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Aortic aneurysm and low back pain ... The forgotten red flag!

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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!

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Aortic aneurysm and low back pain ... The forgotten red flag!

  1. 1. Aortic aneurysm: the forgotten red flag? - low back pain Alan J Taylor @TaylorAlanJ@TaylorAlanJ
  2. 2. 65 year old male with chronic LBP… What are your considerations? Low back pain – dull ache 3-6/10 @TaylorAlanJ
  3. 3. RED FLAG? Differential diagnosis Vascular Link to LBP Medico legal Usual Chronic pain route? @TaylorAlanJ
  4. 4. Normal ±2.5 cm The forgotten red flag – Abdominal aortic aneurysm @TaylorAlanJ
  5. 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. 6. CT scan of Ruptured AAA Aortic aneurysm Blood See Wyngaarden et al 2014 JOSPT for clinical description @TaylorAlanJ
  7. 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. 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. 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. 10. Should I be worried? No … BUT you should be vigilant! @TaylorAlanJ
  11. 11. Clinical challenge • Physiotherapists see many patients with back pain … • Many come directly to see a physiotherapist without seeing a doctor first. @TaylorAlanJ
  12. 12. AAA may = LBP @TaylorAlanJ
  13. 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. 14. Referral for surgery at 5.5cm @TaylorAlanJ
  15. 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. 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. 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. 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. 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. 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. 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. 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. 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. 24. AAA: Clinical Manifestations • Other: – Heart beat “dropped into my stomach” – Early satiety – Pulsatile abdominal mass – Bruit (sound of turbulence) @TaylorAlanJ
  25. 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. 26. Palpation @TaylorAlanJ
  27. 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. 28. Auscultation Bruit? - an abnormal auscultatory sound Rhythmic, pulsatile in nature High Specificity, low sensitivity @TaylorAlanJ
  29. 29. Risk • Risk is increased by: – smoking – high blood pressure – close family history http://aaa.screening.nhs.uk/ @TaylorAlanJ
  30. 30. Via www.knowmedge.com @TaylorAlanJ
  31. 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. 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. 33. We talk a lot about ‘Cauda equina syndrome’ … which is really serious Aortic aneurysm may be deadly …! BUT @TaylorAlanJ
  34. 34. http://www.everydayhealth.com/news/moderate-alcohol-intake-may-lower-aortic-aneurysm-risk/ @TaylorAlanJ
  35. 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. 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. 37. http://www.sciencedirect.com/science/article/pii/S1078588409000902 @TaylorAlanJ
  38. 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

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