Do corticosteroids (steroids) help alleviate sciatica symptoms?

Steroids Have Minimal to No Benefit for Sciatica

Systemic corticosteroids are not recommended for sciatica as high-quality evidence shows they provide minimal to no benefit compared to placebo, while increasing risk for adverse events. 1

Evidence on Corticosteroid Use in Sciatica

Systemic Corticosteroids

• High-quality trials demonstrate that oral steroids (prednisone, methylprednisolone, intramuscular dexamethasone) provide no clinically significant benefit for radicular low back pain 1
• Systemic steroids increase risk of adverse events including:
  • Insomnia
  • Nervousness
  • Increased appetite
  • Transient hyperglycemia
  • Facial flushing 1

Epidural Steroid Injections

• Epidural corticosteroid injections may provide short-term improvement in leg pain and sensory deficits 1
• Recent meta-analysis (2020) found epidural steroid injections were probably more effective than placebo for:
  • Short-term leg pain reduction (MD -4.93 on 0-100 scale)
  • Short-term disability reduction (MD -4.18 on 0-100 scale) 2
• However, these benefits are small and short-term, with moderate-quality evidence 2
• The American Academy of Neurology notes these injections offer no significant functional benefit or reduction in surgery rates 1

Local Corticosteroid Injections

• Local glucocorticoid injections directed at specific sites of musculoskeletal inflammation may be considered 3
• For isolated active sacroiliitis, locally administered parenteral glucocorticoids are conditionally recommended over no treatment 3
• These local injections may be more effective than systemic administration 1

Treatment Algorithm for Sciatica

1. First-line approaches (recommended before considering steroids):

   • Non-pharmacological: maintaining physical activity, local heat, massage therapy 1
   • Pharmacological: NSAIDs/COXIBs at maximum tolerated dosage 1

2. For persistent symptoms:

   • Consider gabapentin for neuropathic pain components (limited evidence) 1
   • Consider epidural steroid injections only for short-term relief when other options fail 1, 2

3. For specific localized inflammation:

   • Local glucocorticoid injections may be considered for specific sites 3
   • Avoid injections around Achilles, patellar, and quadriceps tendons due to risk of tendon rupture 3

Important Caveats

• The benefits of epidural steroid injections are modest and temporary, with effects diminishing over time 2, 4
• One study found that while 65% of patients had sustained improvement at 6 months after epidural steroid injection, 35% lost benefit within that timeframe 5
• Systemic steroids should generally be avoided for sciatica due to unfavorable risk-benefit profile 1
• Short courses of oral prednisone with rapid tapering might only be considered in very limited circumstances as a bridging option 3, 1

When treating sciatica, focus on first-line non-pharmacological approaches and NSAIDs rather than systemic steroids, with epidural or local injections reserved for specific circumstances where benefits may outweigh risks.