My interest was piqued by Jeys et al., with their fascinating article titled, “Sacral chordoma: a diagnosis not to be sat on?” [1] The authors retrospectively studied 31 patients with chordomas arising in the sacrum and two patients with chordomas arising in the coccyx. The most common presenting symptom was pain, reported by 85%. Pain was typically worse with sitting, but I would note that this is also true in most cases of coccydynia, without necessarily helping to definitively distinguish the underlying aetiology. The authors report that 70% of these patients (23 patients) had at least one of the classic symptoms of cauda equina (saddle anaesthesia, bladder or bowel dysfunction).

But based upon anatomical innervation patterns, I would question whether either of the coccygeal chordoma cases caused cauda equina symptoms, unless the tumour had already spread to the sacrum or pelvis. This is an important point, since patients with pain well-localised to the coccyx should probably undergo imaging studies relatively early in their presentation, even in the absence of neurological symptoms or findings.

Many of my patients with coccydynia tell me that for years their primary physicians trivialised or even laughed about them having “pain in the tailbone.” Reportedly, many physicians neglect or delay to order any diagnostic workup or consultations for coccydynia. They incorrectly tell patients that these tests are pointless, under the erroneous explanation that there are no specific treatments for coccydynia anyway. They are unaware that modern interventional pain management procedures can be effective for coccyx pain [2].