What is the treatment for upper back pain with radiation down the left arm using steroid treatment, such as prednisone (corticosteroid)?

Upper Back Pain with Radiation Down Left Arm: Steroid Treatment

Direct Recommendation

Do not use systemic corticosteroids (such as oral prednisone) for chronic upper back pain with radiation down the left arm, as there is no high-certainty evidence of meaningful benefit and these interventions are not recommended for chronic spine pain. 1

Critical First Step: Rule Out Red Flags

Before considering any treatment, immediately evaluate for serious underlying conditions that require urgent intervention:

• Spinal cord compression: Look for progressive weakness, sensory loss, or sphincter dysfunction—this is a medical emergency requiring immediate MRI and high-dose dexamethasone (16-96 mg/day) 1
• Metastatic disease: History of cancer (especially breast, lung, prostate) warrants urgent MRI of entire spine 1, 2
• Infection or inflammatory arthropathy: Fever, night sweats, unexplained weight loss, or known inflammatory conditions 1

If any red flags are present, obtain MRI immediately before considering steroids, as the treatment approach differs fundamentally 3, 2

Evidence Against Steroid Interventions for Chronic Spine Pain

The most recent and highest-quality evidence—a 2025 BMJ clinical practice guideline—provides strong recommendations against all steroid-based interventions for chronic spine pain (≥3 months duration):

• Epidural injections of steroids (with or without local anesthetic): Moderate-certainty evidence shows these probably have little to no effect on pain relief for both chronic axial and radicular spine pain 1
• Joint-targeted steroid injections: Similarly ineffective with moderate-certainty evidence 1
• Intramuscular steroid injections: Low-certainty evidence suggests no benefit 1

The guideline panel found no high-certainty evidence of important pain relief for any interventional procedure, including all steroid-based treatments 1

Systemic Oral Corticosteroids: Limited Role

For radicular pain specifically (pain radiating down the arm from nerve root irritation), systemic oral corticosteroids show only marginal benefit:

• Short-term pain improvement: Moderate-certainty evidence indicates corticosteroids probably provide a clinically insignificant 0.56-point reduction on a 0-10 pain scale 4
• Function: May slightly improve short-term function (19% absolute improvement in likelihood of functional improvement), but this is modest 4
• Duration: Effects are limited to short-term follow-up only 4

For non-radicular pain (axial upper back pain without clear nerve root involvement), systemic corticosteroids may actually be associated with slightly worse outcomes 4

Serious Harms to Consider

While a single dose or short course appears relatively safe, serious adverse events have been documented:

• Between 1997-2014, the FDA captured 90 serious adverse events from epidural corticosteroid injections, including death, spinal cord infarction, paraplegia, stroke, and seizures 1
• Oral corticosteroids carry risks of gastric irritation, HPA axis suppression (lasting 3 weeks), hyperglycemia, osteoporosis, psychiatric disturbances, and infection risk 5, 6
• High-dose dexamethasone (96 mg/day) used for spinal cord compression has 29% side effect rate with 14% serious complications including GI perforation 1

When Steroids ARE Indicated

Systemic corticosteroids have a clear role only in specific emergency situations:

Spinal Cord Compression (Emergency)

• Immediate dexamethasone 16 mg/day (moderate dose preferred over high-dose due to toxicity concerns) if clinical-radiological diagnosis of cord compression is confirmed 1
• Administer before radiographic confirmation if high clinical suspicion, then de-escalate if MRI negative 1
• Taper over 2 weeks 1

Acute Radiculopathy (Not Chronic)

• Patients with acute symptoms (not chronic ≥3 months) may have better response to epidural steroids compared to chronic symptoms 6
• However, even for acute radiculopathy, the 2025 BMJ guideline recommends against routine steroid interventions 1

Recommended Approach for Chronic Upper Back Pain with Radiation

Instead of steroids, the evidence supports:

1. Conservative management: Physical therapy, activity modification, and appropriate analgesia (non-opioid when possible) 1
2. Avoid routine imaging unless red flags present or symptoms persist beyond 6 weeks despite conservative treatment 3
3. Multidisciplinary assessment if symptoms are severe or persistent, but not interventional procedures 1

Common Pitfalls to Avoid

• Do not administer steroids for chronic spine pain based on older guidelines or practice patterns—the 2025 BMJ guideline represents the most comprehensive evidence synthesis to date 1
• Do not assume imaging findings correlate with symptoms—disc abnormalities are common in asymptomatic individuals 3
• Do not use high-dose dexamethasone (96 mg/day) outside of confirmed spinal cord compression due to significant toxicity 1
• Do not abruptly discontinue corticosteroids if already started—taper gradually to avoid withdrawal syndrome and adrenal insufficiency 5