Abdominal Aortic Aneurysm, Clinical Tools for Diagnosis in Low Back Pain

Special Article - Abdominal Aortic Aneurysms

Austin J VascMed. 2016; 3(1): 1013.

Abdominal Aortic Aneurysm, Clinical Tools for Diagnosis in Low Back Pain

Osinski T*

Department of Rheumatology, Hospital Ambroise Pare,France

*Corresponding author: Osinski T, Department of Rheumatology, Hospital Ambroise Pare, 9 avenue Charles de Gaulle, Boulogne Billancourt, France

Received: November 27, 2015; Accepted: January 06,2016; Published: December 28, 2015

Abstract

Introduction: Abdominal aortic aneurysm is a rare but severe cause of low back pain.

Materials and Methods: Here we reviewed the clinical tools that exist to diagnosis this pathology in clinical practice in patient with low back pain

Results: The presence of an abdominal pulsatile mass is a sensitive sign and the auscultation of a bruit in the way of the abdominal aorta is a specific sign for presence of an AAA.

Conclusion: Those two tools permit to identify a severe pathology that can mimic a low back pain and help for the clinical reasoning and differential diagnosis

Keywords: Abdominal aortic aneurysm; Low back pain; Clinical diagnosis

Introduction

The lumbago is a frequent pathology with important consequences on the activities of the affected peoples [1,2]. Several structures can provoke Low Back Pain (LBP) (intervertebral disk, muscle, zygapophyseal joint) [3-5]. Viscera are a part of structures which can provoke a low back pain [6-8]. Among the abdominal structures the abdominal aorta in case of aneurysm, ruptured or not, can be the source of this symptom [9].

If the diameter exceeds 3 cm we talk about aneurysm [10]. This pathology represents a lethal risk in case of break. The lethality of ruptured AAA is around 80 % [11]. This rate of death rises to 100 % in case of no attempt of surgical care [12]. While the rate of death in case of preventive operation of an symptom-free aneurysm at high risk of break is 5 % at one month, and 32.3 % at 6 years [13]. This pathology is the tenth cause of death at the men of more than 65 years and the thirteenth for the women of more than 75 years [14].

This pathology has generally a silent evolution, what makes the diagnosis difficult to do [15]. The prevalence of an AAA in general population varies between less than 1% and more than 7% depends of studies [16,17]. Numerous cases were reported in literature of patient who were addressed to manual therapy for low back pain and were diagnosed with an AAA [9,18-20]. We resume here the evidences about clinical diagnosis of AAA and who are people at risk.

Method

We performed a selective narrative review of clinical relevant literature. We looked for clinical tests useful for the diagnosis of an AAA. Our review was performed on different databases (Medline, Cochrane Library, PEDro). The population of interest was preferentially person with low back pain who were diagnosed with an AAA or people at

risk screen preventively. We regarded to studies which compared clinical diagnosis to a gold standard (ultrasound echography, or MRI) to determine the metrological quality of clinical test for AAA.

Results

Clinical presentation

Low back pain is frequently the main complain of AAA [21]. Numerous cases are reported in literature. Generally the pain is chronic or recurrent in elderly people [18,22-24] but the pain might be more acute in younger people [14,25]. Often patients describe pain as deep and constant. In these patients, consulting for an episode of LBP associated with AAA, generally the clinical examination can't reproduce their complaint. Sometimes patient has abdominal pain but isn't always the case and it's don't seem to be frequent [26,27]. The fact that movement of spine fail to evoke the patient's pain is consider as a red flag for suspicious severe pathology [27]. The presence of an abdominal pulsatile mass is a frequent sign often accompanied by hypotension [9,22].

Clinical testing

The palpation of an abdominal pulsatile mass is a clinical useful tool to rule out an AAA (Figure 1). This test showed a sensitivity of 91 % in the presence of this pathology for subjects with an abdominal perimeter inferior of 100 cm [28]. For patients with an abdominal perimeter superior at 100 cm the sensitivity is 53 % [28]. Globally the sensitivity of palpation varies between studies from 63 % to 95 % [29]. The test's sensitivity is estimated at 29 % if aneurysm has a diameter between 3.0 cm and 3.9 cm. Otherwise the sensitivity increases at 76 % if the diameter of the aneurysm is superior at 5 cm [29].

Figure 1: Palpation to search an abdominal pulsatile mass.

    

    
    

    

    Figure 1:  Palpation to search an abdominal pulsatile mass.

Auscultation is the second clinical tool proposed in literature. Auscultating a breath along the course of abdominal aorta is a high specific test (95 %), a sound can also be detecting on femoral arteries with a high specificity too (85 %) (30).

Discussion

The screening of an AAA is a simple clinical diagnosis which bases on the palpation of an abdominal pulsatile mass. The normal diameter of the abdominal aorta is lower than 3 cm, the estimation of this diameter via an depth palpation in the belly can help to the diagnosis, even if this estimation can be biased by the presence of others structures (Figure 2) [28]. The palpation of an abdominal mass is thus a test with a good sensibility which thus allows eliminating the presence of an aneurysm in case of negative test.

Figure 2: Palpation to estimate the diameter of the abdominal aorta.

    

    
    

    

    Figure 2:  Palpation to estimate the diameter of the abdominal aorta.

To refine the clinical examination it is possible to proceed to the auscultation of the belly. The auscultation of the aorta is made by putting a stethoscope on the route of the artery (Figure 3). It's important to should not push the stethoscope in the belly of the patient, especially if patient is thin because there would be a risk of deforming the artery. Normally the auscultation of the belly has to reveal no sound if it is not digestive noises. In case of aneurysm it is very likely to hear a breath. The presence of a breath has a high specificity and permit to rule in the presence of an aneurysm. The combination of these two tests thus allows making a reliable clinical diagnosis of the need of more exams.

The principle risk factors of AAA are smoking, age, gender, family antecedents, and precedents cardiovascular pathologies [31-35]. Eighty percent of patients with AAA are = 55 years, male have 3 to 13 times more risk to develop an AAA, the effect of tobacco decrease in time to disappear after 20 years of stop [36]. Caucasians are more susceptible to declare this pathology versus Africans, Hispanics and Asians [34,35]. The consumption of vegetables, fruits, nuts and the regular physical exercise can reduced the risk of developed an AAA [28].

Figure 3: Auscultation of the abdominal aorta.

    

    
    

    

    Figure 3: Auscultation of the abdominal aorta.

We recommend to practitioners to know these tests and don't forget that this pathology might be the source of patient's symptoms, particularly for people with high risks. Indeed this pathology can mime musculoskeletal pains and seems very sub-diagnosed, only one patient on six would be detected and operated [36].

The surveillance must be more important for persons over 60 years, even if several cases were described at younger patients as the presented case. Furthermore it is necessary to keep in mind that aneurysms of less than 5 cm in diameter may also break [35].

Conclusion

Even if the evolution of the AAA is generally asymptomatic and even if the discovery is generally fortuitous this pathology can mimic lumbago. The diagnosis tools presented here seem to us essential to use in view of their simplicity and the trend to underdiagnose this pathology.

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Citation: Osinski T. Abdominal Aortic Aneurysm, Clinical Tools for Diagnosis in Low Back Pain. Austin J Vasc Med. 2016; 3(1): 1013.