Systemic Corticosteroids for Back Pain
Systemic corticosteroids (oral, IV, or IM) should NOT be used for back pain, whether radicular or non-radicular, as they provide no clinically meaningful benefit and cause significant adverse effects including insomnia, nervousness, and increased appetite. 1
Evidence Against Use in Non-Radicular Back Pain
For acute non-radicular low back pain, systemic corticosteroids are completely ineffective. Two trials found no differences between a single intramuscular injection or a 5-day course of systemic corticosteroids and placebo in pain or function. 1
Multiple high-quality trials consistently demonstrate no benefit over placebo for pain relief or functional improvement in non-radicular back pain. 1, 2
A randomized controlled trial of 50 mg prednisone daily for 5 days versus placebo in ED patients with musculoskeletal low back pain found no difference in pain scores, return to work, or resuming normal activities—and actually found MORE patients in the prednisone group sought additional medical treatment (40% vs 18%). 3
Evidence Against Use in Radicular Pain (Sciatica)
For radicular low back pain, six trials consistently found no differences between systemic corticosteroids and placebo in pain relief. 1, 2
The largest good-quality trial (n=269) found oral prednisone (starting at 60 mg/day) showed only a small effect on function at 52 weeks (7.4-point difference on ODI), which is not clinically meaningful. 1
Three small, high-quality trials found systemic corticosteroids provided no clinically significant benefit for acute sciatica when given parenterally (single injection) or as a short oral taper. 1
Two trials found no effect of systemic corticosteroids on the likelihood of requiring spine surgery. 1
A 2022 Cochrane review confirmed that while systemic corticosteroids may provide a statistically significant but clinically trivial improvement in short-term pain (0.56 points on 0-10 scale), this effect is too small to matter in clinical practice. 4
Evidence Against Use in Spinal Stenosis
For spinal stenosis, a trial found no differences through 12 weeks between a 3-week course of prednisone and placebo in pain intensity or function. 1
Systemic corticosteroids are probably ineffective for spinal stenosis based on limited but consistent evidence. 4
Significant Harms
Oral prednisone (60 mg/day) increases risk for ANY adverse event from 24% to 49% (number needed to harm = 4). 1, 2
Specific adverse effects include:
Intramuscular dexamethasone increases risk for adverse effects 6-fold (RR 6.32). 1, 2
IV methylprednisolone (500 mg bolus) causes transient hyperglycemia and facial flushing. 1
The Only Exception: Malignant Spinal Cord Compression
High-dose dexamethasone (16-96 mg/day) should be given immediately for malignant spinal cord compression, as this is an oncologic emergency where benefits clearly outweigh risks. 5, 2
This is the ONLY indication where systemic corticosteroids are appropriate for spine-related pain. 2
What to Use Instead
For acute non-radicular back pain:
- NSAIDs (high-quality evidence of effectiveness) 2
- Skeletal muscle relaxants (high-quality evidence of effectiveness) 2
For chronic back pain:
- NSAIDs, duloxetine, or tramadol (moderate evidence of effectiveness) 2
- Non-pharmacologic options: exercise therapy, acupuncture, massage, spinal manipulation, yoga, cognitive-behavioral therapy 2
For radicular pain:
- Consider epidural steroid injections (NOT systemic steroids) for specific cases, particularly disc herniation rather than stenotic lesions 2, 6
Common Pitfall to Avoid
The most common error is prescribing oral prednisone tapers for "sciatica" or acute back pain based on outdated practice patterns. Despite widespread use in emergency departments and primary care, this practice is not evidence-based and exposes patients to harm without benefit. 1, 3