What is the role of steroids, such as prednisone, in treating nerve compression and radicular pain?

Steroids for Nerve Compression and Radicular Pain

Systemic oral steroids should NOT be routinely used for radicular pain, as they provide only modest functional improvement without meaningful pain reduction and increase adverse events; epidural steroid injections may be considered for carefully selected patients with true radiculopathy and imaging-confirmed nerve root compression, but only after conservative treatment failure and as part of multimodal care. 1

Systemic (Oral) Corticosteroids

Evidence Against Routine Use

For radicular low back pain, systemic corticosteroids consistently show no clinically meaningful benefit on pain outcomes. 1

• Six trials consistently found no differences between systemic corticosteroids and placebo in pain relief for radicular low back pain of varying duration 1
• The largest good-quality trial (n=269) of oral prednisone (starting at 60 mg/day, tapering over 15 days) showed only a modest 6.4-point improvement in disability scores at 3 weeks and 7.4 points at 52 weeks, with no improvement in pain scores (0.3-point difference at 3 weeks, 0.6 points at 52 weeks—both not statistically significant) 1, 2
• Oral prednisone significantly increased adverse events (49% vs 24%; P<0.001), including insomnia (26% vs 10%), nervousness (18% vs 8%), and increased appetite (22% vs 10%) 1, 2

Limited Exception: Cancer-Related Nerve Compression

• Steroids should be considered specifically for nerve compression in the context of cancer pain, where they may reduce tumor-related edema and inflammation 1
• This recommendation does not extend to non-cancer chronic spine pain 1

Epidural Steroid Injections

Strong Recommendations AGAINST for Most Patients

The 2025 BMJ guideline issues strong recommendations against epidural injections for both chronic axial and radicular spine pain. 1

• For chronic axial spine pain (≥3 months): strong recommendation against epidural injection of local anesthetic, steroids, or their combination 1
• For chronic radicular spine pain (≥3 months): strong recommendation against epidural injection of local anesthetic, steroids, or their combination 1

When Epidural Injections May Be Considered (Older Guidelines)

Despite the 2025 BMJ strong recommendation against, some older guidelines and clinical practice still support selective use. If considering epidural steroid injections, all of the following criteria must be met:

Mandatory Patient Selection Criteria

• True radiculopathy with pain radiating below the knee (for lumbar) or into the arm with dermatomal distribution (for cervical)—not just axial back or neck pain 3, 4, 5
• MRI-confirmed pathology showing nerve root compression, moderate-to-severe disc herniation, or foraminal stenosis that correlates anatomically with clinical symptoms 3, 4, 6
• Failed conservative treatment for at least 4-6 weeks, including physical therapy, NSAIDs, and neuropathic pain medications 1, 3
• Pain duration exceeding 4 weeks but ideally within 3 months of symptom onset for acute radiculopathy 3, 7

Procedural Requirements

• Fluoroscopic guidance is mandatory for all epidural injections to ensure proper needle placement and minimize complications 1, 3, 4
• Must be performed as part of a comprehensive multimodal pain management program including physical therapy, patient education, and appropriate oral medications 3, 4
• Shared decision-making must include discussion of potential complications: dural puncture, infection, cauda equina syndrome, sensorimotor deficits, discitis, epidural granuloma, and retinal complications 3, 4, 5

Predictors of Success

• Low-grade nerve root compression on MRI predicts better outcomes (75% success rate vs 26% with high-grade compression), suggesting inflammatory rather than mechanical etiology responds better 6
• Previous response to epidural injection (≥50% pain relief for ≥2 weeks) is required before considering repeat injection 3

Critical Pitfalls to Avoid

• Never perform epidural injections for non-radicular (axial) back pain—this is explicitly not indicated and exposes patients to unnecessary risks 1, 5
• Do not repeat injections without documented prior benefit (≥50% relief for ≥2 months)—this represents inappropriate use 3
• Do not bypass conservative treatment—at least 4-6 weeks of physical therapy and medications must be attempted first 1, 3
• Do not perform "blind" injections—fluoroscopic guidance is the standard of care 1, 3, 4
• Do not ignore alternative pain generators—evaluate for sacroiliac joint dysfunction or facet-mediated pain if examination suggests these 3

Clinical Algorithm

Step 1: Confirm True Radiculopathy

• Dermatomal pain distribution (below knee for lumbar, into arm for cervical)
• Positive neurological signs (sensory changes, motor weakness, reflex changes)
• Positive provocative tests (straight leg raise for lumbar, Spurling's for cervical)

Step 2: Obtain Appropriate Imaging

• MRI showing nerve root compression that anatomically correlates with clinical symptoms
• Imaging should be interpreted by clinicians skilled in correlating findings with clinical presentation 1

Step 3: Implement Conservative Treatment (4-6 weeks minimum)

• Physical therapy
• NSAIDs or acetaminophen
• Neuropathic pain medications (gabapentin, pregabalin, duloxetine)
• Patient education and activity modification

Step 4: Reassess

• If significant improvement: continue conservative care
• If persistent severe radicular pain with confirmed nerve compression: consider epidural injection (recognizing 2025 guidelines recommend against this) OR surgical consultation
• If no radicular features: do NOT proceed with epidural injection

Step 5: If Proceeding with Epidural Injection

• Ensure fluoroscopic guidance
• Complete shared decision-making regarding risks
• Integrate into comprehensive multimodal program
• Document baseline pain and function scores
• Plan for reassessment at 2 weeks, 3 months

Quality of Life Considerations

The modest functional improvements seen with oral steroids (6-7 points on 100-point disability scale) must be weighed against significant adverse effects that directly impact quality of life: insomnia, nervousness, and increased appetite 1, 2. For epidural injections, the 2025 guideline's strong recommendation against their use reflects accumulating evidence that benefits do not justify procedural risks for most patients 1. When severe radicular pain significantly impairs function and quality of life despite conservative treatment, and imaging confirms appropriate pathology, epidural injection may be considered as a temporizing measure, but patients should understand this represents an area of evolving and conflicting evidence 1, 3, 4.