Abdominal Aortic Aneurysm and Spinal Manipulation, an Absolute Contraindication?: A Review of the Literature

Original Article

Abdominal Aortic Aneurysm and Spinal Manipulation, an Absolute Contraindication? A Review of the Literature

Adam Sergent, DC, CCSP1, Heather Bowyer DC, CCSP2

1Assistant Professor, Palmer College of Chiropractic Florida Clinical Affairs

2Associate Professor, Palmer College of Chiropractic Florida Clinical Affairs

Published: June 2017

Journal of the Academy of Chiropractic Orthopedists

June 2017, Volume 14, Issue 2

This is an Open Access article which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The article copyright belongs to the author and the Academy of Chiropractic Orthopedists and is available at: http://www.dcorthoacademy.com. © 2017 Sergent and the Academy of Chiropractic Orthopedists.

Objective: To perform a topic review of chiropractic adjustments performed on patients diagnosed with Abdominal Aortic Aneurysm.

Background: A need for this review was prompted when reviewing Medicare absolute contraindications to a significant Abdominal Aortic Aneurysm without defining what significant means.

Methods: Peer reviewed articles were accessed from PubMed from years 1986-2016, Index to Chiropractic Literature 1995-2016; and Medline Complete 2012-1986, using the search terms Chiropractic and Abdominal Aortic Aneurysm, A total of 10 articles with those search terms were returned.

Discussion: Minimal research is currently available discussing spinal manipulative therapy (SMT) in the presence of an abdominal aortic aneurysm (AAA). In the research that is available, no documented adverse reactions to care are present therefore raising the question of whether an AAA is in fact an absolute contraindication to SMT.

Conclusion: For patients diagnosed with abdominal aortic aneurysm, the current peer reviewed literature is insufficient to determine whether chiropractic adjustments in the lumbar spine are absolutely contraindicated. This diagnosis may not be an absolute contraindication to chiropractic adjustments in the region of the aneurysm, as long as special consideration is given.

Key Indexing Terms: Chiropractic and Abdominal Aortic Aneurysm; AA; Manipulation; Adjustment; Abdominal Aortic Aneurysm.


Introduction

Abdominal Aortic Aneurysm (AAA) is defined as a dilatation of the abdominal aorta measuring more than 5cm in diameter. A normal diameter is approximately 3.5cm.1,2.3 Aneurysms are classified into different groups. A saccular aneurysm is eccentric, localized and distended affecting only part of the arterial wall. A true aneurysm is comprised of all layers of the aorta, a partial aneurysm may only consist of one or two layers, and a dissecting aneurysm may hemorrhage into the layers and cause separation.4

AAA’s are more prevalent in men than women, smokers than non-smokers and within an age group of 60 to 80 years of age.3 Approximately 2-4 percent of the general population may have an undetected AAA but that number jumps to 5.9 percent in the 60-80-year-old population.3 This is especially important to the chiropractor who may not screen for AAA or image before the initiation of a general treatment plan to address low back pain that is thought to be mechanical in nature. AAA’s are missed completely or misdiagnosed in up to 30% of cases.5 Current evidence based practices and standard of care allows for 4-6 weeks of treatment before imaging is ordered.6 A PubMed search was performed and, though a number of studies were identified in which a patient had both a dissecting AAA and concomitant LBP, none were identified in which the AAA was determined to be the cause of LBP.

Patients presenting to the chiropractic office often have co-morbidities that must be considered when developing a treatment plan that is safe and effective for the patient. Abdominal aortic aneurysm is most often an incidental finding revealed upon imaging of a patient with low back pain.

Current CMS guidelines regard AAA as an absolute contraindication to a dynamic thrust in the event of “a significant major artery aneurysm near the proposed manipulation”; however, CMS does not define “significant” or “near” and no such definition is found in the literature.7 The American Association for Vascular Surgery and Society for Vascular Surgery guidelines have found an increased risk of spontaneous rupture associated with larger aneurysm size. For an aneurysm smaller than 5 cm, the risk is low compared to those larger than 5 cm. In fact, AAA less than 4 cm were found to have a rupture rate of 0% annually. Surgical repair should be considered at 5.5 cm or when an increase growth rate of >1cm per year is found.8 The purpose of this review is to identify, by a review of available literature, whether the data is sufficient to label AAA as an absolute contraindication to SMT. Further, does the size of an AAA and proximity to the manipulation play a significant role? To date, there are no case studies in which SMT has precipitated an AAA rupture or dissection.9,10

Methods

A literature search was performed using the terms “Chiropractic and Abdominal Aortic Aneurysm” using PubMed returning 9 articles, Index for Chiropractic Literature (ICL) returning 10 articles and Medline Complete returning 9 articles. The search terms “Adjustment and Abdominal Aortic Aneurysm” were limited; therefore, “Manipulation and Abdominal Aortic Aneurysm” was also searched in the same 3 data bases. The second set of searches yielded 276 articles; however, no further articles were found pertaining to chiropractic and abdominal aortic aneurysm. The term Abdominal Aortic Aneurysm was also searched, for information regarding epidemiology, pathophysiology, and diagnostic criteria. Exclusion criteria included when an article described the management of the AAA without being treated utilizing a chiropractic adjustment. In some cases, the AAA was discovered and referred out as management of the case. Inclusion criteria included articles that employed chiropractic adjustments as treatment in the lumbar spine regardless of if the AAA was known before the manipulation was rendered or if it was an incidental finding following a course of conservative chiropractic care. With the inclusion/exclusion criteria there were only 2 papers reviewed that met the inclusion criteria of a chiropractic adjustment in the region of the AAA. The remaining 8 papers discussed the management of the AAA once found based on imaging or physical exam, there are statements in these articles stating that it is not known if an AAA is an absolute contraindication for a chiropractic adjustment.

Discussion

It is apparent that within the search terms used and the articles reviewed in most cases the chiropractic adjustment did not cause any adverse effects related to the AAA In addition, chiropractors play an important role in identifying a potential AAA and referring patients for imaging and surgical consultation. The current literature available for this review is however limited and it is apparent more research and or retrospective studies are needed. The 2 case studies reviewed that met the inclusion criteria revealed that there were chiropractic adjustments for mechanical back pain in patients with undiagnosed AAA who experienced improvement or resolution of pain over the course of a few treatments without adverse event. In both cases an AAA was discovered after undergoing chiropractic adjustments and both patients underwent a successful surgical repair.

A case study by Hadida and Rajwani revealed a 74-year-old male who underwent 5 weeks of manual adjusting using Thompson Drop technique, trigger point therapy and side posture lumbar adjustment, with decreased back pain. Upon the 5th week the patient was put in a side posture adjustment and had immediate relief. During that visit, the patient complained of abdominal pain while lying supine. An abdominal exam was performed and a suspected AAA was found using deep palpation. The patient was referred out for ultrasound and a 5.3cm AAA was revealed. Surgery was performed 2 weeks later and abdominal pain resolved.10 The second case revealed a 25-year-old male with Marfan’s Syndrome undergoing 3 weeks of manual adjusting using a compressive manipulative therapy in the thoracic spine, with resolution of pain in a patient. One week later a routine exam was performed by his family physician and a dissecting aneurysm was revealed and immediate surgical correction was performed. In this case, the patient was found to have an old, healed dissection which correlated with a history of a physical altercation and crushing chest pain on separate occasions one year prior. It is believed that the dissection occurred during one of those reported incidents.11

Of these two articles that included an AAA and chiropractic adjustment, the chiropractic adjustment was not thought to precipitate the development of AAA or result in an aortic dissection. Of the remaining 10 articles that were reviewed 4 specifically state that AAA is not an absolute contradiction to chiropractic adjustment while the others do not comment. The chiropractic literature does not cite cases where spinal manipulative therapy (SMT) was a direct cause of a AAA dissection.12 There is no published evidence that HVLA SMT may cause rupture of an AAA. 9 It is not known if the forces utilized in a SMT are sufficient magnitude to cause rupture of an AAA as all forces among chiropractors are different.13 While more research is needed to determine if it is safe to apply a manipulation to the area with an AAA, it also must be determined the size that makes it safe or unsafe.

While AAA’s are missed in up to 30% of cases, the chiropractic physician should still consider screening for them in older populations.5 AAA’s are more prevalent in Caucasian men ages 60-80 with a history of smoking. This age group of 60-80 year olds are very likely to present in the chiropractor’s office with suspected mechanical low back pain. Knowing the patients age and history should lead the chiropractor to determine if a screening is needed and if an abdominal exam should be performed. Upon exam, there will be a palpable mass if present and abdominal bruits heard. Imaging may be considered as well if AAA is still suspected though not found on physical exam. Current guidelines by U.S Preventive Services Task Force (USPSTF) recommends screening asymptomatic adults over the age of 50 as prevalence can be as high as 7.2%.14 The most current recommendations state that abdominal duplex ultrasonography is the standard of care for AAA screening with a 94-100% specificity and a 98-100% specificity.14 With this being the gold standard it indicates that all suspected AAA should be referred out. Calcification of the AAA is only seen on approximately 50% of x-rays and that is one of the most reliable radiological signs seen by chiropractors.8 This suggests that even when a chiropractor suspects a AAA if they try and rule in or out such diagnosis by imaging they often have in their office up to 50% will still be missed.

With 2-4% of the population regardless of age having a AAA we must ask how many patients with non-symptomatic AAA’s presenting for low back pain or wellness care, are being adjusted as they do not meet the criteria of over 60 with a history of smoking and not necessarily being screened for a AAA. We must consider what the prevalence of finding AAA’s in the office before advanced imaging was readily available. How many people with an AAA that present for suspected mechanical low back pain complete their chiropractic care plan with full resolution of pain while having a AAA?

Conclusion

The current literature reviewed in this paper is sparse at best. More research is needed to determine if adjusting a region near a significant AAA is an absolute contraindication. It also must be determined what the CMS definition of a significant AAA is, and give measurements of what defines significant and near. With the percentages of missed diagnosis of an AAA anywhere from 30% on physical exam and 50% on x-ray imaging, physicians must be aware of differential diagnosis that fall into specific patient populations.

Limitations

With the lack of available peer reviewed articles with the search terms Abdominal Aortic Aneurysm and Chiropractic, one of the limitations is the depth of the paper in that there was a lack of articles to review.

Competing Interests

The author declares that he has no competing interests.

References

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