What is the role of corticosteroids (steroids) in managing lumbar (low back) pain?

From the Guidelines

Steroids are not recommended as a first-line treatment for low back pain, and their use should be carefully considered due to potential side effects and limited benefits for non-specific low back pain. For acute low back pain, conservative measures like staying active, applying heat, and using over-the-counter pain relievers such as acetaminophen or NSAIDs (like ibuprofen or naproxen) are typically more appropriate initial treatments.

• In specific cases where there is significant inflammation or nerve root compression causing radicular pain (sciatica), a short course of oral steroids like prednisone may be considered, typically starting at 20-40mg daily and tapering over 5-7 days.
• Alternatively, epidural steroid injections containing medications like methylprednisolone (40-80mg), triamcinolone (40-80mg), or dexamethasone (4-10mg) might be used for persistent radicular symptoms, as suggested by the 2022 American Society of Pain and Neuroscience (ASPN) Evidence-Based Clinical Guideline of Interventional Treatments for Low Back Pain 1. However, steroids carry significant side effects including elevated blood sugar, mood changes, sleep disturbances, increased infection risk, and potential bone density loss with long-term use, as noted in a systematic review for an American College of Physicians clinical practice guideline 1.
• Their benefit for non-specific low back pain is limited, and they should only be used after careful consideration of risks versus benefits and typically only for short durations in specific clinical scenarios where inflammation is a key component of the pain mechanism. It is also important to consider the findings of a 2007 joint clinical practice guideline from the American College of Physicians and the American Pain Society, which states that systemic corticosteroids are not recommended for treatment of low back pain with or without sciatica, because they have not been shown to be more effective than placebo 1.
• Additionally, a 2017 systematic review for an American College of Physicians clinical practice guideline found that systemic corticosteroids do not seem to be effective for low back pain, and their use is associated with increased risk for adverse events 1.

From the Research

Steroids for Low Back Pain

• The use of systemic corticosteroids for low back pain has been studied, with moderate-certainty evidence indicating that they probably slightly decrease pain versus placebo at short-term follow-up 2.
• Systemic corticosteroids may also slightly increase the likelihood of experiencing improvement in pain at short-term follow-up, and may improve function at short-term and long-term follow-up 2.
• However, the effects of systemic corticosteroids in people with non-radicular low back pain are unclear, and they are probably ineffective for spinal stenosis 2.
• A single dose or short course of systemic corticosteroids for low back pain does not appear to cause serious harms, but evidence is limited 2.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) for Low Back Pain

• NSAIDs are often used in the treatment of low back pain, and have been shown to be slightly more effective than placebo for short-term pain reduction and disability 3.
• The magnitude of the effects of NSAIDs is small and probably not clinically relevant, but they may be beneficial for short-term global improvement 3.
• There is no clear difference in short-term pain reduction when comparing selective COX-2 inhibitors to non-selective NSAIDs, and no clear difference in the proportion of participants experiencing adverse events 3.
• NSAIDs are effective for short-term symptomatic relief in patients with acute and chronic low back pain without sciatica, but effect sizes are small 4.

Management of Low Back Pain

• The management of low back pain includes identification of red flags, exclusion of specific secondary causes, and comprehensive musculoskeletal/neurological examination of the lower extremities 5.
• Reassurance that low back pain will likely resolve and advice to maintain an active lifestyle despite low back pain are the cornerstones of management 5.
• Medications, including NSAIDs and muscle relaxants, are provided not because they change the natural history of the disorder, but rather because they enhance the ability of the patient to become more active, and in some cases, to sleep better 5.
• Nonpharmacologic treatment, such as counseling, exercise therapy, and physical therapy, is first-line management for chronic low back pain, while pharmacologic interventions are second-line treatment 6.