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Medical therapy: Treatment for coccydynia generally falls into either conservative management or surgical intervention categories. Typically, conservative management begins with the use of a nonsteroidal anti-inflammatory drug (NSAID) to reduce inflammation and pain coupled with a donut-shaped pillow or a gel cushion to decrease coccygeal pressure and local irritation. Many physicians also advise the patient to use hot sitz-type baths to further soothe the irritated coccygeal soft tissues.
If this therapy fails, usually after a minimum of 2 months, most authors consider injection of corticosteroid or a physiotherapeutically applied (ultrasound phonophoresis or iontophoresis) topical corticosteroid and analgesic combination. Wray et al, in a study published in the Journal of Bone and Joint Surgery, found that 60% of patients responded to local anesthetics and corticosteroids. The same study showed that 85% responded to this regimen and digital manipulation of the coccygeal ligaments as well as the muscles of the pelvic floor. Various massage and manipulation techniques have been described to help decrease coccygeal pain, but most have been shown to be only temporarily effective.
Other proposed treatments are acupuncture reflex therapy. A cryoanalgesia probe inserted percutaneously through the sacral hiatus into the sacral canal to produce anesthesia at the lower sacral nerve roots has been used. This seems to work best when used multiple times with prolonged freezing. Fluoroscopically guided intradiscal injections of a "caine"-like anesthetic plus a corticosteroid seemed to work well for those coccyges that were found to be hypermobile or prone to luxation.
If traditional injection therapies fail, Holubec et al have described a neurolytic technique in which lidocaine is injected at the junction of the sacrum and coccyx just in front of the junction. This is directed at the fourth and fifth sacral nerves and the coccygeal nerve. If this provides good pain relief, then a radiofrequency thermocoagulation probe can be inserted at the same site and used to ablate these nerves.
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