by James D. Hundley, MD

            There are so many good things about Modern Medicine that I hate to be critical but the following story from one of my friends put a bee in my bonnet:

Dr. X is a retired university Professor of Sociology who is in great health with no known history of cancer or other serious disorder.  He reported that he fell onto his buttocks with a brief duration of tailbone pain several weeks before his office visit that was precipitated by having to sit in a confined space on an airplane for several hours during which he developed “tailbone” tenderness that occurred only when sitting.  He denied pain on lying supine, night pain, back pain, neurologic symptoms, bowel difficulties, and blood in his stools.

Because his tenderness persisted for a few weeks he made an appointment with a capable orthopaedic surgeon and was seen by the surgeon’s PA.  The PA took a history and then did a cursory examination reportedly checking the strength of the patient’s toes and ankles.  An x-ray was “normal”.  The PA ordered an MRI.

Coincidentally, my friend and I were scheduled for a lunch meeting between the office visit and the MRI at which he asked if I thought he needed to have the MRI.  After a discussion during which I did not feel that I could recommend against having the MRI he decided to proceed with it.  Not surprisingly, the MRI was negative.

Here’s the rub.  Why get an MRI before doing a thorough physical examination and using the history as a guide?  With a history like this, what was the PA looking for?  Cancer?  On what basis?

As for the physical exam, here’s what I think should be done:

1. Examine the intergluteal crease over the sacrum and coccyx externally for visible skin changes and tenderness.  Is the problem really his tailbone?  What about a pilonidal abscess or cyst, for example?
2. Perform a rectal examination to check for masses and tenderness of the coccyx which is easy to palpate.  Check the prostate and for occult blood.  How about a thrombosed or abscessed hemorrhoid?
3. Do a back exam to see if this was referred pain.  That would include back tenderness and range of motion, nerve root irritation tests, and a neurologic exam (some of which the PA to his credit reportedly performed).
4. Always remove shoes and stockings and check the ankles and feet for circulation and ulcerations, of course, not to diagnose tailbone tenderness but because you’re a thorough clinician and the opportunity to so is before you.

Assuming the findings of the exam were negative, how about some conservative treatment such as allowing time to recover and advice on how to manage his symptoms.  Since he only had pain on sitting, he didn’t really need analgesics or anti-inflammatory medications.  A simple pad with a cutout in the rear to unload the coccyx (not a “doughnut” which unloads the wrong area) should be very helpful.  Then check him back in a few weeks unless the symptoms have subsided spontaneously.

Interestingly, the patient reported that the tenderness subsided within a week or two after the MRI.  Did the MRI cure the problem?  Of course not.  Did peace of mind have anything to do with it?  Maybe, but he wasn’t very nervous about his condition to begin with and after we discussed his problem before the MRI he said he was even less worried about the basis for his symptom.

If we’re to do our share in reducing the cost of Medicine, we need to avoid unnecessary testing, especially those as expensive as MRI’s.

 

Dr. Hundley is a retired orthopaedic surgeon, a founder and currently the president of OrthopaedicLIST.com, a free, open access, resource website for orthopaedic surgeons and related professionals.