coccygodynia , first described by simpson in 1859 , is disabling pain in the coccyx that is usually provoked by sitting or changing from a sitting to a standing position . this tail bone pain may radiate rostrally to the sacrum or lumbar spine or laterally to the buttocks . patients may rarely present with associated rectal pain or radicular symptoms one third of patients have associated back pain , contributing to misdiagnosis1,2,23,24 ) . due to unfamiliarity with this condition by spine specialist compounding the problem , most neurosurgeons and orthopedic spine surgeons are uncomfortable treating coccygodynia due to lack of surgical training with coccygectomy . fortunately , the knowledge to properly diagnose and surgically treat chronic refractory coccygodynia may be easily acquired . diagnosis is based on the history and physical exam , supplemented by imaging findings and local injection of the coccyx . to raise awareness among our neurosurgical colleagues on coccygodynia and surgical treatment , we review the literature on coccygectomy and describe the surgical technique based on our extensive experience at university of california , davis medical center ( ucdmc ) . relevant articles were retrieved with pubmed using the key words , " coccygodynia " and/or " coccygectomy " . we limited the search to the english - language literature published from 1980 to january 2012 . selected manuscripts were analyzed for the number of patients , age , gender , symptom duration , etiology , radiographic classification , type of surgery , use of antibiotics or drain , complications , and followup period . statistical analysis of the data was performed using the statistical package for the social sciences ( spss ) , version 16.0 ( spss , inc . , continuous variables were expressed as the meanstandard deviation , and categorical variables were expressed as frequencies and percentages . the chi - square test was used to evaluate any potential association of the two different surgical procedures with the postoperative outcome and complication rate . odds ratios ( or ) and 95% confidence intervals ( ci ) , were calculated by means of simple logistic regression analysis . after the uc davis institutional review board approval was obtained , 61 patients who had coccygectomy for chronic refractory coccygodynia between 1997 and 2009 were identified . for a variety of reasons , only 26 patients participated in a telephone survey . x - rays of responders were classified according to the postacchini and masobrio methods ( table 1 ) . outcomes were categorized as excellent ( complete pain relief ) , good ( relief of most pain but mild discomfort after prolonged sitting ) , fair ( minimal or no pain relief ) , or poor ( pain worse after the surgery ) . all patients received a bowel preparation preoperatively to help prevent fecal contamination of the wound and to minimize complications in the unlikely event of a rectal perforation . after the induction of general anesthesia , the patient was positioned prone on a wilson frame . the coccygeal region and anus are prepared with iodine or chlorhexidine . following the skin preparation , the perianal area is isolated with a 3 m 1010 steri - drape , and the incision site is then draped with sterile towels . a midline vertical incision is made over the coccyx followed by an exposure from proximal to distal direction . after removal of the sacrococcygeal disc the coccyx is elevated and separated from the surrounding tissues circumferentially in a subperiosteal plane using monopolar electrocautery , proceeding with an en bloc resection in a rostral to caudal direction in the manner of key at al . ( table 2 ) . dissection from a proximal to distal direction avoids the risk of rectal injury , especially in the case of an anteverted coccyx . in some cases of posterior intercoccygeal subluxation the co-1 is identified anatomically by the cornua at the articulation with the caudal sacral segment , and is usually twice as wide as the co2 segment . it is often helpful to resect the cornu with a kerrison rongeur to facilitate mobilization of the coccygeal segment . in the case of a fused s5-co1 disc , the resection proceeds distal to the first mobile segment , or total coccygectomy is preferred for thinner patients , where the co1 segment may present a symptomatic bony prominence if it is not removed . cutting monopolar electrocautery current on a low setting is favored over coagulating current to limit damage to surrounding tissues that could result in wound infection or rectal injury . a clamp may be appliedat the lateral aspects of the coccyx to aid in posterior elevation and retraction . a complete resection may be ascertained by examining the resected specimen ( fig . 1 ) and by comparing a lateral c - arm fluoroscopic radiograph with preoperative imaging to ensure complete resection . all remaining sharp prominences on the caudal sacrumare smoothed using a rongeur , and bone wax is applied . after hemostasis is ensured , the overlying fascia and skin are closed in layers , with subcutaneous sutures for the skin . a liquid skin adhesive ( dermabond ) is applied to help protect the wound from contamination . broad - spectrum antibiotics are continued for 48 - 72 hours , and the patient receives nursing care in a lateral position or supine on a specialized sacral cutout cushion to avoid direct pressure on the surgical wound . relevant articles were retrieved with pubmed using the key words , " coccygodynia " and/or " coccygectomy " . we limited the search to the english - language literature published from 1980 to january 2012 . selected manuscripts were analyzed for the number of patients , age , gender , symptom duration , etiology , radiographic classification , type of surgery , use of antibiotics or drain , complications , and followup period . statistical analysis of the data was performed using the statistical package for the social sciences ( spss ) , version 16.0 ( spss , inc . , continuous variables were expressed as the meanstandard deviation , and categorical variables were expressed as frequencies and percentages . the chi - square test was used to evaluate any potential association of the two different surgical procedures with the postoperative outcome and complication rate . odds ratios ( or ) and 95% confidence intervals ( ci ) , were calculated by means of simple logistic regression analysis . after the uc davis institutional review board approval was obtained , 61 patients who had coccygectomy for chronic refractory coccygodynia between 1997 and 2009 were identified . for a variety of reasons , only 26 patients participated in a telephone survey . x - rays of responders were classified according to the postacchini and masobrio methods ( table 1 ) . outcomes were categorized as excellent ( complete pain relief ) , good ( relief of most pain but mild discomfort after prolonged sitting ) , fair ( minimal or no pain relief ) , or poor ( pain worse after the surgery ) . all patients received a bowel preparation preoperatively to help prevent fecal contamination of the wound and to minimize complications in the unlikely event of a rectal perforation . after the induction of general anesthesia , the patient was positioned prone on a wilson frame . the coccygeal region and anus are prepared with iodine or chlorhexidine . following the skin preparation , the perianal area is isolated with a 3 m 1010 steri - drape , and the incision site is then draped with sterile towels . a midline vertical incision is made over the coccyx followed by an exposure from proximal to distal direction . after removal of the sacrococcygeal disc the coccyx is elevated and separated from the surrounding tissues circumferentially in a subperiosteal plane using monopolar electrocautery , proceeding with an en bloc resection in a rostral to caudal direction in the manner of key at al . dissection from a proximal to distal direction avoids the risk of rectal injury , especially in the case of an anteverted coccyx . in some cases of posterior intercoccygeal subluxation the co-1 is identified anatomically by the cornua at the articulation with the caudal sacral segment , and is usually twice as wide as the co2 segment . it is often helpful to resect the cornu with a kerrison rongeur to facilitate mobilization of the coccygeal segment . in the case of a fused s5-co1 disc , the resection proceeds distal to the first mobile segment , or total coccygectomy is preferred for thinner patients , where the co1 segment may present a symptomatic bony prominence if it is not removed . cutting monopolar electrocautery current on a low setting is favored over coagulating current to limit damage to surrounding tissues that could result in wound infection or rectal injury . a clamp may be appliedat the lateral aspects of the coccyx to aid in posterior elevation and retraction . a complete resection may be ascertained by examining the resected specimen ( fig . 1 ) and by comparing a lateral c - arm fluoroscopic radiograph with preoperative imaging to ensure complete resection . all remaining sharp prominences on the caudal sacrumare smoothed using a rongeur , and bone wax is applied . after hemostasis is ensured , the overlying fascia and skin are closed in layers , with subcutaneous sutures for the skin . a liquid skin adhesive ( dermabond ) is applied to help protect the wound from contamination . broad - spectrum antibiotics are continued for 48 - 72 hours , and the patient receives nursing care in a lateral position or supine on a specialized sacral cutout cushion to avoid direct pressure on the surgical wound . total of 28 manuscripts met the inclusion criteria and were analyzed ( table 3 ) . only two of them were prospective series19,32 ) . the majority were retrospective uncontrolled case series . in total , the reviewed series included 742 patients with coccygodynia that had coccygectomy as definitive pain management . the youngest patient was 11 and the oldest was 78 with the mean age ranging from 26.4 to 52.8 years3,8 ) . out of 706 patients with their sex identified , 592 were females ( 83.9% ) and 114 were males ( 16.1% ) , with the male to female ratio of 1:5.2 . the etiology of the coccygodynia was reported in all except for five articles , totalling 556 patients6,17,19,26,31 ) . the most common causeof coccygodynia was direct trauma , reported in 325 patients ( 58.5% ) . idiopathic coccygodynia , childbirth , and recent lumbar spinal surgery or rectal surgery or epidural injection comprised of 174 cases ( 31.3% ) . abnomal imaging characteristics have been described , most often using a classification system introduced by postacchini and massobrio which characterizes kyphotic angulation and/or subluxation ( table 1)4,8,11,15,16,24,30 ) . out of 176 x - raysanalyzed , there were 64 type i ( 36.4% ) , 55 type ii ( 31.3% ) , 31 type iii ( 17.6% ) and 26 type iv(14.8% ) . abnormal imaging on plain and dynamic x - rays , including hypermobility , ventral angulation , and subluxation , are associated with coccygodynia but are not sine qua non characteristics . there were four ( one prospective ) comparative studies assessing the efficiency of injections to coccygectomy13,25,30,32 ) . their findings showed that injection with manipulation is effective in providing pain relief , but they also suggested that coccygectomy is a reasonable choice for those in whom the conservative management failed . prior to coccygectomy , the majority of patients had undergone non - operative treatment modalities for a variable period of time , ranging from 3 months to 15 years . in four papers3,6,13,30 ) a second generation cephalosporin was administered for 48 hours postoperatively , while the rest of the studies vary significantly as to the type and duration of their chemoprophylaxis . have recommended the use of a drain for avoiding the void space which could compromise the results6,19,22 ) . on the other hand , the usage of drain in close proximity to rectum may be considered as a cause for increased infection rate , but this systematic review could not confirm any direct relation between the usage of drain and rate of infections . following surgery , laxative or enema together with a low residual diet patient follow - up ranged from 4 months to 16 years after the surgery , with the vast majority of the studies having a mean follow - up period of more than 2 years . our literature review revealed that 623 out of 742 patients treated with coccygectomy had excellent or good outcome ( 84.0% ) . some of the authors used visual analogue scale ( vas ) and the oswestry disability index ( odi ) for evaluating their results3,5,6,13,16,22,23,27 ) . perkins et al.23 ) and hodges et al.13 ) presented a decrease of vas from 8.3 to 4.5 and 7.3 to 3.6 , respectively . similarly the reduction of odi was from 35.6 to 12.5 and 55 to 36 , respectively . cebesoy et al.5 ) also commented that there was a progression of vas reduction through time from 5.18 pre - operatively to 3.18 at 6 months and 2.94 and 2.76 at 12 and 24 months , respectively . kerr et al.16 ) reported that the outcome appeared to be durable over time and not dependent on the cause of pain . perkins et al.23 ) reported only 54% with a good outcome ( 7/13 ) probably due to the fact that most of their patients also had associated lumbar spinal disorders ( 10/13 ) . bayne et al.2 ) reported 40% fair to poor outcome ( 19/48 ) and advocated against the gardner surgical technique ( table 3 ) and for the use of perioperative antibiotics . key 's proximal to distal surgical technique was reported in seven studies3,4,6,16 , 23,25,26,30 ) , whereas in only one study was gardner 's distal to proximal exposure used2 ) . statistical analysis of the incidence of complications between the two different techniques revealed a trend toward a higher complication rate in patients treated with the gardner method ( 10 of 48 patients ; 20.8% ) compared with key 's operation ( 30 of 232 patients ; 12.9% ) , but this difference did not reach statistical signi . overall , the risk of complications was increased by almost 80% among patients who underwent gardner'ssurgical exposure compared with patients managed with key 's technique ( or , 1.77 ; 95% ci , 0.80 - 3.93 ) . patients who underwent key 's operation were more likely to have better results compared with those who were operatedwith the gardner method ; the results of key 's operation were excellent in 203 ( 87.5% ) patients , fair in 11 ( 4.7% ) patients and poor in only 18 ( 7.8% ) patients , while 29 ( 60.4% ) , 11 ( 22.9% ) and 8 ( 16.7% ) of the patients who were managed withthe gardner method had excellent , fair and poor results , respectively . patients who underwent key 's operation were almost five times more likely to experience an excellent result than those who were managed with the gardner method ( or , 4.59 ; 95% ci , 2.28 - 9.21 ) . escherichia coli and staphylococcus aureus were the most frequently recorded bacteria in those series with reported microbiology results . moreover , there were 2 hematomas , 6 wounds dehiscence that lead to further surgical management , 3 persistent drainage and 6 delayed healings . there were 4 cases ( 0.6% ) of re - do operation to excise to re - operation for excision of remnant coccyx or the distal cornua of the sacrum . the average patient age was 42 years ( range 25 - 78 years ) , and the male to female ratio was 1:4 . follow - up telephone survey was able to be obtained only from 26 patients from the entire series ( 42.6% ) . the most common cause of coccygodynia was direct trauma , recorded in 15 patients ( 57.7% ) . of note , three cases ( 11.5% ) developed after esophagectomy , lumbar fusion and lumbar diskectomy ( 1 case each ) . the median duration of follow up from the time of surgery was 37 months ( range 2 - 133 months ) . of the 26 respondents , we could classifythe coccyx according to the schema described by postacchini and massobrio in 24 patients ( table 2 ) . of these coccyges , seven were type i ( 29.2% ) , seven were type ii ( 29.2% ) , two were type iii ( 8.3% ) , and seven were type iv(29.2% ) . the number of patients with outcomes rated as " excellent , " " good , " " fair , " and " poor " were 13 , 9 , 2 , and 2 , respectively . 31% of respondents claimed they had been misdiagnosed as having some other pathological condition explaining their coccygodynia . 85% of respondents stated they would undergo the operation again if faced with the same situation . 96% of respondents would have had the procedure sooner if they had been given the option , and 85% would recommendthe surgery to others . the mean vas score preoperatively was 9.60.8 , and postoperatively it was 3.13.1 ( p<0.001 ) . two patients underwent redo coccygectomy to resect residual coccyx after initial partial coccygectomy , resulting in 1 good and 1 fair result at the time of telephone follow - up . no significant difference in outcome could be detected based on traumatic versus nontraumatic causes ( p=0.33 ) . our numbers were small , but the outcome appeared to be durable over time and not dependent on the cause of pain . the average patient age was 42 years ( range 25 - 78 years ) , and the male to female ratio was 1:4 . follow - up telephone survey was able to be obtained only from 26 patients from the entire series ( 42.6% ) . the most common cause of coccygodynia was direct trauma , recorded in 15 patients ( 57.7% ) . three cases ( 11.5% ) developed after esophagectomy , lumbar fusion and lumbar diskectomy ( 1 case each ) . the median duration of follow up from the time of surgery was 37 months ( range 2 - 133 months ) . of the 26 respondents , we could classifythe coccyx according to the schema described by postacchini and massobrio in 24 patients ( table 2 ) . of these coccyges , seven were type i ( 29.2% ) , seven were type ii ( 29.2% ) , two were type iii ( 8.3% ) , and seven were type iv(29.2% ) . the number of patients with outcomes rated as " excellent , " " good , " " fair , " and " poor " were 13 , 9 , 2 , and 2 , respectively . 31% of respondents claimed they had been misdiagnosed as having some other pathological condition explaining their coccygodynia . 85% of respondents stated they would undergo the operation again if faced with the same situation . 96% of respondents would have had the procedure sooner if they had been given the option , and 85% would recommendthe surgery to others . the mean vas score preoperatively was 9.60.8 , and postoperatively it was 3.13.1 ( p<0.001 ) . two patients underwent redo coccygectomy to resect residual coccyx after initial partial coccygectomy , resulting in 1 good and 1 fair result at the time of telephone follow - up . no significant difference in outcome could be detected based on traumatic versus nontraumatic causes ( p=0.33 ) . our numbers were small , but the outcome appeared to be durable over time and not dependent on the cause of pain . coccygodynia is a disabling pain in the coccyx exacerbated by sitting or rising from sitting . the pain is often pulling or lancinating in quality , may radiate to the sacrum or buttock , and may coexist with lower back pain . all patients should receive a dynamic lateral sacrococcygeal x - ray in both the standing and sitting positions . four types of coccygeal configurations have been described by postacchini and massobrio : type i ( normal , curved slightly forward , seen in 68% of the general population ) , type ii ( more curved , straight forward ) , type iii ( sharply angulated ) , and type iv(subluxed)24 ) . in coccygodynia , patients are less likely to have type i ( 31% ) and more likely to have type iii andiv configurations . fusion of the sacrococcygeal joint appears to be a predisposing factor in coccygeal pain ( 51% versus 37% in people without coccygodynia ) 24 ) . radiographic instability as evidenced by posterior subluxation and hypermobility ( > 20 of sacrococcygeal or intercoccygeal angulation ) is seen in approximately 70% of patients with coccygodynia ( fig . other lesions include anterior subluxation and a bony spicule on the dorsal tip of the coccyx ( seen in 5% and 14% of coccygodynia , respectively ) . lumbosacral mri with contrast is recommended in all patients to define normal and abnormal bony anatomy and to rule out less common causes of coccygodynia , such as abscess or tumors . ct should be ordered in cases of acute pelvic trauma , and as an adjunct to mri in evaluating neoplastic disease . the goal of treatment is to eliminate or significantly reduce coccygeal pain and allow the patient to resume a premorbid lifestyle . incidentally discovered tumors or other pathologies are referred immediately to appropriate specialists . all patients with acute coccygodynia ( symptoms < 2 months ) are prescribed rest and a nonsteroidal anti - inflammatory drug ( nsaid ) for a period of 8 weeks9 ) . a stool softener is recommended in patients who have a history of pain with defecation , also for 8 weeks . additional therapies include sitz baths , hot mud application , acupuncture , and chiropractic manipulation . patients who do not respond in this time frame are treated the same as patients with chronic disease who have failed acute management . no universally accepted guidelines for conservative interventional management exist , but various nonoperative treatment options are available according to the experience and expertise of the physician . non - operative treatment includes ergonomic adjustments such as a specialized cushion for sitting , application of local heat , and oral analgesics14,16,20 ) . patients with newly diagnosed chronic coccygodynia ( symptoms > 2 months ) should receive the same therapies recommended for acute coccygodynia before trying more invasive measures . patients who have failed acute management should obtain dynamic sacrococcygeal x - rays and mri to rule out tumor or other pathology . favorable results are reported after corticosteroid and local anesthetic injections given on an as - required basis20,23 ) . they may be given alone or in combination with invasive manipulation ( i.e. , transrectal flexion and extension ) under general anesthesia , the latter being considered more successful32 ) . the corticosteroid plus local anesthetic should either be injected into the soft tissues around the sides and tip of the coccyx ( using methylprednisolone ) or the sacrococcygeal ( sc ) junction and dorsalperiosteum of the coccyx ( using triamcinolone ) . however , percutaneous sacrococcygeal junction injection is sometimes recommended if local injection and/or manipulation fails , and may be accomplished fluoroscopically , or with digital rectal localization ofthe sc junction . if corticosteroid injections have no effect after 2 successive monthly injections , physical therapy combined with corticosteroid injection is an effective second - line option . physical - therapy measures include transrectal pelvic floor massage and coccygeal mobilization32 ) . in cases of persistent symptoms unresponsive to conservative treatment , different types of surgical treatment have been described but key 's method is most popular ( table 2)3,4,6,7,15,16,19,21,22,23,24,25,26,30 ) . some have even advised against coccygectomy because they found that coccygectomy frequently failedto relieve the symptoms9 ) . statistical analysis revealed that patients who underwent coccygectomy according to key had five times more chances to havea better outcome . according to postacchini and massobrio , the coccyx can be removed either totally or partially with comparablegood results24 ) . in most papers , however , total resection had better outcomes than partial resection and was recommended to reduce the chance of re - do operation11,12,15,16,21,25 ) . a periosteal resection instead of a subperiosteal resrection has also been reported as an option3,22 ) . we feel that the subperiosteal resection , which preserves the ligamentous attachments and anococcygeal ligament , is a safer and more straightforward than a periosteal and ligamentous resection , and could theoretically decrease the rare complication of rectal hernia . in our surgical case series , we encountered no cases of intraoperative rectal perforation or delayed rectal hernia associated with internal wound dehiscience . kerr et al . reported that no significant difference in outcome could be detected based on traumatic versus nontraumatic causes ( p=0.33)16 ) . on the other hand , coccygectomy is more successful in cases of traumatic and postpartum coccygodynia than in idiopathic coccygodynia ( 75% success versus 58% success)2,22 ) . bayne et al . reported that coccygectomy is seldom successful for pain associated with lumbar disc disease requiring lumbar laminectomy and spine fusion2 ) . confining coccygectomy to patients with radiographic instability on dynamic x - rays can result in good or excellent outcomes in 92% of cases ( fig . wound infection is the most common complication after surgery , with rates ranging from 2% to 22%9 ) . wound infection is facilitated by the location of the skin incision in the inter - lineal fold in proximity to the anus . infection rates as high as 50% have been reported , although in recent series the rates are much lower ( 0 - 3%)1,5 ) . overall infection from 28 papers was 64 cases ( 10.0% ) ( table 3 ) . it is notable that smallcase series had the highest complication rates , ranging from 26.7 to 50%5,13,25,30 ) . bayne et al . reported also a large number of complications ( 20.6% ) that was attributed to no antibiotic prescription in contrast to the rest of the authors and protocols2 ) . escherichia coli and staphylococcus aureus were the most frequently recorded bacteria in those series with reported microbiology results . there were several options to decrease the wound infection . among the surgical approaches , key 's surgical exposure showed lower incidence of complications compared with gardner 's technique . patients who underwent key 's operation were almost five times more likely to experience an excellent result than those who were managed with the gardner method . it is of note that some authors reported that sub - periosteal resection gives better results and reduce the risk of infection compared with total coccygectomy3,22 ) . the use of a drain along with postoperative antibiotics may reduce the incidence of postoperative wound problems including infection . bayne et al . reported a large number of complications ( 20.6% ) , but also mentioned that the lack of preoperative antibiotics , which is standard now2 ) . there is no consensus how long antibiotics should be used postoperatively . in most papers , antibiotics were used for 72 hours after the surgery and covered bothaerobic and anaerobic organisms . patient may be given a low residual constipating diet to avoid the need for bowel movements inthe immediate post - operative period . there were 2 hematomas , 6 wounds dehiscence that lead to further surgical management , 3 persistent drainage , and 6 delayed healings . there were 4 cases ( 0.6% ) of re - do operation to excise remnant coccyx or the distal cornua of the sacrum . none of the published case series have reported the complication of rectal hernia or rectal injury but two case reports exist.10 , 18 the overall total complication rate was 13.3% . it is notable that there were 4 case of re - do operation to resection the remnant of the coccyx . several authors reported the advantages of performing total coccygectomy compared with partial one , which appears to be associated with an increased incidence of recurrent pain and revision surgery11,12,15,16,21,25 ) . residual coccygeal fragments or a prominent sacral edge in a thin patient may lead to poor outcomes and necessitate reoperation for redo coccygectomy , or rongeuring of the edge of the sacrum . we recommend total coccygectomy instead of partial coccygectomy to reduce the need for re - do operation . it can be helpful to confirm for any protrusion or remnant with c - arm just before closing the wound . all patients should receive a dynamic lateral sacrococcygeal x - ray in both the standing and sitting positions . four types of coccygeal configurations have been described by postacchini and massobrio : type i ( normal , curved slightly forward , seen in 68% of the general population ) , type ii ( more curved , straight forward ) , type iii ( sharply angulated ) , and type iv(subluxed)24 ) . in coccygodynia , patients are less likely to have type i ( 31% ) and more likely to have type iii andiv configurations . fusion of the sacrococcygeal joint appears to be a predisposing factor in coccygeal pain ( 51% versus 37% in people without coccygodynia ) 24 ) . radiographic instability as evidenced by posterior subluxation and hypermobility ( > 20 of sacrococcygeal or intercoccygeal angulation ) is seen in approximately 70% of patients with coccygodynia ( fig . other lesions include anterior subluxation and a bony spicule on the dorsal tip of the coccyx ( seen in 5% and 14% of coccygodynia , respectively ) . lumbosacral mri with contrast is recommended in all patients to define normal and abnormal bony anatomy and to rule out less common causes of coccygodynia , such as abscess or tumors . ct should be ordered in cases of acute pelvic trauma , and as an adjunct to mri in evaluating neoplastic disease . the goal of treatment is to eliminate or significantly reduce coccygeal pain and allow the patient to resume a premorbid lifestyle . incidentally discovered tumors or other pathologies are referred immediately to appropriate specialists . all patients with acute coccygodynia ( symptoms < 2 months ) are prescribed rest and a nonsteroidal anti - inflammatory drug ( nsaid ) for a period of 8 weeks9 ) . a stool softener is recommended in patients who have a history of pain with defecation , also for 8 weeks . additional therapies include sitz baths , hot mud application , acupuncture , and chiropractic manipulation . patients who do not respond in this time frame are treated the same as patients with chronic disease who have failed acute management . no universally accepted guidelines for conservative interventional management exist , but various nonoperative treatment options are available according to the experience and expertise of the physician . non - operative treatment includes ergonomic adjustments such as a specialized cushion for sitting , application of local heat , and oral analgesics14,16,20 ) . patients with newly diagnosed chronic coccygodynia ( symptoms > 2 months ) should receive the same therapies recommended for acute coccygodynia before trying more invasive measures . patients who have failed acute management should obtain dynamic sacrococcygeal x - rays and mri to rule out tumor or other pathology . favorable results are reported after corticosteroid and local anesthetic injections given on an as - required basis20,23 ) . they may be given alone or in combination with invasive manipulation ( i.e. , transrectal flexion and extension ) under general anesthesia , the latter being considered more successful32 ) . the corticosteroid plus local anesthetic should either be injected into the soft tissues around the sides and tip of the coccyx ( using methylprednisolone ) or the sacrococcygeal ( sc ) junction and dorsalperiosteum of the coccyx ( using triamcinolone ) . however , percutaneous sacrococcygeal junction injection is sometimes recommended if local injection and/or manipulation fails , and may be accomplished fluoroscopically , or with digital rectal localization ofthe sc junction . if corticosteroid injections have no effect after 2 successive monthly injections , physical therapy combined with corticosteroid injection is an effective second - line option . in cases of persistent symptoms unresponsive to conservative treatment , however , coccygectomy is offered as the definitivetreatment option24,28 ) . different types of surgical treatment have been described but key 's method is most popular ( table 2)3,4,6,7,15,16,19,21,22,23,24,25,26,30 ) . nevertheless , controversy exists11,24 ) . some have even advised against coccygectomy because they found that coccygectomy frequently failedto relieve the symptoms9 ) . statistical analysis revealed that patients who underwent coccygectomy according to key had five times more chances to havea better outcome . according to postacchini and massobrio , the coccyx can be removed either totally or partially with comparablegood results24 ) . in most papers , however , total resection had better outcomes than partial resection and was recommended to reduce the chance of re - do operation11,12,15,16,21,25 ) . a periosteal resection instead of a subperiosteal resrection has also been reported as an option3,22 ) . we feel that the subperiosteal resection , which preserves the ligamentous attachments and anococcygeal ligament , is a safer and more straightforward than a periosteal and ligamentous resection , and could theoretically decrease the rare complication of rectal hernia . in our surgical case series , we encountered no cases of intraoperative rectal perforation or delayed rectal hernia associated with internal wound dehiscience . kerr et al . reported that no significant difference in outcome could be detected based on traumatic versus nontraumatic causes ( p=0.33)16 ) . on the other hand , coccygectomy is more successful in cases of traumatic and postpartum coccygodynia than in idiopathic coccygodynia ( 75% success versus 58% success)2,22 ) . bayne et al . reported that coccygectomy is seldom successful for pain associated with lumbar disc disease requiring lumbar laminectomy and spine fusion2 ) . confining coccygectomy to patients with radiographic instability on dynamic x - rays can result in good or excellent outcomes in 92% of cases ( fig . wound infection is the most common complication after surgery , with rates ranging from 2% to 22%9 ) . wound infection is facilitated by the location of the skin incision in the inter - lineal fold in proximity to the anus . infection rates as high as 50% have been reported , although in recent series the rates are much lower ( 0 - 3%)1,5 ) . overall infection from 28 papers was 64 cases ( 10.0% ) ( table 3 ) . it is notable that smallcase series had the highest complication rates , ranging from 26.7 to 50%5,13,25,30 ) . bayne et al . reported also a large number of complications ( 20.6% ) that was attributed to no antibiotic prescription in contrast to the rest of the authors and protocols2 ) . escherichia coli and staphylococcus aureus were the most frequently recorded bacteria in those series with reported microbiology results . there were several options to decrease the wound infection . among the surgical approaches , key 's surgical exposure showed lower incidence of complications compared with gardner 's technique . patients who underwent key 's operation were almost five times more likely to experience an excellent result than those who were managed with the gardner method . it is of note that some authors reported that sub - periosteal resection gives better results and reduce the risk of infection compared with total coccygectomy3,22 ) . the use of a drain along with postoperative antibiotics may reduce the incidence of postoperative wound problems including infection . bayne et al . reported a large number of complications ( 20.6% ) , but also mentioned that the lack of preoperative antibiotics , which is standard now2 ) . there is no consensus how long antibiotics should be used postoperatively . in most papers , antibiotics were used for 72 hours after the surgery and covered bothaerobic and anaerobic organisms . patient may be given a low residual constipating diet to avoid the need for bowel movements inthe immediate post - operative period . there were 2 hematomas , 6 wounds dehiscence that lead to further surgical management , 3 persistent drainage , and 6 delayed healings . there were 4 cases ( 0.6% ) of re - do operation to excise remnant coccyx or the distal cornua of the sacrum . none of the published case series have reported the complication of rectal hernia or rectal injury but two case reports exist.10 , 18 the overall total complication rate was 13.3% . it is notable that there were 4 case of re - do operation to resection the remnant of the coccyx . several authors reported the advantages of performing total coccygectomy compared with partial one , which appears to be associated with an increased incidence of recurrent pain and revision surgery11,12,15,16,21,25 ) . residual coccygeal fragments or a prominent sacral edge in a thin patient may lead to poor outcomes and necessitate reoperation for redo coccygectomy , or rongeuring of the edge of the sacrum . we recommend total coccygectomy instead of partial coccygectomy to reduce the need for re - do operation . it can be helpful to confirm for any protrusion or remnant with c - arm just before closing the wound . when performed for an appropriate indication , coccygectomy provides an effective and long - lasting pain relief .