Where is back pain typically located in a patient with an aortic (aorta) dissection?

Back Pain Location in Aortic Dissection

In aortic dissection, back pain is typically located in the interscapular region for Type B (distal) dissections, while Type A (proximal) dissections more commonly present with anterior chest pain, though they can also cause back pain.

Pain Characteristics by Dissection Type

• Type A dissections (involving the ascending aorta):

  • Most frequently present with chest pain (80%) 1
  • Chest pain is more commonly anterior (71%) than posterior (32%) 1
  • Back pain occurs in 47% of cases, typically as a result of antegrade dissection extending into the descending aorta 1
  • Abdominal pain occurs in 21% of cases 1

• Type B dissections (involving only the descending aorta):

  • Most frequently present with back pain (64%) 1
  • The back pain is typically located in the interscapular region 1
  • Chest pain (63%) and abdominal pain (43%) are also common 1

Pain Quality and Onset

• Pain of aortic dissection is typically:
  • Abrupt in onset (84% of cases) 1
  • Maximum intensity at the beginning, unlike myocardial infarction pain which builds gradually 1, 2
  • Severe in intensity (90% of cases) 1
  • More often described as sharp or stabbing (51-64%) rather than the classic "tearing" or "ripping" quality 1, 2
  • May have a migrating quality (12-55% of cases) as the dissection extends 1

Clinical Significance of Pain Location

• The location of pain can help predict the likelihood of aortic dissection being suspected:
  • When patients present with both chest and back pain, dissection is suspected in 86% of cases 1
  • When only chest pain is present, dissection is suspected in 45% of cases 1
  • When primarily abdominal pain is present, dissection is suspected in only 8% of cases 1

Important Clinical Considerations

• Pain may ease or abate over time, leading to false reassurance for both patients and clinicians 1

• Up to 6.4% of patients with acute aortic dissection present without pain, particularly:

  • Older patients 1
  • Patients on steroids 1
  • Patients with Marfan syndrome 1
  • These patients more commonly present with syncope, stroke, or congestive heart failure 1

• Other symptoms that may accompany back pain in aortic dissection:

  • Syncope (up to 20% of cases) 1, 2
  • Cardiac failure due to aortic regurgitation 1
  • Pulse deficits or limb ischemia due to vessel obstruction 1
  • Paraplegia if intercostal arteries are affected 1
  • Oliguria or anuria with renal artery involvement 1

Clinical Pitfalls to Avoid

• Don't dismiss the possibility of aortic dissection in patients with only back pain 1
• Be aware that pain may migrate as the dissection extends 1
• Remember that hypertension is typically associated with distal (Type B) aortic dissection 1
• Consider aortic dissection in any patient with sudden, severe back or chest pain, especially with a history of hypertension 1, 2
• Maintain high suspicion for aortic dissection in patients with risk factors (hypertension, Marfan syndrome, bicuspid aortic valve, etc.) even with atypical presentations 1