Complications of Chronic Glucocorticoid Therapy – Vertebral Fractures and Surgical Ineligibility: A Case Report

Case Diagnosis: A 65-year-old female with acute lower back pain.

Case Description or Program Description: This patient presented to the emergency department with a one-day history of a severe (8/10), constant, dull ache in her lower back that worsened with movement. Additional symptoms included nausea and vomiting associated with pain. She reported no associated trauma but has a history of multiple vertebral fractures. The patient denied saddle anesthesia, radiculopathy, and incontinence of bowel or bladder.

Past medical history includes Addison’s disease, managed with high-dose prednisone therapy (70 mg daily) for >20 years, insulin-dependent type 2 diabetes mellitus, obesity, and osteoporosis with prior kyphoplasties for compression fractures.

Imaging revealed an acute T4 compression fracture and a subacute L3 endplate fracture, consistent with osteoporosis-related insufficiency fractures. Imaging also revealed early fistulization of the sigmoid colon to the neobladder, a previously undiagnosed complication.

Setting: Tertiary care academic health center

Assessment/Results: Neurosurgery and interventional radiology (IR) evaluated the patient for possible surgical intervention of her acute fracture. However, the patient was deemed to be a poor surgical candidate. The extensive compromise of her bone health, combined with obesity-related immobility, imposed significant perioperative risk. Similarly, her developing colovesical fistula was determined to best managed non-operatively, given her surgical risk factors and history of poor wound healing. The patient was managed conservatively, with an emphasis on pain control and supportive care.

Discussion (relevance): This case highlights the severe complications of prolonged high-dose corticosteroid therapy, which contributed to immobility and progressive osteoporosis with recurrent fractures.

Conclusions: Long-term use of corticosteroids can have profound musculoskeletal complications, limiting treatment options when new pathology arises. In patients requiring chronic steroid therapy, early bone health education should be emphasized, and alternative treatment approaches should be considered to prevent irreversible complications that preclude surgical management.