Is there a role for steroids in treating compressive neuropathy of the common peroneal nerve?

Role of Steroids in Compressive Neuropathy of the Common Peroneal Nerve

Steroids are recommended as a treatment option for compressive neuropathy of the common peroneal nerve, particularly when nerve compression is causing significant symptoms. 1

Rationale for Steroid Use

• Steroids can reduce inflammation and edema around the compressed nerve, potentially improving symptoms in cases of compressive neuropathy 1
• In cases of nerve compression, steroids should be considered as part of the treatment approach, especially when inflammation is contributing to the symptoms 1
• Perineural steroids may provide analgesic efficacy for one to three months in patients with chronic peripheral neuropathic pain of compressive origin 2

Dosing and Administration

• For moderate symptoms with some interference with activities of daily living, oral prednisolone at 0.5-1 mg/kg may be initiated 1
• For severe symptoms that limit self-care or are life-threatening, intravenous (methyl)prednisolone at 2 mg/kg is recommended 1
• When converting from IV to oral steroids, this should be done once improvement is noted, with a suggested oral prednisolone taper over 4-8 weeks 1, 3
• Consider Pneumocystis jirovecii pneumonia prophylaxis and vitamin D supplementation if steroid treatment exceeds 4 weeks 1, 3

Clinical Evidence

• Meta-analysis data shows that perineural steroid injections resulted in lower pain scores compared to local anesthetics or conventional medical management at 1-3 months post-intervention (mean difference: -1.31 points on a 0-10 numerical rating scale) 2
• No significant adverse effects were reported in studies evaluating perineural steroids for compression neuropathies 2

Alternative and Adjunctive Treatments

• First-line treatments should include removing external compression, providing stability to unstable joints, and reducing inflammation 4
• Many peroneal nerve entrapments will resolve with observation and activity modification, but surgical treatment is often required when entrapment is refractory to conservative management 4
• Surgical decompression of the common peroneal nerve should be considered if symptoms persist despite conservative treatment, particularly within 12 months of symptom onset for better outcomes 5, 6
• Physical therapy, occupational therapy, and orthotic devices (e.g., for foot drop) should be considered as part of the comprehensive management approach 1

Monitoring and Precautions

• Regular monitoring for steroid-related side effects is essential, including gastrointestinal symptoms, psychic disorders, hyperglycemia, and insomnia 3
• Be cautious in patients with comorbidities such as diabetes, hypertension, glaucoma, tuberculosis, or peptic ulcer disease 3
• Clinical improvement in motor function after surgical decompression was noted in most patients who presented with motor deficit, with better outcomes associated with shorter time to surgery 6

Special Considerations

• Accurate diagnosis is crucial and should include physical examination, electrophysiological testing, and magnetic resonance imaging where indicated 5, 7
• The combination of MRI and ultrasonography is useful for accurate diagnosis, particularly to rule out other causes such as ganglion cysts 7
• The most common presentation of common peroneal neuropathy is weakness of the tibialis anterior and extensor hallucis longus muscles, and decreased sensation in the distribution of the common peroneal nerve 6