What is the role of oral steroids, such as prednisone, in the management of back pain?

Oral Steroids for Back Pain

Oral steroids are not recommended for non-radicular low back pain due to lack of evidence for benefit and potential for harm. 1, 2

Evidence on Oral Steroids for Different Types of Back Pain

Non-Radicular Low Back Pain

• Moderate-quality evidence shows that systemic corticosteroids provide no benefit for acute non-radicular low back pain 1
• The American College of Physicians guideline specifically states that evidence is insufficient to determine the effect of systemic corticosteroids for chronic low back pain 1
• A randomized controlled trial found no benefit from oral prednisone in emergency department patients with musculoskeletal low back pain 3

Radicular Low Back Pain (Sciatica)

• For radicular pain, moderate-quality evidence shows that systemic corticosteroids provide only a slight decrease in short-term pain (0.56 points better on a 0-10 scale) 4
• While oral prednisone may provide modest functional improvement in acute radiculopathy due to herniated disk, it shows no significant improvement in pain 5
• The American College of Physicians guideline states that moderate-quality evidence shows no differences in pain between systemic corticosteroids and placebo for radicular low back pain 1

Spinal Stenosis

• Limited evidence indicates that systemic corticosteroids are probably no more effective than placebo for short-term pain or function in spinal stenosis 4
• A trial of low-dose oral prednisolone (10mg daily for 1 week) was not effective for refractory lumbar spinal stenosis 6

Adverse Effects of Oral Steroids

• Moderate-quality evidence shows that short-term use of opioids increases risk of adverse events including:
  • Insomnia (26% vs. 10%)
  • Nervousness (18% vs. 8%)
  • Increased appetite (22% vs. 10%)
  • Potential hyperglycemia 2, 5
• In one study, having one or more adverse events was significantly more common in the prednisone group than placebo (49.2% vs. 23.9%) 5

Alternative Approaches for Back Pain

First-Line Treatments

• Maintain physical activity
• Apply local heat
• Consider physiotherapy
• NSAIDs/COXIBs at maximum tolerated dosage as first-line medications 2

For Radicular Pain

• If targeted treatment is needed, epidural steroid injections may be considered for short-term relief when other options fail 2, 7
• Gabapentin may be considered for neuropathic pain components of sciatica 2

Clinical Decision Making

1. Determine if back pain is non-radicular or radicular:

   • Non-radicular: Oral steroids should not be used
   • Radicular: Consider other options first (NSAIDs, physical therapy)

2. For persistent radicular pain:

   • Consider epidural steroid injections rather than oral steroids
   • If oral steroids are considered as a last resort, limit to short courses (≤15 days) with careful monitoring for adverse effects

3. For spinal stenosis:

   • Oral steroids are not effective and should be avoided

Key Pitfalls to Avoid

• Prescribing oral steroids for non-radicular back pain where evidence shows no benefit
• Using prolonged courses of oral steroids, which increase risk of adverse effects
• Relying on oral steroids instead of evidence-based first-line treatments like NSAIDs and physical therapy
• Failing to recognize that the modest functional improvements with oral steroids in radicular pain may not outweigh the risk of adverse effects

In conclusion, oral steroids should not be part of routine management for back pain, particularly non-radicular back pain, given their unfavorable risk-benefit profile and the availability of safer, more effective alternatives.