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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 35  |  Issue : 1  |  Page : 42-45

A comparative retrospective study of the efficacy of caudal epidural with manipulation versus ganglion impar block with manipulation in patients with coccydynia


Department of Anaesthesiology and Pain Medicine, Yashoda Hospital, Secunderabad, Telangana, India

Date of Submission05-Nov-2020
Date of Decision23-Feb-2021
Date of Acceptance09-Mar-2021
Date of Web Publication27-Apr-2021

Correspondence Address:
Dr. Y Govardhani
Department of Anaesthesiology and Pain Medicine, Yashoda Hospital, Secunderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpn.ijpn_152_20

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  Abstract 

Objective: The objective of the study was to compare the effectiveness of caudal epidural with manipulation and ganglion impar block with manipulation in treating patients with coccydynia. Materials and Methods: In this retrospective study, patients (n = 60) were divided into two groups of 30 each. Group C (n = 30) received caudal epidural with transrectal manipulation, whereas Group G (30) received ganglion impar block with transrectal manipulation. Preprocedural and procedural Visual Analog Scale (VAS) scores for 10 days, 1, 3, and 6 months were recorded. Preprocedural painless sitting period and postprocedure painless sitting period in two groups were recorded. Results: Preprocedural VAS score was not statistically significant between the two groups (7.76 ± 0.63 vs. 7.6 ± 0.72; P = 0.16). There was no statistically significant difference in the VAS score after 10 days of the procedure in both the groups. Significant decrease in VAS score was observed in Group G than in Group C after 1, 3, and 6 months of the follow-up. The painless sitting period was increased in Group G than in Group C after 6 months of follow-up (79.33 ± 48.4 min vs. 144.16 ± 37.87 min; P < 0.0001). Recurrence was observed in six patients in Group C. No significant complications were observed in both the groups. Conclusion: Ganglion impar block with manipulation is more effective in improving pain sensation and painless sitting period in patients with coccydynia.

Keywords: Caudal epidural, coccydynia, ganglion impar block, manipulation


How to cite this article:
Govardhani Y, RamMohan G, Abhijith S, Savithri B. A comparative retrospective study of the efficacy of caudal epidural with manipulation versus ganglion impar block with manipulation in patients with coccydynia. Indian J Pain 2021;35:42-5

How to cite this URL:
Govardhani Y, RamMohan G, Abhijith S, Savithri B. A comparative retrospective study of the efficacy of caudal epidural with manipulation versus ganglion impar block with manipulation in patients with coccydynia. Indian J Pain [serial online] 2021 [cited 2021 Jun 19];35:42-5. Available from: https://www.indianjpain.org/text.asp?2021/35/1/42/314691


  Introduction Top

Coccydynia is a pain in the terminal segment of the spine (Coccyx), which is multifactorial in origin. Pain exacerbates in sitting and rising from sitting position. Prolonged standing and sitting in improper positions causes back pain.[1] Chronic or recurrent pain affects activities of daily living and overall quality of life. Coccydynia is due to various causes, but the most common etiologic factor is trauma.[2]

There are various treatment options for a patient with coccydynia including using rubbering cushions, physical therapy, nonsteroidal anti-inflammatory drugs, manipulation epidural steroid injection, ganglion impar blocks, radiofrequency ablation of sacral nerves, and coccygectomy.[3] Usually, coccydynia responds to conservative treatments. However in some cases, pain persists and requires interventional procedures.[4]

We undertook a comparative retrospective study in patients with coccydynia with a history of trauma, who underwent a combined treatment of fluoroscopy-guided caudal epidural with transrectal manipulation of coccyx or fluoroscopy-guided ganglion impar block with transrectal manipulation.


  Materials and Methods Top

We identified all patients who presented to the department of pain medicine at Yashoda Hospital, Secunderabad, with primary diagnosis of coccydynia from January 2018 to December 2019.

Inclusion criteria are
  1. –65 years of age
  2. H/O trauma, prolonged sitting occupation
  3. Coccydynia patients, who do not respond to conservative treatment for 3 months.
Exclusion criteria
  1. Local injection
  2. Bleeding diathesis
  3. Contrast allergy
  4. Previous surgery to the lumbar region
  5. Coccydynia associated with cancer metastasis.

A total of 60 patients who satisfied these criteria underwent either fluoroscopic-guided caudal epidural and manipulation or fluoroscopic-guided ganglion impar block and manipulation. The parameters recorded were patients' age, gender, duration of complaints, and Visual Analog Scale (VAS) scores before and after the procedure (10 days, 1 month, 3 months, and 6 months). VAS score was compared between the two groups. AP/lateral plain Coccyx radiography and magnetic resonance imaging were taken to exclude underlying visceral pathologies. Coccygeal pillow was advised to use for 4 weeks after the procedure also.

Technique

Thirty patients in Group C underwent caudal epidural and manipulation. Under sedative anesthesia, patients were placed in the prone position with lower abdomen support. Sacral cornua was identified on the lateral fluoroscopic image. 22G spinal needle is used. Caudal epidural space was identified and confirmed with nonionic contrast spread in lateral and AP fluoroscopic image [Figure 1] and [Figure 2]. Then, 10 ml of 1% xylocaine and 40 mg triamcinolone were given into caudal epidural space. After caudal epidural steroid injection, transrectal manipulation was performed for 5 min.

Figure 1: Fluoroscopic view of needle placement in caudal epidural

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Figure 2: Fluoroscopic view of caudal epidural after contrast administration

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Thirty patients in Group G underwent ganglion impar block with transrectal manipulation under sedative anesthesia. Patients were positioned prone with lower abdomen support.

Under fluoroscopy C-arm in a lateral position, sacrococcygeal junction or intercoccygeal space was identified. After local anesthesia infiltration, 22G spinal needle with a curved tip was inserted through the skin piercing the dorsal sacrococcygeal ligament at the midline. The needle was inserted into the vertebral disc until the tip was placed anterior to the ventral sacrococcygeal ligament position.Needle tip was confirmed by non-ionic contrast spread into retroperitoneal space [Figure 3]. After confirmation, 4 ml of 1% xylocaine and 40 mg triamcinolone were given. After ganglion impar block, external manipulation of the coccyx was done.

Figure 3: Fluoroscopic view of ganglion impar block after contrast administration

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The pain was assessed using VAS in preprocedure, 10 days after the procedure, and 1 month, 3 months, and 6 months of the procedure. Patients were observed for 2–3 h after the procedure and then discharged.

Failed block was considered when VAS was lowered <50% of the preprocedural measured VAS score.

Follow-up data were obtained by retrospective review of hospital files.

Statistical analysis

Mean and standard deviation are used to represent quantitative data. The quantitative data were analyzed with t-test. A statistical significance threshold of P < 0.05 is considered significant. All analyses were carried out using IBM SPSS Version 21 – Trial version.


  Results Top

The study included 18 females and 12 males in Group C and 21 females and 9 males in Group G. The mean duration of symptoms was 6.7 months and 7.8 months in Group C and Group G, respectively [Table 1].

Table 1: Patient demographics

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When the patient's VAS levels were analyzed, the mean VAS before injection was 7.76 ± 0.63 in Group C and 7.6 ± 0.72 in Group G. The difference between these values was not statistically significant (P = 0.16) [Table 2].

Table 2: Comparision of VAS score

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While the mean VAS after 10 days of procedure was 7.27 ± 0.64 in Group C and 6.8 ± 0.66 in Group G, the difference between these values was not statistically significant (P = 0.01). The mean VAS after 1 month was 6.8 ± 0.81 in Group C and 4.63 ± 1.03 in Group G, at 3 months; it was 5.73 ± 1.17 in Group C and 2.8 ± 1.03 in Group G. At 6 months, it was 5.2 ± 1.73 in Group C and 0.90 ± 1.54 in Group G. P values for all points are <0.0001 which is statistically significant [Figure 4].

Figure 4: Visual Analog Scale score

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Patient painless sitting period before injection was 11.6 ± 4.06 min in Group C and 12 ± 3.85 min in Group G. P = 0.69, which is statistically not significant. One month after the procedure, painless sitting period was 23.83 ± 11.79 min in Group C and 84.03 ± 26.37 min in Group G. 52.83 ± 24.73 min in Group C and 116.83 ± 35.39 min in Group G after 3 months and 79.33 ± 48.4 min in Group C and 144.16 ± 37.87 min in Group G after 6 months [Table 3]. P value in follow-up from 1 month to 6 months is <0.0001, which is statistically significant [Figure 5]. During the follow-up time, recurrence of coccydynia was present in 6 (20%) patients in the caudal group; the second caudal epidural injection was performed. Three (10%) patients in ganglion impar block group complained of persistent postoperative local pain, managed with medical treatment. No other complications were encountered during follow-up.

Figure 5: Painless sitting period in minutes

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Table 3: Comparision of painless sitting period

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  Discussion Top

Coccydynia is a pain radiating to the sacral and perineal area, located around the coccyx. Trauma is the most common cause of coccydynia. Direct hit, prolonged sitting on hard surfaces, and even pressure of the fetus during pregnancy may cause trauma to the coccyx.[2],[3],[5] Females are affected than males at the ratio of 5:1. In our study, patients with a history of trauma are included. Females consisted of 18 in the caudal group and 21 in the ganglion impar group of our study group (out of 30 patients in each group).

Initially, coccydynia was treated by conservative modalities. Pressure-relieving cushions and medical treatment such as nonsteroidal anti-inflammatory drugs are some of the conservative modalities.[6] Kwon et al. accepted 8 weeks for the acute period and stated it as chronic coccydynia if the symptoms persist more than 8 weeks.[7] In our study, we included patients who have persistent pain at coccyx for more than 3 months despite conservative treatment.

In one of the case reports, coccydynia was associated with lumbar radiculopathy. Following epidural injection, manipulation of coccyx under anesthesia along with osteopathic mobilization resulted in a good outcome.[1] Many pain management centers perform caudal epidural steroid injections for coccydynia, a relative paucity of published research supporting epidural steroid use for coccyx pain. In another study, fluoroscopically guided coccygeal injection with triamcinolone acetate was given in 14 cases, following which more than 50% relief of pain was seen.[8] The effectiveness of caudal epidural steroid injection and manipulation with ganglion impar block and manipulation was compared in our study.

Maigne and Chatellier compared three manual treatment methods and reported 29.2%, 16%, and 32% success rates with massage, mobilization, and stretching methods, respectively, after 6-month follow-up.[9] In our study, we combined these techniques of manipulation along with steroid injection. We found no statistically significant difference between the two groups immediately after the procedure, but after 6 months follow-up group which underwent ganglion impar block had significantly lower VAS score. The main problem in coccydynia patient is pain during sitting. In our study, we documented a painless sitting period of the patient before and after the intervention. There is a significant improvement in painless sitting period in patients who underwent ganglion impar block with manipulation.

Limitations

The main limitation of our study is the limited number of patients. Other limitations are a short duration of follow-up, and it is a retrospective design. Previous studies with extended duration follow-up showed repetitive interventions that are required for chronic coccydynia.[10] In Group C patients who did not improve after 6 months, we repeated only caudal epidural injection but not ganglion impar block. Local infiltration is a commonly used modality in coccydynia. It can be used as another modality for comparison which was not included in our study.


  Conclusion Top

Ganglion impar block with manipulation is more effective in improving pain sensation and increasing painless sitting period in patients with coccydynia. It is a safe and easy option before surgical treatment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Emerson SS, Speece AJ 3rd. Manipulation of the coccyx with anesthesia for the management of coccydynia. J Am Osteopath Assoc 2012;112:805-7.  Back to cited text no. 1
    
2.
Patel R, Appannagari A, Whang PG. Coccydynia. Curr Rev Musculoskelet Med 2008;1:223-6.  Back to cited text no. 2
    
3.
Wray CC, Easom S, Hoskinson J. Coccydynia. Aetiology and treatment. J Bone Joint Surg Br 1991;73:335-8.  Back to cited text no. 3
    
4.
Traub S, Glaser J, Manino B. Coccygectomy for the treatment of therapy-resistant coccygodynia. J Surg Orthop Adv 2009;18:147-9.  Back to cited text no. 4
    
5.
Jaiswal A, Shetty AP, Rajasekaran S. Precoccygeal epidermal inclusion cyst presenting as coccygodynia. Singapore Med J 2008;49:e212-4.  Back to cited text no. 5
    
6.
Howard PD, Dolan AN, Falco AN, Holland BM, Wilkinson CF, Zink AM. A comparison of conservative interventions and their effectiveness for coccydynia: A systematic review. J Man Manip Ther 2013;21:213-9.  Back to cited text no. 6
    
7.
Kwon HD, Schrot RJ, Kerr EE, Kim KD. Coccygodynia and coccygectomy. Korean J Spine 2012;9:326-33.  Back to cited text no. 7
    
8.
Mitra R, Cheung L, Perry P. Efficacy of fluoroscopically guided steroid injections in the management of coccydynia. Pain Physician 2007;10:775-8.  Back to cited text no. 8
    
9.
Maigne JY, Chatellier G. Comparison of three manual coccydynia treatments: A pilot study. Spine (Phila Pa 1976) 2001;26:E479-83.  Back to cited text no. 9
    
10.
Gunduz OH, Sencan S, Kenis-Coskun O. Pain relief due to transsacrococcygeal ganglion impar block in chronic coccygodynia: A pilot study. Pain Med 2015;16:1278-81.   Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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