Figure 161

Lateral view of the sacrum and coccyx in individuals not suffering pain. In (A) the coccyx is facing more anteriorly than in (B).

levator ani massage, levator ani stretching, and sacrococcygeal joint mobilization may bring relief to some patients but the overall results are often frustrating.

Coccygeal manipulation in combination with a steroid injection at the sacrococcygeal junction may bring relief to a significant number of patients. These are performed under general anesthesia and can be repeated if a positive response is obtained in the first trial. Patients who fail conservative care and continue with persistent severe pain may be referred for surgery. Partial or total coccygectomy may bring relief to these patients.


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Spinal surgery usually consists of one or more basic operative procedures such as decompression of the neural elements (cord, cauda equina, or nerve roots), reconstruction of the load-bearing capacity of the spine (bone grafting, cement injection, or internal fixation), and correction of spinal deformities (normalization of coronal and sagittal alignment). Many of these operative procedures are performed in concert with fusion surgery.

The most frequent spinal pathology for which surgery is performed is degenerative disc disease. Most patients with this condition do well after spinal surgery, whether it is simple disc excision or more complex fusion procedures. Some patients, however, have persistent or recurrent symptoms that necessitate re-imaging of the spine, and the diagnostic imaging of these patients will be the focus of this chapter.

The yearly increase in the number of spinal surgeries for degenerative disc disease in the United States and worldwide has resulted in a parallel rise in the number of spinal imaging studies that are performed after surgical interventions. The main goal of spinal imaging of symptomatic patients who have undergone previous spinal surgery is to correctly identify the reason for the patient's persistent, recurrent, or new pain. Such imaging studies are undertaken to determine whether or not additional surgery may help the patient.

When evaluating symptomatic patients after surgery, one has to keep in mind the classic three Ws related to failed back or neck surgery: wrong patient selection, wrong diagnosis, and wrong surgery (the latter including a wrong operated level). Mere repetition of diagnostic scans per se obviously cannot remedy poor preoperative patient selection.

A close collaboration between the managing physician and the neuroradiologist is important. Precise knowledge of the patient's symptoms (leg or arm vs. back or neck pain and the symptomatic side of radiculopathy) and what was done in surgery are all-important for the radiological evaluation. Even before performing diagnostic imaging, obtaining a detailed history on the temporal sequence of the patient's complaints after surgery may distinguish between having failed to

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