Abdominal aneurysm diagnosed by plain radiograph

A 75-year-old male with a history of hypertension and diabetes presented with severe, progressive low back pain over the past 6 months after a fall. His examination was significant for tenderness to his lower back bilaterally, no abdominal tenderness, and a normal neurovascular exam. His vital signs were stable with a blood pressure of 168/97. A radiograph of his lumbar spine was obtained showing no acute injury, but a large saccular aneurysm (Fig. 1). A computed tomography scan was obtained showing an 8-cm abdominal aortic aneurysm (Fig. 2).

Fig. 1

(a) Oblique view of lumbar radiograph showing a saccular aneurysm (white arrows). (b) Lateral view of lumbar radiograph showing a saccular aneurysm (black arrows)

Fig. 2

Computed tomography scan showing an 8-cm aneurysm (white arrow)

Diagnosing an abdominal aortic aneurysm (AAA) can be challenging and requires a heightened sense of awareness. Most patients are asymptomatic, but can present with abdominal pain, groin pain or back pain [1]. While aneurysms over 5 cm are palpable on examination, 76% of the time, physical examination is not reliable in ruling out AAA [2].

Bedside ultrasound and computed tomography have been shown to be very accurate in diagnosing AAA. Plain radiographs have limited usefulness in the diagnosis of a ruptured AAA, with characteristic findings of calcified aneurysm, loss of psoas or renal outline, or renal displacement [2]. Treatment is based on stability as well as anatomical considerations. Recent advances utilizing endovascular repair have been shown to be as effective as open repair, with decreased complications associated with endovascular repair [3].