Gravidanza, Puerperio

Patologia coccigea post-partum

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Il coccige è un osso impari e simmetrico, ultimo tratto inferiore della colonna vertebrale. Residuo rudimentale della coda dei mammiferi nel processo evolutivo della specie umana. Deriva il suo nome dal greco κόκκυξ (kòkkyx), propriamente “cuculo”, per via della somiglianza con il becco di tale uccello. Il primo a utilizzare il termine fu  Galeno  nel II° secolo d.C. E’ formato da 4-6 segmenti fusi tra loro, che però non presentano le normali caratteristiche delle vertebre. Sono, al contrario, soltanto abbozzi di queste ultime; infatti, solo la prima vertebra coccigea presenta ancora qualche caratteristica comune alle vertebre precedenti. Si notano solo in questa gli abbozzi dei processi trasversi e dei processi articolari, definiti corni del coccige, situati posteriormente alla base e che si articolano con i corni dell’osso sacro. Nell’insieme l’osso ha forma triangolare con una base superiore, un vertice inferiore, una faccia anteriore, una posteriore e due margini laterali. La base si articola con l’apice dell’osso sacro. Le facce anteriore e posteriore presentano dei solchi orizzontali che segnano i punti di fusione dei segmenti primitivi. Sul vertice del coccige si attacca il tendine dello sfintere esterno dell’ano.

ARTICOLAZIONE SACRO-COCCIGEA – L’articolazione sacro-coccigea è costituita da una sinfisi che mette in comunicazione il corpo dell’ultima vertebra sacrale con il corpo della prima vertebra del coccige. Essa può essere classificata fra le articolazioni intervertebrali; rispetto alle altre sinfisi intervertebrali, la sinfisi sacro-coccigea   presenta un disco intervertebrale particolare, in quanto più sottile, con uno spessore disomogeneo, nel senso che anteriormente e posteriormente è più spesso che sui lati e più solido di quello delle sinfisi intervertebrali. Il disco fibrocartilagineo posto tra le due faccette articolari affrontate, presenta uno sviluppo variabile e nell’adulto spesso ossifica, divenendo una sinostosi. I mezzi di rinforzo dell’articolazione sono dati da:

  • legamento sacro-coccigeo anteriore: allo stesso modo del legamento longitudinale anteriore delle articolazioni intervertebrali, scende lungo la faccia anteriore (superficie pelvica) dell’osso del sacro, fino all’apice del coccige.
  • legamenti sacro-coccigei laterali: allo stesso modo dei legamenti intertrasversali delle articolazioni intervertebrali, si estendono tra gli angoli infero-laterali del sacro ai processi trasversi del coccige. Dall’estremità inferiore della cresta sacrale al processo trasverso della I vertebra coccigea; si distinguono in esterni, medi e interni. Essi formano in tal modo parte del contorno di un foro che corrisponde a un foro sacrale; questo foro è suddiviso in due parti dal legamento medio; il legamento interno si porta dal margine superiore del processo trasverso del coccige alla parte inferiore del sacro che si trova medialmente alla cresta sacrale laterale allo stesso modo dei legamenti intertrasversali delle articolazioni intervertebrali si estendono tra gli angoli infero-laterali del sacro ai processi trasversi del coccige.
  • legamento sacro-coccigeo posteriore: si divide in un fascio profondo che, allo stesso modo del legamento longitudinale posteriore delle articolazioni intervertebrali, scende lungo la superficie posteriore del corpo della quinta vertebra sacrale a quello del I° segmento coccigeo; in un fascio superficiale che dal contorno dello iato sacrale scende sulla superficie dorsale del coccige completando la parte inferiore della volta del canale sacrale. Il fascio superficiale va dalla cresta sacrale media e dai corni sacrali alla faccia posteriore del coccige e ai corni coccigei, chiudendo lo hiatus sacrale.
  • Legamenti intercornuali: si estendono tra i corni del sacro e quelli del coccige.
  • Ligamento pubo-ano-coccigeo: vi si inserisce il muscolo sfintere esterno dell’ano e costituisce il principale organo di sostegno di vagina, uretra e utero.

 

 

 

 

Durante la fase espulsiva del parto, il movimento di retropulsione del coccige può consentire un allargamento dello stretto inferiore fino a 2-3 cm. ma la stessa del coccige può provocare, soprattutto in caso di sproporzione feto-pelvica, le seguenti patologie:

  1. lussazione  del coccige,
  2. frattura del coccige  o
  3. lacerazione dei legamenti sacro-coccigei,

La lussazione anteriore del coccige o coccige instabile: dislocamento del coccige in avanti; la punta del coccige appare curvato in su più del normale a causa della lussazione dell’ultimo segmento coccigeo. 

La frattura del coccige si evidenzia all’esplorazione rettale e all’esame radiografico. La punta del  coccige appare spostata in avanti.

La lacerazione dei legamenti sacro-coccigei può essere evidenziata con l’esplorazione rettale e l’esame ecografico con sonda rettale.

La sintomatologia in tutti e tre i casi è costituita da intenso dolore che aumenta durante la defecazione o assumendo la posizione seduta e persiste per lungo tempo anche dopo la guarigione. La guarigione è spontanea ma richiede diversi mesi.

Diagnosi: è basata sull’anamnesi, la sintomatologia dolorosa, l’esame dinamico ai raggi X in posizione eretta e seduta, l’esame clinico con eventuale esplorazione rettale (1-3).

 

TERAPIA:

  • riduzione manuale della lussazione; 
  • intervento chirurgico per il riposizionamento del coccige in caso di fallimento della terapia fisica e persistenza del dolore.
  • Agopuntura (11).
  • Riposo: Una frattura del coccige non può essere curata chirurgicamente a causa della estrema difficoltà ad immobilizzare questo rudimentale ossso. Nella quasi totalità dei casi, la frattura del coccige guarisce senza problemi nel giro di 4-8 settimane.
  • Coccigectomia: Nei rari casi in cui il dolore fosse insopportabile e persistesse  per un lungo periodo nonostante i presidi terapeutici messi in atto, è indicata la coccigectomia, intervento di non facile esecuzione e che comunque non garantisce la completa scomparsa

    del dolore che persiste nel 20% dei casi. Si richiedono da 3 a 12 mesi per ottenere una completa guarigione e durante questo periodo si continua a soffrire sil dolore soprattutto in posizione seduta. Inoltre data la vicinanza dell’ano all’incisione chirurgica, sono frequenti le complicanze infettive (6). La tecnica che Gardner introdusse nel 1972 è ancora oggi  la più seguita nelle sue linee principali.  Essa prevede:

  1. Anestesia generale
  2. Paziente in posizione genu-pettorale
  3. Incisione cutanea longitudinale interglutea di circa 6-7 cm partendo dalla sinfisi sacro-coccigea e comunque rispettando una distanza di sicurezza di almeno 4 cm dall’ano allo scopo di diminuire i rischi di infezione.
  4. Incisione dei tessuti sottocutanei fino a raggiungere il coccige;
  5. Incisione e scollamento con garza bagnata dei tessuti e legamenti che circondano il coccige fino a mettere a nudo la sinfisi sacro-coccigea e il coccige salvaguardando la fascia rettale.
  6. emostasi accurata; drenaggio laminare se non si è del tutto sicuri dell’emostasi.
  7. Scollamento della parete anteriore coccigea attraverso lo spazio interdiscale anomalo creato dalla lesione.  Esposizione della punta del coccige, eventualmente aiutandosi con un dito introdotto nel retto.
  8. Resezione dei tralci connettivali della punta del coccige
  9. Rimozione del tratto coccigeo lesionato
  10. Eventuale rimozione del tratto coccigeo residuo se troppo prominente; in tal caso si procede alla incisione della sinfisi sacro-coccigea salvaguardandone una parte se la superficie dell’apice del sacro si presentasse irregolare.

I vantaggi di questa tecnica includono una minima dissezione tissutale, minori rischi infettivi e di lesioni rettali ed una più rapida guarigione (7-10).

Per evitare la sindrome da intrappolamento del plesso nervoso coccigeo, lo si può elettrocoagulare se non si è assolutamente sicuri della sua totale esclusione dai punti di sutura.

La paziente deve evitare la posizione seduta per almeno 4 settimane.

  •  Antidolorifici: sono consigliati i FANS come l’ibuprofene somministrati per os, per via parenterale ma anche in gel da applicare con delicati e frequenti massaggi. Con i cortisonici si ottiene un sollievo immediato dal dolore ma di breve durata; inoltre la terapia a lungo termine con i cortisonici può danneggiare l’articolazione sacro-coccigea accelerandone la calcificazione.
  • Anestesia loco-regionale: iniezione di anestetico locale (lidocaina o bipuvicaina) nel plesso nervoso coccigeo (intreccio delle branche anteriori dei primi due nervi sacrali con il 1° nervo coccigeo prima della loro distribuzione periferica). Esso è detto anche ganglio impari ed è posizionato sulla parete anteriore della sinfisi sacro-coccigea. Per arrivare a questo ganglio, si utilizza un ago ricurvo che, sotto guida fluoroscopica, si fa passare da sotto il coccige lungo la parete anteriore, oppure si utilizza un ago retto che perfora l’articolazione sacro-coccigea partendo dalla parete posteriore (4-5).
  • Blocco semi-permanente del nervo mediante criocoagulazione: utilizzando N2  liquido si ottiene il congelamento del plesso nervoso coccigeo e relativo danneggiamento che blocca la trasmissione del dolore per alcune settimane o mesi finchè le fibre nervose non si rigenerano. Può essere ripetuto, se necessario.
  • Blocco del nervo permanente  mediante rizotomia o neurolisi: solitamente questo è ottenuto con elettrodi alimentati  da corrente ad alta frequenza. Questo metodo e’ ritenuto più accurato rispetto ai vecchi metodi come l’iniezione di alcool, fenolo o glicerina che a volte possono danneggiare gli organi viciniori.  Questa tecnica spesso produce una neurolisi permanente ma sono possibili rigenerazioni spontanee del plesso nervoso con ricomparsa della sintomatologia dolorosa in forma accentuata e necessità di ripetere il trattamento. 
  • Anestesia epidurale a livello di L2 in caso di impossibilità a procedere con la precedente terapia. Ha una scarsa efficacia.
  • sedie e sedili morbidi o  ben imbottiti servono a poco perchè aumentano la pressione sul coccige; meglio utilizzare un cuscino coccigeo o sedersi su una ciambella o sdraiarsi a pancia in su mettendo un cuscino sotto le gambe oppure piegarsi leggermente in avanti per scaricare parte del peso sulle gambe  oppure stare seduti poggiandosi su una sola natica alternativamente.  
  • Immersione per 10-20 minuti della regione anale in un recipiente colmo di acqua calda
  • dieta ricca di fibre, frutta, verdure e molti liquidi per favorire la defecazione

References:

  1. Juhl JH, Crummy AB, Kuhlman JE, et al. Paul and Juhl’s Essentials of Radiologic Imaging . 7th ed. Philadelphia, PA:Lippincott, Williams, and Wilkins;1998.
  2. Low back pain. American Academy of Orthopaedic Surgeons website. Available at: http://www.aaos.org/ . Accessed July 15, 2008.
  3. Rosen P, Barkin RM, Braen GR, et al. Emergency Medicine: Concepts and Clinical Practice . 4th ed. St Louis, MO. Mosby-Year Book, Inc;1998.
  4. Foye PMButtaci CJStitik TPYonclas PP.: “Successful injection for coccyx pain”. Am J Phys Med Rehabil.2006 Sep;85(9):783-4.
  5. Staal JB, de Bie RA, de Vet HC, Hildebrandt J, Nelemans P. Spine: “therapy for subacute and chronic low back pain: an updated Cochrane review”. (Phila Pa 1976). 2009 Jan 1; 34(1):49-59.
  6. Hellberg S, Strange-Vognsen HH: “Coccygodynia treated by resection of the coccyx”. Acta Orthopaedica Scandinavica; 1990 Oct; 61(5): 463-465
  7. Richard C Gardner: “An improved technic of coccygectomy”. Clinical Orthopedics, 85: 143-145, 1972
  8. Shaposhnikov: “Surgical treatment of coccygodynia”. Khirurgiia (Moskva): 1997, 9, 47-8 (Original in Russian)
  9. Valen B; Bringedal K: “Coccygectomy for coccygodynia”. idsskrift for Den norske lægeforening; 1999 Apr, 119:10, 1429-30.
  10. Jean-Yves Maigne, Denis Lagauche, Levon Doursounian:  “Instability of the coccyx in coccydynia”. Journal of Bone and Joint Surgery [Br] 2000;82-B:1038-41
  11. Michael Durtnall: “Chiropractic and acupuncture works for acute and chronic coccyx pain/dislocation”. Original posting, 2003-03-16:

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Queste  pagine fanno parte del sito fertilitycenter.it in internet da marzo 2011. I testi, le tabelle, i disegni e le immagini pubblicati in queste pagine sono coperte da copyright ma a disposizione di tutti per copia e riproduzione purchè venga citata la fonte con Link al sito www.fertilitycenter.it.

Ringrazio i lettori per la loro cortese attenzione e li prego di voler comunicare le loro osservazioni e consigli su eventuali errori o esposizioni incomplete.

                  Enzo Volpicelli.


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