A 33-year-old woman, gravida 2 para 2, is evaluated on the postpartum floor due to low back and buttock pain. Yesterday, the patient had a forceps-assisted vaginal delivery after a prolonged induction of labor for preeclampsia with severe features. Epidural analgesia was removed immediately postpartum. Afterward, the patient began to develop low back and buttock pain. The pain is constant but worsens with sitting. She has no chronic medical conditions and did not have these symptoms during pregnancy. Temperature is 37.2 C (99 F), blood pressure is 120/80 mm Hg, and pulse is 78/min. On examination, the uterine fundus is firm, and the perineum is intact with diffuse symmetric vulvar swelling. There is exquisite tenderness to palpation over the coccyx. There is no surrounding erythema. Deep tendon reflexes are 2+. Strength is 5/5 in the bilateral lower extremities. Which of the following is the best next step in management of this patient?

Question

A 33-year-old woman, gravida 2 para 2, is evaluated on the postpartum floor due to low back and buttock pain.  Yesterday, the patient had a forceps-assisted vaginal delivery after a prolonged induction of labor for preeclampsia with severe features.  Epidural analgesia was removed immediately postpartum.  Afterward, the patient began to develop low back and buttock pain.  The pain is constant but worsens with sitting.  She has no chronic medical conditions and did not have these symptoms during pregnancy.  Temperature is 37.2 C (99 F), blood pressure is 120/80 mm Hg, and pulse is 78/min.  On examination, the uterine fundus is firm, and the perineum is intact with diffuse symmetric vulvar swelling.  There is exquisite tenderness to palpation over the coccyx.  There is no surrounding erythema.  Deep tendon reflexes are 2+.  Strength is 5/5 in the bilateral lower extremities.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_da1f_16d6_bc81_d9fe98cb18b4_MD0003_00 This patient with exquisite tenderness to palpation over the coccyx has coccydynia, or tail bone pain. Most cases are secondary to external trauma in which the tip of the coccyx is displaced anteriorly. In the case of vaginal delivery, the coccyx is typically displaced posteriorly secondary to fetal movement through the maternal pelvis; this commonly occurs with a prolonged labor course or forceps-assisted vaginal delivery, as in this patient. Patients with coccydynia typically develop localized low back or buttock pain immediately after injury. The pain is typically worse with sitting and leaning back due to the increased weight on the coccyx. Coccydynia is diagnosed clinically based on exquisite tenderness on palpation of the coccyx with no associated signs of infection (eg, erythema, swelling) or neurologic deficits (eg, reduced strength and reflexes). Most cases resolve spontaneously; therefore, treatment is conservative, with reassurance, protection of the coccyx (eg, sitting on a pillow), and analgesics. Patients with persistent symptoms (eg, >2 months) may require imaging (eg, x-ray) and local anesthetic injections. (Choices A, C, and D) Epidural neuraxial analgesia can introduce bacteria into the epidural space, leading to the rare complication of a spinal epidural abscess. Patients develop localized back pain with associated neurologic signs (ie, motor and sensory deficits) and elevated erythrocyte sedimentation rates; they require blood cultures, empiric antibiotics, and sometimes, MRI of the spine. However, symptoms typically develop 4-10 days after the anesthesia procedure; in addition, this patient is afebrile and has no neurologic deficits, making this diagnosis unlikely. (Choice B) Postdural puncture headaches can occur after epidural analgesia due to an inadvertent puncture of the dura. These patients develop postural headaches (rather than low back or buttock pain) that are worse when sitting or standing upright. Initial treatment is with bed rest and oral analgesics; epidural blood patch is performed for severe or refractory cases. Educational objective: Coccydynia (tail bone pain) can occur after vaginal delivery due to coccyx displacement as the fetus passes through the maternal pelvis during labor and delivery. The diagnosis is clinical; treatment is with reassurance and analgesics because the majority of cases resolve spontaneously.

A 33-Year-Old Woman, Gravida 2 Para 2, Is Evaluated on the Postpartum