Are steroids effective for emergency acute back pain treatment?

Steroids Are Not Effective for Emergency Acute Back Pain

Systemic corticosteroids are not recommended for emergency acute back pain treatment as they have not been shown to be more effective than placebo for pain relief. 1, 2

Evidence Against Steroid Use in Acute Back Pain

• Multiple high-quality trials have consistently found no differences between systemic corticosteroids and placebo in pain or function for acute non-radicular low back pain 2
• A randomized controlled trial specifically examining prednisone (50mg daily for 5 days) in emergency department patients with acute low back pain found no benefit compared to placebo 3
• The American College of Physicians explicitly recommends against the use of systemic corticosteroids for low back pain with or without sciatica 1, 2
• Oral prednisone increases the risk for adverse events, including insomnia, nervousness, and increased appetite, with a number needed to harm of 4 2

Recommended First-Line Treatments for Acute Back Pain

• For acute low back pain, the American College of Physicians strongly recommends nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence) 1
• If pharmacologic treatment is desired, NSAIDs or skeletal muscle relaxants are recommended as first-line options (moderate-quality evidence) 1
• Topical NSAIDs with or without menthol gel are effective first-line therapy for acute musculoskeletal pain 1
• Skeletal muscle relaxants provide effective short-term pain relief for acute low back pain but can cause sedation 1, 4

Second-Line Options

• Acetaminophen was previously recommended but newer evidence suggests it is ineffective for acute low back pain 1
• For mixed pain syndromes, combining NSAIDs with muscle relaxants can provide enhanced pain relief, but increases the risk of central nervous system adverse events 4
• For radicular pain (sciatica), gabapentin may be particularly effective for the neuropathic component 4

Special Considerations

• For patients with radicular pain, six trials consistently found no differences between systemic corticosteroids and placebo in pain relief 2
• Local epidural steroid injections may provide short-term benefit in specific cases of radicular pain, but this is different from systemic steroid administration 5, 6
• Systemic steroid administration for low back pain should be "definitively banned" due to lack of supporting evidence and potential for harm 6

Treatment Algorithm for Acute Back Pain

1. Start with nonpharmacologic approaches: superficial heat, massage, acupuncture, or spinal manipulation 1
2. If additional pain relief is needed, add topical NSAIDs with or without menthol gel 1
3. For moderate to severe pain, add oral NSAIDs or skeletal muscle relaxants 1
4. For radicular symptoms, consider gabapentin for the neuropathic component 4
5. Avoid systemic corticosteroids as they provide no benefit and increase risk of adverse effects 1, 2, 3

In conclusion, despite the common practice of prescribing steroids for emergency acute back pain, the evidence clearly demonstrates they are ineffective while carrying significant risks of adverse effects. Clinicians should instead focus on proven treatments including nonpharmacologic approaches, NSAIDs, and skeletal muscle relaxants.