Oral Corticosteroids Should Not Be Used for Symptomatic Herniated Disc
Neither prednisone nor methylprednisolone dose packs should be prescribed for symptomatic herniated disc with radiculopathy, as multiple high-quality trials consistently demonstrate no benefit for pain relief or functional improvement while significantly increasing adverse events. 1
Evidence Against Oral Steroids for Lumbar Radiculopathy
The American College of Physicians analyzed six trials that consistently found no differences between systemic corticosteroids and placebo in pain relief for radicular low back pain. 1 The largest high-quality trial (n=269) showed only small functional effects, while two other trials found no functional benefits whatsoever. 1 Critically, two trials demonstrated no effect on the likelihood of requiring spine surgery, meaning oral steroids do not prevent progression to surgical intervention. 1
Significant Harm Profile
The adverse event profile is substantial and clinically meaningful:
- Any adverse event occurred in 49% of patients versus 24% with placebo (P < 0.001) in the largest trial using oral prednisone 60 mg/day 1
- Insomnia affected 26% versus 10% (P = 0.003) 1
- Nervousness occurred in 18% versus 8% (P = 0.03) 1
- Increased appetite affected 22% versus 10% (P = 0.02) 1
Critical Distinction: Methylprednisolone Dose Pack is Inadequate Even Where Steroids Work
The commonly prescribed methylprednisolone dose pack (4-mg tablets, 6 tablets first day tapering over 6 days) provides only 84 mg total methylprednisolone, equivalent to just 105 mg prednisone over 6 days. 2 This is grossly inadequate compared to the 540 mg prednisone over 14 days that would be required for conditions where steroids are actually effective. 2 However, this inadequacy is irrelevant for herniated disc because even adequate steroid dosing provides no benefit. 1
Recommended Management Algorithm
First-line conservative management (6 weeks minimum): 3
- NSAIDs for pain control (most effective pharmacologic agent) 3
- Remain active rather than bed rest 3
- Muscle relaxants for associated spasms 3
- Heat/cold therapy as needed 3
- Activity modification without complete restriction 3
- Short-term opioids only for severe pain, used judiciously 3
Natural history supports conservative approach: Most disc herniations show reabsorption or regression by 8 weeks after symptom onset, with improvement generally occurring within the first 4 weeks under conservative therapy. 3
Red Flags Requiring Immediate Evaluation
- Cauda equina syndrome (bladder/bowel dysfunction, bilateral radicular symptoms) 3
- Progressive neurological deficits 3
- Suspected malignancy, infection, or fracture 3
Role of Epidural Steroid Injections (Not Oral Steroids)
If conservative management fails after 6 weeks, epidural steroid injections may be considered as they represent a different delivery mechanism with localized effect. Studies show 42-56% effectiveness for epidural injections in surgical candidates, 4 though this is inferior to discectomy (92-98% success). 4 Epidural injections did not adversely affect outcomes of subsequent surgery if needed. 4
Common Pitfalls to Avoid
Do not extrapolate steroid efficacy from other conditions. The evidence base for lumbar radiculopathy is completely distinct from Crohn's disease, ulcerative colitis, or sudden hearing loss where steroids have demonstrated efficacy. 1 The pathophysiology and steroid responsiveness differ fundamentally.
Avoid patients with contraindications to steroids (if considering epidural route only): poorly controlled diabetes, labile hypertension, history of steroid-induced psychosis, or prior serious steroid complications. 1
Do not order routine imaging in the first 6 weeks unless red flags are present, as it provides no clinical benefit and increases healthcare utilization. 3