Are steroids effective for treating acute back pain?

Steroids for Acute Back Pain

Systemic corticosteroids are not recommended for acute low back pain, with or without radiculopathy, as they have not demonstrated superiority over placebo and provide no clinically meaningful benefit. 1, 2

Evidence Against Systemic Corticosteroids

The American College of Physicians explicitly states that systemic corticosteroids should not be used for acute low back pain based on moderate-quality evidence showing no effectiveness compared to placebo. 1 This recommendation applies to both radicular and non-radicular presentations. 2

For radicular low back pain specifically:

• Systemic corticosteroids may produce a statistically significant but clinically irrelevant reduction in short-term pain (0.56 points on a 0-10 scale), which falls well below the threshold for meaningful clinical benefit. 3
• While one meta-analysis suggested corticosteroids might slightly increase the likelihood of functional improvement at short-term follow-up (19% absolute improvement), the overall evidence remains insufficient to recommend their use. 3
• A single-dose intramuscular methylprednisolone trial in young adults with acute radicular pain showed no significant difference in the primary outcome of pain reduction at 1 month. 4

For non-radicular low back pain:

• Limited evidence suggests systemic corticosteroids may actually be associated with slightly worse short-term pain outcomes. 3

What to Use Instead

First-Line Treatment

• NSAIDs are the preferred initial medication, providing small to moderate improvements in pain intensity (mean difference -7.29 points on 0-100 VAS scale) and disability (mean difference -2.02 points on 0-24 RMDQ). 1, 2, 5
• Prescribe NSAIDs at the lowest effective dose for the shortest duration necessary, assessing cardiovascular and gastrointestinal risk factors before initiating therapy. 2

Second-Line Options

• Skeletal muscle relaxants improve short-term pain relief after 2-4 days (relative risk 0.80 for not achieving pain relief), though they cause sedation as a universal side effect. 1, 2
• Consider muscle relaxants only when NSAIDs are contraindicated or provide insufficient relief after 2-4 days. 2

Essential Non-Pharmacologic Measures

• Advise patients to remain active and avoid bed rest, as activity restriction prolongs recovery and delays return to normal function. 1, 2
• Apply superficial heat via heating pads for short-term symptomatic relief. 1, 2

Critical Pitfalls to Avoid

Do not prescribe systemic corticosteroids (oral, intramuscular, or intravenous) for acute low back pain with or without sciatica, as multiple high-quality guidelines and systematic reviews demonstrate lack of efficacy. 1, 2, 3

Do not confuse systemic corticosteroids with epidural steroid injections, which have conflicting evidence and represent a different intervention not addressed by these recommendations. 6

Do not use extended courses of any medication without clear evidence of continued benefits and absence of major adverse events. 2

Special Consideration: Epidural Steroids

While systemic corticosteroids are ineffective, epidural injection of corticosteroids for radiculopathy represents a separate intervention with conflicting evidence—one meta-analysis suggests small symptomatic improvement for patients with radiculopathy, though this remains controversial. 6 This is distinct from the systemic administration discussed above.