What is the treatment for a 93-year-old female with bilateral sacral alar insufficiency fractures, multilevel thoracolumbar compression fractures, severe degenerative changes of the lumbar spine, and multilevel foraminal and canal stenosis?

Treatment for 93-Year-Old Female with Bilateral Sacral Insufficiency Fractures and Multilevel Spinal Pathology

Conservative medical management is the primary treatment approach for this 93-year-old patient with sacral insufficiency fractures and chronic spinal pathology, focusing on pain control, osteoporosis treatment, and mobilization strategies. 1

Initial Management Strategy

Pain Control and Medical Management

• Initiate analgesic therapy with acetaminophen and NSAIDs if not contraindicated by renal function or gastrointestinal risk 1
• Consider short-term opioid therapy for severe pain during the acute healing phase 1
• The sacral insufficiency fractures are subacute and incompletely healed, requiring 2-3 months for conservative healing 1

Osteoporosis Treatment

• Start bisphosphonate therapy immediately (if not already on treatment) to reduce future fracture risk and aid in pain palliation 1
• Ensure adequate calcium (1200-1500 mg daily) and vitamin D (800-1000 IU daily) supplementation 1
• Perform laboratory evaluation including serum calcium, albumin, creatinine, thyroid function, and vitamin D levels to identify secondary causes of osteoporosis 1
• DXA scanning is not mandatory in this elderly patient with multiple fragility fractures, as treatment is indicated regardless of bone density results 1

Mobilization and Rehabilitation

Early Mobilization Approach

• Avoid prolonged bed rest as immobility increases fracture risk and functional decline in elderly patients 1
• Implement supervised physical therapy focusing on:
  • Gentle weight-bearing as tolerated
  • Core stabilization exercises
  • Balance training to prevent falls 1
• Consider temporary use of assistive devices (walker or cane) for stability during ambulation 1

Bracing Considerations

• Extension bracing may provide symptomatic relief but should not restrict mobilization 2
• In a 93-year-old, compliance with bracing may be limited; prioritize pain control and gentle mobilization over rigid immobilization 2

Addressing Spinal Stenosis

Conservative Management for Stenosis

• The multilevel stenosis and foraminal narrowing are chronic findings and should be managed conservatively unless new neurologic deficits develop 3, 4
• Delordosing physiotherapy (flexion-based exercises) can help relieve stenotic symptoms 3
• Epidural steroid injections may be considered if radicular symptoms are prominent and limiting function 3

When to Consider Intervention

• Surgical intervention is NOT recommended for this 93-year-old patient with chronic, stable spinal pathology unless:
  • Acute cauda equina syndrome develops (absolute indication) 3
  • Progressive motor deficits occur 1, 3
  • Severe neurogenic claudication prevents all mobilization after 3-6 months of conservative treatment 3

Monitoring and Follow-Up

Clinical Surveillance

• Reassess at 6-8 weeks to evaluate fracture healing and pain improvement 1
• Monitor for new compression fractures, which occur frequently in patients with existing vertebral fractures 5
• Watch specifically for new sacral pain, buttock pain, lateral hip pain, or groin pain radiating to the thigh—these indicate potential new or progressive sacral insufficiency fractures 5

Imaging Considerations

• Repeat imaging is not routinely needed unless symptoms worsen or new neurologic deficits develop 1
• If new sacral symptoms develop, obtain MRI of the pelvis/sacrum, as standard lumbosacral imaging often misses sacral fractures 5

Interventional Options (Reserved for Specific Indications)

Sacroplasty

• Consider sacroplasty only if severe, intractable sacral pain persists beyond 2-3 months of conservative management and significantly impairs mobilization 1, 5
• This minimally invasive procedure can provide rapid pain relief in elderly patients unable to mobilize due to sacral pain 2, 5
• The subacute nature of these fractures makes them potentially amenable to augmentation if conservative measures fail 1

Vertebral Augmentation for Compression Fractures

• The multilevel thoracolumbar compression fractures are described as chronic and healed, so vertebroplasty/kyphoplasty is not indicated 1
• Vertebral augmentation would only be appropriate for new acute compression fractures with edema on MRI and refractory pain 1

Critical Pitfalls to Avoid

• Do not pursue surgical decompression/fusion for the chronic stenosis in this 93-year-old with multiple comorbidities—the surgical morbidity and mortality risk far outweighs potential benefit 1, 3
• Do not overlook the sacral fractures as the primary pain generator; physicians commonly attribute all symptoms to lumbar pathology and miss sacral insufficiency fractures 5
• Do not delay osteoporosis treatment; the highest risk for subsequent fractures is immediately after an initial fragility fracture 1
• Avoid prolonged immobilization, which paradoxically increases fracture risk and functional decline in elderly patients 1