From the Guidelines
Steroids are not recommended for radiculopathy due to their limited benefits and potential harms, as evidenced by a systematic review of 10 trials, including 6 good-quality and fair-quality trials, which found no significant differences between systemic corticosteroids and placebo in pain or function for radicular low back pain 1.
Key Points
- The largest good-quality trial found a small effect of systemic corticosteroids on function, but this was not consistent across all trials 1.
- Systemic corticosteroids were associated with an increased risk of adverse events, including insomnia, nervousness, and increased appetite 1.
- There is no evidence to support the use of systemic corticosteroids for chronic nonradicular pain or spinal stenosis 1.
Clinical Considerations
- The potential benefits of steroids for radiculopathy do not outweigh the risks, particularly given the lack of long-term benefits and potential for adverse events 1.
- Alternative treatments, such as physical therapy and pain management strategies, should be considered for comprehensive care 1.
- Epidural steroid injections may be considered for patients with persistent symptoms, as they deliver medication directly to the affected area 1.
From the Research
Steroids for Radiculopathy
- Epidural steroid injections (ESI) can be an effective treatment for radicular pain, providing potential for functional improvement 2.
- The use of epidural corticosteroid injections is increasing, with evidence showing immediate-term reduction in pain and function for radiculopathy, but effects are below predefined minimum clinically important difference thresholds and there are no longer-term benefits 3.
- Transforaminal epidural injections have strong evidence for managing lumbar nerve root pain, while caudal epidural injections have moderate evidence for managing lumbar radiculopathy 4.
- Epidural injections with or without steroids have shown significant effectiveness in managing lumbar radiculopathy or sciatica, with Level I or strong evidence for local anesthetic with steroids and Level II to I or moderate to strong evidence with local anesthetic alone 5.
Types of Injections
- There are 3 main interventional approaches for epidural steroid injections: interlaminar (IL), transforaminal (TF), and caudal, with the TF route having the most robust efficacy data 2.
- The selection of an injection approach should be based on a patient's clinical presentation, pathology, anatomy, consideration of the natural course of pain, and the unique risks and benefits of the particular technique 2.
Diagnosis and Treatment
- Lumbar radiculopathy requires a multimodal and multispecialty team approach for treatment, including physical therapy, occupational therapy, physical and rehabilitation medicine, and pain management 6.
- Diagnostic modalities such as magnetic resonance imaging (MRI), computerized tomography (CT), contrast myelogram, electromyogram (EMG), and nerve conduction velocity (NCV) are involved in the diagnosis and decision-making for lumbar radiculopathy 6.