Numerous treatments have been proposed, and some are offered here for historical purposes ¹⁾ (and to dissuade casual attempts to effect a “new” cure that in reality has already been tried):

1. plaster jackets

2. hot baths (sitz baths), heating pads

3. massage therapy

4. XRT

5. psychotherapy

Most cases resolve within ≈ 3 months of conservative management consisting of NSAIDs, mild analgesics, and measures to reduce pressure on the coccyx (e.g. a rubber ring (“doughnut”) sitting cushion, lumbar supports to maintain sitting lumbar lordosis to shift weight from coccyx to posterior thighs) ²⁾

Management recommendations for refractory cases ^3) 4)

1. local injection: 60% respond to corticosteroid + local anesthetic (40 mg Depo-Medrol® in 10 cc of 0.25% bupivacaine). Recommended as initial treatment; the response should be achieved by 2 injections

2. manipulation of the coccyx: usually under general anesthesia. ≈ 85% successful when combined with local injection

3. ± physiotherapy (diathermy & ultrasound): found to be of benefit only in ≈ 16% (maybe more effective with the addition of gentle manipulation of the coccyx without general anesthesia ⁵⁾)

4. caudal epidural steroid injection

5. blockade or neurolysis (with chemicals or by cryoablation ⁶⁾) of the ganglion impar (AKA ganglion of Walther, the lowest ganglion of the paired paravertebral sympathetic chain, located just anterior to the sacrococcygeal junction): some success has been described with this technique (traditionally used for intractable sympathetic perineal pain of neoplastic etiology ⁷⁾)

6. neurolytic techniques directed to S4, S5, and coccygeal nerves

7. coccygectomy (surgical removal of the mobile portion of the coccyx, followed by smoothening of the residual bony prominence on the sacrum): was required in ≈ 20% of patients in one series, ⁸⁾ with a reported success rate of 90%. However, many practitioners do not view this as a highly effective treatment and feel that great restraint should be used in considering this form of therapy

In the acute phase the first choice of treatment are NSAIDs. Treatment for patients with severe pain in the chronic phase consists of manual therapy and/or a local injection of local anesthetic and corticosteroid into the painful segment (2 C+). Other interventional treatments such as intradiscal injections, ganglion impar block, radiofrequency treatment and caudal block are advised only under study conditions.

Coccygectomy is not recommended because of long-term moderate results and the chance of major complications ⁹⁾

Ganglion impar block appears to be effective in patients who have coccygodynia resistant to conservative therapy, with high success rates and prolonged duration of effect. Controlled studies are required to reveal the mechanism of this effect ^10) 11).