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COCCYDYNIA AND LUMBAR DISK DISEASEHISTORICAL CORRELATIONS AND CLINICAL CAUTIONS DEWEY A. NELSON* The lowly coccyx (tailbone) is a vestige of an ancient primate tail, a rudiment of which is present in human embryos. Why should a discussion of surgery on such an arcane appendage become part of a medical review of the well-known lumbar herniated nucleus pulposus ("slipped disk")? Of course, both coccydynia and lumbar disk disease affect the lower spine and its numerous adjacent nerve roots, but those are nebulous correlations. More significantly, even though more than 90 years have passed since coccyges began to be removed and 55 years have elapsed since lumbar herniated disks were first operated upon, there are similar enigmas in their historicity. In the early part of this century, coccydynia was a very popular diagnosis in many practices, and coccygectomies were frequently performed, but no more. Just as certainly as coccyx surgery fell into disrepute, there is every indication that medicine in the 1990s will have to face the "crisis of the slipped disk." For these reasons, we should scrutinize the results of 55 years of diskectomy and compare it with 90 years of coccygectomy in an attempt to learn from their controversial histories. Perhaps the pathway for future therapy will be illuminated. Because the tides of diagnoses change course, what is fashionable and accepted in one era is rejected in another. Interestingly, in this day and age, less than 1 percent of patients in pain clinics have coccydynia, an "antique disease" that has been virtually abandoned. By contrast, apNote of appreciation.—A special thanks goes to the librarians of the Medical Center of Delaware for their patient help at desk and computer and for their long hours of researching sources. They are: Mrs. Christine Chastain-Warheit, Mrs. Patricia Patterson, and Mrs. Ann Gallagher. *Professor of neurology, ThomasJefferson Medical College, 1025 Walnut Street, Philadelphia , Pennsylvania 19107. Mailing address: 48 Omega Drive, Omega Professional Center , Newark, Delaware 19713.© 1991 by The University of Chicago. AU rights reserved. 003 1-5982/91/3402-07 19$01 .00 Perspectives in Biology and Medicine, 34, 2 ¦ Winter 1991 \ 229 proximately 30-50 percent of patients with chronic pain have had lumbar disk disease, diskectomies, and the multiple postsurgical problems now labeled "failed-back syndrome." This is a reversal of disease incidence of today when compared with 1900, the age when patients with coccydynia flooded every clinic. Thus, low back pain and lumbar radiculopathy rival headache as the prime diagnosis of patients who now populate the rapidly growing pain clinic population. When pain originates in the structural elements of the back (bones, joints, ligaments, muscles), it is classified as "mechanical," compared with neurogenic pain that radiates down nerve roots and is labeled "radicular ." Known in American lexicon as: "O, my aching back," these ubiquitous diseases are often mistakenly considered as synonymous, but they are really quite different. Low back pain will ultimately plague almost every adult; similarly, sciatica with its neuralgic pain that radiates down the leg will some day affect half of us and require medical attention. Frequently diagnosed, they have partially disabled 12 million patients, have permanently disabled over 5 million more, and result in the loss of over $18 billion annually in compensation payments and productivity [I]. In addition, 200,000 patients annually have diskectomies in the United States, which overall represents almost 6 million individuals, or 2 percent of the population [I]. Between 1977 and 1981, the rate of disability from low back syndromes increased at an astounding rate of 14 times the rate ofpopulation growth [2]. Why should this be? Frymoyer and Cats-Baril [2] published a recent study that described a tool designed to predict low back pain disability that considered the following: injury factors, job, demographic factors, anthropometric qualities, psychological variations, health behavior, as well as medical and diagnostic findings. The part played by on-the-job injuries was found to be controversial (see below). Concerning diskectomies, the authors [2] stated: "Many studies have shown that the chronically disabled low back population includes a disproportionate number of failed surgical procedures, some of which occurred because the original indications for surgical intervention were unclear, and a smaller number who had the appropriate...


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