How would you prescribe steroids for a 17-year-old with persistent back pain and tingling sensation following a back injury, who has already received physical therapy (Physical Therapy)?

Steroid Management for a 17-Year-Old with Persistent Back Pain

Systemic corticosteroids are not recommended for this 17-year-old with persistent back pain, tingling, and numbness following a back injury. 1, 2

Assessment and Treatment Approach

First-Line Management

• NSAIDs are the recommended first-line pharmacological treatment for persistent back pain with radicular symptoms 1, 2
  • Oral NSAIDs should be used with consideration of cardiovascular, gastrointestinal, and renal risks 1
  • Topical NSAIDs with or without menthol gel can also be considered 2
  • Acetaminophen (up to 3000mg/day) is an alternative first-line option due to its safety profile 2

Local Steroid Injections vs. Systemic Steroids

• Local corticosteroid injections directed at the site of musculoskeletal inflammation may be considered 1

  • These should be performed under fluoroscopic guidance 1
  • Should only be considered after failure of conservative management 2

• Systemic glucocorticoids for axial back pain are not supported by evidence 1, 3

  • The 2011 ASAS/EULAR guidelines explicitly state: "The use of systemic glucocorticoids for axial disease is not supported by evidence" 1
  • A 2022 Cochrane review found that systemic corticosteroids may only slightly improve short-term pain and function in radicular back pain, with unclear benefits for non-radicular back pain 3

Non-Pharmacological Approaches

• Physical therapy with supervised exercises should be continued and optimized 1, 2

  • Home exercises are effective but supervised exercises (land or water-based) are more effective 1
  • For a 17-year-old, this is particularly important to avoid long-term medication dependence

• Consider other non-pharmacological approaches:

  • Mind-body approaches (mindfulness-based stress reduction, tai chi, yoga) 2
  • Massage therapy for short-term relief 2
  • Spinal manipulation if there's history of good response 2

Medication Considerations for Adolescents

Safety Concerns with Steroids in Adolescents

• Prednisone has significant risks that outweigh benefits in this case 4
  • Growth and development concerns in adolescents on prolonged corticosteroid therapy 4
  • Bone growth inhibition and risk of osteoporosis 4
  • Risk of adrenocortical suppression with longer use 4

Alternative Medication Options

• If neuropathic symptoms (tingling, numbness) persist:
  • Consider gabapentin or pregabalin as second-line medications 2
  • Muscle relaxants may be used for short periods (2-3 weeks) only 2
  • Avoid opioids as risks generally outweigh benefits 2

Red Flag Assessment

• Monitor for progression of neurological symptoms
  • Current presentation (tingling and numbness without bladder/bowel incontinence) doesn't warrant urgent intervention 2
  • Regular reassessment is necessary to detect any worsening 2
  • Consider MRI if symptoms worsen or new neurological symptoms develop 2

Follow-up Plan

• Regular reassessment of pain and function
• Adjustment of treatment plan based on response
• Consider specialist referral if pain persists beyond 4-6 weeks despite conservative treatment 1, 2
• Maintain tolerable physical activity and avoid prolonged bed rest 2

By following this evidence-based approach, focusing on NSAIDs, physical therapy, and non-pharmacological interventions, this 17-year-old patient can receive appropriate care while avoiding the significant risks associated with systemic corticosteroid use.