Aortic aneurysm is the forgotten red flag of low back pain. This short presentation is a reminder why structure and pathology do matter ... and why sound clinical reasoning is essential in physiotherapy practice. Remember, today's CLBP may be tomorrow's surgical case!

1. Aortic aneurysm: the forgotten
red flag? - low back pain
Alan J Taylor
@TaylorAlanJ@TaylorAlanJ

2. 65 year old male with chronic LBP…
What are your considerations?
Low back pain –
dull ache 3-6/10
@TaylorAlanJ

3. RED FLAG?
Differential
diagnosis
Vascular
Link to
LBP
Medico
legal
Usual
Chronic
pain route?
@TaylorAlanJ

4. Normal ±2.5 cm
The forgotten red flag – Abdominal aortic aneurysm
@TaylorAlanJ

5. 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

6. CT scan of Ruptured AAA
Aortic aneurysm
Blood
See Wyngaarden et al 2014 JOSPT for clinical description
@TaylorAlanJ

7. 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

8. 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

9. 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

10. Should I be worried?
No … BUT you should be vigilant!
@TaylorAlanJ

11. Clinical challenge
• Physiotherapists see many patients with back
pain …
• Many come directly to see a physiotherapist
without seeing a doctor first.
@TaylorAlanJ

12. AAA may = LBP
@TaylorAlanJ

13. 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

14. Referral for surgery at 5.5cm
@TaylorAlanJ

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. AAA: Clinical Manifestations
• Other:
– Heart beat “dropped into my stomach”
– Early satiety
– Pulsatile abdominal mass
– Bruit (sound of turbulence)
@TaylorAlanJ

25. 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

26. Palpation
@TaylorAlanJ

27. 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

28. Auscultation
Bruit? - an abnormal auscultatory sound
Rhythmic, pulsatile in nature
High Specificity, low sensitivity
@TaylorAlanJ

29. Risk
• Risk is increased by:
– smoking
– high blood pressure
– close family history
http://aaa.screening.nhs.uk/
@TaylorAlanJ

30. Via www.knowmedge.com
@TaylorAlanJ

31. 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

32. ‘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
Someexamples….

33. We talk a lot about ‘Cauda equina syndrome’
… which is really serious
Aortic aneurysm may be deadly …!
BUT
@TaylorAlanJ

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

35. 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

36. 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

37. http://www.sciencedirect.com/science/article/pii/S1078588409000902
@TaylorAlanJ

38. ‘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