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Lateral radiograph
A 78-year-old man presents to your office with chronic lower back pain. He denies history of known injury. He has no pain or weakness in his lower extremities. Lateral radiograph shows multilevel degenerative changes in the lumbar spine and an incidental, 5.2-cm abdominal aortic aneurysm. He denies any abdominal pain or dizziness.
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A high index of suspicion for an abdominal aortic aneurysm is warranted in male patients aged >60 years with risk factors such as a smoking history, hypertension, and atherosclerosis. Back pain can be a sign of a ruptured abdominal aortic aneurysm; therefore, from an orthopedic standpoint, men aged >60 years who present with atraumatic back pain and risk factors should undergo an abdominal examination to rule out a pulsatile mass. An abdominal aortic aneurysm that expands >0.5 cm in 6 months or is >5 cm in diameter is at high risk for rupture and probably should be repaired. Surgical repair is not without potential complications, such as cardiac events and stroke; therefore, risks and benefits should be discussed with the patient and his/her primary care physician.1,2
Rupture of an abdominal aortic aneurysm is a surgical emergency that is associated with a high mortality rate. Symptoms of a ruptured abdominal aortic aneurysm can be variable, and the diagnosis is often missed. The classic pulsatile abdominal mass may not be found in all patients. The misdiagnosis rate was reported as high as 30% in one study.1 In patients who were misdiagnosed, the most common physical examination finding included abdominal pain (70%), shock (57%), and back pain (50%).1 Early diagnosis before rupture of an abdominal aortic aneurysm is critical in reducing the mortality rate. Therefore, if you see an abdominal aortic aneurysm on lumbar radiographs, it is important to educate the patient on further evaluation and treatment.1,2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).
References
- Marston WA, Ahlquist R, Johnson G, Meyer AA. Misdiagnosis of ruptured abdominal aortic aneurysms. J Vasc Surg. 1992;16(1):17-22.
- Van Wyngaarden JJ, Ross MD, Hando BR. Abdominal aortic aneurysm in a patient with low back pain. J Orthop Sports Phys Ther. 2014;44 (7):500-507.
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