National Medical Policy

National Medical Policy
Subject:
Coccygectomy for Coccygodynia
Policy Number:
NMP390
Effective Date*:
November 2007
Updated:
February 2011, October 2011
This National Medical Policy is subject to the terms in the
IMPORTANT NOTICE
at the end of this document
The Centers for Medicare & Medicaid Services (CMS)
For Medicare Advantage members please refer to the following for coverage guidelines first:
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Current Policy Statement (Update October 2011 – A Medline search failed to reveal
any studies that would cause Health Net, Inc. to change its current position)
Health Net, Inc. considers coccygectomy medically necessary for treatment of coccygodynia
when all of the following are met:
Coccygectomy for Coccygodynia Oct 11
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1. Patient has severe, persistent pain in or around the coccyx which is poorly tolerated,
chronically disabling or, at times, functionally limiting; and
2. Direct pressure on the coccyx or movement of the coccyx on digital rectal examination
reproduces the pain; and
3. Patient has a history of any of the following:
 Trauma to the coccyx (e.g., fracture or dislocation from a fall, sacrococcygeal
joint is forced out of alignment during childbirth, horseback riding, extensive bike
riding or rowing)
 Patient has degenerative arthritis in the sacrococcygeal discs and/or
intercoccygeal discs
 Patient has radiological instability of the coccyx as judged by intermittent
subluxation or hypermobility* seen on lateral dynamic radiographs when standing
and sitting
 Patient has a small bony excrescence on the dorsal aspect of the tip of the
coccyx, i.e., a coccygeal spicule or spur which may harm the subcutaneous
tissues when sitting
 Patient has a bone scan demonstrating an ongoing inflammatory process in or
around the coccyx
* Note: Flexion in the sacrococcygeal joint larger than 25-30 degrees represents
hypermobility and slipping larger than 25% represents luxation.
4. Pain has persisted despite at least an 8-month trial of maximal conservative therapy,
including all of the following:
 Non-steroidal anti-inflammatory drugs (NSAIDs), e.g., ibuprofen, naproxen, COX2 inhibitors; and
 Usage of a donut-shaped pillow or a gel cushion to help take pressure off the
coccyx when sitting on hard surfaces; and
 Digital manipulation of the coccygeal ligaments with the rectal finger and/or
massages of the pelvic muscles (levator ani or piriformis); and
 Physical therapy with ultrasound; and
 Repeated local injections of steroid and an anesthetic in and around the coccyx;
and
 Intradiscal injections under fluoroscopy in patients with luxation or hypermobility;
and
Note: Even though coccygectomy is the treatment of last resort for coccydynia, it is a
required treatment for sacrococcygeal teratoma and other germ cell tumors involving the
coccyx.
Codes Related To This Policy
ICD-9 Codes
724.79
Coccydynia
CPT Codes
27080
Coccygectomy, primary
Coccygectomy for Coccygodynia Oct 11
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HCPCS Codes
N/A
Scientific Rationale Update – October 2011
Kerr et al. (2011) completed a retrospective review of 62 successive coccygectomy
surgeries for coccygodynia, in 61 patients identified from the surgical database; they had
been treated between 1997 and 2009. The authors succeeded in contacting 26 patients for
follow-up (42.6%). A retrospective chart review was performed, and a telephone
questionnaire was administered to these patients. Data collected included cause, pre- and
postoperative visual analog scale, a graded outcome measure, and patient satisfaction. The
median follow-up time was 37 months (range 2-133 months). The clinical results among the
26 patients with follow-up were as follows: 13 excellent, 9 good, 2 fair, and 2 poor. The
overall favorable (excellent and good) outcome after coccygectomy was 84.6%. There were
3 wound infections (11.5%). There were no rectal injuries. An overwhelming majority of
patients were satisfied with the procedure. The authors report the results of their clinical
case series, which to date is the largest in North America. The results closely concur with
previously published case series from Europe. Coccygectomy for chronic intractable
coccygodynia is simple and effective, with a low complication rate.
Scientific Rationale Update - February 2011
In general, prolonged conservative treatment is usually successful in treating coccydynia.
For those that have persistent coccygeal pain that does not respond to conservative
management, coccygectomy may be an option.
Karadimas et al (2010) performed a systematic review is to evaluate the results of
treatment of coccygectomy. Literature retrieval was performed excluding case reports and
tumor related case series, as well as articles published in other languages. In total 24
manuscripts were analyzed. Only 2 of them were prospective studies whereas 22 were
retrospective case series; five were classified as Level III studies and the remaining as Level
IV studies. In total, 671 patients with coccygodynia underwent coccygectomy following
failed conservative management. The sex ratio, male/female was 1:4.4. The most popular
etiology for coccygodynia was direct trauma in 270 patients. 504 of the patients reported an
excellent/good outcome following the procedure. There were 9 deep and 47 superficial
infections. Other complications included two hematomas, six delayed wound healings and
nine wound dehiscence. The overall complication rate was 11%. Patients with history of
spinal or rectal disorders, as well as idiopathic or with compensation issues, had less
predictable outcome than those with history of trauma or childbirth. The reviewer concluded
coccygectomy can provide pain relief to as high as 85% of the cases. The most common
reported complication was wound infection.
In a retrospective study, Trollegaard et al (2011) reported results of 41 patients who
underwent total coccygectomy for coccydynia after failure to respond to six months of
conservative management. Of these, 40 patients were available for clinical review and 39
completed a questionnaire giving their evaluation of the effect of the operation. Excellent or
good results were obtained in 33 of the 41 patients, comprising 18 of the 21 patients with
coccydynia due to trauma, five of the eight patients with symptoms following childbirth and
ten of 12 idiopathic onset. In eight patients the results were moderate or poor, although
none described worse pain after the operation. The only post-operative complication was
superficial wound infection which occurred in five patients and which settled fully with
antibiotic treatment. One patient required re-operation for excision of the distal cornua of
the sacrum. The reviewer concluded total coccygectomy offered satisfactory relief of pain in
the majority of patients regardless of the cause of their symptoms.
Coccygectomy for Coccygodynia Oct 11
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Scientific Rationale - Initial
The coccyx, colloquially referred to as the tailbone because it is considered to be a vestigial
remnant of a tail in animals, is the final segment of the human vertebral column, and
consists of four fused coccygeal vertebrae inferior to the sacrum. It is attached to the
sacrum in a fibrocartilaginous joint, which permits limited movement between them. Most
anatomy books wrongly state that the coccyx is normally fused into one rigid segment by
adulthood in most people. In fact, several well-designed X-ray studies (Postacchini [1983];
Kim [1999]) have shown that it is more common for it to be in 3-5 individual bony
segments. Only about 5% of the population have a coccyx in one piece, separate from the
sacrum, as described in anatomy books. This error in anatomy teaching can lead doctors to
diagnose a 'fractured coccyx' when they see a coccyx in several segments on x-ray. These
studies also showed that two thirds of people have a coccyx that curves down and slightly
forward, and one third have a coccyx that points straight forward. The spinal cord does not
extend into the coccyx. The coccyx is attached by ligaments to the base of the sacrum,
which is the part of the spine that forms the back of the pelvis. The coccyx provides an
attachment for nine muscles, such as the gluteus maximus, and as something of a shock
absorber when the person sits down. The muscle that is necessary for defecation attaches
to the coccyx.
Coccydynia is a medical term meaning pain in the coccyx or tailbone area, usually brought
on by sitting. Coccydynia is also known as coccygodynia, coccygeal pain, coccyx pain,
coccaglia or, in layperson's terms, buttache. A number of different conditions can cause pain
in the general area of the coccyx, but not all involve the coccyx and the muscles attached to
it. The first task of diagnosis is to determine whether the pain is related to the coccyx.
Physical examination, high resolution x-rays and MRI scans can rule out various causes
unrelated to the coccyx. Although there may be no definitive cause for coccydynia, trauma
from falling or being bumped, repetitive action (horseback riding, extensive bike riding or
rowing), or childbirth can cause tailbone pain. Tailbone pain and lower back pain can mimic
coccydynia in sciatica, infection, pilonidal cysts, and fractured bone. The symptoms and
examination findings of localized tenderness upon direct palpation of the coccyx and/or by
rectal exam is typically all the physician needs to diagnose coccydynia. A simple test to
confirm the diagnosis involves an injection of local anesthetic into the area. If the pain
relates to the coccyx, this should produce immediate relief. Demonstration of radiological
instability of the coccyx as judged by intermittent subluxation or hypermobility seen on
lateral dynamic radiographs when standing and sitting is often seen. If there is any question
about the diagnosis, a CT scan or MRI can be ordered to rule out infection or tumor as a
cause of pain. Rarely, coccydynia is due to the undiagnosed presence of a sacrococcygeal
teratoma or other tumor in the vicinity of the coccyx. In these cases, appropriate treatment
usually involves surgery and/or chemotherapy.
In general, prolonged conservative treatment is usually successful in treating this condition.
The key to treatment is to allow enough time for the symptoms to respond to therapy,
usually more than 12 months. Conservative management should begin with the use of a
nonsteroidal anti-inflammatory drug (NSAID) to reduce inflammation and analgesics to
reduce pain. Initially, this is coupled with a donut-shaped pillow or a gel cushion to decrease
coccygeal pressure and local irritation while sitting. Many physicians also advise the patient
to use hot sitz-type baths to further soothe the irritated coccygeal soft tissues. If this
therapy fails, usually after a minimum of 2 months, most authors consider injection of
corticosteroid and analgesic combination. Local nerve blocks also can be beneficial,
especially when fluoroscopic guidance is used. For patients with recurrent or persistently
troublesome tailbone pain, a therapeutic injection can provide quick, thorough, and
sometimes lasting relief; for some patients, the injection completely resolves the symptoms.
Wray et al (1963) found that 60% of patients responded to local injections of anesthetics
Coccygectomy for Coccygodynia Oct 11
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and corticosteroids. The same study showed that 85% responded to this regimen when
combined with digital manipulation of the coccygeal ligaments and the muscles of the pelvic
floor. If traditional injection therapies fail, a neurolytic technique in which lidocaine is
injected at the junction of the sacrum and coccyx just in front of the junction can be tried.
This is directed at the fourth and fifth sacral nerves and the coccygeal nerve. If this provides
good pain relief, then a radiofrequency thermocoagulation probe can be inserted at the
same site and used to ablate these nerves. In 2006, Foye et al published that sometimes
even just a single local nerve block injection at the ganglion impar can give 100% relief of
coccydynia when performed under fluoroscopic guidance.
For those few people who have persistent pain that is not alleviated or well-controlled with
conservative treatment, coccygectomy becomes an option in the form of a partial or
complete surgical removal of the coccyx. Although many surgeons are reluctant to perform
this surgery due to its proximity to the anus and the risk of rectal perforation and infection,
it is, however, a relatively simple operation in the hands of those surgeons who are familiar
with the anatomy. The best indications of being a good candidate appear to be an unstable
coccyx on lateral dynamic radiographs or a spur on the coccyx. A one to two-inch incision is
made right over the top of the coccyx, which is located directly under the skin and
subcutaneous fat tissue. There are no muscles to dissect away. The periosteum is then
dissected away from the bone starting on the back and carried around to the front. Staying
in this plane of tissue is very safe, and allows the coccyx to be dissected free and then
separated from the sacrum. The coccyx is then removed and can be sent to pathology if
there is any question as to whether or not it contains a tumor. To preserve normal
defecation, coccygectomy normally is accompanied by re-attachment of the two levator ani
muscles. The operation takes about thirty minutes to perform and can be done on an
outpatient basis. Recently, a limited coccygectomy has been proposed that involves only the
resection of the mobile or hypermobile segment of the coccyx. This has been identified by
fluoroscopic evaluation and local anesthetic injection prior to any surgery being attempted.
The most trying part of the operation is that it may take anywhere from three months to a
year after the surgery before the patient may begin to experience any relief from their
symptoms. The main risk with the surgery includes severe infection, if the surgical plane of
dissection strays from the subperiosteal region around the coccyx causing the rectal vault to
be violated.
Overall, there is only a number of small to modest-sized case series that have seemed to
indicate that a significant amount of properly selected patients may receive significant rates
of symptomatic relief after coccygectomy, but that postoperative complications (especially
infection) are common. The authors of these reports have generally indicated that surgery
was performed in only a small percentage of the patients presenting with coccydynia,
stating that prolonged conservative treatment (from 6 to 12 months) is more often than not
successful in treating coccydynia in the vast majority of patients (80%) prior to considering
surgery. They report that those who do not respond to a thorough course of nonsurgical
treatment and demonstrate radiological instability of the coccyx have a good a chance of
cure (90%) with coccygectomy. In those patients whose coccydynia had been preceded by
trauma, superior surgical results have been reported in the medical literature.
Wray et al (1985) reported in the British Journal of Bone and Joint Surgery that they had a
90% success rate for the procedure in 20 patients. Maigne et al (2000) established that
patients with luxation or hypermobility were better responders to a local intradiscal
corticosteroid injection than patients with normal coccyges. About two months after the
injection, 50% of the patients with luxation or hypermobility were improved or healed,
whereas only 27% of the patients with normal coccyges improved. In case of relapse, a
second injection may be performed. If the result is better after this second injection (a
Coccygectomy for Coccygodynia Oct 11
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longer relief), the prognosis is good. If the relief is shorter, injections do not appear to be
the right treatment. Usually, spicules (spurs) do very well after one or two injections.
Maigne et al (2000) also attempted to define criteria for selection of patients for
coccygectomy. They chose to prospectively study 37 patients with chronic pain secondary to
coccygeal instability unrelieved by conservative treatment and who were not involved in
litigation. Patients were followed up for a minimum of two years after coccygectomy, with
independent assessment at two years. There were 23 excellent, 11 good and three poor
results. The mean time to definitive improvement was four to eight months. Their
conclusion was that coccygectomy gave good results in this group of patients.
Wood (2004) retrospectively reviewed his experience with coccygectomy and compared it
with injections for the relief of coccygodynia in 51 consecutive patients to determine rates of
success, patient satisfaction and complications. All of the patients complained of pain while
sitting and had localized pain to external and internal palpation of the coccyx on physical
examination. Nonoperative treatment (medications, cushions, manual therapy) had failed to
relieve the patients' symptoms. All patients were seen in follow-up for physical examination
and completed a questionnaire by an independent examiner. Follow-up of the patients was
26 months (range 12-59 months). Follow-up data were available on 45 of the 51 enrolled.
The patients were divided as follows: 20 patients were treated with total coccygectomy and
25 patients were treated with injection therapy. Of those treated operatively, 18 patients
(90%) felt improved and were satisfied with the procedure. Two patients felt their
symptoms to be unchanged and were dissatisfied. Postoperative complications included
seven wound problems: four superficial infections and three patients with persistent
drainage. All resolved with local wound care and oral antibiotics. No further surgery was
necessary. There were no bowel injuries and no reports of rectal sphincter problems. Of
those treated with injections, 5 of the 25 (20%) felt improvement and were satisfied.
Sixteen (64%) were not improved, and four (16%) felt worse. Five (20%) eventually were
treated with coccygectomy, four with eventual satisfactory relief in symptoms. They
concluded that, despite the potential for wound problems, coccygectomy for relief of
coccygodynia can be a safe and effective treatment option with a high patient satisfaction
rate. Fogel (2004) came to the same conclusion that coccygectomy usually is successful in
carefully selected patients, with the best results in those with radiographically demonstrated
abnormalities of coccygeal mobility.
Doursounian et al (2005) reported their experience of 61 patients with instability-related
coccygodynia to validate an objective criterion for patient selection: radiological instability of
the coccyx (intermittent luxation or hypermobility of the coccyx). All patients were
unrelieved by conservative treatment, and not involved in litigation. Twenty-seven patients
had hypermobility of the coccyx and 33 subluxation. In all cases, the unstable portion was
removed through a limited incision directly over the coccyx. The outcome was assessed
using a detailed questionnaire. Follow-up was between 12 months and more than 30
months. The outcome was rated excellent or good in 53 patients, fair in one, and poor in
seven. There were nine patients with infection requiring reoperation. The average time to
definitive improvement was 4 to 8 months, which is fairly long, but in line with other
authors' reports. They proposed that such a long interval of time could be explained by a
'phantom limb syndrome' with coccygectomy being an amputation. When improvement is
slow to appear, they prescribed Elavil (amiltriptyline) that seemed to alleviate the constant
pain.
Sehirlioglu (2007) retrospectively analyzed 74 patients who were surgically managed for
traumatic coccygodynia after a failure of conservative treatment and performed a critical
review of the results obtained in comparison to the literature. The mean follow up was 4.1
years (range, 2-8 years). The mean age of patients on the date of surgery was 43.4 years
Coccygectomy for Coccygodynia Oct 11
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(range, 16-65 years). The average duration of pain prior to surgery was 7 months (range, 3
months to one year). They discovered that all but three patients had either good or
excellent results after surgery. Three patients reported postoperative pain lasting 3-6
months. All three had good results after re-operation of a proximal segment without
excision. Five postoperative complications, four superficial and one deep infection were
observed. In patient’s wit, conservative therapy-resistant, posttraumatic coccygodynia, they
surmised that coccygectomy is a feasible management option. They recommend total or
partial coccygectomy confined to the removal of the mobile bony element using a
longitudinal incision in carefully selected and well-informed patients.
To summarize, coccydynia has been a somewhat neglected topic and coccygectomy remains
a controversial subject in the medical literature. Some authors have reported good results;
however, selection criteria are ill-defined. Others advise against this procedure. Pyper
(1957) stated “there is no constant factor in the history, no reliable physical sign, and no
specific radiographic change that can be regarded as a definite pointer in advising
operation”. Although most papers report retrospective analyses of particular treatments or
offer anecdotal comments on a handful of cases, one can come to the conclusion that the
outcome of coccygectomy is largely dependent on pre-operative patient selection and
remains a treatment of last resort, reserved for the small percentage of patients who fail to
obtain adequate relief via nonsurgical treatments. A logical, step-wise approach is to almost
always provide the full spectrum of modern pain management interventions prior to
considering surgery.
Review History
November 2007
Medical Advisory Council initial approval
February 2011
Update – no revisions
October 2011
Update. No Revisions.
Patient Education Websites
English
1. MedlinePlus. Tailbone Disorders. Available at:
http://www.nlm.nih.gov/medlineplus/tailbonedisorders.html
2. MedlinePlus Medical Encyclopedia. Available at:
http://search.nlm.nih.gov/medlineplusEncy/query?DISAMBIGUATION=true&SERVER1=s
erver1&SERVER2=server2&FUNCTION=search&PARAMETER=tailbone
Spanish
1. MedlinePlus. Enfermedades del coxis. Available at:
http://www.nlm.nih.gov/medlineplus/spanish/tailbonedisorders.html
2. MedlinePlus Medical Encyclopedia. Available at:
http://www.nlm.nih.gov/medlineplus/spanish/medlineplus.html
This policy is based on the following evidence-based guidelines:
1. Foye, PM. Coccyx Pain. Emedicine. Last Updated: Aug 3, 2007. Available at:
http://www.emedicine.com/pmr/topic242.htm
2. Medical papers relevant to coccydynia. Available at:
http://www.coccyx.org/medabs/index.htm
Coccygectomy for Coccygodynia Oct 11
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References – Update October 2011
1.
2.
3.
Fletcher RH. Coccygectomy for Coccygodynia. May 13, 2010. Available at:
http://www.uptodate.com/contents/coccydynia-coccygodynia?view=print
Kerr EE. Coccygectomy for chronic refractory coccygodynia: clinical case series and
literature review. J Neurosurg Spine. 01-MAY-2011; 14(5): 654-63.
Aarby NS. Coccygectomy can be a treatment option in chronic coccygodynia]. Laeger
U. 14-FEB-2011; 173(7): 495-500.
References – Update February 2011
1.
2.
3.
4.
5.
Bilgic S, Kurklu M, Yurttaş Y, et al. Coccygectomy with or without periosteal resection.
Int Orthop. 2010 Apr;34(4):537-41.
Lyons M. Coccygodynia: Treatment. eMedicine. Oct 2009. Available at:
http://emedicine.medscape.com/article/1264763-treatment
Karadimas EJ, Trypsiannis G, Giannoudis PV. Surgical treatment of coccygodynia: an
analytic review of the literature. Eur Spine J. 2010 Nov 3.
Patijn J, Janssen M, Hayek S, et al. Coccygodynia. Pain Pract. 2010 NovDec;10(6):554-9
Trollegaard AM, Aarby NS, Hellberg S. Coccygectomy: an effective treatment option for
chronic coccydynia: retrospective results in 41 consecutive patients. J Bone Joint Surg
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Cebesoy O, Guclu B, Kose KC, et al. Coccygectomy for coccygodynia: Do we really have
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Sehirlioglu A. Coccygectomy in the surgical treatment of traumatic coccygodynia. Injury
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Important Notice
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Health Net's National Medical Policies (the "Policies") are developed to assist Health Net in administering plan
benefits and determining whether a particular procedure, drug, service or supply is medically necessary. The
Policies are based upon a review of the available clinical information including clinical outcome studies in the peerreviewed published medical literature, regulatory status of the drug or device, evidence-based guidelines of
governmental bodies, and evidence-based guidelines and positions of select national health professional
organizations. Coverage determinations are made on a case-by-case basis and are subject to all of the terms,
conditions, limitations, and exclusions of the member's contract, including medical necessity requirements. Health
Net may use the Policies to determine whether under the facts and circumstances of a particular case, the
proposed procedure, drug, service or supply is medically necessary. The conclusion that a procedure, drug, service
or supply is medically necessary does not constitute coverage. The member's contract defines which procedure,
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drug, service or supply is covered, excluded, limited, or subject to dollar caps. The policy provides for clearly
written, reasonable and current criteria that have been approved by Health Net’s National Medical Advisory Council
(MAC). The clinical criteria and medical policies provide guidelines for determining the medical necessity criteria for
specific procedures, equipment, and services. In order to be eligible, all services must be medically necessary and
otherwise defined in the member's benefits contract as described this " Important Notice" disclaimer. In all cases,
final benefit determinations are based on the applicable contract language. To the extent there are any conflicts
between medical policy guidelines and applicable contract language, the contract language prevails. Medical policy
is not intended to override the policy that defines the member’s benefits, nor is it intended to dictate to providers
how to practice medicine.
Policy Effective Date and Defined Terms.
The date of posting is not the effective date of the Policy. The Policy is effective as of the date determined by
Health Net. All policies are subject to applicable legal and regulatory mandates and requirements for prior
notification. If there is a discrepancy between the policy effective date and legal mandates and regulatory
requirements, the requirements of law and regulation shall govern. * In some states, prior notice or posting on the
website is required before a policy is deemed effective. For information regarding the effective dates of Policies,
contact your provider representative. The Policies do not include definitions. All terms are defined by Health Net.
For information regarding the definitions of terms used in the Policies, contact your provider representative.
Policy Amendment without Notice.
Health Net reserves the right to amend the Policies without notice to providers or Members. In some states, prior
notice or website posting is required before an amendment is deemed effective.
No Medical Advice.
The Policies do not constitute medical advice. Health Net does not provide or recommend treatment to members.
Members should consult with their treating physician in connection with diagnosis and treatment decisions.
No Authorization or Guarantee of Coverage.
The Policies do not constitute authorization or guarantee of coverage of particular procedure, drug, service or
supply. Members and providers should refer to the Member contract to determine if exclusions, limitations, and
dollar caps apply to a particular procedure, drug, service or supply.
Policy Limitation: Member’s Contract Controls Coverage Determinations.
The determination of coverage for a particular procedure, drug, service or supply is not based upon the Policies,
but rather is subject to the facts of the individual clinical case, terms and conditions of the member’s contract, and
requirements of applicable laws and regulations. The contract language contains specific terms and conditions,
including pre-existing conditions, limitations, exclusions, benefit maximums, eligibility, and other relevant terms
and conditions of coverage. In the event the Member’s contract (also known as the benefit contract, coverage
document, or evidence of coverage) conflicts with the Policies, the Member’s contract shall govern. Coverage
decisions are the result of the terms and conditions of the Member’s benefit contract. The Policies do not replace or
amend the Member’s contract. If there is a discrepancy between the Policies and the Member’s contract, the
Member’s contract shall govern.
Policy Limitation: Legal and Regulatory Mandates and Requirements
The determinations of coverage for a particular procedure, drug, service or supply is subject to applicable legal and
regulatory mandates and requirements. If there is a discrepancy between the Policies and legal mandates and
regulatory requirements, the requirements of law and regulation shall govern.
Policy Limitations: Medicare and Medicaid
Policies specifically developed to assist Health Net in administering Medicare or Medicaid plan benefits and
determining coverage for a particular procedure, drug, service or supply for Medicare or Medicaid members shall
not be construed to apply to any other Health Net plans and members. The Policies shall not be interpreted to limit
the benefits afforded Medicare and Medicaid members by law and regulation.
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