Coccygectomy, surgical excision of the coccyx, may be used to treat coccydynia, a chronic and disabling condition of the lowest part of the spine. It is a controversial and infrequently performed operation that many surgeons are reluctant to perform due to the risks of rectal perforation and infection. The criteria for patient selection for coccygectomy remain ill-defined. We present a single surgeon case series of 17 patients who underwent coccygectomy for chronic coccydynia.

This was a retrospective observarional case series analysis. Case notes of 17 patients who underwent coccygectomy from 1999 -2009 were obtained and analysed. We then carried out telephone survey for which only 15 patients were contactable. We used the Milton Keynes Orthopaedic Patient Satisfaction survey and the modified Oswestry low back pain disability questionnaire.

All patients had a two to three year history of coccydynia; 15 following trauma, one following a caudal injection and one following birth delivery. All patients had received between one and five lignocaine/methylprednisolone injections prior to coccygectomy, with documented initial symptom relief. All 17 patients had documented hypermobile sacro-coccygeal joints. Post-operative symptom relief varied between 60% and 100%, with all patients reporting that they would have their surgery again. Complications included three post-operative wound infections. There were no cases of rectal perforation. Coccygectomy for intractable coccydynia is sometimes the only option available. With good patient selection, including identification of a hypermobile joint with initial symptom relief following local injection, coccygectomy is a successful and safe treatment.

Introduction: Lumbar disc disease comprises of a heavy portion of the workload in spinal as well as general orthopaedic clinic.

It is well accepted that nerve root tension signs such as straight leg raise (SLR) & Lasegue’s test are sensitive at diagnosing nerve root impingement secondary to lumbar disc degeneration. In isolation, however, they lack specificity & have a poor positive predictive value (PPV). This can lead to uncertainty in clinical diagnosis.

Our study proves that a structured approach to clinical examination with cumulative nerve root tension signs (RTS) significantly increases the tests’ specificity and PPV, therefore giving clinicians more confidence in their diagnosis.

Methods: Prospective review of 1303 patients seen in one Orthopaedic consultant’s spinal clinic from 2004 until 2008. Data was collected using a standardized proforma. Pattern of pain as well as RTS (SLR, Lasegue, bowstring and crossover) were recorded and cross-referenced with subsequent MRI findings. In our dataset a positive MRI result was one in which the demonstrated disc lesion and nerve impingement corresponded with patient symptoms. Patients included were all those presenting with lower back and/or neuropathic leg pain. Patients had to be excluded from series due to incomplete datasets & missing MRI scans.

Results: N = 858. Our results showed that as we progressed from 1 RTS up to 4 RTS there was a significant increase in the PPV : 1RTS PPV = 0.333 (CI 0.25 – 0.43), 2RTS PPV = 0.78 (CI 0.69 – 0.86), 3RTS PPV 0.87 (CI 0.81 – 0.91), 4RTS PPV 0.93 (CI 0.66 – 0.99). There was also significant increases in specificity compared with 1RTS: 1RTS 0.75 (CI 0.70 – 0.8), 2RTS 0.94 (CI 0.91 – 0.96), 3RTS 0.92 (CI 0.89 – 0.95), 4RTS 0.99 (CI 0.98 – 0.99).

Discussion: This study shows that combining root tension signs as part of a structured assessment leads to a significant cumulative increase in the PPV and specificity of the diagnosis of nerve root impingement. Hence proving the importance of clinical examination. This method of sequential, cumulative RTS has not previously been documented in the literature.

The role of muscle function in the aetiology of recurrent dislocation of the patella has been examined. Eleven of the 12 patients we studied had joint hypermobility. Muscle biopsies from eight of nine patients treated by surgery had a predominance of abnormal Type 2C fibres, and three of six patients whose quadriceps muscles were studied by electromyography also had abnormal results. Our preliminary findings suggest that there may be a primary muscular defect in many cases of recurrent dislocation of the patella.

A woman with neurofibromatosis (von Recklinghausen's disease) presented with a giant plexiform neuroma of the arm and chest wall, with dysplastic scoliosis and a pseudarthrosis of the humerus. Her arm resembled that of the "Elephant Man" described by Sir Frederick Treves.