Dexamethasone Is Not Effective for Treating Back Pain
Systemic corticosteroids including dexamethasone are not recommended for treatment of back pain with or without sciatica, as they have not been shown to be more effective than placebo for pain relief.1
Evidence on Dexamethasone for Different Types of Back Pain
Acute Non-radicular Low Back Pain
- Multiple trials have consistently found no differences between systemic corticosteroids and placebo in pain or function for acute non-radicular low back pain 1
- Two good-quality trials (n=86 and n=67) found no differences between a single intramuscular injection or a 5-day course of systemic corticosteroids and placebo in pain or function 1
Chronic Non-radicular Low Back Pain
- No trials have specifically evaluated systemic corticosteroids for chronic non-radicular back pain 1
Radicular Low Back Pain (Sciatica)
- Six trials consistently found no differences between systemic corticosteroids and placebo in pain relief for radicular low back pain 1
- For function, the largest good-quality trial (n=269) found that systemic corticosteroids were associated with small effects (difference in Oswestry Disability Index at 52 weeks), but two other trials found no effects 1
- Two trials found no effects of systemic corticosteroids on the likelihood of spine surgery 1
Spinal Stenosis
- One trial (n=61) found no differences through 12 weeks of follow-up between a 3-week course of prednisone and placebo in pain intensity or function for spinal stenosis 1
Adverse Effects of Systemic Corticosteroids
- In the largest trial, oral prednisone (initial dose, 60 mg/d) increased risk for any adverse event (49% vs. 24%; P < 0.001) 1
- Specific adverse events included insomnia (26% vs. 10%), nervousness (18% vs. 8%), and increased appetite (22% vs. 10%) 1
- A smaller trial (n=39) found that intramuscular dexamethasone was associated with increased risk for adverse effects (32% vs. 5%) 1
Special Circumstances: Spinal Cord Compression
- Spinal cord compression is a medical emergency where dexamethasone does have a role 1
- High-dose dexamethasone should be given immediately when clinical-radiological diagnosis of spinal cord compression is obtained 1
- Doses typically range from moderate (16 mg/day) to high (36-96 mg/day), sometimes preceded by an intravenous bolus 1
- However, there appears to be no advantage of high-dose (100 mg IV) versus conventional dose (10 mg IV) dexamethasone for initial treatment of metastatic spinal cord compression 2
Alternative Treatments for Back Pain
- For acute low back pain: NSAIDs and skeletal muscle relaxants have shown evidence of effectiveness 1
- For chronic low back pain: NSAIDs, duloxetine, and tramadol have shown moderate evidence of effectiveness 1
- Non-pharmacologic options with proven benefits include:
Epidural Steroid Injections
- While systemic corticosteroids are not effective, epidural steroid injections may be considered for specific cases of radicular pain 1
- Some evidence suggests that epidural dexamethasone (4-8 mg) may be effective for lumbar radiculopathy, particularly for disc herniation rather than stenotic lesions 3, 4
- However, guidelines differ on recommendations for epidural injections:
Conclusion
For back pain management, systemic corticosteroids including dexamethasone should be avoided as they provide no significant benefit over placebo while carrying risks of adverse effects. The only exception is in cases of spinal cord compression, where dexamethasone is indicated as emergency treatment.