What is the role of corticosteroids (steroids) in managing severe radiculopathy-related pain?

From the Guidelines

Oral corticosteroids are not recommended for severe radiculopathy pain due to lack of evidence showing significant benefits over placebo, as seen in a systematic review of 10 trials evaluating systemic corticosteroids 1. The use of systemic corticosteroids for radiculopathy has been studied in several trials, with most showing no significant difference in pain or function compared to placebo.

• A typical regimen of prednisone starting at 60mg daily for 5 days, then tapering by 10mg every 5 days for a total duration of 15-20 days, may be considered in some cases, but the evidence supporting its use is limited.
• Common side effects of steroids include insomnia, increased appetite, mood changes, and elevated blood glucose, which are generally temporary with short courses.
• Before starting steroids, patients should be screened for contraindications including uncontrolled diabetes, active infection, or peptic ulcer disease.
• Steroids should be taken with food to minimize gastrointestinal irritation.
• Other treatments such as physical therapy and activity modification should be used alongside steroids, if prescribed.
• If pain persists beyond 4-6 weeks or neurological deficits worsen, further evaluation with imaging and specialist consultation is warranted. The largest good-quality trial found that systemic corticosteroids were associated with small effects on function, but two other trials found no effects 1. In addition, the use of systemic corticosteroids has been associated with increased risk for adverse events, including insomnia, nervousness, and increased appetite 1. Therefore, the use of oral corticosteroids for severe radiculopathy pain should be approached with caution and considered on a case-by-case basis.

From the Research

Steroids for Severe Radiculopathy Pain

• The use of steroids for severe radiculopathy pain has been studied in several clinical trials 2, 3, 4.
• A randomized, double-blinded, placebo-controlled trial found that oral prednisolone significantly decreased neck disability index (NDI) and verbal rating scale (VRS) scores in patients with cervical radiculopathy 2.
• Another study found that oral prednisone improved function and pain in patients with acute radiculopathy due to a herniated lumbar disk, but the improvement in pain was modest 3.
• A systematic review and meta-analysis found that systemic corticosteroids probably slightly decrease pain and improve function in people with radicular low back pain not due to spinal stenosis 4.

Comparison of Steroids and Other Treatments

• A study compared the effectiveness of pregabalin and gabapentin in patients with lumbar radiculopathy and found that pregabalin was more effective in reducing pain at short-term follow-up 5.
• Another study found that both pregabalin and gabapentin can be equally used to reduce pain in lumbar radiculopathy patients who underwent transforaminal epidural steroid injection 6.

Safety and Efficacy of Steroids

• The safety and efficacy of steroids for severe radiculopathy pain have been evaluated in several studies 2, 3, 4.
• A study found that oral prednisone was associated with a higher incidence of adverse events, but the difference was not significant 3.
• A systematic review and meta-analysis found that systemic corticosteroids are not associated with increased risk of any adverse event, serious adverse events, withdrawal due to adverse events, or hyperglycemia 4.