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Thursday, April 07, 2005

Coccyx
Originally uploaded by rooxalgia.

Correct medical terminology refers to the âtailboneâ as the coccyx or the sacrococcygeal joint(s), pronounced sa-kr Ã -kok-sijil . Since these medical words are difficult to pronounce we will refer to the sacrococcygeal segments (tailbone) as the âS/Câ joints.

The coccyx has a very specific range of motion. This motion must be unrestricted in order for the rest of the spine to function properly. We will discuss our hypothesis regarding the relationship of the coccyx to the rest of the spine. If the S/C is injured, problems can develop in the joints, muscles and nerves of the back. There are signs and symptoms that classically indicate S/C injuries. Finally, effective treatments and measurable results will be presented.

GENERAL INFORMATION ABOUT THE COCCYX

Most experts agree that optimal spinal flexibility permits any person to easily touch the floor with their finger tips or palms, the extremely young or elderly excepted. There are very few body types which do not permit this degree of flexibility. It is extremely rare for a person to have legs too long or arms too short to easily reach the floor or below, when standing with the feet together and the knees locked. This is assuming that spinal alignment and S/C flexibility is optimal.

Coccyx injuries, leading to the S/C Syndrome usually occur from auto accidents, sporting collisions, or falls.

COCCYGEAL âSUPER SPRING" SPINAL FLEXIBILITY MECHANISM

Normal uninjured S/C ligaments permit up to ten times the flexibility of other spinal joints. The function is to allow freedom of motion of the spine, spinal cord and the spinal nerve roots . The spinal cord needs to move freely within the spinal canal. Similarly, spinal nerves need to move freely within the lateral recesses (holes where the spinal nerves emerge from the spinal canal on their way to the various tissues of the body). The way that the S/C permits both spinal cord and spinal nerve roots freedom of movement is very simple. But first it is essential to understand that the spinal cord and it's covering, the âdura", anchor to the coccyx.

When the spine is moving normally through its wide ranges of motion, the S/C joints function as a flexible anchor for the spinal cord, nerves and the dura. The dura (tough outer lining of the meninges) becomes continuous with the nerve roots at the sleeves. The dural tube coalesces with the cord at the filum terminale internum and externum. You might say, the S/C joints and ligaments serve as a "super springâ, allowing optimal freedom of movement for the spinal cord and nerve roots.

S/C DISLOCATIONS APPEARING AS FRACTURES

The coccyx is nearly impossible to break or fracture. In the normal, uninjured spine, the S/C joints are the most flexible of all spinal joints (90 degrees) if you combine forward and backward movement. We believe that we can demonstrate that 70-100 degrees is the optimal range of motion for the S/C.

For this reason and due to its relatively dense composition, the coccygeal bones rarely break , in the classic sense. However, the ligaments, which connect these bones, frequently tear , giving the appearance of fracture on X-ray. Once torn, the coccyx usually becomes bent forward. If the coccyx "heals" with forward angulation, some of its flexibility will be lost. Ligaments that tear never heal to a point where they are as strong or flexible as they were before the injury. This is because ligaments âhealâ with scar tissue. Scar tissue, under microscopic view, looks like a birds nest with poorly organized structure. Undamaged ligament tissue looks something like a train trestle with very strong and resilient linkages. If the ligaments were torn badly enough to appear dislocated or fractured on x-ray, the natural range of movement of the S/C segments would also be damaged. This is one way that the S/C syndrome begins. Once the natural movement of the coccyx is lost, the spinal cord and nerves are more susceptible to becoming pinched or stretched. When this happens more scar tissue grows around the irritated nerves sometimes resulting in adhesions forming around the spinal nerves into the epidural space.

This condition can lead to:

â¢ Epidural Adhesions- Where the dural layer of the meninges sticks to the wall of the canal.

â¢ Periarticular Fibrosis- Scar tissue around the joint.

â¢ Perineural Fibrosis- Scar tissue around the nerve.

â¢ Canal Stenosis- Narrowing of the spinal canal.

SPRAINS "HEAL" WITH SCAR TISSUE (FIBROSIS)

It is very important to understand that our use of the word "heal" refers to how the torn ligaments at the dislocated S/C joints load up with scar tissue. This fibrosis, or scar tissue "healing", usually decreases the natural flexibility of any joint that is dislocated. Joints commonly affected by fibrosis include: Ankle, knee, hip, wrist, elbow or shoulder joints. The tailbone is particularly susceptible to injury. When flexibility is decreased, or restricted by fibrosis, the natural shock absorbing function of the S/C joints is compromised. In effect, the springs movement is shortened. This is being shown clinically to cause a variety of symptoms.

The authors have examined and treated several thousand patients. In approximately 90% of these examinations it was found that S/C restriction caused up to 20 inches or 60 degrees of restricted back motion. When the restricted S/C motion was restored most patients could immediately and freely touch the floor. In most cases dramatic decrease of nerve and muscle tension was reported by the patient. The immediacy and amount of relief varied with the age, gender and the physical condition of the patient.

HISTORY OF S/C INJURY

There are several histories and clinical signs or symptoms which lead the orthopedic chiropractor, physiatrist, general practitioner or surgeon to suspect S/C syndrome. Listed below, not necessarily in order of likelihood, are typical ways the coccyx can be injured:

1. A history of a hard fall on the buttocks, usually on a pointed object such as a rock, curb, or the balance beam. Such a fall can result in nearly paralyzing pain and in difficulty sitting for days or weeks. These injuries, where the S/C joints are seen displaced on x-ray examination, are frequently missed diagnosed as fractures.

2. History of repetitive and less severe falls on the buttocks where intense pain is not felt at any one time. This kind of trauma is typically caused by falls on the buttocks while roller skating, skateboarding, rollerblading, snowboarding, snow skiing, rodeo, excessive or forceful spanking of children, "W" sitting, or improper bicycle seat shape or size, etc.

3. X-rays may show abnormal alignment of the S/C even though there is no history of trauma, suggesting an injury in the pre-memory childhood years.

4. Front-end crashes where the body weight "ramps" forward onto the coccyx. This is where the lap belt actually increases axial loading by ramping onto the pelvic floor. This type of injury can cause compression fractures of S/C subluxation, subdislocation or dislocation.

SIGNS AND SYMPTOMS OF THE S/C INJURY

1. When a person cannot freely reach the floor, or when the spine appears rigid when flexed, the S/C Syndrome is suspected. This is the most common external orthopedic sign which may indicate S/C injury (Note: The most accurate diagnostic test for S/C injury is the intra-rectal orthopedic range of motion test). In cases where the S/C is responsible for limiting spinal motion, the orthopedic examiner may observe that most of the patient's spinal flexion occurs at the hip sockets , not along the course of the lumbar or thoracic spine, as it should. Patients with S/C Syndrome typically insist that they can't reach the floor because their âhamstrings are too tightâ. These patients usually present hip socket, sacroiliac and/or radiating nerve or joint pain because the coccyx restriction has caused the hip to be "hypermobile ". "Hypermobile", refers to an abnormal increase of spinal movement at one area in compensation to an abnormal decrease of movement at another area.

2. Presence of recurring pain or numbness in the lower back, arms, or legs , in the absence of disc damage. Many times the S/C Syndrome affects people who are in good physical condition and are otherwise free of other symptoms.

3. Inability to retain spinal alignment corrections for long periods of time.

4. A noticeable forward angulation of the coccyx upon internal or external examination.

5. Tailbone soreness after sitting.

6. Sensation of "sitting on a rope" where there is a "twinge" or mild "snapping" feeling when the person transfers his/her weight from one buttock to the other.

7. Inability to do sit-ups without feeling a stiffness and discomfort near the tailbone.

8. An ongoing diagnosis of "sciatica" which flares up after sitting for long periods of time such as driving on vacations, trips overseas or cramming for final exams.

9. Inability to achieve vaginal delivery. We have documented several cases where normal delivery is possible after treatment relieved coccygeal restriction. Back labor, tailbone pain or sciatica is often preventable if S/C restriction is diagnosed and treated before pregnancy.

DIAGNOSIS AND TREATMENT

Initial consultation is made to determine if a patient has suffered significant trauma to the spine. Once the persons history has been taken, explanation is made as to what signs and symptoms are suggestive of spinal misalignment and dural tension. If it is likely that the symptoms could be related to the spine, careful examination is provided. Explanations of the findings are made throughout the examination. If the doctor is sure that the spine can be successfully treated the patient is x-rayed and given a detailed report of the findings.

Exercises are prescribed for every patient so that the minimum number of treatments are needed to achieve maximum results. Exercises primarily include stretching and range of motion routines. Some strengthening and aerobic exercises are also included. Exercise routines typically include 3-10 minutes in the early morning and 3 minutes before each meal. Walking, swimming and low impact aerobics are highly encouraged.

If several weeks of exercise and alignment treatments do not restore full spinal range of motion, the S/C segments are examined to determine if the âS/C Syndromeâ is present. It is usually not necessary to physically examine the S/C on the initial history-examination visit. We have seen a significant number of patients regain normal coccygeal motion simply by doing the prescribed exercises with minimal chiropractic treatments. When correct flexibility and alignment are restored symptoms usually clear up rapidly. If spinal flexibility and alignment remain poor after several weeks of diligent effort on the part of the patient, the physician can provide the orthopedic rectal examination. This exam takes approximately 30 seconds and is not painful.

Reliable diagnosis of restricted S/C joint motion is made upon digital examination of the motion of the S/C segments. The doctor places one finger approximately two inches within the rectum on the front aspect of the S/C. The doctor's thumb of the other hand is positioned on the external surface of the S/C segments. A gentle forward and backward pressure is applied to the S/C joints to determine what degree of flexibility or inflexibility exists. This diagnostic procedure is referred to as the orthopedic rectal sacrococcygeal examination. One or two S/C x-rays are also taken to complete the diagnosis. Once diagnosed, the coccygeal segments are carefully freed with the patient assisted into the flexed and extended position. Detailed description of the S/C procedure is available for referring physicians.

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