Issue 01/April 2024

Spinal Health: Focusing on the Head and Tail Ends

By: Dr. Bharat Dave

Authors: Dr. Bharat Dave, Dr Ajay Krishnan, Dr D Devanand, Dr Shivanand Mayi, Dr Ravi Ranjan Rai, Dr Mirant Dave, Dr Abhijith Anil, Dr Rohan Killekar, Dr Panthackel Mikeson, Dr Kishor Murkute.

Atlantoaxial arthritis (C1C2) and coccydynia are conditions that affect the head end and tail end of the spine and can be very disabling. Atlantoaxial arthritis has multiple varied presentations but requires a high index of suspicion for detection. With improvements in modern healthcare, the average lifespan is increasing, and our population is ageing. The incidence of atlantoaxial osteoarthritis should also be increasing proportionately, but this is not being seen due to the lack of awareness among both clinicians and patients, leading to missed diagnoses.

Non traumatic Coccydynia, on the other hand, is easily diagnosed, but a lack of awareness of the available treatment options among healthcare practitioners has led to large numbers of inadequately treated patients suffering unnecessarily. Coccydynia, too, is increasing in prevalence with increasing urbanization and two wheelers/motor travel, increasing the stresses on the coccyx.

This paper aims to highlight the need for a high index of suspicion in diagnosing these conditions, which are essential to maintaining spine health at the head and tail ends.

ATLANTO AXIAL OSTEOARTHRITIS

Magnitude of disease burden

According to a 2017 report by the United Nations Population Fund (UNFPA), around 12.5% of India's population will be 60 years and older by 2030. The share of older persons, those aged 60 years or above, in India's population is projected to increase to nearly 20 per cent in 2050. Thus, with the increasing population, the burden of geriatric problems is also bound to increase. One such geriatric issue is Atlantoaxial Osteoarthritis (AAOA) with a prevalence of around 4% in the outpatient setting with the typical age of presentation being around 50-90 years.[1]  The actual prevalence of AAOA is much higher than reported as the diagnosis is often missed by clinicians.

Diagnostic Dilemma

Atlanto-axial osteoarthritis (AAOA) is a relatively rare degenerative cervical spine disorder in which the lateral atlanto-axial articulation is considered to be the pain generator and the pain may be referred or radicular, through the greater occipital nerve. The patients usually present with upper neck, occipital, or postauricular pain, and AAOA is usually not associated with myelopathic features. The patients may also report visual problems and painful audible crepitus with neck movements and the patient having to support the head with his hands while rotating. The dorsal ramus of C2 is found to be located posterior to the lateral atlanto-axial articulation.  This position of the ganglion predisposes the nerve to irritation from degenerative osteophytes and to radicular symptoms.[2,3]  The diagnosis of atlantoaxial osteoarthritis is made on the open mouth radiographs and CT scans, which showed reduced atlantoaxial facet joint space, subchondral sclerosis, erosion, cystic degeneration or osteophyte formation(Fig 1). It is important to obtain flexion-extension lateral radiographs in order to rule out associated atlantoaxial instability.(Fig 4)

Treatment options

The first line of management in AAOA is conservative management, which includes NSAID’s, non-opioid analgesics, cervical soft collar immobilization. If non-invasive measures fail, then the patients are referred for fluoroscopy guided intra-articular injections with a combination of local anaesthetic and corticosteroid.[4,5] Patients not relieved by medication alone are referred for fluoroscopy guided intra-articular atlanto-axial facet injections with a combination of corticosteroid and local anaesthetic or atlanto-axial facet pulsed radiofrequency treatment.[13] Intra-articular atlantoaxial facet injections have been shown to give > 50% initial pain reduction in 80% of patients and statistically significant pain relief up to 3 months.[14] Apart from the systemic side effects associated with corticosteroids, intra-articular injections may be associated with infection, damage to C2 nerve root and vertebral artery.[15] In our Institute, we had the practice of atlanto-axial intra-articular steroid injections earlier but one of our patients had a catastrophic complication in the form of intra-dural injection leading to quadriparesis and respiratory paralysis in the patient. The patient was intubated immediately and we were able to resuscitate the patient successfully. However, this incident prompted us to find an alternative method to alleviate pain which would be safer but as effective as the intra-articular steroid injection. Thus, we developed the Greater Occipital Nerve Block as an alternative to atlanto- axial intra- articular steroid injections. A few of the cases managed conservatively showed pain relief with restriction of neck movements at 18 to 24 months follow-up. On getting a CT in these patients, it was found that there was auto-fusion at the affected atlantoaxial facet joint (Fig 2, Fig 3). Though there is no literature supporting this, we propose that it is a compensatory mechanism of the body to stabilize the arthritic joint. Finally, the patients not responding to conservative management and with incapacitating pain are offered surgical treatment in the form of atlanto-axial fusion, which may be achieved with a number of methods including Gallie or Brooks wiring, transarticular screws, screw rod construct and rod plate construct fixation.

We had conducted a study to prove the role of conservative management in the treatment of AAOA. The study included 108 patients diagnosed with AAOA clinically and with facet joint changes on an open mouth view radiograph. In our study, only 4 patients out of the 108 did not respond to conservative management and required surgical treatment.

References

1. Buraimoh MA, Massie LW, Montgomery DM. Lateral Atlanto-axial Osteoarthritis: A Narrative Literature Review. Clin Spine Surg. 2017 Dec;30(10):433-438

2. Ehni G, Benner B. Occipital neuralgia and the C1-2 arthrosis syndrome. J Neurosurg. 1984;61:961–965.

3. Vanelderen P, Lataster A, Levy R, et al. Occipital neuralgia. Pain Pract. 2010;10:137–144.

4. Zhou L, Hud-Shakoor Z, Fau-Hennessey C, et al. Upper cervical facet joint and spinal rami blocks for the treatment of cervicogenic headache; 2010.

5. Aprill C, Axinn MJ, Bogduk N. Occipital headaches stemming from the lateral atlanto-axial (C1-2) joint. Cephalalgia. 2002;22:15–22

6. Elliott RE, Tanweer O, Boah A, et al. Atlanto-axial fusion with transarticular screws: meta-analysis and review of the literature. World Neurosurg. 2013;80:627–641.

7. Elliott RE, Tanweer O, Smith ML, et al. Outcomes of fusion for lateral atlanto-axial osteoarthritis: meta-analysis and review of literature. World Neurosurg. 2013;80:e337–e346.

8. Star MJ, Curd JG, Thorne RP (1992) Atlantoaxial lateral mass osteoarthritis. A frequently overlooked cause of severe occipitocervical pain. Spine 17:S71–S76

9. Halla JT, Hardin JG Jr (1987) Atlantoaxial (C1–C2) facet joint osteoarthritis: a distinctive clinical syndrome. Arthritis Rheum 30:577–582

10. Harata S, Tohno S, Kawagishi T. Osteoarthritis of the alanto-axial joint. Int Orthop. 1981;5:277–282.

11. Ghanayem AJ, Leventhal M, Bohlman HH. Osteoarthrosis of the atlanto-axial joints. Long-term follow-up after treatment with arthrodesis. J Bone Joint Surg Am. 1996;78:1300–1307.

12. Kuklo TR, Riew KD, Orchowski JR, et al. Management of recalcitrant osteoarthritis of the atlanto-axial joint. Orthopedics 2006;29:633–8.

13. Star MJ, Curd JG, Thorne RP (1992) Atlantoaxial lateral mass osteoarthritis. A frequently overlooked cause of severe occipitocervical pain. Spine 17:S71–S76

14. Mehnert MJ, Freedman MK. Update on the role of z-joint injection and radiofrequency neurotomy for cervicogenic headache. Pm r. 2013;5:221–227.

15.  Halim W, Chua NH, Vissers KC. Long-term pain relief in patients with cervicogenic headaches after pulsed radiofrequency application into the lateral atlanto-axial (C1-2) joint using an anterolateral approach. Pain Pract. 2010;10:267–271.

Non traumatic coccygodynia

What is it, and How big of a problem is it?

Coccydynia was first described by Simpson as pain or discomfort localised around the bottom end of the spine that is triggered by prolonged sitting. Coccydynia can be caused by axial trauma to the coccyx region, small cumulative trauma due to sitting position causing pressure on the coccyx, and disc degeneration in the coccyx region after childbirth. Risk factors for the development of coccydynia are obesity and female gender.(1,2) Women are at a higher risk of developing coccydynia than men due to the gynoid shape of the pelvis.

When a person sits, the weight of the body is supported on an imaginary triangle, with its base formed by the ischial tuberosities and apex formed by the coccyx. Leaning back while sitting increases weight transmission through the coccyx and has been postulated to cause coccydynia; however, the exact cause is often difficult to determine.

The exact incidence of coccydynia has not been reported. Coccydynia has been assumed to account for less than 1% of all cases with lower back ache. With the increasing prevalence of obesity and the poor conditions of roads in our country, coccydynia is being encountered with a greater frequency than ever before.

Coccydynia is a clinical diagnosis, and conservative measures are the mainstay of management. Important differential diagnoses to rule out include other local causes of pain, such as pilonidal sinus, fistulae, hemorrhoids or local infections. Other causes of coccygeal pain are osteomyelitis and malignancy. Coccydynia can also be a referred pain due to urogenital or gastrointestinal problems.

Diagnosis and Management of coccydynia

The mainstay of initial management of coccydynia is conservative.(3) Our team obtains lateral dynamic radiographs in all patients with coccydynia at the first visit.

Sitting and standing lateral radiographs are a must to decide on the management of coccydynia refractory to conservative management. This dynamic imaging is used to assess coccygeal mobility in the form of the intercoccygeal angle (ICA) and find the direction of subluxation. The ICA is the angle formed between a straight line bisecting the first coccygeal segment in along its long axis and a similar line bisecting the last coccygeal segment. Coccygeal mobility is determined by the difference in ICA measured on the sitting and standing radiographs. If the difference in ICA is less than five degrees, the coccyx is considered immobile; if the angle is between five and 25 degrees, it is considered to be normal; and, if the angle is more than 25 degrees, then it is considered as hypermobile. If the coccyx is identified as hypermobile, then the sagittal direction of displacement is noted as either flexion(Fig 5) or extension(Fig 6).(4) CT and MR imaging too help in the diagnosis.

All patients were given NSAID’s and a cushion for the first six weeks. Patients with the coccyx going into extension were given a firm cushion with a hole while those with the coccyx going into flexion are given a soft cushion. The hole protects the tip of the subluxating coccyx from repetitive trauma.

Figure 5 (Below): Dynamic X-Ray showing coccyx going into flexion

Figure 6 (Below): Dynamic lateral radiographs of the coccyx in extension

Patients with no response at six weeks were given a local steroid injection, and NSAIDs and cushions were continued for a further six weeks. While not followed by our team, ganglion impar block has also been described as effective in the management of refractory cases of coccydynia. We avoid this technique due to the significant patient discomfort, high risk of rectal perforation and incidences of needle breakage and injection of neurolytics into the rectum.

For patients not responding to these measures, we recommend coccygeal manipulation under general anesthesia with injection of steroid around the tip of the coccyx. This increases the success rate of steroid injections to over 70%. Flexion, extension and circumduction of the coccyx are repeated five to ten times prior to steroid injection.(4)

Coccygectomy is performed only in patients with persistent symptoms following conservative management for at least six months. Coccygectomy has been reported to have satisfactory outcomes, with success rates in the literature varying from 74 to 90%. (1)

In summary, while coccydynia is increasing in incidence a systematic plan of management gives excellent results. The majority of patients have excellent relief with conservative management while a few patients with refractory symptoms may eventually need surgery.

References

1. Wray C, Easom S, Hoskinson J. Coccydynia. Aetiology and treatment. J Bone Joint Surg Br. 1991 Mar;73-B(2):335–8.

2. Lirette LS, Chaiban G, Tolba R, Eissa H. Coccydynia: an overview of the anatomy, etiology, and treatment of coccyx pain. Ochsner journal. 2014;14(1):84–7.

3. Nathan ST, Fisher BE, Roberts CS. Coccydynia. J Bone Joint Surg Br. 2010 Dec;92-B(12):1622–7.

4. Dave B, Bang P, Degulmadi D, Samel P, Shah D, Krishnan A. A clinical and radiological study of nontraumatic coccygodynia in Indian population. Indian Spine Journal. 2019;2(2):128.

5. Nagappa S, Alshameeri Z, Elmajee M, Hashmi Y, Bowry A, Jones M, et al. Clinical Outcome of Coccygectomy Using a Paramedian Curvilinear Skin Incision in Adults and Children With Meta-Analysis of the Literature Focusing on Postoperative Wound Infection. Global Spine J. 2023 Sep 1;13(7):1878–93.

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