July 1996, it’s a hot day and I’m entering the golf club at Hadden Hill.  Two older men are there. One of them, seeing me, says to his friend, while pointing at me: ‘This man saved my life’! I then realise that it’s Norman, who I had seen the previous year in the clinic. I stumble over my greeting, embarrassed at his praise. I hadn’t saved his life at all……

The previous August, I had seen him as a new patient. He was getting back pain. In those older days we didn’t have access to MRI scans, and I had an X-Ray unit in the clinic. To keep the exposure to a minimum, we would compress the patient to the unit with a band. As I tightened up the compression band, Norman said to me; “I can feel a pulse in my abdomen’. My heart sank: I hadn’t even felt his abdomen during my examination routine. In a pitiful attempt to salvage some dignity from my poor examination, I said: ‘I’ll have a feel of your abdomen once I’ve taken the X-Ray’. Sure enough, when we were done with taking the X-Ray, I could feel a pulsation in his abdomen when I examined it.

What was the pulsation? The X-Ray showed a calcified abdominal aortic aneurysm. It looked quite big. An aneurysm is a bulge of the wall of an artery [1]. The aorta is the largest artery in the body, taking blood to the lower half of the body. Large aortic aneurysms can rupture. You don’t want your aorta to burst. If the vascular surgeons can see that the aorta gets to 5.5cm or more, or if it enlarges by more than 5mm in 6 months  then surgical repair of the aneurysm is indicated [2] [3]. After I wrote to his GP, Norman was referred to the vascular unit at the JR Hospital and had surgery to repair his aneurysm. He survived the surgery, as you now know. It was many years ago. Norman has long since passed away of other causes.

What did I learn from my basic omission? That I should always examine the abdomen of patients who have back pain. If I can feel a large pulsatile mass, then the patient may have an abdominal aneurysm, and an ultrasound scan is indicated. If the aneurysm has an internal diameter of less than 3cm, it is not considered to be of concern [3], but should be reassessed to ensure that it’s not enlarging rapidly. Anything over 3cm, and the hospital likes to monitor it. You can’t always feel an aneurysm when you examine the abdomen, so we should be careful not to assume that ‘it’s fine’ if we can’t feel anything. Suspicions should be higher in older, male patients who have smoked, or who have high blood pressure, or elevated cholesterol levels [4].

When aneurysms rupture, they cause back pain, but do stable aneurysms cause back pain? Although some authors suggest that they commonly do [5, 6], other authors suggest they the opposite [1, 4, 7]. They are sometimes detected incidentally in some patients with back pain [5, 8-15], suggesting that they could possibly be a cause of back pain. Personally, I think that large aneurysms can cause back pain, and in my limited experience, aneurysms of the iliac arteries, which traverse anteriorly to the sacroiliac joints, can also cause back pain. It’s also worth noting that some patients who I have scanned and found an aortic aneurysm, have not had palpable pulsatile masses in their abdomens.

How often do chiropractors see patients with abdominal aortic aneurysms? Before I did my ultrasound certificate, I would have said: ‘quite rarely’. However, In the past 12 months I have seen 8 patients with abdominal aortic aneurysms. This is approximately 5% of my new patient consultations. These aneurysms have been seen with abdominal ultrasound scan. 4 of those patients had aneurysms that were less than 3cm in diameter. These may not even be considered to be aneurysms at all by some. 3 of the other patients had aneurysms that were between 3 and 4cm in diameter. 1 patient had an aneurysm that was 5.5cm in diameter and had already been identified by the hospital. The patients with the aneurysms more than 3cm were all referred, via their GPs for assessment at the vascular unit at the hospital. All the patients were male, except for one female. Whether any of the 8 patients with aneurysms were getting back pain from their aneurysms is difficult to tell.

Doing investigations like this will inevitably cause some anxiety for patients [16]. This is the downside to all investigations. Does it mean that we shouldn’t do these investigations? Although there are strong arguments that screening a population without symptoms is not helpful [17, 18], I think that it’s important to remember that in the chiropractic setting, the patient does have symptoms: back pain. We are searching for the cause of this, and one possibility (in certain patient groups), includes an aortic aneurysm. There is evidence that using ultrasound at the point of care increases patients feelings of being taken seriously and sense of satisfaction [19]. If Norman had suffered a rupture of his abdominal aneurysm, he would have missed out on the last few years of his life. I regard it in a similar light to measuring a patient’s blood pressure: If it’s normal, no problem, everyone is happy. If it’s too high, let’s get something done about it before it causes a problem. Inevitably, that will cause stress for those patients whose blood pressure is found to be high, but hopefully a crisis can be averted. 

The latest guidelines on the management of Abdominal Aortic Aneurysms, produced by the National Institute for Health and Care Excellence (NICE) in March 2020, can be found here.

It was fortunate that Norman felt the pulsation in his abdomen and mentioned it to me when I was compressing his abdomen during the X-Ray procedure. Now, when someone says to me’ thanks for referring me back to my GP with that aneurysm’, I think: ‘Don’t thank me, thank Norman’. 

Thanks Norman. RIP

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3.         Abdominal aortic aneurysm: diagnosis and management. 2020.

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8.         de Boer, N.J., S.F. Knaap, and A. de Zoete, Clinical detection of abdominal aortic aneurysm in a 74-year-old man in chiropractic practice. J Chiropr Med, 2010. 9(1): p. 38-41.

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16.       Broeren, M., M. Langenskiöld, and M.E. Pettersson, Psychosocial consequences after screening of abdominal aortic aneurysm among 65 year old men. J Vasc Nurs, 2023. 41(3): p. 95-102.

17.       Howard, D.P., et al., Population-Based Study of Incidence of Acute Abdominal Aortic Aneurysms With Projected Impact of Screening Strategy. J Am Heart Assoc, 2015. 4(8): p. e001926.

18.       Johansson, M., et al., Benefits and harms of screening men for abdominal aortic aneurysm in Sweden: a registry-based cohort study. Lancet, 2018. 391(10138): p. 2441-2447.

19.       Andersen, C.A., et al., Patients’ experiences of the use of point-of-care ultrasound in general practice – a cross-sectional study. BMC Fam Pract, 2021. 22(1): p. 116.