Systemic Steroids Should NOT Be Used for Low Back Pain
Do not prescribe systemic corticosteroids (oral prednisone, intramuscular methylprednisolone, or intravenous dexamethasone) for low back pain with or without sciatica—they provide no clinically meaningful benefit and are explicitly not recommended by the American College of Physicians. 1, 2
Why Steroids Don't Work Despite Anti-Inflammatory Properties
The evidence against systemic corticosteroids is remarkably consistent across multiple high-quality trials:
For acute sciatica/radicular pain: Three high-quality trials consistently showed no clinically significant benefit when systemic corticosteroids were given parenterally (single injection) or as a short oral taper compared to placebo 3, 1
For non-radicular low back pain: A single intramuscular injection of methylprednisolone (160 mg) showed no difference in pain relief through 1 month compared to placebo in patients with negative straight-leg-raise tests 3, 2
Recent Cochrane review findings: While systemic corticosteroids may produce a statistically detectable difference in radicular pain (0.56 points better on a 0-10 scale), this effect is too small to be clinically meaningful 4
Real-world ED trial: A 2014 randomized controlled trial of 50 mg prednisone daily for 5 days in emergency department patients with musculoskeletal low back pain found no benefit in pain, function, return to work, or resuming normal activities—and actually found more patients in the prednisone group sought additional medical treatment (40% vs 18%) 5
Harm Profile
While short courses don't cause serious complications, adverse effects are common:
- Oral prednisone increases risk for any adverse event with a number needed to harm of 4, including insomnia, nervousness, and increased appetite 2
- Intramuscular dexamethasone carries a 6.4-fold increased risk for adverse effects 2
- Transient hyperglycemia and facial flushing can occur with high-dose intravenous methylprednisolone 3
What to Prescribe Instead
First-Line Treatment
- NSAIDs are the preferred first-line medication, providing small to moderate improvements in pain intensity 1, 6
- Prescribe at the lowest effective doses for the shortest periods necessary after assessing cardiovascular and gastrointestinal risk factors 6
- For radicular pain specifically, NSAIDs combined with gabapentin target both inflammatory and neuropathic components 1
Essential Non-Pharmacologic Measures
- Advise patients to remain active and avoid bed rest—activity restriction merely prolongs recovery and delays resumption of normal activities 1, 6
- Application of superficial heat via heating pads provides short-term symptomatic relief 6
Second-Line Options
- Skeletal muscle relaxants improve short-term pain relief after 2-7 days but cause sedation 6
- Spinal manipulation by appropriately trained providers provides small to moderate short-term benefits for acute low back pain 6
For Chronic Low Back Pain
- NSAIDs, duloxetine, and tramadol have moderate evidence of effectiveness 2
- Non-pharmacologic options include exercise therapy, acupuncture, massage therapy, yoga, cognitive-behavioral therapy, or progressive relaxation 2
The One Exception: Spinal Cord Compression
High-dose dexamethasone (16-96 mg/day, sometimes preceded by IV bolus) should be given immediately when clinical-radiological diagnosis of malignant spinal cord compression is obtained 2. This is an oncologic emergency, not routine low back pain management.
Epidural Steroid Injections: A Different Consideration
While systemic steroids don't work, epidural steroid injections may be considered for specific cases of radicular pain, particularly for disc herniation rather than stenotic lesions 2. However, evidence quality is low, and efficacy appears limited to short-term benefits only 7, 8.
Critical Pitfall
The most common mistake is assuming that because low back pain involves inflammation, anti-inflammatory corticosteroids should help. Clinical trials consistently prove this assumption wrong—systemic corticosteroids do not provide meaningful pain relief for sciatica despite their anti-inflammatory properties 1, 4.