Total Coccygectomy for Refractory Coccydynia: A 10-Year Single-Center Retrospective Cohort Study with Comprehensive Outcome Analysis

Total Coccygectomy for Refractory Coccydynia: A 10-Year Single-Center Retrospective Cohort Study with Comprehensive Outcome Analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Total Coccygectomy for Refractory Coccydynia: A 10-Year Single-Center Retrospective Cohort Study with Comprehensive Outcome Analysis Burhan Ulhaq, Tehniat Khaliq, Simon John, Saadia Ziaulhaque, Shahzad Ahmed Qasmi, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9516506/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Coccydynia causes chronic coccygeal pain, and while most respond to conservative therapy, some remain symptomatic. Total coccygectomy is considered for refractory cases. This study evaluates its effectiveness and safety at a tertiary neurosurgical center in Pakistan. Methods We retrospectively reviewed 21 patients (9 males, 12 females; mean age 34.2 years) who underwent total coccygectomy from May 2009 to May 2019 after ≥ 6 months of failed conservative therapy. Pain was measured using the Visual Analogue Scale (VAS, 0–10) preoperatively and at last follow-up. Outcomes were classified as excellent/good (≥ 50% VAS reduction or VAS ≤ 3), fair (VAS 4–5.9), or poor (VAS ≥ 6). Complications were categorized as major or minor. Paired t-test compared pre- and postoperative VAS (P < 0.05). Results Mean symptom duration was 17.2 months. Mean VAS improved from 8.4 to 3.2 at a mean follow-up of six months (P < 0.001). Excellent/good outcomes occurred in 15 patients (71.4%), fair in 3 (14.3%), and poor in 3 (14.3%). Four patients (19.0%) developed wound infections: one major (4.8%) requiring vacuum-assisted closure and three Minor (14.3%) managed conservatively. No neurological deficits or reoperations occurred. Conclusion Total coccygectomy provides significant pain relief with acceptable complication rates in selected patients with refractory coccydynia. Prospective studies with longer follow-up are needed to assess long-term durability. Neurosurgery Coccydynia Coccygectomy Coccyx pain Spine surgery Surgical outcomes Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Coccydynia, also termed coccygodynia, refers to localized pain arising from the coccyx and was first described by Simpson in 1859 [ 1 ]. Although relatively uncommon, it accounts for approximately 1–5% of all patients presenting with low back pain [ 2 ]. Clinically, the condition manifests as focal coccygeal pain that may radiate to the sacrum, buttocks, or rectal region. Symptoms are typically exacerbated by prolonged sitting, rising from a seated position, defecation, or sexual intercourse [ 3 , 4 ]. Coccydynia predominantly affects adults and demonstrates a higher prevalence in women, likely due to childbirth-related trauma, pelvic morphology, and increased coccygeal mobility [ 3 , 5 ]. Psychological factors, including depression and somatization, may further modulate symptom perception and chronicity [ 6 ]. The pathophysiology of coccydynia is multifactorial. Proposed mechanisms include repetitive microtrauma, pelvic floor dysfunction, degenerative changes of the sacrococcygeal joint, coccygeal hypermobility or instability, and the presence of a coccygeal spicule [ 4 , 7 ]. Additionally, altered nociceptive transmission through the ganglion impar has been implicated in pain perpetuation, forming the basis for targeted interventional therapies [ 8 ]. Secondary causes such as rapid weight loss, neoplastic lesions, and degenerative disc disease must also be excluded during evaluation [ 4 ]. Dynamic lateral radiographs obtained in both standing and seated positions remain the standard imaging modality for assessing coccygeal instability and abnormal angular mobility [ 9 , 10 ]. Magnetic resonance imaging (MRI) provides complementary information by detecting inflammatory changes, bone marrow edema, disc pathology, and occult neoplastic processes [ 11 ]. Initial management is conservative and includes nonsteroidal anti-inflammatory drugs (NSAIDs), donut-shaped cushions, physical therapy, intrarectal manipulation, corticosteroid injections, ganglion impar blocks, and radiofrequency thermocoagulation [ 4 , 12 ]. While the majority of patients improve with non-operative measures, approximately 10–30% develop chronic, refractory symptoms [ 13 ]. Coccygectomy remains the definitive surgical option for patients with refractory coccydynia who fail conservative management, and several operative techniques have been described in the literature. The conventional approach involves resection of the coccyx from proximal to distal, allowing controlled dissection under direct visualization [ 14 ]. In contrast, Gardner advocated a distal-to-proximal (tip-to-base) technique; however, this method has been criticized because the surgeon works in a relatively blind plane, potentially increasing the risk of rectal injury [ 15 ]. Postacchini and Massobrio reported that both total and partial coccygectomy can yield comparably favorable clinical outcomes, suggesting that the extent of resection may be individualized based on pathology and intraoperative findings [ 12 ]. More recently, Bilgic et al. compared coccygectomy with and without periosteal resection, highlighting the potential advantages of subperiosteal dissection in minimizing soft tissue trauma and complications [ 16 ]. Collectively, these variations underscore the ongoing evolution of surgical strategies aimed at optimizing safety and functional outcomes in coccygectomy. However, despite encouraging outcomes reported in retrospective series, the existing literature remains limited by small sample sizes, heterogeneous patient selection, short follow-up durations, and a paucity of data from low- and middle-income countries. This retrospective cohort study aims to evaluate postoperative pain reduction, functional outcomes, and complication rates following standardized total coccygectomy in patients with refractory coccydynia at Combined Military Hospital, Pakistan. To our knowledge, this represents one of the few studies from a low- and middle-income country evaluating standardized total coccygectomy outcomes over a 10-year period. Materials and Method This retrospective observational single-center cohort study was conducted at Combined Military Hospital Rawalpindi between May 2009 and May 2019. The study adhered to Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. The Institutional Review Board of CMH Rawalpindi granted an exemption because the study involved retrospective analysis of de-identified medical records. A total of 27 consecutive patients who underwent coccygectomy for chronic coccydynia during the study period were identified from the departmental surgical database. Of these, 21 patients met the inclusion criteria and were included in the final analysis (Fig. 1 , Flow Diagram). Patients were included if they were ≥ 14 years old, had chronic coccydynia persisting for ≥ 6 months despite optimized conservative management, demonstrated localized coccygeal tenderness on clinical examination, had radiographic evidence of coccygeal pathology (hypermobility, subluxation, spicule, or degenerative changes), and had a minimum postoperative follow-up of 24 months. Patients were excluded if they had an underlying malignancy (n = 1), active sacrococcygeal infection (n = 0), congenital coccygeal anomalies (n = 0), prior coccygeal surgery (n = 0), incomplete medical records (n = 2), or were lost to follow-up before 24 months (n = 3). All patients underwent detailed clinical assessment. Pain was typically exacerbated by prolonged sitting, positional transitions, defecation, and sexual intercourse. Physical examination of the lumbosacral region demonstrated localized tenderness over the sacrococcygeal area in all cases. Preoperative pain severity was assessed using the Visual Analog Scale (VAS). Routine laboratory investigations included complete blood count, renal and liver function tests, C-reactive protein, erythrocyte sedimentation rate, and serum electrolytes were performed. Radiological evaluation consisted of plain radiographs of the lumbosacral spine, pelvis, and coccyx, along with computed tomography and magnetic resonance imaging of the lumbosacral region to confirm diagnosis and exclude alternative pathology. Radiographic findings included coccygeal hypermobility in 9 patients and degenerative changes in 12 patients. Type I: Coccyx curved slightly forward Type II: More marked forward curvature, tip directed anteriorly Type III: Sharp anterior angulation Type IV: Subluxation or hypermobility Under general anesthesia, patients were placed in the prone position on a Wilson frame. A 4-cm longitudinal midline incision was made over the sacrococcygeal junction. We utilized the proximal-to-distal (Key) technique : the sacrococcygeal joint was first identified and disarticulated, followed by subperiosteal dissection of the coccygeal segments. This approach allowed for early identification of the plane between the coccyx and the rectum, minimizing the risk of visceral injury. The distal tip was removed last. Following excision, the prominent lower end of the sacrum was beveled to ensure a smooth contour, and the wound was closed in anatomical layers to eliminate dead space. The primary outcome measure was the change in VAS score from preoperative assessment to final follow-up. Secondary outcomes included postoperative complications, patient satisfaction, and need for revision surgery. Data were extracted from the medical records and anonymized before analysis. Descriptive statistics were calculated for all variables. Continuous variables are presented as mean ± standard deviation, whereas categorical variables are expressed as frequencies and percentages. Preoperative and postoperative visual analogue scale (VAS) scores were compared using a paired two-tailed t-test. A p-value of < 0.05 was considered statistically significant. All statistical analyses were performed using IBM SPSS Statistics for Windows, Version 17.0 (IBM Corp., Armonk, NY, USA). Results Participant Characteristics A total of 21 patients met the inclusion criteria. The cohort includes 9 males (42.9%) and 12 females (57.1%), with a mean age of 34.2 ± 11.1 years (range 14-56). Etiology of coccydynia was traumatic in 9 patients (42.9%) and idiopathic/degenerative in 12 patients (57.1%). The mean duration of preoperative symptoms was 17.2 ± 7.4 months (range 6-36). All patients had failed prolonged conservative management before surgery (Table 1 ). Table 1. Baseline Characteristics (N = 21) Variable Value Male 9 (42.9%) Female 12 (57.1%) Age, mean (range), years 34.2 (14–56) Trauma etiology 9 (42.9%) Degenerative/Idiopathic etiology 12 (57.1%) Duration of symptoms, mean (range), months 17.2 (6–36) Table 1: Data are presented as n (%) for categorical variables and mean ± standard deviation (SD) or range for continuous variables. No inferential statistics were performed for baseline characteristics. SD, standard deviation Patient Outcomes Total coccygectomy led to a significant reduction in pain. Mean preoperative Visual Analogue Scale (VAS) score was 8.4 ± 1.1, which improved to 3.2 ± 1.9 postoperatively, corresponding to a mean reduction of 5.2 points (95% CI: 4.1-6.3; p < 0.001, paired t-test). Functional outcomes, categorized based on postoperative VAS, demonstrated that most patients achieved clinically meaningful improvement: Good (occasional discomfort, VAS 7): 3 patients (14.3%) These results indicate that over 70% of patients achieved excellent or good pain relief following surgery (Table 2 ). Surgical complications were uncommon. One patient (4.8%) developed a major wound infection requiring vacuum-assisted closure (VAC). Minor wound infections occurred in three patients (14.3%) and were successfully managed with daily dressing and local care. No neurological or systemic complications were observed. Table 2. Functional Outcomes and Complications (N = 21) Outcome / Complication Pre-op VAS mean ± SD Post-op VAS mean ± SD N % Good (occasional discomfort, VAS 7) 8.0 ± 1.0 7.5 ± 0.7 3 14.3 Major infection (required wound VAC) – – 1 4.8 Minor wound infection (managed with daily dressing) – – 3 14.3 Table 2. Functional outcomes and complications following total coccygectomy (N = 21). Pain was assessed using the Visual Analogue Scale (VAS) pre- and postoperatively. Statistical comparison of pre- and postoperative VAS scores was performed using the paired t-test. Data are presented as n (%). VAS, Visual Analogue Scale; VAC, vacuum-assisted closure. Discussion In this single-center retrospective cohort of 21 patients, total coccygectomy resulted in significant pain reduction, with mean Visual Analogue Scale (VAS) scores improving from 8.4 preoperatively to 3.2 postoperatively (p < 0.001). Furthermore, 71.4% of patients achieved good or excellent outcomes, reflecting both statistical and clinical significance despite the modest sample size. These findings align with prior literature. Karadimas et al., in an analytic review of 671 patients, reported satisfactory outcomes in approximately 75% of cases with an overall complication rate of 11% [ 17 ]. Sarmast et al. demonstrated VAS improvement from 9.62 to 2.25 with low wound complication rates in their five-year single-center experience [ 18 ]. Similarly, Kulkarni observed reduction from 7.33 to 2.11 following coccygectomy [ 19 ], and a pooled analysis of 742 patients by Kwon et al. found good-to-excellent outcomes in 84.6% with an infection rate of 11.5% [20]. The magnitude of pain relief in our cohort compares favorably and lies at the higher end of reported ranges, potentially reflecting careful patient selection, standardized surgical technique, and structured postoperative mobilization. The surgical approach to coccygectomy has evolved since Key's original proximal-to-distal description in 1937 [ 15 ]. Postacchini and Massobrio later advocated a distal-to-proximal technique to reduce rectal injury risk and allow safer dissection under direct visualization [ 12 ]. In our series, a uniform distal-to-proximal subperiosteal excision was employed, as described by Bilgic et al. [ 16 ]. No rectal injuries or deep infections occurred, underscoring the importance of meticulous dissection and layered closure. Wound infection remains the most common complication due to proximity to the perianal region. In our cohort, four patients (19.0%) developed postoperative wound infections, including one major infection (4.8%) requiring vacuum-assisted closure therapy and three minor infections managed conservatively. All infections resolved without long-term sequelae, and no neurological deficits or reoperations were observed. Although slightly higher than some pooled analyses, this complication profile remains comparable to prior reports [17,]. The 19% infection rate, while elevated relative to some Western series, likely reflects the challenges of wound management in the intergluteal cleft, particularly in a warm climate, and underscores the need for meticulous perioperative care. Existing literature suggests that anatomical factors such as coccygeal spicules, marked hypermobility, or Type III-IV morphology according to the Postacchini classification may predict improved surgical outcomes when mechanical instability is the primary pain generator [ 11 , 12 ]. Conversely, obesity and psychological comorbidities have been associated with increased complication rates and lower satisfaction [ 17 ]. Although subgroup analysis was limited by sample size in our study, careful radiographic assessment and exclusion of secondary pathology likely contributed to the favorable outcomes observed. The 71.4% success rate in our cohort confirms that surgery is a viable "last-resort" option in our patient population when conservative measures fail. This is particularly relevant for low- and middle-income country settings where access to chronic pain management services may be limited and patients often present with advanced, refractory symptoms. Strengths of this study include a consecutive single-center design, standardized technique performed by fellowship-trained spine surgeons, and clearly defined outcomes using validated VAS scoring. This study contributes data from a tertiary-care center in a low- and middle-income country, a population underrepresented in the coccygectomy literature. However, this study has several limitations. The retrospective single-center design introduces potential selection and information bias. The relatively small sample size (n = 21) limits statistical power, precludes meaningful subgroup analysis, and restricts the ability to perform multivariable regression to identify independent predictors of outcome or complications. The mean follow-up duration of six months restricts assessment of long-term durability of pain relief and late recurrence. Although postoperative infections were observed, no clear association with obesity was identified in our cohort; however, the limited sample size precludes definitive conclusions regarding risk factor stratification, and unmeasured confounders may have influenced complication rates. Importantly, validated functional outcome measures such as the Oswestry Disability Index or quality-of-life instruments were not utilized, which limits comprehensive functional assessment beyond pain reduction. Additionally, the absence of a control group managed non-operatively restricts comparative effectiveness evaluation. Finally, as data were derived from a tertiary referral center, external generalizability to broader community settings may be limited. Larger prospective multicenter studies with longer follow-up and standardized outcome measures are necessary to confirm the durability and reproducibility of these findings. Future research should incorporate validated functional outcome scores, quality-of-life assessments, and cost-effectiveness analyses to better define the role of coccygectomy in the management of refractory coccydynia, particularly in low-resource settings. Conclusion Total coccygectomy is a safe and effective surgical option for selected patients with refractory coccydynia. In this cohort, significant pain reduction was observed (VAS 8.4 to 3.2; p < 0.001), with 71.4% of patients achieving excellent or good outcomes. Complications occurred in 19.0% of cases and were predominantly minor infections, with no rectal injuries, neurological deficits, or reoperations. These findings are consistent with international literature and support coccygectomy as a definitive treatment in appropriately selected patients, although prospective studies with longer follow-up are needed to confirm long-term durability. Declarations Written informed consent for participation was waived by the institutional ethics committee due to the retrospective nature of the study. Patient confidentiality and anonymity were maintained throughout the study in accordance with institutional and ethical guidelines. References Simpson JY (1859) Clinical lectures on the diseases of women. Lecture XVII: Coccygodynia and diseases and deformities of the coccyx. Med Times Gaz 40:1–7 Patel R, Appannagari A, Whang PG, Coccydynia (2008) Curr Rev Musculoskelet Med 1(3–4):223–226. 10.1007/s12178-008-9028-1 Nathan ST, Fisher BE, Roberts CS (2010) Coccydynia: a review of pathoanatomy, aetiology, treatment and outcome. J Bone Joint Surg Br 92(12):1622–1627. 10.1302/0301-620X.92B12.25486 Maigne JY, Lagauche D, Doursounian L (2000) Instability of the coccyx in coccydynia. J Bone Joint Surg Br 82(7):1038–1041. 10.1302/0301-620X.82B7.10596 Wray CC, Easom S, Hoskinson J, Coccydynia (1991) Aetiology and treatment. 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Spine (Phila Pa 1976) 19(8):930–934. 10.1097/00007632-199404150-00011 Postacchini F, Massobrio M (1983) Idiopathic coccygodynia: analysis of fifty-one operative cases. J Bone Joint Surg Am 65(8):1116–1124 Fogel GR, Cunningham PY 3rd, Esses SI (2004) Coccydynia: evaluation and management. J Am Acad Orthop Surg 12(1):49–54. 10.5435/00124635-200401000-00007 Bilgic S, Kurklu M, Yurttaş Y, Ozkan H, Oguz E, Sehirlioglu A (2010) Coccygectomy with or without periosteal resection. Int Orthop 34(4):537–541. 10.1007/s00264-009-0805-2 Key JA (1937) Operative treatment of coccygodynia. J Bone Joint Surg Am 19(3):759–764 Karadimas EJ, Trypsiannis G, Giannoudis PV (2011) Surgical treatment of coccygodynia: an analytic review of the literature. Eur Spine J 20(5):698–705. 10.1007/s00586-010-1617-1 Sarmast AH, Kirmani A, Bhat A (2018) Coccygectomy for coccygodynia: a single center experience over 5 years. Asian J Neurosurg 13(2):277–282. 10.4103/1793-5482.228568 Kulkarni AG (2012) Coccygectomy for coccygodynia. J Orthop Surg (Hong Kong) 20(2):209–212. 10.1177/230949901202000215 Kwon HD, Schrot RJ, Kerr EE 3rd, Kim KD (2012) Coccygodynia and coccygectomy. Korean J Spine 9(4):326–333. 10.14245/kjs.2012.9.4.326 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9516506","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":628944982,"identity":"749551a5-5be8-4023-89c1-b155117feadc","order_by":0,"name":"Burhan Ulhaq","email":"","orcid":"","institution":"Combined Military Hospital","correspondingAuthor":false,"prefix":"","firstName":"Burhan","middleName":"","lastName":"Ulhaq","suffix":""},{"id":628944983,"identity":"42f46184-6391-450d-ab5c-474b8d6808aa","order_by":1,"name":"Tehniat Khaliq","email":"","orcid":"","institution":"Jinnah Postgraduate Medical Centre","correspondingAuthor":false,"prefix":"","firstName":"Tehniat","middleName":"","lastName":"Khaliq","suffix":""},{"id":628944984,"identity":"fad69925-3c96-47bb-9528-d1e7fb7daf87","order_by":2,"name":"Simon John","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEUlEQVRIiWNgGAWjYDACZiCWYGADMcGEHIg48ICQFguwamawFmOwlgRCNlVANIO1JDaASHxa5Nu5kz/cYODL45/df+zBxz116fPDDj8E2mInp9uAXYvBYd5tkjMY2Iol7hxmN5zx7HDuxttpBkAtycZmB3BoYebdxgz0fmLDjWQ2aZ4DB3I3zk4AaTmQuA2HFvlm3s2f/wC1zAdp+XOgLt1wdvoHvFoYDvNukADZsgGkheEAc4K8dA5+W0B+kZAwYCs2vJFsJtlz4LDhBumcggMJBrj9It9/dvMHiYpjeXI3Ep9J/DhQJy8/O33zhw8VdnK4tEDtOpaAYINVGuBTDgY1CC3yDQRVj4JRMApGwQgDAGZBYAQj0nSHAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0009-0003-8131-9506","institution":"United Medical \u0026 Dental College","correspondingAuthor":true,"prefix":"","firstName":"Simon","middleName":"","lastName":"John","suffix":""},{"id":628944985,"identity":"47c3f863-215b-4d78-b4cc-8d22664c14c3","order_by":3,"name":"Saadia Ziaulhaque","email":"","orcid":"","institution":"Akhtar Saeed Medical and Dental College","correspondingAuthor":false,"prefix":"","firstName":"Saadia","middleName":"","lastName":"Ziaulhaque","suffix":""},{"id":628944986,"identity":"f21756dd-deb1-441c-be27-a1f6d9906538","order_by":4,"name":"Shahzad Ahmed Qasmi","email":"","orcid":"","institution":"Combined Military Hospital","correspondingAuthor":false,"prefix":"","firstName":"Shahzad","middleName":"Ahmed","lastName":"Qasmi","suffix":""},{"id":628944987,"identity":"a999a89b-ec59-4cfd-b0f1-182aefe6aa11","order_by":5,"name":"Siraj Ulhaq","email":"","orcid":"","institution":"Asfendiyarov Kazakh National Medical University","correspondingAuthor":false,"prefix":"","firstName":"Siraj","middleName":"","lastName":"Ulhaq","suffix":""}],"badges":[],"createdAt":"2026-04-24 11:15:55","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":true,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-9516506/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9516506/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107865230,"identity":"6a974f86-2a1f-410a-b516-5bc886714e49","added_by":"auto","created_at":"2026-04-27 06:31:28","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":117170,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003ePatient Selection and Flow Diagram\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePatients were included if they were ≥14 years old, had chronic coccydynia persisting for ≥6 months despite optimized conservative management, demonstrated localized coccygeal tenderness on clinical examination, had radiographic evidence of coccygeal pathology (hypermobility, subluxation, spicule, or degenerative changes), and had a minimum postoperative follow-up of 24 months. Patients were excluded if they had an underlying malignancy (n=1), active sacrococcygeal infection (n=0), congenital coccygeal anomalies (n=0), prior coccygeal surgery (n=0), incomplete medical records (n=2), or were lost to follow-up before 24 months (n=3).\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9516506/v1/266895cc708f92ca99f93739.png"},{"id":107870274,"identity":"34e0fe20-7a2e-4ab9-9908-91aa9859d9cf","added_by":"auto","created_at":"2026-04-27 07:39:13","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":167725,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eRadiographic findings were classified according to the Postacchini and Massobrio classification:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eType I: Coccyx curved slightly forward\u003c/p\u003e\n\u003cp\u003eType II: More marked forward curvature, tip directed anteriorly\u003c/p\u003e\n\u003cp\u003eType III: Sharp anterior angulation\u003c/p\u003e\n\u003cp\u003eType IV: Subluxation or hypermobility\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9516506/v1/1f80639052f801962514971e.png"},{"id":107865232,"identity":"0c77e1a9-113d-468e-ae6f-83f36500d347","added_by":"auto","created_at":"2026-04-27 06:31:28","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":551125,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePreoperative Imaging.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(A) Lateral Radiograph:\u003c/strong\u003e Demonstrates an increased intercoccygeal angle (arrows), suggesting Type II/III morphology according to the Postacchini and Massobrio classification, correlating with the patient’s localized pain.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(B) Sagittal T2-Weighted MRI:\u003c/strong\u003e Reveals hyperintense signal changes at the second intercoccygeal space (arrowhead), indicative of bone marrow edema and chronic inflammatory change.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-9516506/v1/9d04c64b042838b7a5142db8.png"},{"id":107870255,"identity":"03d43a44-bc93-4a05-8be2-dc9090f780db","added_by":"auto","created_at":"2026-04-27 07:39:12","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":829464,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eIntraoperative view and Resected Coccyx\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(A) Surgical Bed:\u003c/strong\u003e Intraoperative view following total coccygectomy showing the preserved retrorectal space and beveled sacral terminus.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(B) Resected Specimen:\u003c/strong\u003e Macroscopic view of the excised coccygeal segments showing marginal sclerosis and degenerative changes of the fibrocartilaginous dis\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-9516506/v1/9f0d98e78852cb83a70a6ad4.png"},{"id":108181094,"identity":"9f044ae2-616a-4e5a-a1a6-455cf783133f","added_by":"auto","created_at":"2026-04-30 08:57:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2581879,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9516506/v1/35167e9f-fbe3-4eb2-9c94-ef2766d4b7d0.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eTotal Coccygectomy for Refractory Coccydynia: A 10-Year Single-Center Retrospective Cohort Study with Comprehensive Outcome Analysis\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCoccydynia, also termed coccygodynia, refers to localized pain arising from the coccyx and was first described by Simpson in 1859 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Although relatively uncommon, it accounts for approximately 1\u0026ndash;5% of all patients presenting with low back pain [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Clinically, the condition manifests as focal coccygeal pain that may radiate to the sacrum, buttocks, or rectal region. Symptoms are typically exacerbated by prolonged sitting, rising from a seated position, defecation, or sexual intercourse [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Coccydynia predominantly affects adults and demonstrates a higher prevalence in women, likely due to childbirth-related trauma, pelvic morphology, and increased coccygeal mobility [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Psychological factors, including depression and somatization, may further modulate symptom perception and chronicity [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe pathophysiology of coccydynia is multifactorial. Proposed mechanisms include repetitive microtrauma, pelvic floor dysfunction, degenerative changes of the sacrococcygeal joint, coccygeal hypermobility or instability, and the presence of a coccygeal spicule [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Additionally, altered nociceptive transmission through the ganglion impar has been implicated in pain perpetuation, forming the basis for targeted interventional therapies [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Secondary causes such as rapid weight loss, neoplastic lesions, and degenerative disc disease must also be excluded during evaluation [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDynamic lateral radiographs obtained in both standing and seated positions remain the standard imaging modality for assessing coccygeal instability and abnormal angular mobility [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Magnetic resonance imaging (MRI) provides complementary information by detecting inflammatory changes, bone marrow edema, disc pathology, and occult neoplastic processes [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eInitial management is conservative and includes nonsteroidal anti-inflammatory drugs (NSAIDs), donut-shaped cushions, physical therapy, intrarectal manipulation, corticosteroid injections, ganglion impar blocks, and radiofrequency thermocoagulation [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. While the majority of patients improve with non-operative measures, approximately 10\u0026ndash;30% develop chronic, refractory symptoms [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCoccygectomy remains the definitive surgical option for patients with refractory coccydynia who fail conservative management, and several operative techniques have been described in the literature. The conventional approach involves resection of the coccyx from proximal to distal, allowing controlled dissection under direct visualization [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In contrast, Gardner advocated a distal-to-proximal (tip-to-base) technique; however, this method has been criticized because the surgeon works in a relatively blind plane, potentially increasing the risk of rectal injury [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Postacchini and Massobrio reported that both total and partial coccygectomy can yield comparably favorable clinical outcomes, suggesting that the extent of resection may be individualized based on pathology and intraoperative findings [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. More recently, Bilgic et al. compared coccygectomy with and without periosteal resection, highlighting the potential advantages of subperiosteal dissection in minimizing soft tissue trauma and complications [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Collectively, these variations underscore the ongoing evolution of surgical strategies aimed at optimizing safety and functional outcomes in coccygectomy.\u003c/p\u003e \u003cp\u003eHowever, despite encouraging outcomes reported in retrospective series, the existing literature remains limited by small sample sizes, heterogeneous patient selection, short follow-up durations, and a paucity of data from low- and middle-income countries. This retrospective cohort study aims to evaluate postoperative pain reduction, functional outcomes, and complication rates following standardized total coccygectomy in patients with refractory coccydynia at Combined Military Hospital, Pakistan. To our knowledge, this represents one of the few studies from a low- and middle-income country evaluating standardized total coccygectomy outcomes over a 10-year period.\u003c/p\u003e"},{"header":"Materials and Method","content":"\u003cp\u003eThis retrospective observational single-center cohort study was conducted at Combined Military Hospital Rawalpindi between May 2009 and May 2019. The study adhered to Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. The Institutional Review Board of CMH Rawalpindi granted an exemption because the study involved retrospective analysis of de-identified medical records.\u003c/p\u003e \u003cp\u003eA total of 27 consecutive patients who underwent coccygectomy for chronic coccydynia during the study period were identified from the departmental surgical database. Of these, 21 patients met the inclusion criteria and were included in the final analysis (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Flow Diagram).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003ePatients were included if they were \u0026ge;\u0026thinsp;14 years old, had chronic coccydynia persisting for \u0026ge;\u0026thinsp;6 months despite optimized conservative management, demonstrated localized coccygeal tenderness on clinical examination, had radiographic evidence of coccygeal pathology (hypermobility, subluxation, spicule, or degenerative changes), and had a minimum postoperative follow-up of 24 months. Patients were excluded if they had an underlying malignancy (n\u0026thinsp;=\u0026thinsp;1), active sacrococcygeal infection (n\u0026thinsp;=\u0026thinsp;0), congenital coccygeal anomalies (n\u0026thinsp;=\u0026thinsp;0), prior coccygeal surgery (n\u0026thinsp;=\u0026thinsp;0), incomplete medical records (n\u0026thinsp;=\u0026thinsp;2), or were lost to follow-up before 24 months (n\u0026thinsp;=\u0026thinsp;3).\u003c/em\u003e \u003c/p\u003e \u003cp\u003eAll patients underwent detailed clinical assessment. Pain was typically exacerbated by prolonged sitting, positional transitions, defecation, and sexual intercourse. Physical examination of the lumbosacral region demonstrated localized tenderness over the sacrococcygeal area in all cases. Preoperative pain severity was assessed using the Visual Analog Scale (VAS). Routine laboratory investigations included complete blood count, renal and liver function tests, C-reactive protein, erythrocyte sedimentation rate, and serum electrolytes were performed. Radiological evaluation consisted of plain radiographs of the lumbosacral spine, pelvis, and coccyx, along with computed tomography and magnetic resonance imaging of the lumbosacral region to confirm diagnosis and exclude alternative pathology. Radiographic findings included coccygeal hypermobility in 9 patients and degenerative changes in 12 patients.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eType I: Coccyx curved slightly forward\u003c/p\u003e \u003cp\u003eType II: More marked forward curvature, tip directed anteriorly\u003c/p\u003e \u003cp\u003eType III: Sharp anterior angulation\u003c/p\u003e \u003cp\u003eType IV: Subluxation or hypermobility\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eUnder general anesthesia, patients were placed in the prone position on a Wilson frame. A 4-cm longitudinal midline incision was made over the sacrococcygeal junction. We utilized the \u003cb\u003eproximal-to-distal (Key) technique\u003c/b\u003e: the sacrococcygeal joint was first identified and disarticulated, followed by subperiosteal dissection of the coccygeal segments. This approach allowed for early identification of the plane between the coccyx and the rectum, minimizing the risk of visceral injury. The distal tip was removed last. Following excision, the prominent lower end of the sacrum was beveled to ensure a smooth contour, and the wound was closed in anatomical layers to eliminate dead space.\u003c/p\u003e\u003cp\u003eThe primary outcome measure was the change in VAS score from preoperative assessment to final follow-up. Secondary outcomes included postoperative complications, patient satisfaction, and need for revision surgery.\u003c/p\u003e \u003cp\u003eData were extracted from the medical records and anonymized before analysis. Descriptive statistics were calculated for all variables. Continuous variables are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, whereas categorical variables are expressed as frequencies and percentages. Preoperative and postoperative visual analogue scale (VAS) scores were compared using a paired two-tailed t-test. A p-value of \u0026lt;\u0026thinsp;0.05 was considered statistically significant. All statistical analyses were performed using \u003cb\u003eIBM SPSS Statistics for Windows, Version 17.0\u003c/b\u003e (IBM Corp., Armonk, NY, USA).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eParticipant Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 21 patients met the inclusion criteria. The cohort includes 9 males (42.9%) and 12 females (57.1%), with a mean age of 34.2 \u0026plusmn; 11.1 years (range 14-56). Etiology of coccydynia was traumatic in 9 patients (42.9%) and idiopathic/degenerative in 12 patients (57.1%). The mean duration of preoperative symptoms was 17.2 \u0026plusmn; 7.4 months (range 6-36). All patients had failed prolonged conservative management before surgery (Table\u0026nbsp;\u003ca href=\"javascript%3Avoid(0)\"\u003e\u003cem\u003e1\u003c/em\u003e\u003c/a\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1. Baseline Characteristics (N = 21)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"3\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 53.9936%;\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46.0064%;\"\u003e\n \u003cp\u003eValue\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 53.9936%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46.0064%;\"\u003e\n \u003cp\u003e9 (42.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 53.9936%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46.0064%;\"\u003e\n \u003cp\u003e12 (57.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 53.9936%;\"\u003e\n \u003cp\u003eAge, mean (range), years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46.0064%;\"\u003e\n \u003cp\u003e34.2 (14\u0026ndash;56)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 53.9936%;\"\u003e\n \u003cp\u003eTrauma etiology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46.0064%;\"\u003e\n \u003cp\u003e9 (42.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 53.9936%;\"\u003e\n \u003cp\u003eDegenerative/Idiopathic etiology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46.0064%;\"\u003e\n \u003cp\u003e12 (57.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 53.9936%;\"\u003e\n \u003cp\u003eDuration of symptoms, mean (range), months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46.0064%;\"\u003e\n \u003cp\u003e17.2 (6\u0026ndash;36)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 1: Data are presented as n (%) for categorical variables and mean \u0026plusmn; standard deviation (SD) or range for continuous variables. No inferential statistics were performed for baseline characteristics.\u003c/p\u003e\n\u003cp\u003eSD, standard deviation\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTotal coccygectomy led to a significant reduction in pain. Mean preoperative Visual Analogue Scale (VAS) score was 8.4 \u0026plusmn; 1.1, which improved to 3.2 \u0026plusmn; 1.9 postoperatively, corresponding to a mean reduction of 5.2 points (95% CI: 4.1-6.3; p \u0026lt; 0.001, paired t-test).\u003c/p\u003e\n\u003cp\u003eFunctional outcomes, categorized based on postoperative VAS, demonstrated that most patients achieved clinically meaningful improvement:\u003c/p\u003e\n\u003cp\u003eGood (occasional discomfort, VAS \u0026lt;3): 15 patients (71.4%)\u003c/p\u003e\n\u003cp\u003eFair (reduced pain, VAS 3-6): 3 patients (14.3%)\u003c/p\u003e\n\u003cp\u003ePoor (persistent severe pain, VAS \u0026gt;7): 3 patients (14.3%)\u003c/p\u003e\n\u003cp\u003eThese results indicate that over 70% of patients achieved excellent or good pain relief following surgery (Table\u0026nbsp;\u003ca href=\"javascript%3Avoid(0)\"\u003e\u003cem\u003e2\u003c/em\u003e\u003c/a\u003e).\u003c/p\u003e\n\u003cp\u003eSurgical complications were uncommon. One patient (4.8%) developed a major wound infection requiring vacuum-assisted closure (VAC). Minor wound infections occurred in three patients (14.3%) and were successfully managed with daily dressing and local care. No neurological or systemic complications were observed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Functional Outcomes and Complications (N = 21)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"3\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eOutcome / Complication\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePre-op VAS mean \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePost-op VAS mean \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGood (occasional discomfort, VAS \u0026lt;3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7.8 \u0026plusmn; 1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.1 \u0026plusmn; 0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e71.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eFair (reduced pain, VAS 3\u0026ndash;6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7.5 \u0026plusmn; 1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.5 \u0026plusmn; 0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e14.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePoor (persistent severe pain, VAS \u0026gt;7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8.0 \u0026plusmn; 1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7.5 \u0026plusmn; 0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e14.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMajor infection (required wound VAC)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMinor wound infection (managed with daily dressing)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e14.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 2. Functional outcomes and complications following total coccygectomy (N = 21). Pain was assessed using the Visual Analogue Scale (VAS) pre- and postoperatively. Statistical comparison of pre- and postoperative VAS scores was performed using the paired t-test. Data are presented as n (%). VAS, Visual Analogue Scale; VAC, vacuum-assisted closure.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this single-center retrospective cohort of 21 patients, total coccygectomy resulted in significant pain reduction, with mean Visual Analogue Scale (VAS) scores improving from 8.4 preoperatively to 3.2 postoperatively (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Furthermore, 71.4% of patients achieved good or excellent outcomes, reflecting both statistical and clinical significance despite the modest sample size.\u003c/p\u003e \u003cp\u003eThese findings align with prior literature. Karadimas et al., in an analytic review of 671 patients, reported satisfactory outcomes in approximately 75% of cases with an overall complication rate of 11% [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Sarmast et al. demonstrated VAS improvement from 9.62 to 2.25 with low wound complication rates in their five-year single-center experience [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Similarly, Kulkarni observed reduction from 7.33 to 2.11 following coccygectomy [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], and a pooled analysis of 742 patients by Kwon et al. found good-to-excellent outcomes in 84.6% with an infection rate of 11.5% [20]. The magnitude of pain relief in our cohort compares favorably and lies at the higher end of reported ranges, potentially reflecting careful patient selection, standardized surgical technique, and structured postoperative mobilization.\u003c/p\u003e \u003cp\u003eThe surgical approach to coccygectomy has evolved since Key's original proximal-to-distal description in 1937 [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Postacchini and Massobrio later advocated a distal-to-proximal technique to reduce rectal injury risk and allow safer dissection under direct visualization [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In our series, a uniform distal-to-proximal subperiosteal excision was employed, as described by Bilgic et al. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. No rectal injuries or deep infections occurred, underscoring the importance of meticulous dissection and layered closure.\u003c/p\u003e \u003cp\u003eWound infection remains the most common complication due to proximity to the perianal region. In our cohort, four patients (19.0%) developed postoperative wound infections, including one major infection (4.8%) requiring vacuum-assisted closure therapy and three minor infections managed conservatively. All infections resolved without long-term sequelae, and no neurological deficits or reoperations were observed. Although slightly higher than some pooled analyses, this complication profile remains comparable to prior reports [17,]. The 19% infection rate, while elevated relative to some Western series, likely reflects the challenges of wound management in the intergluteal cleft, particularly in a warm climate, and underscores the need for meticulous perioperative care.\u003c/p\u003e \u003cp\u003eExisting literature suggests that anatomical factors such as coccygeal spicules, marked hypermobility, or Type III-IV morphology according to the Postacchini classification may predict improved surgical outcomes when mechanical instability is the primary pain generator [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Conversely, obesity and psychological comorbidities have been associated with increased complication rates and lower satisfaction [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Although subgroup analysis was limited by sample size in our study, careful radiographic assessment and exclusion of secondary pathology likely contributed to the favorable outcomes observed.\u003c/p\u003e \u003cp\u003eThe 71.4% success rate in our cohort confirms that surgery is a viable \"last-resort\" option in our patient population when conservative measures fail. This is particularly relevant for low- and middle-income country settings where access to chronic pain management services may be limited and patients often present with advanced, refractory symptoms.\u003c/p\u003e \u003cp\u003eStrengths of this study include a consecutive single-center design, standardized technique performed by fellowship-trained spine surgeons, and clearly defined outcomes using validated VAS scoring. This study contributes data from a tertiary-care center in a low- and middle-income country, a population underrepresented in the coccygectomy literature.\u003c/p\u003e \u003cp\u003eHowever, this study has several limitations. The retrospective single-center design introduces potential selection and information bias. The relatively small sample size (n\u0026thinsp;=\u0026thinsp;21) limits statistical power, precludes meaningful subgroup analysis, and restricts the ability to perform multivariable regression to identify independent predictors of outcome or complications. The mean follow-up duration of six months restricts assessment of long-term durability of pain relief and late recurrence. Although postoperative infections were observed, no clear association with obesity was identified in our cohort; however, the limited sample size precludes definitive conclusions regarding risk factor stratification, and unmeasured confounders may have influenced complication rates.\u003c/p\u003e \u003cp\u003eImportantly, validated functional outcome measures such as the Oswestry Disability Index or quality-of-life instruments were not utilized, which limits comprehensive functional assessment beyond pain reduction. Additionally, the absence of a control group managed non-operatively restricts comparative effectiveness evaluation. Finally, as data were derived from a tertiary referral center, external generalizability to broader community settings may be limited.\u003c/p\u003e \u003cp\u003eLarger prospective multicenter studies with longer follow-up and standardized outcome measures are necessary to confirm the durability and reproducibility of these findings. Future research should incorporate validated functional outcome scores, quality-of-life assessments, and cost-effectiveness analyses to better define the role of coccygectomy in the management of refractory coccydynia, particularly in low-resource settings.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eTotal coccygectomy is a safe and effective surgical option for selected patients with refractory coccydynia. In this cohort, significant pain reduction was observed (VAS 8.4 to 3.2; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with 71.4% of patients achieving excellent or good outcomes. Complications occurred in 19.0% of cases and were predominantly minor infections, with no rectal injuries, neurological deficits, or reoperations. These findings are consistent with international literature and support coccygectomy as a definitive treatment in appropriately selected patients, although prospective studies with longer follow-up are needed to confirm long-term durability.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eWritten informed consent for participation was waived by the institutional ethics committee due to the retrospective nature of the study. Patient confidentiality and anonymity were maintained throughout the study in accordance with institutional and ethical guidelines.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSimpson JY (1859) Clinical lectures on the diseases of women. Lecture XVII: Coccygodynia and diseases and deformities of the coccyx. 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Asian J Neurosurg 13(2):277\u0026ndash;282. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4103/1793-5482.228568\u003c/span\u003e\u003cspan address=\"10.4103/1793-5482.228568\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKulkarni AG (2012) Coccygectomy for coccygodynia. J Orthop Surg (Hong Kong) 20(2):209\u0026ndash;212. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/230949901202000215\u003c/span\u003e\u003cspan address=\"10.1177/230949901202000215\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKwon HD, Schrot RJ, Kerr EE 3rd, Kim KD (2012) Coccygodynia and coccygectomy. Korean J Spine 9(4):326\u0026ndash;333. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.14245/kjs.2012.9.4.326\u003c/span\u003e\u003cspan address=\"10.14245/kjs.2012.9.4.326\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Combined Military Hospital","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Coccydynia, Coccygectomy, Coccyx pain, Spine surgery, Surgical outcomes","lastPublishedDoi":"10.21203/rs.3.rs-9516506/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9516506/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eCoccydynia causes chronic coccygeal pain, and while most respond to conservative therapy, some remain symptomatic. Total coccygectomy is considered for refractory cases. This study evaluates its effectiveness and safety at a tertiary neurosurgical center in Pakistan.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e We retrospectively reviewed 21 patients (9 males, 12 females; mean age 34.2 years) who underwent total coccygectomy from May 2009 to May 2019 after \u0026ge;\u0026thinsp;6 months of failed conservative therapy. Pain was measured using the Visual Analogue Scale (VAS, 0\u0026ndash;10) preoperatively and at last follow-up. Outcomes were classified as excellent/good (\u0026ge;\u0026thinsp;50% VAS reduction or VAS\u0026thinsp;\u0026le;\u0026thinsp;3), fair (VAS 4\u0026ndash;5.9), or poor (VAS\u0026thinsp;\u0026ge;\u0026thinsp;6). Complications were categorized as major or minor. Paired t-test compared pre- and postoperative VAS (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eMean symptom duration was 17.2 months. Mean VAS improved from 8.4 to 3.2 at a mean follow-up of six months (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Excellent/good outcomes occurred in 15 patients (71.4%), fair in 3 (14.3%), and poor in 3 (14.3%). Four patients (19.0%) developed wound infections: one major (4.8%) requiring vacuum-assisted closure and three Minor (14.3%) managed conservatively. No neurological deficits or reoperations occurred.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eTotal coccygectomy provides significant pain relief with acceptable complication rates in selected patients with refractory coccydynia. Prospective studies with longer follow-up are needed to assess long-term durability.\u003c/p\u003e","manuscriptTitle":"Total Coccygectomy for Refractory Coccydynia: A 10-Year Single-Center Retrospective Cohort Study with Comprehensive Outcome Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-27 06:31:24","doi":"10.21203/rs.3.rs-9516506/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c2e5948e-310a-4f96-8a9e-17c51403f677","owner":[],"postedDate":"April 27th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":66945467,"name":"Neurosurgery"}],"tags":[],"updatedAt":"2026-05-04T09:13:08+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-27 06:31:24","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9516506","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9516506","identity":"rs-9516506","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}