What is the steroid of choice for acute radiculopathy?

Steroid Selection for Acute Radiculopathy

For acute radiculopathy, oral prednisone is the steroid of choice, typically administered at 50-60 mg daily for 5 days with a taper over the subsequent 5 days. 1, 2

Evidence for Systemic Corticosteroids

Oral Prednisone

• The most recent high-quality evidence supports oral prednisone for radicular pain:
  • A randomized, double-blind, placebo-controlled trial showed that oral prednisone (50 mg/day for 5 days with 5-day taper) significantly improved neck disability index scores and verbal rating scale scores compared to placebo in cervical radiculopathy 1
  • A large (n=269) good-quality trial demonstrated that a 15-day course of oral prednisone (60mg, 40mg, 20mg for 5 days each) resulted in improved function at both 3 weeks and 52 weeks compared to placebo for lumbar radiculopathy 2
  • Functional improvement was clinically meaningful with a 6.4-point greater improvement in Oswestry Disability Index at 3 weeks and 7.4-point greater improvement at 52 weeks 2

Dosing Recommendations

• For cervical radiculopathy: Prednisone 50 mg daily for 5 days with taper over the next 5 days 1
• For lumbar radiculopathy: Prednisone 60 mg daily for 5 days, 40 mg daily for 5 days, then 20 mg daily for 5 days (total dose 600 mg) 2

Limitations and Adverse Effects

• Despite functional improvements, systemic corticosteroids have shown inconsistent effects on pain relief in radiculopathy 3
• Common adverse effects include:
  • Increased risk of any adverse event (49% vs 24% with placebo) 3
  • Insomnia (26% vs 10%) 3
  • Nervousness (18% vs 8%) 3
  • Increased appetite (22% vs 10%) 3
  • Potential effects on blood glucose in diabetic patients 4

Alternative Administration Routes

Epidural Steroid Injections

• Epidural steroid injections may be considered when oral steroids fail or are contraindicated 5
• For epidural administration, dexamethasone is often preferred:
  • A single dose of 5-8 mg epidural dexamethasone can provide significant pain relief 4, 6
  • Ultrasound-guided caudal epidural steroid injections using dexamethasone have shown efficacy in emergency settings 6

Clinical Decision Algorithm

1. First-line: Oral prednisone for acute radiculopathy

   • Cervical: 50 mg daily × 5 days with 5-day taper
   • Lumbar: 60 mg × 5 days, 40 mg × 5 days, 20 mg × 5 days

2. If contraindications to oral steroids exist (severe diabetes, psychiatric disorders, active infection):

   • Consider epidural steroid injection with dexamethasone 5-8 mg

3. If inadequate response to oral steroids after 2-3 weeks:

   • Consider epidural steroid injection
   • Reassess for surgical indications if persistent severe symptoms

4. Monitor for:

   • Functional improvement (primary outcome measure)
   • Pain reduction (secondary outcome)
   • Adverse effects (insomnia, mood changes, hyperglycemia)

Important Caveats

• Benefits of steroids appear more pronounced for functional outcomes than for pain relief 3, 2
• Effects on preventing surgery are not well-established 3
• Short-term adverse effects are common but serious complications are rare 3
• Steroids should be used cautiously in patients with diabetes due to potential effects on blood glucose 4

Remember that while steroids can provide short-term improvement, their effects on long-term outcomes remain less clear, and they should be used as part of a comprehensive treatment approach that may include physical therapy and other non-opioid analgesics.