases it is known that the cause of pain is the coccyx. In the case of x-ray and MRI they can show bone or soft tissue lesions respectively as a source of coccydynia. Depending on the diagnosis and severity coccydynia can be managed or treated several different ways. Moderate coccydynia symptoms can be managed by employing a doughnut cushion when sitting, applying ice packs to reduce inflammation and by sleeping on the side and placing a pillow between the knees (Ramse, Toohey & Neidre, 2003). Medication such as non-steroidal anti-inflammatory drugs (NSAIDs) and analgesics can be also taken to reduce inflammation and, or pain. In cases of coccydynia due to subluxation manual manipulation of the coccyx is done as well as physical therapy to straighten and strengthen the ligament and muscles around the coccyx (Dalton, 2006). For sever coccydynia corticosteroid coccyx injection can be done by injecting the corticosteroid around the coccyx or in the sacrococcygeal joint, the pain can be gone from one month up to one year depending on the individual ("Injections and needles," 2013). Lastly, for the most severe of cases an operation known as coccygectomy can be performed. Coccygectomy is the surgical removal of the coccyx.
During a coccygectomy the surgeon makes a 1 to 2 inch incision in the back side of the patient right over the coccyx. The peritoneum is dissected away from the bone to allow the either partial or complete removal of the coccyx. The operation takes about 30 minutes to perform; however, recovery time is lengthy ranging from 3 months to one year (Staehler, 2010). As with any procedure there is a high risk of post-operative infection, also having the ganglion impar located just anteriorly to the coccyx runs the potential risk of damaging the paravertebral sympathetic nerves. Injury to the rectal musculature can occur causing fecal inconsistency associated to injury to the sphincter ani externus, also damage to the levator ani group muscle can cause pelvic floor sagging. A complication and major concern of the patient is continuing of the pain (Lakshmana, Khalid & Kent, 2013).
In conclusion, after radiological review of 3 images that consisted of an AP axial sacrum, AP axial coccyx and lateral sacrum/coccyx a 33 years old female was diagnosed with sacrococcygeal angle due to coccygeal injury resulted to a traumatic fall. Coccygeal injury is one of several causes of coccydynia which is generally defined as pain in the coccygeal area. Coccydynia can be caused by several different risk factors from being idiopathic to traumatic falls, obesity, and gender being one of the top risk factor of coccydynia. A female is at a much higher risk of having coccydynia mostly from the anatomical structure and placement of the coccyx within the pelvis. Coccydynia may be diagnosed by anesthetic injection, palpation, x-ray and MRI. Symptoms and treatment for coccydynia range from moderate to severe depending on individual and situation. For moderate coccydynia simple doughnut cushions, ice, NSAIDs or analgesics could be used. In case of coccydynia due to subluxation manipulation and physical therapy is used. However, in severe cases of coccydynia corticosteroids could be injected around the coccyx or in the sacrococcydeal joint. In more drastic of cases cocygectomy can be performed by partial or complete removal of the coccyx. Similar to any other surgical procedure there are complications and recovery can be extensive with no guaranty of pain fading. Nevertheless, no matter the risk factors or symptoms there are many ways to manage the symptoms or even treat it.