aortic aneurysm and low back pain ... the forgotten red flag!
DESCRIPTION
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!TRANSCRIPT
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Aortic aneurysm: the forgotten red flag? - low back pain
Alan J Taylor
@TaylorAlanJ @TaylorAlanJ
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65 year old male with chronic LBP…
What are your considerations?
Low back pain –dull ache 3-6/10
@TaylorAlanJ
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RED FLAG?
Differential diagnosis
VascularLink to
LBP
Medicolegal
UsualChronic
pain route?
@TaylorAlanJ
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Normal ±2.5 cm
The forgotten red flag – Abdominal aortic aneurysm
@TaylorAlanJ
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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
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CT scan of Ruptured AAA
Aortic aneurysm
Blood
See Wyngaarden et al 2014 JOSPT for clinical description
@TaylorAlanJ
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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
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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
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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
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Should I be worried?
No … BUT you should be vigilant!@TaylorAlanJ
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Clinical challenge
• Physiotherapists see many patients with back pain …
• Many come directly to see a physiotherapist without seeing a doctor first.
@TaylorAlanJ
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AAA may = LBP
@TaylorAlanJ
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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
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Referral for surgery at 5.5cm
@TaylorAlanJ
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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
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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
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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
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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
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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
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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
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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
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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
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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
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AAA: Clinical Manifestations
• Other:
– Heart beat “dropped into my stomach”
– Early satiety
– Pulsatile abdominal mass
– Bruit (sound of turbulence)
@TaylorAlanJ
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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
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Palpation
@TaylorAlanJ
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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
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Auscultation
Bruit? - an abnormal auscultatory sound
Rhythmic, pulsatile in nature
High Specificity, low sensitivity
@TaylorAlanJ
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Risk
• Risk is increased by:
– smoking
– high blood pressure
– close family history
http://aaa.screening.nhs.uk/@TaylorAlanJ
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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
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‘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 …
.
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We talk a lot about ‘Cauda equina syndrome’
… which is really serious
Aortic aneurysm may be deadly …!
BUT
@TaylorAlanJ
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http://www.everydayhealth.com/news/moderate-alcohol-intake-may-lower-aortic-aneurysm-risk/
@TaylorAlanJ
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The Pulse of Thought:
Haemodynamics of the Brain and Mind
Via http://alteredhaemodynamics.blogspot.co.uk/
Thanks for your comments
or feedback . . .
@TaylorAlanJ @TaylorAlanJ
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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
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http://www.sciencedirect.com/science/article/pii/S1078588409000902
@TaylorAlanJ
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‘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