Mind the Gap: Paramedian approach for coccygectomy

Background Context Coccydynia is pain in the coccyx that typically occurs idiopathically or from trauma. Most forms are self-limiting. However, if symptoms persist, non-surgical treatment options can include offloading, NSAIDs, physical therapy, and steroid injections. If all treatment options fail, a growing body of evidence supports a coccygectomy for symptomatic relief. The standard approach for a coccygectomy involves a midline incision cephalad to the anus along the gluteal cleft. Historically, this method has had high rates of infection. Purpose To improve healing and decrease infection rate, we propose the paramedian approach to a coccygectomy. This approach has the benefit of distancing the surgical site from the anus, diminishing the crevice effect of the incision, and increasing the dermal and subdermal thickness for improved surgical closure. Study Design/Setting We present a case series study of 41 patients who underwent the paramedian approach coccygectomy using a 4-6 cm incision, approximately 0.5-1.5 cm lateral to the midline, for coccyx removal. These patients were evaluated post-operatively to determine infection rate and various outcome measures. Patient Sample 41 patients suffering from refractory coccydynia had a coccygectomy via the paramedian approach between 2011 and 2022 by the senior author. Outcome Measures Outcome measures included self-reported measures (Oswestry Disability Index (ODI), Visual Analogue Scale (VAS) pain scale and satisfaction with procedure), physiologic measures (presence of infection and treatment provided) and functional measures (return to vocation/avocation) Methods Data was compiled and transferred to Microsoft Excel and analyzed. Two-tailed T-tests were used to compare the patient improvement in VAS and ODI as appropriate for statistical analysis. Results The patients' average age was 45.8 years. Patients' average body mass index was 27.9, with 71% of patients overweight or obese. 68% of patients were female. Trauma was the most common precipitating factor (75.6%). Five patients presented with post-operative complications (12.1%), one requiring an incision and drainage, and four others were treated with antibiotics for wound erythema. Post-operative evaluations showed continual improvement, with the most significant improvement reported greater than one-year post-operatively. The Visual Analogue Scale for pain dropped from 7.5 to 2.3 (P<0.001), and the Oswestry Disability Index improved from 30.1 to 9.6 (P<0.001). 86.7% percent of patients reported either a good or excellent result. Conclusion Coccygectomies via the midline approach have a variable infection rate, likely due to proximity of the incision to the anus and due to the crevice effect of the gluteal cleft in terms of aeration. These contributing factors are overcome in the paramedian approach, making it an effective option for treating refractory coccydynia that is non-responsive to conservative management.