Corticosteroids Should NOT Be Used for Sciatica
Systemic corticosteroids (oral or intramuscular) are not recommended for the treatment of sciatica, as multiple high-quality trials and current guidelines consistently demonstrate no clinically meaningful benefit over placebo for pain relief or functional improvement. 1, 2, 3
Evidence Against Systemic Corticosteroids
The American College of Physicians explicitly states that systemic corticosteroids should not be used for low back pain with or without sciatica based on consistent evidence showing lack of efficacy. 2, 3 This recommendation is supported by:
- Six trials consistently found no differences between systemic corticosteroids and placebo in pain relief for radicular low back pain (moderate strength of evidence). 1, 3
- Three high-quality trials specifically demonstrated no clinically significant benefit when systemic corticosteroids were given either parenterally or as a short oral taper for acute sciatica. 2
- The largest good-quality trial (n=269) found only a small effect on function (ODI difference of 7.4 points at 52 weeks), which is below the threshold for clinical significance, while showing no effect on pain or likelihood of spine surgery. 1
Harm Profile
While serious adverse events are rare with short courses, corticosteroids cause significantly more adverse effects than placebo:
- Oral prednisone increases risk for any adverse event (49% vs 24%; P<0.001), with a number needed to harm of 4. 3
- Common adverse effects include insomnia (26% vs 10%), nervousness (18% vs 8%), and increased appetite (22% vs 10%). 1, 3
- Intramuscular dexamethasone carries a 6-fold increased risk for adverse effects (RR 6.4). 3
Recommended Treatment Approach Instead
First-line therapy should be NSAIDs, which provide small to moderate improvements in pain intensity for acute low back pain. 2
- Naproxen 500 mg twice daily or ibuprofen 400-800 mg three times daily are appropriate choices. 4
- Allow at least 8 weeks for full NSAID effect, as time to response is approximately 1 month. 4
For inadequate response to NSAIDs alone, add gabapentin or pregabalin to target the neuropathic component of radicular pain. 2, 4
- Gabapentin shows small to moderate short-term benefits specifically for radiculopathy. 4
- This combination targets both inflammatory and neuropathic pain components. 2
Advise patients to remain active and avoid bed rest, as activity restriction delays recovery. 2
Critical Pitfall to Avoid
Despite the anti-inflammatory properties of corticosteroids and their theoretical appeal for treating nerve root inflammation, clinical trials consistently demonstrate they do not provide meaningful pain relief for sciatica. 2 Do not be misled by the pathophysiologic rationale—the empirical evidence is clear that systemic corticosteroids are ineffective for this indication.
Special Consideration: Epidural Steroid Injections
While systemic corticosteroids are not recommended, epidural steroid injections may be considered for specific cases of radicular pain, particularly for disc herniation rather than stenotic lesions. 3