Sacral erector spinae plane block for postoperative pain management following coccyx removal: A case report

Abstract

Sacrococcygeal dislocation commonly occurs after trauma and may cause coccydynia. Although most cases of coccydynia after sacrococcygeal dislocation resolve with conservative and medical treatment, surgery is also an option with refractory pain. Sacral erector spinae plane block (SESPB) is a novel approach for sacrococcygeal procedures and may be effective in the postoperative pain of this region. In this article, we present a case of a successful median approach SESPB for postoperative pain management following coccyx removal in a patient with sacrococcygeal dislocation. In conclusion, SESPB seems to be a promising regional anesthesia technique for pain originating from the coccyx.

Introduction

Coccydynia is defined as the pain at the region of coccyx. Sacrococcygeal dislocation usually occurs after trauma and may cause coccydynia.[1] Most cases of coccydynia after sacrococcygeal dislocation resolve with conservative and medical treatment; however, surgery is also an option with refractory pain.

Sacral erector spinae plane block (SESPB) is a novel approach for sacrococcygeal procedures and may be effective in the postoperative pain of this region. Since SESPB was first suggested, multiple case reports showed SESPB as a useful and safe technique to reduce pain at sacral regional surgeries.[2-4]

In a recent cadaveric and radiological study, Keleş et al.[5] showed local anesthetic (LA) distributions with median and intermediate approaches to SESPB. In the median approach, LA distributed to the anterior part of the sacrum through sacral foramina; however, in the intermediate approach, the LA was seen only at the posterior part of the sacrum.

In this article, we present a case of a median approach SESPB in a patient with sacrococcygeal dislocation.

Case Report

A 34-year-old, 65 kg, American Society of Anesthesiologists (ASA) Class I, female patient presented with sacrococcygeal dislocation due to a fall onto the buttocks. She did not respond to conservative or medical treatment and was scheduled for a coccyx excision surgery. The patient was taken to the operating room after sedation with 2 mg of midazolam intravenously (IV). Following standard monitorization, anesthesia induction was done with fentanyl 1 µg· kg^-1, propofol 2 mg· kg^-1 and rocuronium 0.6 mg· kg^-1 IV, and the patient was orotracheally intubated. Before the start of the surgery, the patient was turned to prone position. Under aseptic conditions, a linear ultrasound probe was placed longitudinally above the sacrum to identify median sacral crests and erector spinae muscles.

Median approach SESPB was performed with a 22-gauge, 80-mm needle (B. Braun Melsungen, Germany) using in-plane technique. The needle was inserted with a cranial to caudal direction until the tip touched to the top of the fourth median sacral crest. After negative aspiration, a single shot block with 20 mL of 0.25% bupivacaine was injected to the area and craniocaudal spread of the LA was confirmed (Figure 1). The surgery lasted for 3 hours without any complications. At the end of the surgery, 400 mg of ibuprofen IV, 1 g of paracetamol IV, and 30 mg of pethidine IV were administered to the patient. A patient-controlled analgesia (PCA) device through IV line was set to deliver 1 mg of morphine bolus dose and 8-min lock-out for the first postoperative day was initiated in the post-anesthesia care unit (PACU).

Figure 1. Ultrasound image of median approach sacral erector spinae plane block, white arrow represents the block needle and the point of injection. LA, local anesthetic.

Postoperatively, the patient was evaluated with Numeric Rating Scale (NRS) score for pain. In the PACU, the patient’s NRS for pain was 1 and no additional analgesics were needed and she was transferred to the surgical ward.

Paracetamol 1 g IV t.i.d. and dexketoprofen 50 mg b.i.d. were routinely given to the patient in the surgical ward in addition to PCA. The patient was re-evaluated at one, three, six, 12, and 24 hours postoperatively and NRS for pain scores were 0, 6, 0, 0, 0, respectively. No signs or symptoms of LA toxicity or motor block were seen. A total of 2 mg of morphine was administered to the patient via IV PCA at the end of 24 hours. No other rescue analgesics were needed. A written informed consent was obtained from the patient for publication of this case report.

Discussion

Sacrococcygeal regional pain may be refractory to conservative treatment and patients may undergo surgical removal of the coccyx. This pain may be difficult to manage and may present a challenge to anesthesiologists. Multimodal approach including regional anesthesia techniques may provide opioid sparing anesthesia, fast recovery time, and favorable patient satisfaction.

The SESPB is a novel approach in sacral regional postoperative pain. It has been shown to be effective in lumbosacral regional surgeries including gender reassignment, parasacral reconstructive surgeries and anal regional surgeries.[2-4] A recent cadaveric and radiological imaging study of Keleş et al.[5] studied the LA distribution in median and intermediate approach of SESPB and showed that radiopaque solution was distributed to both subcutaneous area at the S1 and S5 horizontal planes and at the S2 to S5 levels through the sacral foramina via the spinal nerves. In the median approach, the LA spread from sacral foramina to the anterior of the sacrum. However, in intermediate approach, all the LA stayed at the posterior part of the sacrum. In our case, we used the single-shot median approach SESPB, and found to be clinically useful for treating postoperative pain following surgical coccyx removal. The patient was also re-evaluated six months after surgery. The NRS score for pain at the sacrococcygeal region was 0. The patient was satisfied with the perioperative pain management.

In this case, we employed SESPB as an adjunct for postoperative analgesia following coccyx removal in a patient with sacrococcygeal dislocation. While preliminary evidence suggests that SESPB may provide effective pain relief in certain sacral and coccygeal procedures, its use should not be considered routine for all surgeries in this region. The decision to implement SESPB should be guided by individual patient factors and clinical assessment. Although our case demonstrates favorable outcomes, further prospective studies and randomized-controlled trials are warranted to establish the generalizability and optimal application of SESPB in various surgical indications.

In conclusion, SESPB seems to be a promising regional anesthesia technique for pain originating from the coccyx. It may be considered a useful and technically straightforward component of the postoperative multimodal analgesia regimen after surgical removal of the coccyx. Further randomizedcontrolled trials are needed to further evaluate the effectiveness of SESPB.

Cite this article as: Manici M, Özdemir İ, Sincer Y, Gürkan Y. Sacral erector spinae plane block for postoperative pain management following coccyx removal: A case report. Agri 2026;38(2):134-136. doi: 10.5606/agri.2026.47.

M.M., I.O., Y.S., Y.G.: Idea/concept, design, data collection and/or processing, analysis and/or interpretation, writing the article, critical review, references and fundings, materials; M.M., Y.G.: Control/supervision; M.M., Y.S., Y.G.: Literature review.

The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

The authors declare that artificial intelligence (AI) tools were not used, or were used solely for language editing, and had no role in data analysis, interpretation, or the formulation of conclusions. All scientific content, data interpretation, and conclusions are the sole responsibility of the authors. The authors further confirm that AI tools were not used to generate, fabricate, or ‘hallucinate’ references, and that all references have been carefully verified for accuracy.

The authors received no financial support for the research and/or authorship of this article.

Data Sharing Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.

References

1. Lirette LS, Chaiban G, Tolba R, Eissa H. Coccydynia: An overview of the anatomy, etiology, and treatment of coccyx pain. Ochsner J 2014;14:84-7.
2. Gupta A, Diwan S, Shankar V. Sacral ESP for pain management in transforaminal lumbar interbody fusion cases: A case series. Saudi J Anaesth 2023;17:437-9. doi: 10.4103/sja.sja_185_23.
3. Aksu C, Gürkan Y. Sacral Erector Spinae Plane Block with longitudinal midline approach: Could it be the new era for pediatric postoperative analgesia? J Clin Anesth 2020;59:38-39. doi: 10.1016/j. jclinane.2019.06.007.
4. Aksu C, Cesur S, Alparslan V, Kuş A. Is it time to replace caudal block: Above or below the bone? J Clin Anesth 2020;61:109676. doi: 10.1016/j.jclinane.2019.109676.
5. Keleş BO, Salman N, Yılmaz ET, Birinci HR, Apan A, İnce S, et al. Comparison of the median and intermediate approaches to the ultrasound-guided sacral erector spinae plane block: A cadaveric and radiologic study. Korean J Anesthesiol 2024;77:156-63. doi: 10.4097/ kja.23604.

Figure and Tables

Figure 1. Ultrasound image of median approach sacral erector spinae plane block, white arrow represents the block needle and the point of injection. LA, local anesthetic.