Aortic aneurysm: the forgotten red flag? - low back pain

Alan J Taylor

@TaylorAlanJ @TaylorAlanJ

65 year old male with chronic LBP…

What are your considerations?

Low back pain –dull ache 3-6/10

@TaylorAlanJ

RED FLAG?

Differential diagnosis

VascularLink to

LBP

Medicolegal

UsualChronic

pain route?

@TaylorAlanJ

Normal ±2.5 cm

The forgotten red flag – Abdominal aortic aneurysm

@TaylorAlanJ

AAA: Description

• Visceral cause of LBP

– Makes up around 2% of LBP cases (Jarvic & Deyo 2002)

• Abnormal widening of blood vessel

– (>3cm in diameter)

• Weakening of tunica media

– middle “layer” of blood vessel

• ±75% of aneurysms occur in…

– abdominal aorta@TaylorAlanJ

CT scan of Ruptured AAA

Aortic aneurysm

Blood

See Wyngaarden et al 2014 JOSPT for clinical description

@TaylorAlanJ

AAA Prevalence - UK

±6,000 deaths each year in England and Wales

– from ruptured AAA

Deaths from ruptured AAA account for around

– 2 % of all deaths in men aged 65 and >

Around 4 % of men aged 65-74 in England

– have an AAA (approximately 80,000 men)

@TaylorAlanJ

AAA: Silent killer?

• Majority related to atherosclerotic changes

• Approximately 10% related to inflammatory process of blood vessel wall

• Many undiagnosed or found incidentally, but potential complication is dissection and death …

– Risk prediction models developed for AAA surgery

Grant et al 2014 Brit J Surg

@TaylorAlanJ

So what…?

• LBP is one of the symptoms of AAA

– ‘The prevalence of CLBP is HIGH among AAA patients … Tsuchie et al 2013 PMID: 23759898

• Clinical challenge?

@TaylorAlanJ

Should I be worried?

No … BUT you should be vigilant!@TaylorAlanJ

Clinical challenge

• Physiotherapists see many patients with back pain …

• Many come directly to see a physiotherapist without seeing a doctor first.

@TaylorAlanJ

AAA may = LBP

@TaylorAlanJ

CT chest scan showing large ascending aortic aneurysm (9.5×10 cm)

Antón E , and Echeverría M Circulation. 2005;112:116-117

Copyright © American Heart Association, Inc. All rights reserved.

http://circ.ahajournals.org/content/112/9/e116.figures-only

@TaylorAlanJ

Referral for surgery at 5.5cm

@TaylorAlanJ

Clinical challenge

• As autonomous and accountable diagnostic practitioners

• Physiotherapists of all levels of experience …

• Need to be able to identify those patients who need urgent medical review and act accordingly

http://www.csp.org.uk/professional-union/practice/insurance/learning-litigation@TaylorAlanJ

Use clinical reasoning

•Structure & pathology do matter

•CLBP + concomitant AAA?

– It’s possible!

•Symptoms worsening????????????

•Don’t be blinkered by one school of thought@TaylorAlanJ

Abdominal Aortic Aneurysm

“…Delay in referring an at risk patient, in

order to offer a trial of therapy may be

indefensible morally, clinically and in a

medico-legal context”

Crawford CM et al 2003 JMPT 26(3) PMID

@TaylorAlanJ

Medico-legal …implications

• The basis for ML claims is that:

– the practitioner failed to: examine the patient properly; act on 'red flags' present, refer on or investigate with sufficient urgency

• This does not just affect doctors and surgeons.

– Physiotherapists have been found to be clinically negligent for failing to act and/or refer on appropriately …

http://www.csp.org.uk/professional-union/practice/insurance/learning-litigation

@TaylorAlanJ

Dissecting AAA …?

• Make sure you act to 'refer-on' immediately by phone:

– to a doctor or A&E

• If you have a suspicion a patient is presenting with dissecting AAA

– A written referral may take too long

– Timing is critical

@TaylorAlanJ

Pain

science

Biomedical

model

Medico

legal

Clinical reasoning

and the imaginary division between ‘pain-science’ and the ‘bio-medical model’

The clinical reasoning bottom line …

and why structure & pathology may matter

REMEMBER vigilance, pathology, delay@TaylorAlanJ

Risk factors AAA

• The main risk factors are

age and being male

• 95 per cent of ruptured AAA

occur in men over 65

• The condition is 6-8x more

common in men than women@TaylorAlanJ

AAA: Clinical Manifestations

• 75% asymptomatic at time of Dx

• Back Pain or maybe abdominal pain

• Aneurysmal pain may be linked to

– The aneurysm itself

– Or due to erosion into the vertebral body

• Inflammatory AAA

– more likely to be linked to pain

• Tends to be an unchanging ache

– night pain??@TaylorAlanJ

Potential Complications

• Dissection!!– Pain that is sharp-hot-ripping-tearing-searing

– Men aged > 65yrs highest risk group

– Risk of dissection tied to diameter• < 5cm risk is <2%

• 5-6 cm risk is 5-10%

• > 7cm risk is up to 20%

• Surgery considered if 5.5 cm or >

• Mortality ranges from 2-5% associated with surgery

@TaylorAlanJ

AAA: Clinical Manifestations

• Other:

– Heart beat “dropped into my stomach”

– Early satiety

– Pulsatile abdominal mass

– Bruit (sound of turbulence)

@TaylorAlanJ

Screening

• Risk Factors … Subjective screening

• Palpable pulsatile abdominal mass, but..

– Only detectable 35-40% of time

– Ability to palpate is influenced by girth and

diameter of aneurysm

– Overall ability: sensitivity of 68%; specificity of 75%

@TaylorAlanJ

Palpation

@TaylorAlanJ

Screening and diagnosis

Palpable pulsatile abdominal mass, but..

Sensitivity increased to 82% if diameter > 5cm

Abdominal girth

< 100cm = sensitivity of 91%

> 100cm = sensitivity of 53%

If girth is < 100cm and aneurysm > 5cm sensitivity increased to 100%

@TaylorAlanJ

Auscultation

Bruit? - an abnormal auscultatory sound

Rhythmic, pulsatile in nature

High Specificity, low sensitivity

@TaylorAlanJ

Risk

• Risk is increased by:

– smoking

– high blood pressure

– close family history

http://aaa.screening.nhs.uk/@TaylorAlanJ

Via www.knowmedge.com@TaylorAlanJ

65 year old male with chronic LBP…

What are your considerations?

Low back pain –dull ache 3-6/10

AAA …?

Rare but … may be there!

Sound clinical reasoning and vigilance are the key

@TaylorAlanJ

‘FLARE UPS’ IN CHRONIC LOW BACK PAIN

RED FLAGS… are they ever ‘covered’

Chronic low back pain and TIME

Developing cauda equina syndrome

Developing osteoporotic fracture

Developing tumour or AAA

Clinical reasoning – ‘The gradual unfolding of information over time’

DELAY may = DISABILITY

DELAY may = DEATH

@TaylorAlanJ

So

me e

xam

ple

s …

.

We talk a lot about ‘Cauda equina syndrome’

… which is really serious

Aortic aneurysm may be deadly …!

BUT

@TaylorAlanJ

http://www.everydayhealth.com/news/moderate-alcohol-intake-may-lower-aortic-aneurysm-risk/

@TaylorAlanJ

The Pulse of Thought:

Haemodynamics of the Brain and Mind

Via http://alteredhaemodynamics.blogspot.co.uk/

Thanks for your comments

or feedback . . .

alan.taylor@nottingham.ac.uk

@TaylorAlanJ @TaylorAlanJ

Resources & further reading

• http://www.medpagetoday.com/Cardiology/Prevention/46471?linkId=8618210

• http://aaa.screening.nhs.uk/cms.php?folder=2454

• http://www.sciencedirect.com/science/article/pii/S1078588409000902

• http://www.ncbi.nlm.nih.gov/pubmed/24766359

• http://www.sciencedirect.com/science/article/pii/S1078588411007647

Simone Knaap and Wayne Powell II (2011)

@TaylorAlanJ

http://www.sciencedirect.com/science/article/pii/S1078588409000902

@TaylorAlanJ

‘Aortic atherosclerosis and stenosis of

the feeding arteries of the lumbar spine

were associated with disc degeneration

and LBP.’

http://www.sciencedirect.com/science/article/pii/S1078588409000902

@TaylorAlanJ