Can pulmonary embolism (PE) cause back pain?

From the Guidelines

Pulmonary embolism (PE) can indeed cause back pain, particularly pleuritic back pain, as noted in the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Cancer-Associated Venous Thromboembolic Disease, Version 2.2024 1. The presentation of PE can vary, but common symptoms include unexplained shortness of breath, chest pain, tachycardia, apprehension or tachypnea, syncope, and hypoxemia 1. Back pain associated with PE may be due to a large embolism causing strain on the right side of the heart or irritation of the pleura near the spine 1. Key points to consider in the diagnosis of PE include:

• The most common presenting symptoms of PE are dyspnea, pain, and tachypnea, which were present in 85%, 40%, and 29% of patients with PE, respectively 1.
• The preferred imaging technique for the initial diagnosis of PE is CT angiography (CTA), which allows for accurate imaging of mediastinal and parenchymal structures and indirect evaluation of pulmonary vessels 1.
• Alternative imaging modalities used for the diagnosis of PE include X-ray pulmonary angiography with contrast, MR angiography with contrast, and ventilation-perfusion (VQ) scan if CTA is contraindicated 1. It is crucial to recognize that back pain alone is rarely the only symptom of PE, and if you experience unexplained back pain along with breathing difficulties, chest discomfort, or other concerning symptoms, seeking immediate medical attention is essential 1. The treatment of PE typically involves anticoagulant medications, such as heparin initially, followed by oral anticoagulants like warfarin, apixaban, rivaroxaban, or dabigatran for at least 3-6 months 1.

From the Research

Pulmonary Embolism and Back Pain

• Pulmonary embolism (PE) can present with atypical symptoms, including back pain, as reported in a case study published in Cureus 2.
• The study highlights the importance of considering PE in the differential diagnosis of patients with back pain, especially in those with a history of recent surgery or other risk factors.
• Another study published in Archives of physical medicine and rehabilitation found that bed rest for low back pain can increase the risk of deep venous thrombosis and pulmonary embolism 3.

Atypical Presentations of Pulmonary Embolism

• PE can present with a range of symptoms, including chest pain, hemoptysis, syncope, and shock, as well as more atypical symptoms such as flank pain 4 and itinerant chest pain with migratory pleural effusion 5.
• These atypical presentations can make diagnosis challenging, and clinicians should consider PE in the differential diagnosis of patients with unexplained symptoms.
• The use of computed tomography pulmonary angiography (CTPA) can help diagnose PE in patients with unexplained symptoms, as reported in a case series published in The Journal of emergency medicine 4.

Diagnosis and Treatment of Pulmonary Embolism

• Early diagnosis and treatment of PE are critical to reducing morbidity and mortality, as reported in a study published in Cureus 2.
• Anticoagulation is the first-line treatment for PE, but in some cases, inferior vena caval filters (VCFs) may be used to prevent further emboli, as discussed in a review published in The Cochrane database of systematic reviews 6.
• However, the effectiveness and safety of VCFs are still unclear, and further studies are needed to assess their role in the prevention of PE.